HomeMy WebLinkAboutMiscellaneous - 280 JOHNSON STREET 4/30/2018 (2)co
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07T �8M LV; STUOMPUMV 9POD 1-931.4nia spisnilvessuN Z102;
This certifies that ..... /1)
has permission to perform ........
wiring in the building of
at Mass.
...... . .... North Andover,
0../
e
Fe(4.3,5. c, Lic. N ...
Check ELECTRICAL INSP�� Tf
112 0" 7
I
Official Use Only
Commonwealth of Massachusetts
Department of Fire Services Permit No. L 2 -
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Pev.i/o71 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfortned in accordance with the Massachusetts Electrical Code Q%4EC), 527 CMR 12.00
(PLEASE PRWT IN)YK OR TYPEALL RWORkU TION) Date: / 2- - 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)
Owner or Tenant A
Owner's Address
M
/7 & -f
Is this permit in conjunction with a building permit? Yes LL -
Purpose of Building 1 ,& 4q,,- 1141-�
Telephone No.
`N -o, El (check Appropriate ]Box)
Utility Authorization No.
- Existing Service Am�s -VoKts Overhead D
New Servic — Amps Volts Overhead n
Number of Feeders and Ampacity
UndgrdF]
Undgrd [I
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: 1w �& - -
e� �- -11 . fff-t7
Completion ofthe following table may be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above EJ In-
arnd. grnd. El
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. 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
Totals:
I.NpMl er
I
I Tons
I .........................
I KW
I .......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Municippl 0 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
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Atiach additional detail ifdesired, or as required by the Inspector of 07res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 1.7- - 3 -12_. -- Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: linless 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 coverag
.�.�orce, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE P-15OND [] OTBER 0 (Specify:)
I certify, tinder thepains andpenalties ofperjury, that the in orniation on this application is true and com
plete.
FIRMNAME: �J LIC. NO.:
e, 4 .5
;4�e /��
Licensee:,d,,, Signature4,e� Z- I C. NO.:
�)Wn�,, -
(1fapplicable, ter "exempt" in the license number line)
B us. Tel. No.
Address: Z -%41- - Alt. Tel. No.:
*Per M.G.L c. 14l, s. 57-61, security work requires Departni of Public Sa "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage nornially
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._ PPRMIT 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 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.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass IN
Failed
Re- Inspection Required 11
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTUL ROUGH INSPECTION:
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGtl INSPECTION:
A
F71 \/
Pass 10A
Failed
Re- Inspection Required 0
\�
Inspectors Comments:
AA
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
S.\_ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizati6n/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. D I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. 1 am a sole proprietor or partner-
E]
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
114o workers' comp. insurance
5. El We are a corporation and its
. 14 1
requIreu.,
officers have exercised their
3. 1 am a homeowner doing all work
E]
right of exemption per MGL
myself. [No workers' comp.
c. 152 § 1(4), and we have no
insurance required.] t
emplo�ees. [No workers'
—
comp. insurance required.]
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. El Electrical repairs or additions
11. n Plumbing repairs or additions
12T] Roof repairs
13F] Other
kny applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such-
�ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjo*b site
iformation.
isurance Fompany N
olicy # or Self -ins. Lic. #:
)b Site Address:
Expiration Date:
City/State/Zip:
.ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Etilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
: up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Lvestigations of the DIA for insurance coverage verification.
do h ereby certify under Ih e pains an dpen aides ofp erjury th at th e information pro vided ab o ve is tru e an d correct.
.gnature: Date:
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):
I. 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 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 confirmation 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 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 of 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
.evised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Mett-ife Auto & Home A,L I
Homeowner Operations Field Claim Office
Mail Processing Center
P.O. Box 2201
Charlotte, NC 28241
(800) 854-6011
M0 /--,\
V fkao-'mMS
March 7, 2014
North Andover Building Inspection
1600 Osgood St
Suite 2035
North Andover, MA 01845
Our Customer: Polly B. Pyle and Duncan S. Pyle
Our Claim Number: JDE13332 87
Date of Loss: February 26, 2014
Dear Sir or Madam:
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
ZD
provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 280 Johnson Street North Andover MA 01845
Sincerely,
Jeanna M. Larsen - DR
Metropolitan Property and Casualty Insurance Company
Claim Adjuster
(800) 854-6011 Ext. 7262
Fax: (855) 718-7709
Email: jlarsenl@metlife.com
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its Affiliates, Warwick, RI
VIPL BLANK Printed �n U.S.A X, 3
Date... .. ..............
,40RTH
0
TOWN OF NORTH ANDOVER
L/
PERMIT FOR GAS INSTALLATION
no
................... .......
This certifies that J<J 44 -e
S41,4
Us permission for gas installation ..... �Tq C/
. ...................
in the buildings of ... yo!'.If .................................
at T -Q. ZQ �-�X ... North Andover, Mass.
-P-
Fee. . Lic. No.. .
OR
Check# / YW- 0
65034
r
MASSACHUSEM UNIFORM APPUCk-TON FOR PERMrr TO DO GAS ffMNG
(Type or print)
NORTH ANDOVEI;t, MASSACHUSETTS Date
BuildinLy I-nnatinne A -If A, -4 , - r I I
Owner's Name
New Renovation Replacement a
Name ofLicensed Plumber'or Gas Fitter
Permit # tl/1,0-91
pAmount S
Plans Submitted El
Check one: Certificate Installing Company
0 Corp.
0 Partner.
-1 hereby certi Uwner t" Agent
ry that all of the details and infb—rmnaFtion�l—hav—e,
submitted (orentere—d) in ove ap;lication
ons pe -n�d
best of my knowledge and that all plumbing work and in rmed under P are true accurate to the
ermit Is ued for this application will be in
compliance with all pertinent provisions of the Mass use State Code anolh of the Gdheral Laws.
I By:
Title
City/Town�
APPROV, ED (OFFICE USE ONLY)
..��ignature of Li
E3PIumber
[j Gas Fitter
13 -Master
0 Joumeyman
sm fflumber Or Gas Fitter
, -? L
Lice—nse7g6er '
DateA
40RTH
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . P - . T . . ��. -e....
has permission for gas installation ... 0:�O 7�!k:f. A�
I.,
in the b *ld' of Ij. 5 . 4�� -I ...
7 . ................
pii,ngs
at ........................ North Andover, Mass.
Fee. Lic. No—I'l?'16.
GAS INSPE6��R
C heck#
6 2 14k 3
MASSACHUSETrS UNUMMAPPLICATION FDRPERNIrr TO DO GAS FrrnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building LKations
14
Date
Permit #
Amn"n* 4t
Owner's Name pq
New Renovation Replacement 13— Plans Submitted
(Print or type)
Name le Z � * /�,�u M —,� /��— /—/
Address X L
ATZI a t) Ly 77
Name of Licensed Plumber�or Gas Fitter
Check one: Certificate Installing Company
0 Corp.
[] Partner.
13-rlr—m/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 10— No1:3
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0-- Other type of indemnity 0 Bond 13
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:
Signature of Owner or Owner's Agent Owner 13 Agent 13
1 hereby certify that all of the details and inform have submitted (or entered) in above application are true and accurate to the
best of , my knowledge and that all plumbing work and instal lations-nerformed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusett��G
yo&de and �hapter 142 of the G_qneral Laws.
I By:
Title
own�
JAPPROVED (OFFICE USE ONLY)
C -3 -Pignature of Licensed Olumber Or Gas Fitter
lumber
Gas Fitter — Z2
License Number
13 --master
0 Joumeyman
z'
Z
Z
z
Q
z
0
>
z
z
Z
>-
Ul
z
0
>
SU B-BASEM ENT
>
BASEM ENT
T—
I ST. F L 0 0 R
2 N D . F L 0 0 R
3R D. F L 0 0 R
4 T H IF L 0 0 R
5 T H F L 0 0 R
6 T H F L 0 0 R
T H F L 0 0 R
8 T H F L 0 0 R
(Print or type)
Name le Z � * /�,�u M —,� /��— /—/
Address X L
ATZI a t) Ly 77
Name of Licensed Plumber�or Gas Fitter
Check one: Certificate Installing Company
0 Corp.
[] Partner.
13-rlr—m/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 10— No1:3
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0-- Other type of indemnity 0 Bond 13
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:
Signature of Owner or Owner's Agent Owner 13 Agent 13
1 hereby certify that all of the details and inform have submitted (or entered) in above application are true and accurate to the
best of , my knowledge and that all plumbing work and instal lations-nerformed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusett��G
yo&de and �hapter 142 of the G_qneral Laws.
I By:
Title
own�
JAPPROVED (OFFICE USE ONLY)
C -3 -Pignature of Licensed Olumber Or Gas Fitter
lumber
Gas Fitter — Z2
License Number
13 --master
0 Joumeyman
Location
No.
Date '0/
,4007rol
TOWN OF NORTH
ANDOVER
.jammilk
Certificate of Occupancy
$
Building/Frame Permit Fee
$
S.? C"
Foundation Permit Fee
$
Other Permit Fee
$
Sewer 8on"ne"Rbh"Fee
$
W6er Connection Fee
I
G
$
TOTAL
Building Inspector
q tZ 7,77-7—Ul V. Public Works
PER111T NO.. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE I
MAP +40.
LOT NO.
2 RECORD OF OWNERSHIP DATE
BOOK �PAGE
ZONE
SUB DIV. I& NO.
LOCATION "14
4 2,
PURPOSE OF BUILDING Avo
f fA f/0 J�: AL
OWNER'S NAMk L
NO. OF STORIES SIZE
OWNER'S DRESS N
BASEMENT OR SLAB
ARCH� A
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BU11*ftR'S NAME
PAN
DISTANCE TO NEAREST BUILDING
OL, a v tj f
DIMENSIONS OF SILLS
DISTANCE FROM STREET :K�&IJWA41� li
DISTANCE FROM LOT LINES - SIDES REARr'
" POSTS
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
- -tj/
DATE FILED ()-02
SIGNATURE OF OWNER OR AUTHORIZED AGENT
wjmm TEL, #
F E E rONTR. TEL
9 ',j 3 �'il CONTR.LIC.'#
PERMIT' GRANTED
Z6 0 7-- 19
- I
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
buiubma imspid7o—R
BUILDING RECORD
I OCCUPANCY 12
SINGLE FAMILY S �ORIES I
MULTI. FAMILY
_rOFFICES
APARTMENTS I
CONSTRUCTION
2 FOUNDATION
8 INTERIOR
FINISH
CONCRETE
PINE
3
1
2 13
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M T* AREA
V, 1/7 1/1
FIN. ATTIC AREA
NO BMT
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
2
3
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
HARDVV D
COMMON
VERT. SIDING
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STIRS. & FLOOR
BRICK ON FRAME
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE I
GAMBRE L
FLAT
BATH 13 FIX.)
-dip
MANSARD
TOILET RM. (2 FIX.1
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES_
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FU�N.
TIMBER SMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W T'R OR VAPOR
WOOD RAFTERS_
AIR CONDITIONING
RADIANT H'T G
UNIT HEATERS
7 NO. OF ROOMS
G S
B'M'T 2nd
l.t I I 3,d
CTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
O�PARTMENT OF PUSUC SAFETY
COMMONWEALTH ..4 AVE.
OF BOSTON,M ASS. 02215
MASSACHUSETTS
LICENSE
CONSTR. SUP ERVISOR
�,b
EXPIRATION DATE st7oo
06/30/199 3 86 �'EFFECTLVE DATE - LIC -NO.
RESTRICTIONS' 91
106/30/19
.020889
NONE
..jH:EOD0RE G VANDORNE
1`27 'PERRY AVE
-qp -33-3 7 -;,NAS HUA.- KH - 03060, P;
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PHOTO (BLASTING OPP ONLY) FEE:
1-1010 -E
.100.00
11A TIL SIGNED BY LICENSEE AND OFFICIALLY
�;NOT LID UN
HEIGHT: STAMPED -`OR SIGNAT URE OF THE COMMISSIONER
7IBLAS11Nr
DOB: D
0 4/16/194
AATU�R�
THIS DOCUMENT MUST BE K r; SIGI E OF LICENSE
CARRIED ON THE PE RSON OF I
J.
,I
THE HOLDER WHEN Ep�,,GTAG; MMLSSIONER
;�fc
0
OTHERS - RIGHT THUMB PRINT ED IN THIS OCCU. w
200M 2 87-8 1429
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KAREN FI.P. NELSON, DIIIEC'1*011
12() Street
North Andover,
WSSM-111 ISCHS () 1845
(6 17) 685-4775
In accordance witi 11
Number tl) ic provisions of MGL c 40, S 54, a condition of Building Permit
---qw is that the debris resulting from this work shall be
disposed of in a �-roperlyliccnscd solid waste disposal facility as defined by MGL c ill, S
150A.
717he debris will be disposed of in:
(Location of Facili
'Signature Of Permit Applicant
ol,
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
0 4
OFFICES OF:.
0
Town of
APPEALS
NORTH ANDOVER
130ILDING
...........
CONSE'RVA'110N
DIVISION 01:
HEALTH
PLANNING
PLANNING
& COMMUNITY DEVELOPMENT
KAREN FI.P. NELSON, DIIIEC'1*011
12() Street
North Andover,
WSSM-111 ISCHS () 1845
(6 17) 685-4775
In accordance witi 11
Number tl) ic provisions of MGL c 40, S 54, a condition of Building Permit
---qw is that the debris resulting from this work shall be
disposed of in a �-roperlyliccnscd solid waste disposal facility as defined by MGL c ill, S
150A.
717he debris will be disposed of in:
(Location of Facili
'Signature Of Permit Applicant
ol,
Date
NOTE: 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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2 ITS.
' / / - �i—
Date -, I
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Acm
N%(9QQ Permit Fee $
_j&wer Connection Fee $
-water Connection Fee $
$
XIAV I Building Irispector
Div. Public Works
PER,xfff Ko. +16
MAP +40.
3
I
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
/PAGE 1
INSTRUCTIONS
4
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
P/DATE FILED, .0
SIGNAT"E OVOWNER OR AUTHOJfIZED AGENT
F E E j- .w � ---�
PERMIT GRANTED
19
113
'5-� 157 (
OWNER TEL. # &PCAJ-vy�
CONTR. TEL #-22-7-
CONTR. LIC. #
411. & IOIA17
3 PROPERTY INFORMATION
LAND COST
"'EST. BLDG. COST coo
EST. BLDG. COST PER 84. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD Of SELECTMEN
BUILDING INSPECTOR
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK '.PAGE
ZONE
SUB DIV. LOT NO.
0
�07 C ZAT 10 N�a �e
PURPOSE OF BUILDING lzw
OWNER'S NAME,."p
,,oay -4
NO. OF STORIES SIZE
bWNER-S ADDRESS Z&
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
'BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES
REAR
GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
&
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
4
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
P/DATE FILED, .0
SIGNAT"E OVOWNER OR AUTHOJfIZED AGENT
F E E j- .w � ---�
PERMIT GRANTED
19
113
'5-� 157 (
OWNER TEL. # &PCAJ-vy�
CONTR. TEL #-22-7-
CONTR. LIC. #
411. & IOIA17
3 PROPERTY INFORMATION
LAND COST
"'EST. BLDG. COST coo
EST. BLDG. COST PER 84. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD Of SELECTMEN
BUILDING INSPECTOR
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY
S ' -ORIES
MULTI. FAMILY
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
Pli�E
a
L
3
CONCRETE BL'K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
1"-GNF IN
3 BASEMENT
AREA FULL
FIN. B M T AREA
1/1 1/2
FIN. ATTIC AREA
�!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
I
DROP SIDING
CONCRETE
WOOD SHINGLES
EARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
HARDW'D
COMMCN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS
CONC.OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
_LUPER IOR PC®R
I ADEOTATE NONE
ONE
5 ROOF
10 PLUMBING
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GAMBRE L
MANSARD
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FLAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
DERN FIXTURES
ILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER EMS. & COLS.
STEAM
STEEL EMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
IT
RADIANT H*T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B*M'T 2nd
7;, 1 �,d
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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OWN
HOME IMPROVEMENT CONTRACTORS REGISTRATION
Board of Building Regulations And Standards
one Ashburton Place - Room 1301
Boston, Massachusetts 02108
HOME IMPROVEMENT CONTRACTOR
Registration 101217 Expiration 06/25/94
Type - INDIVIDUAL
Osgood Construction
Ralph H. Osgood,
88 East St - P.O. Box 913
Middleton MA 01949
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1 Dan HurN Insurance Agency
I Chestnut reen Suite 4
1 Seven Federal kreet
I Danvers, MR
1 01923
1 PHONE 508-777-9394
1 ------------------------------------------------
I INSURED
I
I OSGOOD CONSTRUCTION
I Dial ou nor_1nnr% nnr%
CONFERS NO RIGHTS U"i THE CERTIFICATE H33ER. THIS-Cfffl
DOES NOT WEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANYLETTERA American National Fire Ins Co
CO',TANY LETTER B Cigna Insurance Company
I---------------------------------------------------------------------------
I P. 0. BOX 913 1 CO,"PANY LETTER C
I MIDDLETON MA I ---------------------- - ----------------
- --------------------- - ----------
1 01949- 1 COMPANY LETTER D
I---------------------------
I COI'�PANY LETTER E
— -------------------- - -----------------------
1) COVERAGES
I THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELVA HAVE BEEN ISSUED TO
THE INSURED NArED ABOVE FOR THE POLICY
I PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRL-T OR OTHER DOCMENT WITH RESPECT TO
I WHICH THIS CERTIFICATE HAY BE ISSUED OR MY PERTAIN THE INSURANCE AFFORDED BY
I ALL TERMS, EXCLUSIONS, AND
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
CONDITIONS OF SUCH POLICIES.
I--------- ---------------------------------------------------------------------------------------------
I Col TYPE OF INSURANCE I POLICY 10BER I POLICY EFF I POLICY EXP I LIMITS
ILTRI I I DATE I
I--- I -------------- - -- -
DATE I
----------- I --------------------------- --------------- ------
I IGENERAL LIABILITY I
- ------ I --------------------- — ----------
1BODILY INJURY OCC. I
I Al I)G COePREHENSIVE FORI I SPP 117353701 1 01 16/92 101 16/931BODILY INJURY AGG. I
I Al 00 PREMISES/OPERATIGNS I
I ----------- - ------ I --------------
1 11 3 UNDERGROUND EXPLOSION I
1PROP. DAMAGE OCC. I
I I & COLLAPSE HAZARD I
1PROP. NVAGE AGG. I
I A I DO PRODUCTS/CMPLETED OPER. I
I ------------------- I --------------
i A 11)0 CONTRACTUAL I
IBI & PD COS. OCC. 200000
I A 100 INDEPENDENT 011TRACTORS I
IBI & PD COIB. AGG. L300000
I Al IX BROAD FORM PROPERTY DAMAGE I
------------------- --------------
I Al 00 PERSONAL INJURY
I I
I--- I ------------ - - -- - ----------- ---------------------------
IPERS. INJURY AGG. L300000
--------------- -----------
I 1AUTOMOBILE LIAB I
- - I -------------- - --- I - -- - --------
1BODILY INJURY I
1 11 1 ANY AUTO
II
I(PER PERSON) I
I I I I ALL OWNED AUTOS (PRIV PASS) I
I --------- - -------- I --------------
1BODILY INJURY I
I I I
I (PER ACCIDENT) I
I I I I ALL OWNED AUTOS (OTHER THANI
I ------------------- I --------------
I I PRIV PASS)l
1PROPERTY I
I I I I HIRED AUTOS
II
IDAMAGE I
I I I I NON-OWINED AUTOS
I ---------- ------ - I ---- ---------
I I I
I I
1BODILY INJURY & I
1 11 1 GARAGE LIABILITY
IPROPERTY DAPAGE I
I I [ I
II ------------------------------- I ---------------------------
I MIB I tEED I
I --------------- I --------------
I 1EXCESS LIABILITY I
I ------------------- I --------------
1EACH OCCURRENCE I
I I I I UIBRELLA FORM I
I ------------------- --------------
1 11 1 OTHER THP64 MBRELLA FORM I
------------------------------- --------------------------- --------------- --------------
1AGGREGATE
-------------------
I --------------
I ISTATUTORY LIMITS1
I B1 WORKERS" COMP I WOCC31246775 1 02/ 18/92 102/ 18/931EACH ACCIDE14T 1180000
I I AND I I I
IDISEASE-POL. LIMIT 500000
1 1 EMPLOYERS' LIAB I I I
I--- I ------------------------------- ---------------------------
IDISEASE-EACH EMP. 1100000
--------------- --------------
I IOT"ER
I I
--------------------------- - -----
I I
I---------------------------------------------------------------------------------------------------------------------------------
I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
1) CERTIFICATE HOLDER CANCELLATIM
I = SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX -
I For Information Only. If cer— PIRATION DATE THEREOF, THE
ISSUING COTANY WILL ENDEAVOR TO MAIL 10
I tificate holder wishes to be = DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER =..ED TO THE LEFT BUT
I named Tlease contact the Dan = FAILURE TO MIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY CF
I Hurle� nsurance Agency. = ANY KIND UPON THE CWTANY,
---------------------------------------------
ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
- ----------------------------
I-A,MRD 25 (7/90) Daniel J Hurley
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Home Improvement Contractor Registration
- — - — - — - No.101217
4z�--F CONSTRUCTION Builder's License No. 042439
P.O. Box 913 * Middleton, NIA 01949 508*777*8950
RESIDENTIAL CONTRACTING AGREEMENT
Read this agreement and make sure you understand it before signing it.
This agreement has legal force and effect and binds those who sign it.
Notice: All home improvement contractors and subcontractors engaged in home improvement contracting must be
registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to
the Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA
02108.
This agreement is made on Auc�ust 18, 1992 betweenOSC300D CONSTRUCTION
of 88 East Street, (date)P.O. Box 913, Middleton, (contractor)MA 01949
hereinafter called "Contractor" and
Duncan anC Polly Pyle
of 280 Johnson Street, North Andover, MA 685-8451 hereinafter
called "Owner". (address) (phon . a number)
1. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the
following:
Tearout o -L17 existing appliances, cabinetry, floor and ceiling f
kitchen, removal of existing and installation of new PELLA wind w,
rpinrahinn nf s ' t-.nvp, sealinQ two wall n;)enincis, rpinratinn of
- laundry rbut-.p cinar, installatinn and su;)iDly of six rerpssed
- rpilinq liqhtlq, tim GPT prntPrtPd nutlpts, npi�,, blupboart' and
- �)Iaster reilinc;, new har�wond floor, installation of owner suj��Qlied
- �abinetry, fabrication and installation of plastic 1 -aminate
- cnuntert-.4s, connection of owner suipplied apipliances, removal n
- debris (ailowance $400,00). A& ve_j,7t-_
DETAILED DESCRIPTION OF MATERIALS TO USE
Materials to be used in performing the above described work consist of the following:
If. PRICE
Contractor agrees to do all work described in Section I for the total price of
Ei(.;1ht thousand two laundred fiftj three--- 11/100-- $8,253.11
Ill. PAYMENT
v n - -
Payment will be made as follows:
- 33% — % ($ 2791 -04
) upon signing Contract;
15 % ($ 1 2 -17 - 97
upon completion of: rniiqb
electrical
- 2 _5 % ($ 2.06-3.28
) upon completion of: cabi n et.
i nqta 1 1 a tion
- 15 — % ($ 1 237 , 97
upon completion of: count-,prt-,op
installation
and the remaining 1 1 2 / 3 % ($ 962.85 ) upon verification of the work by Owner and Contractor
as having been satisfactory completed, which verification shall take place promptly after completion.
Payments due and unpaid under the contract documents shall bear interest from the date payment is due at the rate
entered below.
Fifteen (15%) percent
Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more
than one-third of the total contract price or the total amount of all deposits or payments which the contractor
must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment,
whichever amount ia greater,
IV. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,
unless specified here in writing. Contractor will begin the work on or about - 9/14/92 (date). Barring delay
caused by circumstances beyond Contractor's control, the work will be completed by 10/2/92 (date).
The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are
not avoidable by the Contractor shall not be considered as violations of this Agreement.
Notice: Notice of this agreement may be filed with the Registry of Deeds of County in order to create a mechanic's lion
on the Owner's property to secure the payment of amounts due under this Agreement. Failure to make the
agreed upon payments could result in the loss of your home.
V. VARIATIONS
The owner hereby acknowledges and agrees that in certain remodeling work, the demolition of portions of the pre-
existing structure may reveal additional defects, conditions or the need for additional work, which must be repaired,
altered or carried out in order to commence or to complete the work described under this contract. In such cases the
homeowner agrees that the duration of the work and the scheduled date of completion may diff er from the date contained
in Section IV above, and that such variation which is not avoidable by the Contractor shall not be considered to be a
violation of this Contract.
Hidden conditions may require adjustment in the Overall price of the necessary work related to this Agreement. In such
case the Contractor shall inform the Owner of such conditions forthwith and where necessary a written amendment of this
Agreement will be negotiated and executed by the Contractor and Owner.
V11. INSURANCE
Contractor warrants that he is fully covered under Worker's Compensation Insurance, Liability insurance, and Motor
Vehicle insurance.
VII. SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party,
Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner.
Vill. CONSTRUdTION-R ELATED PERMITS
The following construction -related permits will be necessary in order to complete the scope of work included in this
Agreement: Building Permit
Plumbing Permit
Electrical Permit
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction -
related permits. The contractor shall not be deemed responsible for delays in the work described in this Agreement
caused by regulatory, permit granting or inspectional agencies, authorities or individuals.
Notice: K the homeowner obtains his own construction -related permits for the work described under this agreement, the
homeowner is hereby advised that in the event of a dispute, judgment and nonpayment of the contractor, the
homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter
142A, M.G.L.
IX. MODIFICATION
This Agreement, including the provisions relating to price (Section 11) and payment schedule (Section 111) cannot be
changed except by a written Change Order signed by both Contractor and Owner. However, cancellation by Owner is
allowed in accordance with the Notice of Cancellation (annexed).
X. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a
period of one year following completion and shall comply with the requirements of
this Agreement. In the event any jdefect in workmanship or materials, or damage caused by the Contractor, his
subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the
Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or
replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any
inspection performed in connection with the agree -upon work.
All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturer's
for such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturer's'
warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of
such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which
failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such
equipment.
This warranty gives the owner specific legal rights, and owner may also have other rights which vary from state to state.
Under Massachusetts law, sales of goods carry an implied warranty of merchantability and fitness for a particular
purpose.
XI. COMPLETENESS OF AGREEMENT FOR EXECUTION
The Owner is hereby advised that he should not sign this agreement unless and until all blank sections have been filled in
or marked as void, deleted or not applicable, and until all exhibits and related or reference documents that are incorporate
herein are attached hereto.
The Contractor and Owner agree that the following additional documents, plans, and specifications, are attached hereto
and incorporated into this agreement. Any duly executed subsequent Change Order becomes incorporated in like
manner.
XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed
copy hereof given to the Owner at the time of execution, No work under the Agreement shall begin prior to the signing of
the Agreement and transmittal to the owner of a copy thereof.
RIGHTS TO CANCEL
The owner may cancel this agreement if it has been signed by the owner at a place other than an address of the
contractor which may be his main office or branch thereof, provided that the owner notifies the contractor in writing at his
main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement. See attached Notice of Cancellation.
ARBITRATION OF DISPUTES
Contractor and owner hereby mutually agree in advance that in the event of a dispute concerning this contract or the
labor, materials and equipment supplied or to be supplied hereunder, the Parties shall submit such dispute to a private
arbitration service that has been approved by the Secretary of the Executive Off ice of Consumer Affairs, as provided in
Chapter 14 f the General Laws orior to ither party proceeding to legal action in the Courts.
0 7%E��z 1,2 Date
10, �1,
HOMEOWNER:
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANKSPACES.
Owne
ignature
Signed
4.. 6
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only NAME OF CITY/TOWN
Permit No.
Date C)
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLc. 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, inprovement, removal, demolition,
or construction of an addition to -any pre-existine owner -occupied building containingat least one but not more than four dwellini! units .... or
to structures which are adiacent to such residence or building" be done by registered contractors, with certain exceptions, along with other
requirements.
'1�pe of Work: Est. Cost 91'2�
Address of Work c9j�pxc> 0—bt��Tz>o %Trja_�
Owner Name:
Date of Permit Application: F— /5-- 9 2--
I hereby certify that:
Registration is not required for the following reason(s):
—Work excluded by law
—Job under $1,000
—Building not owner -occupied
—Owner pulling own permit
—Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as t a nt of theA), ner:
_20/
Date .Contractor Nan2�/ Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date
Owner Name