HomeMy WebLinkAboutMiscellaneous - 28 LINCOLN STREET 4/30/2018OD
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MetLife Auto & Home
Homeowner Operations Field Claim Office
Attention: Claims
P.O. Box 6040
Scranton, PA 18505
(800) 854-6011
March 27, 2015
North Andover Building Inspection
1600 Osgood St, Suite 2035
North Andover, MA 0 18 4 5
Our Customer:
Mania S. Kavosi
Claim Number:
JDF00485 4X
Date of Loss:
March 5, 2015
Dear North Andover Building Inspection:
Pursuant to M.G.L. 139 § 3B, please be advised that a property loss at the address referenced below has
been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars.
Please let us know within ten (10) days if there is a pending or existing lien against the property as
provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 28-30 Lincoln St, North Andover, MA
Sincerely,
Larry Branco - FLD
Metropolitan Property and Casualty Insurance Company
Senior Claim Adjuster
(800) 854-6011 Ext. 7177
Fax: (866) 958-0736
Email: lbranco@metlife.com
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI
MPL MA-REGDEPT Printed in U.S.A 0698
MetLife Auto & Home
Homeowner Operations Field Claim Office
Mail Processing Center
P.O. Box 2201
Charlotte, NC 28241
(800) 854-6011
September 17, 2014
North Andover Building Inspection
1600 Osgood St, Suite 2035
North Andover, MA 0 1845
Our Customer:
Claim Number:
Date of Loss:
Mania S. Kavosi
JDE64886 4X
September 6, 2014
Dear North Andover Building Inspection:
Pursuant to M.G.L. 139 § 3B, please be advised that a property loss at the address referenced below has
been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars.
Please let us know within ten (10) days if there is a pending or existing lien against the property as
provided by M.G.L. 139 § 3B, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 28-30 Lincoln St, North Andover, MA
Sincerely,
Larry Branco - FLD
Metropolitan Property and Casualty Insurance Company
Senior Claim Adjuster
(800) 854-6011 Ext. 7177
Fax: (866) 958-0736
Email: lbranco@metlife.com
Mett-ife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI
MPL MA-REGDEPT Printed in U.S.A 0698
MetLife Auto & Home
Homeowner Operations Field Claim Office
Mail Processing Center
P.O. Box 2201
Charlotte, NC 28241
(800) 854-6011
September 17, 2014
North Andover Health Department
1600 Osgood St, Suite 2064
North Andover, MA 0 1845
Our Customer:
Claim Number:
Date of Loss:
Mania S. Kavosi
JDE64886 4X
September 6, 2014
Dear North Andover Health Department:
Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has
been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars.
Please let us know within ten (10) days if there is a pending or existing lien against the property as
provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 28-30 Lincoln St, North Andover, MA
Sincerely,
Larry Branco - FLD
Metropolitan Property and Casualty Insurance Company
Senior Claim Adjuster
(800) 854-6011 Ext. 7177
Fax: (866) 958-0736
Email: lbranco@metlife.com
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, Rl.
MPL MA-REGDEPT Printed in U.S.A 0698
10281
..........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Thiscertifies that .................................... . .... ................ ........................................
has permission to perforr .......
plumbing in the buildings of. . ...... ..................................................
r.. ca ..... .... ....... North Andover, Mass.
Feel.P!��i�? ... Lic. No.,Zq��!6.
PLUMBING INSPECTOR
Check #
8P �A-
u,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'r
UCITY
nL)Ove
— 4 1 MA DATE[ if 1A I/ Q PERMIT#
JOBSITE ADDRESS ;11,n S7— = OWNERS NAME
POWNER
ADDRESS TEL= --.--.IIFAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: [9"' REPLACEMENT: D PLANS SUBMITTED: YES 01 NO[:]!
FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM [I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _J
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _J .__.__J1 11
FLOOR/AREADRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK . . -1 _j F__j I
. . . .
LAVATORY
ROOF DRAIN I _j
SHOWER STALL
SERVICE I MOP SINK
TOILET
UR'INAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES IL I A A
WATER PIPING Jl= L.2
INSURANCE COVERAGE:
UIve a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2/NO MI
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND Ell
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 1E]
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this 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 mpliance with all Pertinent provision of the
IMassachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L�T, �6 =-D& C, LICENSE # SIGNATURE
MP DI ip 01 CORPORATION MI # PARTNERSHIPO# LLC U
COMPANY NAME ADDRESS f
CITY !STATE ZIP lq&o TEL
et I I
FAX CELL
I
EMAILElo-
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The Commonwealth ofMassachusetts
Fzi nk==1 Department of IndustrialAccidinits
Office of Investigations
600 Washington Street
Boston., MA 02111
VP www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual): ��Oq 4DvM1t,,r_
Ad-&ess:_ r Paulc_ *9,-4 4 c54,
City/State/Zip: L,,HU Aw Ma, OY66 Phone#: SOL JV- Pq�C
Are you an employer? Check the appropriate box:
-;n
Type of project (required):
1. 6K, a employer with -_9
4. El I am a general contractor and 1
6. 0 New construction
employees (full and/or part-time).*
2.0 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet I
7. [J Remodeling
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
5. El We are a corporation and its
9. [:] Building addition
[No workers' comp. insurance
officers have exercised their
10.E] Electrical repairs or additions
required.]
3. El I am a homeowner doing all work
right of exemption per MGL
ME] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.Q Roof repairs
insurance required.] t
employees. [No workers'
13.0 other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepollcy andjob site
information.
Insurance Company Name:. )) Frarlc�ts �kd_pc)l
Policy # or Self -ins. Lic. 9: tk PIS -2 3 i C_ Expiration Date:
JobSiteAddress: -3d Lln-COLfl (34 City/State/Zip: AlorE—IV
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or oner-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 ceryfy under the pains andpenalties ofperjury that the information provided above is true and correct
Q;�nfilrp- 4A Date: 1(1,11113
Phone#:
,Sc2 -,3q? - Z(Y�,
Official use only. Do not write in this area, to he 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
0
information and -Instruction*'s
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 employerIs defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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
ownerofadwelli house having not more than three apartments and who resides therein, or the occupant of the
Mg
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 employment 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 orto construct bui d gs the commonwea th r a
-acceptable evidence of compliance with the insurance coverage required."
applicant who has not produced I in in I fo ny
Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdivi , sions 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 I
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 anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirm�ationof 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 printedlegibly. 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.
Pleas ' e 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 permit/license applications in any given year, need only submit one, affidavit indicating current
Policy information (ifnecessary) 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 commercial venture
(i.e. a dog license or p* ermit to burn 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
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 oyd 406 or 1-877,TMASSAFF,
Revised 5-26-05 Fax # 617-727-7749
__wWW-masS,80V1dia
Nt
I t
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ? >,-, b 0 0 r?- R -- e�
.......................................................................................................................
has permission to perform ��q ) 6,cj��- re VV G k 0-k
..............................................................................................
wiring in the building of ............ v * 0 " -S
DAI/
at .... 5 /^-M
(0 �2 ......... over, Ma
�te .............................. Lic. No�PP ..... 14
Check # ELE CAL S 0
12019
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. I ?k6 11
Occupancy and Fee Checked
[Rev. 1/071 ae
,ave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
(PLEAS All work to be performed in accordance with the Massachusetts Electrical Code (NMQ� 527 CMR 12.00
E PRTNTflVNK OR TYPEALL NFORMTION) Date: I i @I I
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the -undersigned glyes notice of his or her intention to perform the electrical work described below.
Location (Street & Number) aw_ � r) c -a I , s r- ) s -c nuo (—,
Owner or Tenant AA ct r\ � o, Vk�; v o %'I
Owner's Address ZO Uyxe-alvi S-7
Telephone No. S6 0 9 9 Y
Is this permit in conj ctio with a building permit? Yes D� No F] (Check Appropriate Box)
Purpose of Buildin � (Auv(-Tiod Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd No. of Meters
New Servic Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: bq-111
Completion ofthe following table mav be waived bv the Insvector of Wires.
No. of Recessed Luminaires
No. of Ce1-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generkpors KVA
'No. of Luminaires
Swjmmls�gpool Above E] In- E]
Lrrnd. grnd.
No. of Emlergency Lighting
Battery Unils
No. of Receptacle Outlets
No. of Oil Bur
FIRE ALAR -AS
I N*o. of Zones
No. of Switches
No. of Gas 1BurjieA\
No. of Detection bnd
Initiating DeAces
No. of Ranges
No. of Air Cond. Total
\ Tons
No. of Alerting Devi"Ces
No. of Waste Disposers I
Heat pump
Totals:
JKW ...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
cipp [JL
Local El Muni ' 1 Other
Connection
No. of Dryers
-Water
Heating Appliances K\W
Security Systems:*
No. of Devices or Equivalent
No. of
j A Heaters KW
No. of No. of
Signs - Ballasts
Data, Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring.
No. of Devices or Equivalent
qTHER:
Attach additional detail ifdesired, or as required by the Inspector of
Estimated Value 4E�cctrical Work: 1qQD (When required by municipal policy.)
Work to Start: i I (a (I I _� Inspections to be requested in accordance with NIEC 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 operatioif '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.
CBECK ONE: INSURANCE Pj""iONDEI OTBER 0 (Specify:)
I cert�ry, un der th e pains an dpen alties ofp erjury, th at th e information on th is application is true an d com
plete.
FIRM NAME: &'b Co cyech C-1 LIC. NO.:f:---: 3 9 3 00
Licensee: qA��t G� e\rec� . Signature LIC. No.: t 353 03
(Ifapplicable enter "exempt" in the licpg ni ber line� Bus.Tel.No.:22U31-69
Address: 9�j.) rlo-r Ll I Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" Licens—e: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coveragenormally
required by law. By in), signature below, I hereby waive this requirement. I am the (check on�) n owner El owner's agent.
Owner/Agent
Signature Tejephone No. EPERMIT FEE: $
MIN", eawku.-be_ a-k&WR_+ tihst kv
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications�shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G1 c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass R r
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed
Re- Inspection Required El
Inspectors Comments:
4
ors SigKature:
//
Date:'
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhoid@townofmerrimac.com L/
The Commonwealth ofMassachusetts
Department of lndustriqlAccid��ts
ce ofInvestigations
600 Washington Street
Boston., MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization&dividual): \/3,3 rv--,o-
Address: 9 C, 7
City/State/Zip:�ymnlo�,ir5, DIV6,�, Phone#:
Are you an employer? Check the appropriate box:
L.El I am a employer with
4. El I am a general contractor and I
employees (MI and/or part-time).*
have hired the sub -contractors
2. E41Z a sole proprietor or partner-
listed on the attached sheet.
ship and'haveno employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
-i myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. El New con ' struction
7. E] Remodeling
8. E] Demolition
9. E] Building addition
10.E1 Electrical repairs or additions
ILEI Plumbing repairs or additions
12.E] ' Roof repairs
13.0 other
TAny appIicantthat checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they dre doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjoh site
information.
Insurance Company Name:.
Policy 9 or Self -ins. Lic.
Expiration Date;
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
A
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
1md\up to $1,500.00 and/or one�year imprisonment, a's well as civil penalties in the form of a STOP. WORK ORDER and a fine
ofuh 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 h ereby certtryuVer th e p ains an dp en alties ofp erjury th at th e information pro vided ab o ve is tru e an d correct.
A
Phone 9: 9 &-- F-3-? - () 2 e-)
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
PermitUcense #
) k / 13
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspec tor
6. Other
Contact Pers
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 ajohat 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 ffie
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 employment 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 commonwealth 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 cany workers' compensation insurance. If an LLC or LLP does have
employees, a policy is. required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmationof 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,
Pleas ' e 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 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 now 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 commercial venture F
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigationswould 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:
Tho Commonwalth of Mossachusetts
Dopartmeut ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, 9 617-727-4900 oxt, 406 or 1-877,�MAS' SAFE
Revised 5-26-05 Fax # 617-727-7749
__Www-mass.gov/dia
1 0028 Date
bF,
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
'Phis certifies that
....... V,"A-
has permission to perf6 - -e - wy-�
rm.
plumbing in the buildings of ... ........... ..........
....... North Andover, Mass.
Fee �Z.( ... Lic. NA47&9JZ-�)
PLUMBING INSPECTOR
Check #I � Z,01
I
� IF)
NIZN
.1
IC
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
P
TYPE OR
PRINT
CLEARLY
CITY A42fifif --fiAbb-0—L-3 MA. DATE 10 17" 4�0 PERMIT # I &� 11V
JOBSITE ADDRESS Z29-30 OWNER'S NAME
OWNERADDRESV"- ki;1eoijV ST. TE FAX
OCCUPANCY TYPE: COMMERCIAL F1 EDUCATIONAL RE81DENTIAL Ej
NEW: RENOVATION: REPLACEMENT�A PLANS SUBMITTED: YES NO,
FIXTURES I FLOOR- BSMT 1 2 3 4 5 6 7 -F8-F9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATEITSPECIAL WASTE SYS
DEDICATED GAS/OIIJSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER.
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/ MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION j
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes No El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND E]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.42 of the
Massachusetts General Laws,land that mysIgnature. on this permit application waives this requirement.
,Signature of Owner or Owner's Aqent CHECK ONE BOX ONLY: OWNER AGENT E]
I hereby certify that all of the details and Information I have'submitted (or entered) regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 114424 off the Gen r, I L aws.
PLUMBER NAME SIGNATURE
LIC#1- 9,7&;3 mpic jPn CORPORATION It # PARTNERSHIP LLC #
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COMPANYNAME-Dapio fiv)?I10#001A ADDRB�:
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PLU11,13ERS AND GAbP-ITTkKti ' %
*.ICEN'. *D AS A MASTER PLUMBER tl\
DA�ID M IURPHY
131 FAIRM,'.IUNT ST
LOWE MA 01852-3719 y
1723 05/01/14 147849
Date .... 0// .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that (`C�XV/ C f
.......... �/ ......................... ...............
has pennission toperfonn-A 3egov—
............... ; ...............................................................................
wiringin the building of ..... ...............................................................................
at �- - -3 () I- I -,j 0 0 It'i 5Le-Q-+
.............. . ..... .................................................................. orth Andover, Mass.
Lic. No. ....... V4 ......... &� . .............
ELA4CAL IN�?PE�
6heck #
11799
11�1
40
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. )1119
Occupancy and Fee Checked
,[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NIE 527 CMR 12.00
(PLEASE PRTNT INJYK OR YYPE ALL HFORAM TION) Date: V/0L L-3
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street& Number)— 2 � -so yt4�
Owner or Tenant MqpjA 1<,qvbs,, Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes D No El-- (Check Appropriate Box)
Purpose of Building Utility Authorization No. /3-474!75-1
Existing Service 15d Amps 11, / rw Volts OverheadD- Undgrd [:]
New —Service �)q, Amps t2c / 2,16 Volts OverheadE]-'--UndgrdE]
Number of Feeders and Ampacity
No. of Meters z -
No. of Meters I
Location and Nature of Proposed Electrical Work: -?
lktt-, ave qmp See-weerc 4/, -/A eve 1"�/
Cnmnlptinn nf thp fn711) Lvina tnh7p m/71) hp wi—hyod hi) Ao T—opt— �Ir Wi. v
No. of Recessed Luminaires
No. of Cefl.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
0' of Lumm
Above Ei In- F,
Swimming pool
No. of Emergency Lighting
Zo.
grind. und.
Battery Units
of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches
No. of G2s Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Hea
J.KW ...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local n Municippl n Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Data Wiring:
igns Ballasts
No. of Devices or Equivalent
"io. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
Attach additional detail i(desired, or as required by the Inspector of 97res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NIEC 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 operation7' coverage or its substantial equivalent. The
undersigned certifies that such cov5eWe is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E BONDE] OTBER [:] (Specify:)
I certtfy, under thepains andpenallies ofperjury, that the information on this application is true and complete.
FIRM NAME: . -R�hc,-., r-1, ,j- / se�cllc.,-, . , LIC.NO.: -?Iqiy-,*
Licensee: &4c��cv --t-,A,�I,cf , -- Signature LTC. NO.: 2 1 96Y- -4
(1fapplicable, enter "exempt'� in the license number line.)
Address: Bus.Tel.No.- LhLt2j--1114-1
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 WAI[VER: 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) El owner El owner's agent.
Owner/Agent
Signature . Telephone No. PPRAHT FEE: $
J
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, th ?"( f : 0
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE,INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
2 4� fi7 ler !15�z�
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass R?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPE�TIQN:
Failed
Re- Inspection Required 0
Inspectors Comments:
I Inspectors Signature:
Date: '9-072f2
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusefts
Department of lndustrialAccid�nts
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibty
Name (Business/Organization/Individual):
Address:
City/State/Zip: -b-4.4 .,4- ,, t,1q,&c Phone #:
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
,,employees (fall and/or part-time).*
have hired the sub -contractors
2. FM I 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. 1 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n New con,struction
7. F1 Remodeling
8. [] Demolition
9. EJ Building addition
10. El Electrical repairs or additions
11. El Plumbing repairs or additions
12. n Roof repairs
13.0 other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they dre doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 workers'compensation insuranceformy employees. Below isthepollcy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. 9: Expiration Date:
Job Site Address: City/state/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Faii�re to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
finf 'up to $1500 00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
'I to $250'.00 a* day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
of u
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct
Phone#: C/;79- �73--
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License 9
4 S-/P—
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 ofhire,
express or implied, oral or written."
An employeris defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 employment 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 commonwealth nor any of its political subdivi , sions 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. !he 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.
Pleas ' e 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 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 loc*ations 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 commercial venture
(i.e. a dog license or permit to burn 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 Commonwealtil of massach,0sftts
Deparbnent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
__WWW.Mass,goV1dia
u
nweanh pi ivl&��
Divislon of Regts6btiok�-"
i,,Board of Electfi
STE
530
DRACUT,
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a ter Elect
07/31/2013
21464!-A
I. License No. �Expiratjon Date.
Ise
�1016�578
Sedal No.
4.
Date....
.. ... ...........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... C 4
. .................
has permission to perform ...... .......................
wmng in the building of ..........
7 ...............................
_K -
at 38 L eAt,� si--
..................................... ............................................
0%
Fie ... F)6 .. . ........... Lic. No.2.4?1 )I ....
.............
CFkck # 13LeD
11677 2�e
I-ec. 1S31zV1"%
.........................................................
...........................................................
............ . Morth Andover, Mass.
I �........... ... ............. .... .
E mc
LEc AL INSPECTOR
4\_ Commonwealth of Massachusetts Official Use Only
mkoRilw
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7j
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (I�MC), 527 CMR 12.00
(PLE, 4 SE PR TNT IN INK OR TYPE, 4 L L J NFOR MA TION) Date: 6 - -?- - I -?
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned giye�gotice of his or her intention to perform the electrical work described below.
Location (Street& Number) s
OwnerorTenant m4n),q kAyo,;,; Telephone No.
Owner's Address
Is this permit in'conj unction with a building permit? Yes [�' No [] (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd [j
New Service Amps Volts OverheadEl Undgrd 0
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: k, 4,4,-,7 /10 m
No. of Meters
No. of Meters
Completion ofthe followinjz table mav be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminalre Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In- F1
grnd. grnd.
Ao. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 5—
No. of Oil Burners
FIRE ALARMS
JN'o. of Zones
No. of Switches 3
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
NR b.er
I Tons
1-'
I KW
1"------
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El municipal El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
1\1,"o. Hydromassage Bathtubs
No. of Motors Total IP
Telecommunications Wiring:
No. of Devices or quivalent
OTHER: I
Attach additional detail ifdesired, or as required by the Inspector of 97res.
Estimated Value of Electrical Work: 'a000,61, (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with h4EC 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 operatioe' 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.
CBECK ONE: INSURANCE B� BOND [I OTHEREI (Specify:)
I certiry, under thepains andpenalties ofperjury, that the information on this application is true and com
plete.
FIRM NAME: . ?r1k1,rC1,4 elf
Se LIC.NO.:
Licensee: Signature 5;�_� LTC. NO.:
(Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.*
Address: 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 noiZally
required by law. By my signature below, I hereby waive this requirement. I am the (che one)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. P UMIT FEE: $
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act ftirtbers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
— — .4\— I Faued u Re- Inspection Required (S.) El
Comments:
Inspectors Signature:— Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
0 Rule 8 — Permit/Date Closed:
0 Permit Extension Act — Permit/Date Closed:
Note: Reapply for new permit 0
Trench inspection
Pass IN Failed
Re- Inspection Required
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass Failed
Re- Inspection Required
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUG H INSPECTION:
Pass Failed
Re- Inspection Required
Inspectors"Comme
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass Failed
Re- Inspection Required
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
D-1 n? N/
— — .4\— I Faued u Re- Inspection Required (S.) El
Comments:
Inspectors Signature:— Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts
Department ofIndustrialAccidi�ts
Office of Investigations
600 Washington Street
Boston, MA 02111
Uf www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
Name (Business/OrganizatiorvTndividual): t1ec4-1<_.q i Ser(.,l r -e s,
Address:
City/State/Zip: -DrAc,,�_ m,, o /6ze Phone #: '09- y/6
Are you an employer? Check the appropriate box:
Type of project (required):
I - Ell—am a employer with
4. El I am a general contractor and 1
6. F1 New construction
employees (full and/or part-time).*
have hired the sub -contractors
7. El Remodeling
211 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub-contracton have
8. El Demolition
working for me in any capacity.
insurance
workers' comp. insurance.
5. El We are a corporation and its
9. E] Building addition
[No workers' comp.
10 -El Electrical repairs or additions
required.]
officers have exercised their
1 am a homeowner doing all work
right of exemption per MGL
11-F1 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.] t
employees. [No workers'
11dother
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they tire doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors 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 workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company N
Policy 4 or Self -ins. Lic. 9: Expiration Date:
Job Bite Address: Pity/State/Zip:
Attich a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failtre 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 certify un der th e pains an dpen afties ofperjury th at th e information pro vided above is true an d correct
Simature: Date:
Official use only. Do not write in this area, to be completed by city or town offilciaL
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 employei is defirted as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 employment 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 commonwealth 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 confirm�ation 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.
Pleas ' e 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 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 fillqd out each
year. Where 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 burn 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 ofladustrial Accidents
Office of 111vestigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www-mass,govldia
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License No. 'Expiration Date.
Serial No.
IN
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License No. 'Expiration Date.
Serial No.
7648 Date. . A ....
11-IRIV -
'o
0 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
P/
/7 1pt� . - /
This certifies that ... kto ..... .. .............
has permission for gas installation .......
in the buildings of .... ..........................
at C.)" North Andover Mass
Fe#,�5%�70 Lic. No..
GASINSPECTOR
Check# Vdt�- ?
<Izx
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
uCity/Town:
Ir
A/ AV40,11'EIZ _,MA. Date: 01'11;,2111— Permit#
Building Location: 9 0 4" S7 own' I Na I : IL4e0t, / 5
ers me
GType
of Occupancy: Commercial E] Educational F1 Industrial F] Institutional El Residential
New: 0 Alteration: [] Renovation: Ej Replacement: n--,�`Plans Submitted: Yes El No E9---
cly'ri loco
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes S-114'oEl
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2--� Other type of indemnityE] Bond F�
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this pe—rmit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent 0
By checking this box E1, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
n ...... f. #� fj— k—, - — — —. — - . . .. - - -
WWI ft0IIU IIIb1dIIdL1vn5 perFormea unaertne permit issued for this application will be in
—0— IUOWL� CIIXILU r-IUIFIUIFIU t�vue ano S.Mlller 142 OT the General Laws.
By Type of License:
El Plumber
Title EJ Gas Fitter
- El Master Signature of Licensed Plumber/Gas Fitter
City/Town Eliourneyman
APPROVED (OFFICE USE ONLY) El LP Installer License Number: 13 �� -7/
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Address: )"City/Town:
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State:
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Business Tel: 70 S -S 6 7 Fax:-� ro/ Z 7.2 - 611f
El Partnership
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0
Name of Licensed Plumber/Gas Fitter: 494,�Z 7-0
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes S-114'oEl
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2--� Other type of indemnityE] Bond F�
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this pe—rmit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent 0
By checking this box E1, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
n ...... f. #� fj— k—, - — — —. — - . . .. - - -
WWI ft0IIU IIIb1dIIdL1vn5 perFormea unaertne permit issued for this application will be in
—0— IUOWL� CIIXILU r-IUIFIUIFIU t�vue ano S.Mlller 142 OT the General Laws.
By Type of License:
El Plumber
Title EJ Gas Fitter
- El Master Signature of Licensed Plumber/Gas Fitter
City/Town Eliourneyman
APPROVED (OFFICE USE ONLY) El LP Installer License Number: 13 �� -7/
N
The Commonwealth of Massachusetts
4.0 1 arn a general contractor and I
Department of Industrial Accidents
,E I A AU,
1 ",4
Office of Investigations
.3
I "In .
600 Washington Street
These sub -contractors have
Boston, M4 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: /,T
City/State/Zip: �1� Phone #- � 79 S-S� -R / 7
A e 0 n employer? Check the appropriate box:
17 �Iam a employer with /
4.0 1 arn a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. 1 am a sole proprietor or partner-
0
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5.0 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' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. 0 New construction
7. E] Remodeling
8. R Demolition
9. E] Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12. R Roof repairs
13.R Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. '
t 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 mid 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 Name:_ �1--li
Policy # or Self -ins. Lic. Expiration Date: z
Job Site Address 0 City/State/Zip: O� eY571
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 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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance . coverage verification.
I do hereby certify under 111�,�andpenalties of peijuty that the information provided above is true and correct
��f �-Y� R/7
Offifeial use only. Do not write in this area, to be completed by city or town offilcial,
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 I
Contact Person:
Phone #:
0
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 employment 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 commonwealth 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 nurnber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partner ' ships (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 -insure d 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 bottorn
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 inust submit multiple pen-nit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Jo ' b 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 commercial venture
(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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Date/-7115��
TOW 0 N - TH .'. NDOVER
PERMIT FOR PLUMBING
This certifies that ........... ..............
has permission to perform .................
plumbing in the buildings of
at ..... ...... North'Andover, Mass.
Fee'W.'. Lic. No.--7;� ...............................
Z�'
PLUM-SiN INSPECTOR
Check ff C7 '311
7621
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
ftnt or Type)
WMass. Date Permit #
Owner's Name
Building Location
Type of Occupancy
, New 0 Renovation 0 ReplacementT,,, Plans Submitted: Yes 0 No
B.P.r4 I SEWER# FIXTURES SEPTIC#
Installing. Company Namel-)AVI-1> -A U)25A Check one: Certificate #
Address
El Corporation
0 Partnership
Business Telephone 't3 hrm/Co.
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curZZ!)t liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 0
If you have Je�cked Yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 111� Other type of Indemnity 0 Bond El
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 C3
or
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that al plumbing work and installations i>erformed under the permit issued f this application YAII be in compliance vAth all
pertinent provisions of the Massachusetts State Piu d er al Laws.
M 17 �K
T'We SignStuib-6t Licenied KumbeT-
City/Town Typ e of Ucense: Master C3 Journeyman
A P P F 0 M 7 F0 FF -ICT -USIC —ON—L YT Ucense Number �3
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Installing. Company Namel-)AVI-1> -A U)25A Check one: Certificate #
Address
El Corporation
0 Partnership
Business Telephone 't3 hrm/Co.
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curZZ!)t liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 0
If you have Je�cked Yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 111� Other type of Indemnity 0 Bond El
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 C3
or
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that al plumbing work and installations i>erformed under the permit issued f this application YAII be in compliance vAth all
pertinent provisions of the Massachusetts State Piu d er al Laws.
M 17 �K
T'We SignStuib-6t Licenied KumbeT-
City/Town Typ e of Ucense: Master C3 Journeyman
A P P F 0 M 7 F0 FF -ICT -USIC —ON—L YT Ucense Number �3
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
It A, . - Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # !��2 2z
$
$ 2,1,
Building Inspe66r
4�
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.3 ZoninE�Iufbrrnation:
Zoning District Proposed Use
I A Property Dimensions:
Lot Area (st) Fr-tage (ft)
1.6 BUI1,I)ING SETBACKS (ft)
Front Yard Side Yard
BUELDING PERNUT NUMBER:
DATE ISSUED:
Provided
Req*red
Provided
SIGNATURE:
Building Commissioner/IEMtor of Buildings Date
I :1011ULLUIN I-SIIE INFUMMATION I
1.1 PropertyAddress
C;2f
1.2 Assessors Map and Parcel Number:
7D 411
Map Number Parcel NuInber
1.3 ZoninE�Iufbrrnation:
Zoning District Proposed Use
I A Property Dimensions:
Lot Area (st) Fr-tage (ft)
1.6 BUI1,I)ING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
Req*red
Provided
d
154)
—
1-7 Water Supply M.G.L.C.40 1.5. Flood Zone Inform atian :
Public 0 Private D Zone Outside Flood Zone 0
1.8 Sewerage isposal System:
D
Municipal 0 On Site Disposal System 0
I lufN 2 - YHOYERTY UW1NEKS1ttP/AUTHOR1ZED AGE14T
2.1 Owner of Record
C9 A& 0
Name (Print) Address for Service
Signature
T
2.2 Owner of Record:
Nam,- Print
L Signature
I
: SECTION 3 -CONSTRUCTION
-1.1 Llcensea konstruction Nupprvisor:
Liccn.d Construction Supervisor:
21 &--,, . dws—
Address
Signature
3.2 Registered Home Improvement Contractor
Company Name
Address
Telephone
Address for Service:
Not Applicable 0
6) -3 Vo
License Number
1,::2 — 6 F —
Expiration Date
Not Applicable 0
Registration Number
Expiration Date
0
z
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0
SECTION 4 - WORKERS CONMENSATION (NLG.L C 152 § 25c(6) ___1
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 applicable)
New Construction 0 ExistT, Building 0!4;RRe;pair(s) 0 Alterations(s) 0
Accessory Bldg. 0 'Demolifion 01 Other 0 -Snecifv
Brief Description of Proposed Work:
SECTION 6 - RSTIMATIM CnNQ7V1TCT1rn1V 9-n4VrQ_ --I— I
Item
Estimated Cost (Dollar) to be
"p'--:'
by permit applicant
1. Building
-Completed
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
7
Construction
.3 Plumbing____
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
17 Total (1+2+3+4+5)
Check Number
I QrJ1r1rf'%M '7- r% XYX�W
��IVJ_r AIrl L JVILF W UJI IN iN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PEIMIT
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 applica—tion
Signature of Owner
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
Date
as ON-nier/Authorized Agent of subject
property
Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
of Owner/
NO. OF STORIES
BASENIENT OR STTB
SIZE OF FLOOR TIIVIBERS
SPAN
DMENSIO S OF SILLS
DM4ENSIONS OF POSTS
DMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CHDANEY
IS BUILDING ON SOLID OR FILLED LAND—
IS BUILDING CONNECTED TO NATURAL GAS LINE
Date
SIZE
F�
THICKNESS
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�� ��
~ REPAIRS FREE ESTIMATESTelephone (978) 682-4266
MARIO CASTRICONE
` 31 Court Street, North Andover, Mass. 01845
i/we, the owner ��the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, hoinstall, construct and place the improvements according to the following specifications, terms and
conditions,-
-------------------
7 [�
Job Addmoa''�����\—������— . . _________. _ __S��_?//(Z
SPECIFICATIONS
� -------_--------------------''-------'~--- ---
�
� -----------------' --'---------'--'—'—. ...........................
� Ma�ha�and labor bucou $��� ��.�6�/.----------- Payable
Materials —and bu�nuein----
monthly installments of $........ ................................. each, payable on ........................................ day of each and every month thereafter until paid
infull L—..—'%charge per year istobeadded toabove cost oflabor and materials and isincluded � monthly payments.)
�
Contractor will doall nfsaid work inagood workmanlike manner.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a
completion as% requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid
immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in
addition = the amount due and unpaid, that shall unincurred menforcing the terms and conditions mthis contract and/or any lien inconnection therewith.
nisfurther agreed that this contract may boassigned bycontractor; and also dhadhoobligations hereof shall bind and apply mtheir heirs, successors nrestates
ofthe parties.
The undersigned wanont(o)that hoia(they are) the uwno,(x)of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall bevoid and ofnueffort ifcredit approved ofuwmens)iorefused.
There are no mpmoontationo, guaranties or warranties, except such as may be herein inuorpusated, it any, nor any agreements collateral homm nor is thisoonuao dependent upon oreu�aotmany oondidununot hamina��d.Any subsequent uQmemominm�mnoeham�shall bobinding only ifinw,i�n8'and signed
uyall parties.
Cover attic storage cleaning not included.
�
Receipt oxocopy oxthis contract iohereby acknowledged, and itiufurther acknowledged Uythe undersigned that the foregoing provisions have been read and
the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and
understandings ofsaid parties are contained herein.
Owner n,Owners are not responsible for Property Damage urLiability while job ioin
. �
�
IN WITNESS WHEREOF, the parties have hereunto signed their names this ........�
Accepted:
�
Signed ....................^��� ...................................
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) ' oer�
Per
^ �- .......................
Representative
Signed
Owner
I
11
11
11P
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
414
Numberf, CS 034049
Birthdate: 12108/1923
Expiress I
2/08/2001 Tr. no: 10391
Res&icted To: 00
MARIO T CASTRICONE
31 COURT ST
N ANDOVER, MA 01845
Administrator
HOME IMPROVEMENT CONTRACTOR
1�� Registration: 103317
Expiration: 0710712002
Type: OBA
CASTRICONE ROOFIN6 SIDIN
�� qHio Castricone
7�' , Court 't.
ADMINISTRATOR N. Andover MA � 01845
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Locatio
No. —2Z Date
TOWN OF NORTH ANDOVER
OL
Certificate of Occupancy $
Building/Frame Permit Fee $
Check #",-J
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspectbir
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCTREPAIR, RENOVATf OR DEMOLISH A ONE OR TWO FAMILY DWELLING
W
51 1,
", W -11M.
W" M
DATE
BUELDING PERMIT NUMBER: "71 ISSUED:
A A - A"X1 ?
SIGNATURE: '/fa4&Wf e FO�
Building Comn-dssioner/IEEMtor of Buildings Date 0/
1 bEU11Vf4 1-bilh MFUNKMATIOIN I
1. 1 Property Address,
1.2 Assessors Map and Parcel
Map Nudiber
Number:
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf)
Froritage (it)
1.6 BUIELDWG SETBACKS (ft)
Front Yard ,
Side Yard
Rear Yard
Required Provide
Rx�red Provi&d
equIred
Provided
�54)
1.7 Water Supply M.G.L.C.40.
Public 0 Private 0
1.5. Flood Zone Information:
zone Outside Flood Zone 0
I . 8
Municipal
Sewerage Disposal System:
0 On Site Disposal System 0
bZU.lJ1VIN,Z - JrKVk'KK1 Y UW1NKKSkflF/AUJlH0K1ZED AGENT
2.1 Owner of Record
Name (Print) Address for Service
Signature Telephone
0
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Constructi Supe7isor: Not Applicable 0
-9��ervisor:
icens -CoAtruCtion
License Number
Address
Signature Expiration Date
Telephone
3.2 Registered Home Improvement Contractor Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Sianature Telephone
A
Cox,
rpoW
40
SECTION 4 - WORXERS COMEPENSATION (NLG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description of Proposed Work (check an applicable)
New Construction 0 1 Existing Building 0 1 Repair(s) [I
Accessory Bldg. 0 Demolition 0 1 Other 0 Specify
Brief Description of Proposed Work:
k!
I SECTION 6 - ESTIMATED CONWRFTCTION CnQT-. I
Failure to provide this affidavit will result
0 1 Addition 0
Item
Estimated Cost (Dollar) to be
i'qVr!2 'V��"-
Completed by permit applic t
1. Building
(a) Building Permit Fee
Multi lier
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
&3r1%-JLX%.P1'q I a %.FVVi'qJr11% Iku 1"UrL�lk I luil I" DE %-U1VLrJbE I h" W11EIN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
Date
U
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
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T1rVMERS OT 2 ND 3 PJ)
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOO`flNG X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND ---
I IS BUILDING CONNECTED TO NATURAL GAS LINE
I
I mprsonmen..t.�n'swellisk'i,dvilO.�hiltiisi�iheiormof ......... us a ilsic up to 3 i;:)uv.uu anuicir
one years' I ' 'I � � - I I
cbroy or this statement I � I I - � I" . a ST P'WORKORDER xAJ ilnhi asioo.tio a day against Me. I understand that a
'fifay, e drwnrdid-to the OlTicebtlhvesilgailon'
9 U the DIA for coverage verifl6tion.
I do h'ereby cerley- u :nder'llie,,,Oaiiii.,,6mdpetial(lis ofpedury that the Informatl6n provided above Is true aVCOrrec�
SignEltuit
--Date i 31n
Print name
--Phonel
ME121 use bnly do nolvilte 16 th'ii"hies to be completed by illt� or iown official
city or town:
permit/lIcense N ___ORuIldIfig,Dcpartmcnl
t] check If Immediate response Is rcqul�ed ClUcefisihg Board
oSelectmen'i Me
�contactrierson: 011ealth Department
phone#; —Other
(revised 3/95
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MAS�ACHUSETTS UNIFORM APPLICATION FOP, PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER Mass. Date
4uilding Location._- g -_30 r) r al n Permit #
Owners Name Wi'jlftf� fl
7--1 Renovation Replacement F
New — Plans Submitted
FlX"r-l-'R=-1-z
I
(Print or Type)
Check one: Certificate
Installing Company Name (De&hip
Corp.
Address 6� �S 19 fj �k cr," -S N U
M )I o Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverag- Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy FX7 Other type of
indemnity = Bond
Insurance Waiver: 1, the undersicned, have
been made aware that the licensee of
this application does not have any one of the
above three insurance coverages.
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SIUR—aSIMT.
,BASEMENT
ISTFLOOR
2ND FLOOR
3RQ FLOOR
4TRFLOOR
STHFLOOR
6THFLOOR
.7TKFLOOR
STHFLOOR
I
(Print or Type)
Check one: Certificate
Installing Company Name (De&hip
Corp.
Address 6� �S 19 fj �k cr," -S N U
M )I o Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverag- Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy FX7 Other type of
indemnity = Bond
Insurance Waiver: 1, the undersicned, have
been made aware that the licensee of
this application does not have any one of the
above three insurance coverages.
Signature of ownerlagent of property Owner 17 Agent F7
I hereby certify that all of the dc(Ails and information I have zubmitted (or cntcrcd) in above application are true and accurate to the best of my
knowledge and Mat &U plumbing work and Installations pctformaj under 1'ermit juued for this appticition wiLl-be in compLiance with a1i p=tLnent
provisions or tho mAssachusetts State Cas Code and Chapter 14'. of tho Cencral Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
,TYPE LICENSE:
Plumber
— Gasf itter- Signature of Licensed
Master Plumber or Gasfitter
— Journeyman az, 3 9� �s
License Number
Date.
TN
TOWN OF NORTH ANDOVER
0 IL
PERMIT FOR'GAS INSTALLATION.
Z'
SACHU
This certifies that
. .........................................
has permission for gas installation ..... I-
.......................
in,the'buildings of ..........................
at ... North Andover, MasC
Fee..?.%,. Lic. No..?.-?.—).
INsPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File