HomeMy WebLinkAboutMiscellaneous - 275 DALE STREET 4/30/2018 (2)5
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___ -- - - - - � --- ---- � -- --- -- --- - ---�- r
AMERICAN CLAIMS SERVICE
MULTI -LINE ADJUSTERS
Letter 143
February 16, 2016
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Attention: Building Inspector
Board of Health and/or
Board of Selectman
Insured:
Lippman - Licciardello
Location:
275 Dale Street North Andover, MA 0 1845
Policy:
PHO 0100 90 79 69
Loss Date:
2/14/16
Loss Type:
Pipe burst
ACS File:
160049
Dear Sir/Madam,
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under, Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to the attention of the writer and include a reference to the captioned insured,
location, policy, loss date and file.
On this date, February 16, 2016, 1 caused copies of this notice to be sent to the persons
named above at the addresses indicated above by first class mail.
Unless a response is received within the next ten days we will not be obligated to pay any
portion of this claim to you.
Respectfully submitted,
Craig Gillespie
Claims Representative
7 KIMBALL LANE BUILDING C LYNNFIELD, MA 01940
PHONE 781-245-9516 FAX 781-245-1077
c lai ms.acs(W-verizon. net
9750
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Z&
This, certifies that ..... I ............... ...... ..................
has permission to perform ................ ............
wiring in the building of ................. .........................................
...... ... ..... ...
at ........ .......... P1,46 ....... ......... North Andover, Mass.
Lic. No./.-�.9.2-�� ........... . ........
ELEcTRicAL INsPEc%R
Check #
-C\- Commonwealth of-Afassachusetts Official Use Only
UMM� 0
Www Permit No. z�75-0
Department of Fire Services Pem)"No'
�) �r ar
Occupancy and Fee Checked
F,
UV BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (ME9, 527 C 12.00
(PLEASE PRTNT IN INK OR TYPEALL 17VFORAA� TION) Date:
City or Town of- A&AA11-z' Am B 0 o the Inspector of Wires:
By this application the undersigre—d giviFs-nitife of hig or hFFr inteffition to Perform the electrical work described below.
Location (Street & Number) .) ?'s- /I 1-e 's 4 --
Owner or Tenant
Owner's Address
191
Telephone No.
Is this permit in conjunction with a buUding permit? Yes U--" NoE]BLDG PERART
Purpose of Building Utility Authorization No.
Existing Service Amps Volts OverheadE] UndgrdF] No. of Meters
New Service Amps Volts OverheadEl Undgrd 0 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
-5 S S 64e,,(
No. of Recessed Luminaires
- =1-._11 -J --J----,5
No. of Ceil.-Susp. (Paddle) Fans
— "'"Y U� wutmu by the inspecror oj wires.
No. of Total
Transformers K -VA
No. of Luminaire Outlets
No. of Hot Tubs
Generators K -VA
No. of Luminaires
Swimmingpool Above F-, In-
Swimming Po
No—.01 Emergency Liglifling
__.grnd. grnd.
Battery Units
No. of Receptacle Outlets
No. of Oill Burners
r
FIRE ALARMS
iNo. of Zones
No. of Switches
2!
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting D,evices
No. of Waste Disposers
11catPU__M`pFN.Mmb
..........
Tons
........................
!71
KW
.......................
No. of Self -Contained
Totals:
I
Detection/Alerti :7 Devices
No. of Dishwashers
Space/Area Heating KW
Local Municipal her
Conn ction
No. of Dryers
Heating Appliances KW
Security �iystems:-
-so. of Water
Heaters JKW
No. o
No. of Devices or Equiva ent
Data Wiring:
Signs Ballasts
No. of Devices or Eguivale t
No. Hydromassage Bathtubs
No. of Motors Total HP
T-elecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Aiiach additional detad t(desireg or as required by the Inspector of Wires.
Estimated Value of Electr',al Work: _�KO�W, 4:�d (When required by municipal policy.)
Work to Start: Iltl .3 ZCIC) Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability i ufance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office.
BON
CBECK ONE.: INSURANCE 5;� DEI OTBEREJ (Specify:)
I certtfy, under th ndpenalde&4nj�f perj; , that th -
Itrmakon on th'
a pplication is true and complete.
FIRM NAME: J"t J - A,- LIC. NO.:W,/,?19
Licensee: -, I2.044O.'r /IV-<- Signatur LIC. NO.: 9 > .9
(Ifapplicable, enter "exe "in the license number line-) x
Address:-�9_ _5'<_,#X0rL, 4 leal-I /11/�, C),,,:�p�>Bus.Tel.No..
Alt Tel. No..
*Per M.G.L. c. 147, s. 57-6 1, §ecurity work requires Departmeift of Public Safety "S" Licen LIC. NO.:
C5
OMWERIS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (che one) [] owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
1. ROUGH ECTLO-N)
Passed – Failed – f I Re -inspection required ($50.00) -
Inspectors' reomments:
(Inspectors' Signature- no initials) 1/17 C�11 _4 Date J—)4 —?-0
4;ij�_A1,J*4kP'ECTION:
Failed – Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initi�als) Date
3. UNDER GROUND INSPECTION:
Passed – [ I Failed – f I Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
4. INSPECTION – SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed – f I Failed – Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
5. INSPECTION - OTHER:
Passed – f I Failed – Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
The Commonwealth offfassachusetts
-Department ofIndustrialAceldents
,U Office ofInvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affida-vit: Builders/Contractors[FIectricians/Plumbers
Applicant Information Please -Print Legib
NaME) (Business/Organizatiorvindividual):
Address: -S-0 A, r
Phonc#:
Are you an employer? Check the appropriate box:
I ain a employer with
4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2.1;J�_ a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacit_V.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. El I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have. no
insurance required.]
employees. [No workers'
comp. insurance required.]
7�`e -,
Type of project (required):
6. F1 Now construction
7. E] Remodeling
8. E] Demolition
9. F1 Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12.F] Roof repairs
1311 other
!Any applicant that checks box41 mustalsofill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
IContractoTs that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding worke"S' compensation insurancefor my employee�. Below is thepollcy andjoh site
information.
Insurance Company
Policy # or Self -ins. Lic. Expiration Date:
Job Site Address: City/State/Zip-___
Attach a copy of the workers' compensation policy declaration page (showing thepolicy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDBR and a fine
of up to $250.00 a day against the violator. Be * advised that a copy ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage ver'ification.
I do hereby certify under thepains an4penaldes 0?f that the informadonprovidedabo7ex T d -eet.
an co`f
Phone#: 5�' D c) 2 6
Ofji-eial use onbi. Do not write in this area, to be completed by city or town official
City or Town:
FermitMeense 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. C!WTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactFerson: Phone 4:
Date.
4,
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING-
ACHUS
This certifies that
............ .......
has permission to perform ...
..............
plumbing in the buildings of ........................
2. D eii ...........
0
N Mass.
Fee No ... .....
....... . . . . .
P ui�j3 I.N.
Check # 3 ((
A.
ORM AppL-ICATION FoR PEFMT TO ID 0 PLUAMING
-MASSACRUSETTS UNIF
(1)?p a or print)
NOFMI ANDUVER, MASSACHUSEY0 D ate
armit
owners Name I?
BuildingLo-cafijn_,A Amount
T of OccuPancy
Plans Submitted YeS NO
Renovation Replaceme&
j,TeW
ChezIc one: k-UUI.LW4LQ
(Print-ortype) -----------------
installing Company Nam,
Address 0 Partner.
Firm/cc),
.......... 77� —7 El
bUSMOSS ..........
OfLiccns�d Plumber:
'Name pfiata bOX:
Ins ra a: ludir th type f irguTance coverageby checking the applo
Go Covera -ate a' Other type of indemnity Bond
Liability insurance policY n-- s nol ha-�e any one oftbe kbove
I the undersigned, have been made aware that the licensee ofthis application doe
,Insiirance Waiver:
three Risurance
'�ignature " 1 1. O)�raer E] Agent El
Is and informatioul have, submitted (or -,nf&rd) in above application are.trae awl accurate to the
I hereby certifY that all Of the deta-1 .11 , )?65-4ed under I?cm-dt Issued for this application -will be in
best ofmYlmowledge and that all plumbing work aSaipsta ations I I -
' a with all pertinent provisions ofthe Cob and Chapter 142 ofthe Gen6ral laws
complianc
.1--Y. - . —. — Z Type of Plumbing License
Title /-/-' 2' //, P / - /7 ---- 'T.--yMan
cityiTovM rLj-cejjg-0BjIM or ".t.'
APPROVED (OFFIcE uSE ONLY
The commonwealth qfMasNachusetts
Depattment qfrndrzsft-IaI_4cddan&
ofi7ce 0_f�hivesggaaons
600 Wi7sIzington Street
BO-S't022, I�M 02111
Workers' CompengaijoxL Ingurance -AffCTXVRt: BaUders/Contractors/Electd"-an
. I ra S/Phmbers
. Name- 03usiness/Organization/ln4i-�,idu�d):.
e)
City/State/Zip._L
Phon,�,-
-A�e 3,.Qean employer? Check the aPpropriate box;
I. Vr am a employer �vith 0
4. El I am a gahral rontra,tor and I
cmployees (fiAl and/or part-time).*
hav6 hirod -the sub -r onb=ton
2.ETI am -a sole proprietor or parbaor-
'listed On tbZ afthchcd shtnt
ship and have no omployces
These sub-coiatractors hE�ve,
,wo rlcingg for mb'M' any caparity�
workers' C'OMP. insurance.
[No workers, COMP. inmiranco
:5. El Wg-, are a cc)rporatjou and its
roquixedj
Officers ha.-Va oxtroised their
3. F-1.1 am a homeowner doinE all v�ork
right of cxegmption per MGL
myself, [No workers' comp.
152, 6-10), and We, have no
insumacorequired.] t
0uTloY=S_ [No *orkersl
06MI). m9nrance reqniredl
TYPe of Project (.required):
6.. El coastrartion
7.
8. F1 Demojifion
9. E] DI�Jdiqgg addition
10 -El Electricafrepairs- or additions -
.1 LETTT.bing regairs or additions
12.El Roof repaim
ME] Other
A . f I
bax�Q mt--also a, cat jL= E b -
c -b -on - 1�y
I 1101-nebwnetrs who submifthis affidavit indicatiaX LbSt a --e, dchlz all - -Ik d --poEi -=±:Cm.
Ar an thra 1L'M-GUts'C'e cop-tEact-o's �4&-t 9-11bMit a 'law iffi&vit indicating such.
"Contractc)rs thatc�-t& this addifional sh the� T`m D .0f the sub-contmd= ad th" w '
eir orlc='comp—.PD—Hryi—nfomn—d-ei—L
!am an coin ezzsauonzrzs7zranceforwyampl6yeag.
p Baloh) is Z�eporicj) andjobsite
Insurance compiny
POlicY # or Solf-ias. Lic.
EX�pirafion.Date:
Job Sitf- Address:
City/State/Zip:
Attach a copy -of the workers' compensation policy declarati4on Vage (shoydng ihe policy numbe'r-and expiraflon date).
Failure. to S (-- cura c overage, as re quire d und--r S e otion 2 5A 0 f M CiL c. 152 c an Ir, a d to the inap o sition o f criminal p en alfica o f a
fiab up to $1,500.00 and/or one-yoarimpriswlTnen�, as wall as civiipenalties in th6 form Ca. STOP WORK ORDER and a En�,-
Of
.P to S250-.00 a day aiainftthf, violator. Be -advised that a copy of this StafCMCntxniy be forwarded tothc. Of dcc, of
la-ve:stigations of the DJA for insurance coverage verffioafioiL
',do 4,�raby Cg��7nderyhgpq
'3"hcrtthe informa2lon.providedabovo*is2�rue unit correct-
OfficiaZ zrsa only. Do not wrl&in thisarez; to be completed hl, ci , 0., '
town offi-ciaL
City or Toym:
Issuing Authority' (circle one). ' .
I. Board of Health 2. BuUdinl- Department 3. 0WTqwn Clerk
6. other
Contact Per -sun:
4. ElectricalTnspector S. Plumbing luspe&tor
)?hone*#.
,&ORTH
'33,
Date.. ... ..................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....................................
.....................
has permission to perform ..................
wiring in the building of
............................ 1. .....................................................
at ... Z� ....... ................ North Andover, Mass.
Fee�� ........ ..... Lic. NQ.("— �74qv-'� ...........
ELEC-MCAL I�NSPE�CTOR
Check #
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS . [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforined in accordance with the Massachusetts Electrical Code (M Q, 527 MR 12.00
�f
(PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date:-// 6
City or Town of. NORTH ANDOVER To the In;11ector'6fWires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & ��lber) v212S-- 'D,4- le- S,7—
Owner or Tenant
Owner's Address
(,> Al -2
Is this permit in conjunction with a building permit? Yes
Purpose of Building ��, F. ID ,
Telephone No.
No [4 (Check Appropriate Box)
Utility Authorization No.
Existing Service 100 Amps /,LO AY& Volts Overhead Undgrd No. of Meters
New Service A- =14- Amps Volts Overhead Undg,d No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electri Work: Z/O A c2 L/O V6 e� Ve AI- Ct
n2 k' D,, 5P Z-S44A-1) OL,7-14-7-5-
lCompletion of the llowing able"maybe waived the speclor of eires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In-
grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 11-7
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
I.NPTP�.r
[T9��
..K.W ............
No. of Self -Contained
1'
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Ej Municipal
Local Connection 0 Other
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of W—ater
KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wirm&:
No. of Devices or Equivalent
OTHER: I
f
7o Attach additional detail if desired, or as required by the Inspector of Wires.
,,Z
Estimated Value of Electrical Work 06. 1 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE- BOND [] OTHER Fj (Specify:)
I certi , A
.fy, under the ' andpe alties ofperjury, that the information on this application is true and complete.
pry
�ME.
FIRM NA t�A�,2- -r� r, , LIC. NO.:
/c'� Signature r
Licensee- [--)-e ri e? t f LIC. NO.:Lf-,�?-7 I Z
(Ifopplicable —enter "�xmpl " in the lice"
Ze number line.) Bus.Tel.No.:�?21'
Addressi--/z Lpt::� Z- S 7-rb 2,)
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)E] owner 0 owner's a t
1-.
Owner/Agent C�6_4�9 tent]
Signature Telephone No. PERMIT FEE: S
Date..//—/�-o 71
...............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .........
.......................................
has permission to perform ........................................
'-- , I
wiring in the building of
....................................................
atC;� ....... .. ..... . ............ North Andover, Mass.
R.............. Lic. No....= ...... .................
Fec�-- :AL I§E
- &LE
Check #
Commonwealth of Massachusetts Official Use Only
it No. —ye) VP
Department of Fire Services Perm
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
J[Rev- 1107] (leave bl k)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRflVTRV1NK OR YYTE ALL LVFORMATION). Date: 11-16,-ag
City or Town of. NORTH ANDOVER To the Inspector Of Wires:
By this application die undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street& Number)
Owner or Tenant /L/10'yAZ Telephone No.
Owner's Address -ts�-
-,
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps volts Overhead Undgrd E] No. of Meters
New Service Amps Volts OverheadEj UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 000� /.4
Q --, e
--mun- ue.0 u aesirea, or as required by the Inspector of Wires.
Estimated Value of Electric . al Work: (When required'hy municipal policy.)
WorktoStart: Y -A; -0k Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof orfe to/the permit issuing office.
CHECK ONE: INS E BOND 0 OTHER El (Specify:) _ e._ _ 5 'r
ns a��d'p',-A,,alfies ofperjury, that the infor"a �n on this appli tion is true and complete
I cer6ft, under the j =,u
FIRM NAME: /- ,
-e /0,., e� A, LIC. NO.:
Licensee:
t1ol'-Azle ,L Au , ,-Z 1/45ignatur
(If applicahle, enter exe t 11 inthelicense ;iiiiin;oerlijo) LIC. NO.:
Address: ,!P, I Bus. Tel. No.: 1
10 121�,5 S
!,11 1111II11P, 3a -2 9
Alt. Tel. No..%�-e& K2,V-
*Per M.G.L c. 147, s. 57-61, security work requireDepartinent of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I here . by waive this requirement. I am the (check one) [] owner
Owner/Agent El owner's agent.
Signature Telephone No. PERMT FEE. -
,�y,� J
GL,�"
y�
R
��
►�
The Commonwealik of Massachusetts
Department of Industrial Acciden&
Qjftce of Investigations
600 Washington Street
Boston, MA 02111
r -; . www.mass.govldia
Workers' Compensation Insitrance Affidavit- Buflders/Contractors/Eiectricians/PI I ambers
Applicant Information
Please Print Legibly
Name (Business/Organizafionlindividual),
Address:
City/State/Zip:
Type of Project (required):
6. [3 New construction
7. *Remodeling
8. [3 Demolition
9. Building addition
10. Electrical repairs or additions
f 1 -0 Plumbing repairs or additions
12.[] Roof repairs
13.[].Other
e — a ow ng their woi kett ompensation policy IntiormatiotL
Homeowners who submit this affidavit indicating they are doring all work and then hire outside contmeton must submit a new affidavit indicatin I g such�
1COntla-6ton; that check this box must attached an additialtal sheet sho
wing, the name of the sub-colittitcton; and their worken;' comp. Policy ittibmiation.
am an employer thatis Prividing workers' c0MPenSad0A insurancefor nV englloyeeL Below is. th —
informwion. f e po&y andjob site
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/State/Zip-
Attach a copy ofthe workers' compensation policy declaration page (showing the Policy number and expiration date) -
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby n pa, dp Perju at the infOrmadon provided above is vue and co
rrecL
Signature:
Date:
zz_
Lhone 4: d
Officiat Use Only. Do not write in this area, 'to be complered by chy or town official
City or Town:
PermittLicense #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Ile -
Are you an employer? Check the appropriate box:
1: am a employer with
4. 0 1 am a general contractor and I
employees (full and/or part-time).*
2.9 1 am. a sole proprietor. or partner-
have hired the sub -contractors
listed on the attached sheet I
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp. insuranc'e
5. We are a corporation and its
required.]
3.[3 1 am a homeowner doing all work
officers have exercised their
right of exemption per MOL
myself. [No-workirs, conip.
c. 1.52, § 1(4),'and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.)
*Any a licant that checks boi # I must also fill out the section 1- 1 1.
Type of Project (required):
6. [3 New construction
7. *Remodeling
8. [3 Demolition
9. Building addition
10. Electrical repairs or additions
f 1 -0 Plumbing repairs or additions
12.[] Roof repairs
13.[].Other
e — a ow ng their woi kett ompensation policy IntiormatiotL
Homeowners who submit this affidavit indicating they are doring all work and then hire outside contmeton must submit a new affidavit indicatin I g such�
1COntla-6ton; that check this box must attached an additialtal sheet sho
wing, the name of the sub-colittitcton; and their worken;' comp. Policy ittibmiation.
am an employer thatis Prividing workers' c0MPenSad0A insurancefor nV englloyeeL Below is. th —
informwion. f e po&y andjob site
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/State/Zip-
Attach a copy ofthe workers' compensation policy declaration page (showing the Policy number and expiration date) -
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby n pa, dp Perju at the infOrmadon provided above is vue and co
rrecL
Signature:
Date:
zz_
Lhone 4: d
Officiat Use Only. Do not write in this area, 'to be complered by chy or town official
City or Town:
PermittLicense #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Ile -
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an mWloyee is defined as "...every person in the servic'e of another under any contact of hire,
express or implied, oral or writtem"
An effployer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in ajoint enftr�rise, and including the legal representatives of a decrased employer, br the
r=iver or trustee -of an individual, partnership, association or other legal entity, employing employees. 'However the
owner -of a dwelling house having not more than three apaitments and who resides thereiN or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair wdti� on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MOL chapter 152, §25C(6) also states tW "every. state oe,loicall licensing agency shall withhold the issuance or
renewal of a license or permit 6 operate a bastni.eisS o'r to'construct buildings in the commonwealth for any
applicant who has n'ot produced acceptable evidence.of compliance with the insurance I coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of comp6nce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also'be sure to sign and date the affidavit 7be affidavit should
be returned to the city or town that the application for fine pem'it or license is being requested, not'the Department of
Industrial Accidents. Should you have any questions r6garding the law or if you -are required to obtain a workers!
compensation policy, please call the Department at the number liked below, Self-insured companies should enter their
self-insuranc'e"license number on the*appropriate line.
City or Town Officinis
Please be sure thai the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitAicense applications in any given yW, need only submit one affidavit indicatingcurrent
policy information (if necessary) and Lmdzr,."Job Site Address" the applicant should write "all locations in city or
town)." A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidaVit is on file for future permits or licenses. A new affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Offica of Investiptions would like to, thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.,
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Departmcnt of IndustrW Accid=ts
Office of Envestigations
600 Washington Sti=t
Boston, 1\4A 02111
Tel. # 617-727-4900 6xt 406 or 1-977-MASSAFE
Revised 5-26-05' Fax 4 617-727-774�
www.mass.gov/dia
TOWN OF NORTH ANDOVER
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845-2909
Thnothy J. Willett
Water & Sewer
Distribution Superintendent
Ms. Diana Hastings
275 Dale Street
North Andover, MA 01845
RE: Sewer Connection
Dear Ms. Hastings:
J. WILLIAM HMURCIAK, DIRECTOR, P.E.
Telephone (978) 685-0950
Fax (978) 688-9573
As we discussed, the newly installed sewer lines on Dale Street and Great Pond Road have passed all
required tests. We are awaiting the submission of an As -Built Drawing from the contractor to confirm
the sewer lines have been constructed according to plan. We expect the As -Built Drawing to be
submitted within 2 to 3 weeks. We will allow house connections to the new sewer if the As -Built
Drawing is satisfactory.
All properties within this project will be assessed a betterment fee of $3,858.00 per lot according to the
town's betterment fee policy. The properties will be assessed a few months after the sewer lines
become active and ready for connections.
Very truly yours,
Timothy J.4illett
Water & Sewer Superintendent
CC: Susan Sawyer, Health Agent
No
Date. ........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
W -
This certifies that ... .17Z
has permission to perform .... //.L"L ...........
plumbing in the buildings of . . 51 .......
at. . ............... North Andover, Mass.
Fee.,;,. . . . . Lic. No .. ...... ......
�11PL*U'MBING INSPECTOR
Check# 3,� V
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
Mass. Date c43 t#
P ml
OWL's N Ye
c Building Location.
Type of Occupancy_Residential
New L -J Renovation 0
Replacement IN Plans Submitted: Yes El No 0
FIXTURES
02-7
Installing Company Name ileritage Htg-&P19- Co. Inc. Check one: Certificate
Address 35 Pleasant Street EX Corporation 714
Stoneham, Ma 02180 []. Partnership
Business Telephone 7 8 1 – 43 8--=— F.1 Firm/Co. —
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes E-1 No 171
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy M Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit. application waives this requirement.
Check one:
owner El Agent 0
I hereby certify that aH of the details and information! have submitted (or entered);rl above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massacliusetts State Plumbing Code and Chapter 142 of the Gen. oral Laws.
By__ IAeg�'g A
S�tj�n,t�uw, -0cons, uber &1- -
Title Type of License: Master [X Journeyman 0
City/Town --F
APPPAYVED OrFICIE-US—EORL—Y) License Number 8 3 2 2
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5TH FLOOR
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7TH.FLOOR
STH FLOOR
Installing Company Name ileritage Htg-&P19- Co. Inc. Check one: Certificate
Address 35 Pleasant Street EX Corporation 714
Stoneham, Ma 02180 []. Partnership
Business Telephone 7 8 1 – 43 8--=— F.1 Firm/Co. —
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes E-1 No 171
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy M Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit. application waives this requirement.
Check one:
owner El Agent 0
I hereby certify that aH of the details and information! have submitted (or entered);rl above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massacliusetts State Plumbing Code and Chapter 142 of the Gen. oral Laws.
By__ IAeg�'g A
S�tj�n,t�uw, -0cons, uber &1- -
Title Type of License: Master [X Journeyman 0
City/Town --F
APPPAYVED OrFICIE-US—EORL—Y) License Number 8 3 2 2
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Date .... .....
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slow
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... 0-�'
............... ( ............ .... F.S .................................
has permission to perform ...... .....................................................................
wiring in the building of ........ An...,o . .....................................................
at ......... .............................. ;�N ilh�dGver, MaWl
0
Fee.... ... .... Lic. No. ............ ..... ......... . .......
ELEMICAL NSPECTOR
Check # 0)
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TRFC0W0NWE4LTH0F314MCJHJSE77S Office Use only
DEPART3ffiW0FPVBL1C&4FM Permit No. A�;
BOARD OFMEPREVE7MONRWMTIOAS5270M 12-00 Occupancy & Fees Checked
VJ4
APPUCATION FOR PERAff TO ARFORM ILECMCAL WORK�
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perfbrm the electrical work described below.
Location (Street & Number) R 7 6- D oJe-
Owner or Tenant �3 ( t� (CLV\ tA O -S --h A ZS
Owner's Address 50M r -
Is this pen -nit in conjunction with a building permit: Yes rM No (Check Appropriate Box)
b -.-N
Purpose of Building C I o .5.e_j _5 c�. r�, cl 60 1 r\ 4o L,3 Utility Authorization No.
Existing Service Amps Volts Overhead Underground No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. ofLighting Outlets
f
No. ofHot Tubs
No. ofTransformers
Total
KVA
No. of Lighting Fixtures
6
Swimming Pool Above
Below
Gen erators
KVA
ground
E3
ground
t
�0. ofReceptacle Outlets
No. ofOil Burners
No. of Emergency Lighting Battery Units
-v �o. ofSwitch Outlets
8
No. of Gas B umers
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. ofSounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER ------
1-03=COWFagC� R19MtIDI�CMWM)MtSdNL%mdusdisGmaW Laws
I hawaamutLrbiltyhwxa=Pbbcyark&gCanpleteOpwafionsComaWcr�sskstitiaI equi�-� YES 0 NO E]
I ha%c%hniWdvandPW0f0FS3r1e1D1heOTm YES M NO M lf�uuhmedudW YES, pkmemdcalethr�peofom�by&ddTthe
appruprmum
INRRANCE F-1 BOND OTHER (PlmeSpeffy)
WcrkiDStm lnspac6mDaleRo*xsW
ro-TRIN, "I, "NA tZ
Fstim&d Valueoffiedrical Work $
Rough Fr"
Silpiedut,Ix'&%ulk-sofp,�w. ry\
FIRM NAME 'SS Lim-&-- %
-fWrF-;r, - AiTdNa.
OWMIZ'SPWRANUWAfVEI;�lamawmtxttheLjmmdmid
(Plea6feck one) Owner Agent
�t� VY\ %�;Pl Telephone No. PERMIT FEE$ 6��3 r
b Location cR f2,5-- ;D,,q I E S /-
4� No. �t) Date 7-10 -0-3..
V
"ORTN TOWN OF NORTH ANDOVER
AL
L r Certificate of Occupancy $
Building/Frame Permit Fee $
CH
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 6
Check # /,-3 C//
165'18
Building Inspector
nm
r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATIO' N TO CONMUCI! RENOVATE, Olt DEMOUSH A ONE OR TWO FAMMY DWEIMNG
= WAR R115951 105.Rl .5,
BUILDING PERMIT NUMBEFL ISSUED: 7
A-�
C
SIGNATURE:
Building Foqtrqi!g�� Of Bw!t� Date
SECTION I -SITE EWORMATION
1.1 Property Address:
L2 Assemn Map and Pared Numbw.
0 '4
0(9q, 0 glocj< oo?7
Map Number ParcclNumber
,13 Zorringlaformation:
1.4 Property Dinunsiom
-f3'q00 15-01
znning
Ld Arm W
1.6 BURbING SETBACKS (ft)
Front Yard SidCYatd RW Yard
Provide RCQWWd =PMwdcd Provided
Lec.
.E!md
u now z0ft wermxfim Simor
7AM 0OWWO Flow zom 0 municip] 0 onsittempml System 0
13 fthatc 0 -
SECTION 2 - AR—OPERTY OWNERSHIP/AUTHORMED AGENT
2.1 Owner of Record
�J i0rd^ ad, 0 1 o- e,— fivs-h
Namc(Print) Address for Savice:
97S 5 -?o 9 70%
signature Telephone
22 Owner of Record:
Name Print Addrcss; for Scrviw.
Signature
SECTIO14 3 - CONSTRUCTION SERVICES
3.1 LiccnscdConstructionSupervisov. Not Applicable 0
Licensed Consmxtion Supervisor
LiemseNumber
Addrm
Expiration Date
Signature Telcphono
32 Registered Home Improvement Contractor Not Applicable 0
CompanyName
Registration Numbff
Address
Expiration Date
Signatuic ug±M
19
M
X
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G)
giC—n& 4 - WORKERS COMPENSATION MG -L C 152 § 2Sq6)
Wmkcrs Compensation Insurance affidevit most be completed and submifted.wft this �icatioa. failure to rovide this affidavit will result
SECTIONS D61crdfivAtion Proposed work (dwckaMe�ble) I
New Censtruction" 0 Exi . stingBuilding; 0 0 IAIW,,tim,(,) 07tion '13,
Accessory Bldg. - 0 Demolition 0 FG: 0 Specify
BriefDescription of Proposed Work'
A4M,�,r- arok I'- X a' e\ r,,j
,r^C%V
item
Estimated Cost (Dollar) to be
yo
Completed by applicant
1.
Building
000
(a) Building PeTmit Fee
muld
2
Electrical
(b) Estimated Total Cost.of
-Con�on
3
4
Plumbing
Mechanical (HVAQ
Building Permit fee (a) x.(b)
5
FireProtection
6
Total Q 3+4+5)
Check Number
WSO-ILAU111 to - - ".-"
OWNERS AGENT OR CONTRACTOR APPLES FOR BUILDING PERN[IT
L as Owner/Authorized Agent of subject propert�
Hereby authorize. to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature Of Owner Date
as OwnerlAuthorized Agent of subject
property
Hereby declum that the statements and.infDrmation on the foregoing application are true and accm�at�, to the best of my knowledge
and belief
Print Name
Si ature of OwnedAgent Date
NO. OF STORIES SIZE
BASBENT OR SLAB 2NU
SIZE OF FLOOR TIMBERS 3
SPAN
D14ENSIONS OF SILLS
DIMENSIONS OF POSTS
DWENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING x
MATERIAL OF CHNINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDINO CONNECTED TO NATURAL GAS LINE
Tel: 978-688-9545
Town of North Andover
Building Department
27 Charles Street
North Andover MA 01845
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE -7
JOB LOCATION
Number Street Address Section of Town
"HOMEOWNER S 0 rv,-�
Number Home Phone Work Phone
PRESENT MAILING ADDRESS 97S 0 d -k -9-
N 0 -r -R, Prr40,j-<F 0\ ok ?Vs—
City Town I State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1. 1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one to six farrvily dwelling, attached or detached structures ac-
cessory to such use and and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner. Such "homeowner* shall submit to the Building Official,
a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner' certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requir(pments.
HOM EOWNER'S SIGNATURE W Ck/U(ffM A\
APPROVAL OF BUILDING OFFICIA
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
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Location -P,
No. 40 19, Date
Check#
18585
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
2,,
'-�—Building Inspe �r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
A X'.
BUILDING PERNUT NUMBER: DATE ISSUED:
SIGNATURE:
Building CommissioEEftq2r f Buildings Date --0,5
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning DiAhct Proposed Use
Lot Area (sf) Frontage (11)
1.6 BUELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required ProvidW
RecIttired T- Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone 0
municipal 0 On Site Disposal System 0
,
SECTION 2 - PROPERTY OWNERSEEIP/AUTHORMED AGENT
I
nistoric Uistrict: Yes —No
2.1 Owner of Record
0-1 A,, -SL -
Name (Print) V Address for Service:
'7-2y - 7
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
I SiRnature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor:
!�-3
License Number
g-S —�
A(lclress
a —� Ir— 0
Expiration Date
Telephone
3.2 Registered Home Improvement Contractor
Not Applicable 0
(2e �4e
Company Name
Registration Number
// -'2- - o-5
ress
L�
?,9 �-&5 7'?-
Expiration Date
-
Sjj;?r7e Telephone
00
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I SECTION 4 - WORKERS COMPENSATION (XG.L C 152 6 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the.building permit.
Signed affidavit Attached Yes L,3<6 _ No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s
71i�
C rations(s) 11
Addition 0
Accessory Bldg. 0
Demolition 0
Other 11 Specify
Brief Description of Proposed Work:
-SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
I . Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
-6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUHDING PERAHT
_C1 C �nl of�ect property
Owner/Authorizedfg
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application
� I P .'_ -2-
-Signature of Owner Date
-SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print
igna riTZ5wner/Age_nt Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T11VIBERS Isr 2 No 3 RD
-SPAN
-DIMENSIONS OF SILLS
-DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
-MATERIAL OF CHRANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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G�41dl
Sold To:
Address: 2 7C
HIC Registration #129774 Federal ID #04-3277886
Pella Windows & Doors of Boston
"Viewed to be the Best"
umh
city: IV M-4 ev CIL
Job site Address (If different):
10.
11.
12.
13.
14.
15.
16.
ENTRY SYSTEM CONTRACT
State: - ItIA zip: 01 �,Lf!r —
All workman's compensation and liability insurance maintained
Pella Windows & Door,,
45 Fondi Road
Haverhill, MA 01832
PH: (800) 866-9886
Service: Ext. 124
Fax: (978) 556-0394
Sales: (866) Pella06
— Date: Aiev
Phone (Home) (y],
Phone (Work)
Phone (Cell
il - vos LO Cp
E-mail: t4rY_
Warranty mailed to customer upon ?om t )n,
pile ic Jen full payment is received.
Total Project Amount $ US3 - -
Financed If Yes: Amount Financed $ (Reference #
Deposit Received $ ato
x�
Balance on Substantial Completion $ (Payment Is payable to installer at completion of job)
Additional Comments:A� &Cf -Vi td— 1-�� L, 10,,i r., , , hLnA__-1
fI
,fm _6q 30!� s,�a
PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS.
PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES
ORWINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION
OF YOUR NEW ENTRY SYSTEM. INSTALLERS ARE NOT RESPONSIBLE
FOR THE REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS.
bsloe) C 14,whA'r
SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE
ANY REPRESENTATIONS OTHER THAN CONTAINED INTHIS AGREEMENT
AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR
RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY
FILLED IN DUPLICATE OFTHIS AGREEMENT.
CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A WARRANTY CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION
PROBLEM. DEPARTMENT.
This contract - Is. a legal document. Your Pella products will be specially made-to-order for you. U -MR NO CIRCUMSTANCES WILL REVISIONS 0
Pella Rep. Signature:
Customer Signature:
,Q_4�
White - Original Yellow - Customer
Date: 1__� ) / / -)�
Pink - Store
1-4N
In, N
WN. ILI' 111
Z, I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
Name (Business/Organization/Individual): PIC::— It 6�
Address:—
City/State/Zip: (( et,,(4 e -1,13 -e -Phone #:
Are you an employer? Check the appropriate box:
I X I am a employer with 2`5-
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.0 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' cornp.
c. 152, § 1 (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required
Type of project (required):
6. F-1 New construction
7. 0 Remodeling
8. E] Demolition
9. E] Building addition
10. FT Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.F Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy infon-nation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Narne:_
Policy #orSelf-ins. Lic. #: Expiration Date: 701/—D
Job Site Address: City/State/Zip: llf--
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unde r the pains andpenalties 9f perjury that the information provided above is true and correct.
Si2nature: Date:
r �&2140—s—
Phone#: 17,?– TC 5-- -7 2- t;�
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such emplo ment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the co ' mmonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confin-nation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or cornmercialventure
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
6,00 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 4 617-727-7749
Revised 5-26-05 www.mass.gov/dia
NORTH ANDOVER BUILDING DEPARTMENT,
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in: .
Fire Department Sign off-
Dumpster Permit
/7
(Location of Facility)
Signature of Permit Applicant
Date
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Location IE 3
No. Date 5—
TOWN OF NORTH ANDOVER
07
jri;�L 'S.
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
13 Ou "S
$
building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERNUT NUMBER: DATE ISSUED: —62 -CD
SIGNATURE: 16�
Building Coml(hissioner/InTector of Buildings Date
SECTION I- SITE INFORMATION
LI Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning DiArict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frovitage (R)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 11
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEEIPIAUTH 171.1) AGENT
F
2.1 Owner of Record
G � � 1 1+&4 for, D t.�,
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
A —'ress
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
&V 5�c..-Le– ?7��m F, -r,5
Not Applicable 0
Company'Name
,9--),5- t)
Registration Number
V es
L--1 ACL40,
Expiration Date
a tu re:� Telephone'
00
M
X
z
0
0
z
M
90
0
I SECTION 4 - WORNERS COMPENSATION (MG.L. C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check aDDlicable)
New Construction 0
Existing Building 0
Repair(s)- 11
Alterations(s) 11
Addition El
Accessory Bldg. 0
Demolition 0
Other W Specify ;-"A, A 'c
Brief Description of Proposed Work:
I:e--(, a 6)7 13: Q-
NeL4J
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by pen -nit applicant
F F....'TC 1AL'1-'r-SE"qNLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
.3
4 Mechanical (HVAC)
5 Fire Protection
Total (1+2+3+4+5)
Check Number
.6
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, -!S�a yJ —,4,4 a e-e� as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
-A& A a he 174
ame
��Ct"7
�i�ature of Owner/Agent Date
-0 111 1 ". gl, 11MI
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TITVIBERS iST 2 ND 31w
SPAN
DIMENSIONS OF SILLS
DRvIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Town of North Andover tAORTH
0
Building Department 0
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542 . Ofl?Are
se- - _
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a.
The debris will be disposed of in /at:
Facility location
Signature of Applicant
05-Jazled
Date/ I
NOTE: A demolition permit fforn the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Please Print
M �M
Name:
Location:
city Phone
= am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
F;Zi7 I am an employer providing workers' compensation for my employees working on.this job.
Lr -J
rnmnnnv nnmp- 41 -<4,4p f?,4v A -ri
e4 I- It'
Company name:
Address
'5�-
City: Phone #:
7f
��-e
Insurance Co. Poligy # MmAiiiim
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DLA for coverage verification.
I do herby certify under the pains and penaides of perjury that the information provided above is true and corTect
Sionattire g::5e-z,.r1
44�� Date tl��
Print
Official use only do not write in this area to be completed by city or town official'
[:]Check If immediate response is required Building Dept
Contact person i Phone #.-_
FORM WORKMAN'S COMPENSATION
Building Dept
Licensing Board
Selectman's Office
E] Health Department
0 Other
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No. Date �, -,�2iov
401ITp,
TOWN OF NORTH ANDOVER
Certificate of Occupancy s
S CMU
Building/Frame Permit Fee s
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
Building Insp4ct6r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERM[IT NUMBER: DATE ISSUED:
�J&
SIGNATURE: Building CommissionELng=lor of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
-75
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning hifinmiation:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (11)
1.6 BUIELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Rapired Provide Required
Provicu
Reqwred Provickd
T
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT
I Owner of Record
-� /,j �11 I rv� C--
Nam`e�Pyi'nt) Address for Service:
W404--,-, ty\ 7 9 rf,4 —Ai'1,7,
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check appUcable)
New Construction
Existing Building 0
Repair(s) El
Altefation
�ddition 11
Accessory Bldg. 0
Dimoli�ion
Othef4- 0 $pecify
Brief Description of Proposed Work:
1 r4 '�o uo
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by pern -dt applicant
10
—21
,I. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
Building ennit fee (a) x (b)
Mechanical (HVAC)
.4
5 Fire Protection
.6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT, -
1, �Jilha'fvx VV\ R0*'-b-)rr\ (�orized Agent of subject property
Hereby authorize to act on
ZM b��ers relntu"74=orized by this building permit application.
svi'gnature of Owner V'V\ '9 Date 19/.2 1 / C) 0
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Siature of Owner/Aient Date
NO. OF STORIES SIZE
BASENIENT OR SLAB
iST ND
SIZE OF FLOOR TINIBERS 2 3
SPAN
DINIENSIONS OF SILLS
DINENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF, FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVMY
IS BUILDING ON SOLID OR FILLED LAND
1S BUILDING CONNECTED TO NATURAL GAS LINE
14ORT11
Town of North Andover
#0
Building Department
27 Charles Street A
04
North Andover, MA. 01.845 ,CHU
D. Robert Nicefta
Building Commissioner
(978) 688-9545
:(978) 688-9542 Fax
HOMEOWNER UCENSE EXEMPTION
Please print
DATE 9 /..?, (/ 0 0
JOB LOCATION_ ;Z 75- �()CAe Sj,��
Number
"HOMEOWNER �j d1c,
Name
PRESENT MAILING ADDRESS
City Town
Street Address
61 / 77
Map / lot
?78- 5-7o '17oo
ne Phone Work Phone
S�� gA'V -c -
State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner"certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S
APPROVAL OF BUILDING OFFICIAL
Fri
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
0
0
AcHU
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting fi7om the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c 11, s I 50a.
The debris will be disposed of in /at:
01-f
1*t-�--Cy CCA t -(Cr CO.
Facility location
Signature of Applicant
8'1.�k t I o Q
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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