HomeMy WebLinkAboutMiscellaneous - 281 BEAR HILL ROAD 4/30/2018N
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address
Policy Number:
Date/Cause of Loss
File or Claim Number:
Katherine Doherty & Brian O'Donnell
281 Bear Hill Road
HP3084491
1/10/2015, Pipes Froze & Burst
30757-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
On this date, I caused copies of this Notice to be sent to the pers s named above at the
addresses indicated above by First Class Mail.
Signaturond Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Date.!�hx ............
I
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ... /�., ....................................................... .. ................................................
has permission to perform ............ P,,,o "p 61-�
.............
wiring in the building of ..........
..................................
at.......................................... ................................................................ . Arth Andover, Mass.
.. . .......
........ Lic. No. ..........
.... .........
................. ............... ....... ... ...... ............ .... ..
E AL INSPECTOR
Check Oyy�
12061
-4
-<L\� Commonwealth of Massachusetts Official Use Only
ENA�-�
Department of Fire Services PermitNo.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLE,4 SE PRTAT N.MW OR TYPEA LL HFORMA TION) Date:
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the -undersigned gives ice o s or er inte tion to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant -,/— Telephone No.
if- , Id/ Of2i
Owner's Address arl .1
Is this permit in- conjunction with a building permit? Yes El No Pa"' --(Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps volts Overhead Undgrd No. of Meters
New Service Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity 7
Location and Nature of Proposed Electrical Work: CS AL4
Completion ofthe following table ma -v be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No.'of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above El In- E]
NomofEmergency Jbighiing
grnd . grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
I.KW ...........
No. of Self -Contained
Totals:
I
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Mun'c'PP' F! Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No._of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
1---� Attach additional detail ifdosired, or as required by the Inspector of Wires.
Estimated Value of Ele ical Work: ZIRV (When required by municipal policy.)
Work to Start:- 11 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE 9,0�VRAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability ance including "completed operatioe' coverage or its substantial equivalent. The
c
undersigned certifies that such ov e is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSUIRANCE � EBOND n OTHEREI (Specify:)
I certify, under thepa# an enaltlesiM!f. erJury, thatthe information on this application is true and com
plete.
F HIMM N LIC. NO. d
t
Licensee: Sig:Z LIC. NO.: ef3VAu 0
c
(Ifapplicable, enter "exe in the lil e numb 7 Bus. Tel. No., ---'762-32Z
, . A
's
Address: 2 Alt. Tel. I
*PerM.G.Lc.l47,s.57-6l,securi work requires Departiftent of Public Safeky "S" Lice—D-se- Lic. No.
OWNER'S INSURANCE WAYVER: I am aware that the Licensee does not have the liability insurance coverage nbrmally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) D owner 0 owner's agent.
Owner/Agent PERWTFEE.- $
Signature Wephoiae No I
(Qtr&4-YL 4 qp�5 otep--o-4-
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
theActs 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 M I
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments: .
Inspectors Signature:
Date:
PARTML ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
lnspecto�s Signature:
Date:
ROUGH�SPECTION:
Pass
Failed
Re- Inspection Required 0
Inspector4comments:
Inspectors Sig�,ature:
Date:
FINAL INSVECT,
Pass
Failed
Re- Inspection Required 0
Inspectors Commeyffsl\
Y-4 -4
Inspectors Signature: E
L
Date:
V
DEBWEINHOLD ...TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
_k
The Commonwealth ofMassachusetts
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
kvi www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
NaMe (Business/Organization/Individual):
Address:
Phone
Are you an emfloyer? Check the appropriate box:
I. F1 I employer with
�P'
4. El I am a general contractor and I
loyees (M and/or part-time).*
have hired the sub -contractors
2. 1 am a sole proprietor or partner-
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. We are a corporation and its
required.]
officers have exercised their
3.EII am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. E] New construction
7. FJ Remodeling
8. E] Demolition
9. F1 Building addition
10.El Electrical repairs or additions
11. 0 Plumbing repairs or additions
12.E] Roof repairs
11d Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation poliryinfonnation.
i Homeowners who submit this affidavit indicating they tiie 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 einp7oyer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company
Policy # or Self -ins. Lie. 9: Expiration Date:
Job Site Address: Citv/State/Ziv:
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 o. 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 ceJ6*V-n-714 the pains an dpen alties ofperjury that th e information provided above is true and correct.
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
Permit/License 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact)?erson:- Phone
J7'
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 employerls defmed 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 ofpublic; 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'Iegibly. 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*p-ermit not related to any business or commercial venture
(i.e. a dog license or p* ermit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would Re 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 a�nd fax number:
The Comm awoalth of M,9
�ssac�h-v
0
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 W 406 or. 1-877,:MASSAFE
Revised 5-26-05 Fax # 617-727-7749
Al
uj
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..—&6 ........
...................... ...................... .. ...... . (! . . ..........................................
'6 has permission for gas installation ........ I.0 . . .....................
- j
in the buildings of ......... Ag7:4N .. VN
at ..... 2�kl .......
. ....... North Andover, Mass.
Fee.3.( . . . ....... Lic. No. AI.5,kK ...... tl�r . .....................................................
GASINSPECTOR
Check #
89,82
X\41`1-
MASSACHUSETTS UNIFORM APPLIC—'ATION —FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY j MA DATE V*�XUERMIT
JOBSITE ADDRESS r126--1OWNER'S NAME
GOWNER
ADDRESS 'TE
TYPE OR
PRINT
AN Y
OCCU�PANC PE COMMERCIAQ- EDUCATIONAL RESIDENTIAL
CLEARL-Y
NEW: -RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOF]
APPLIANCES -1 FLOORS— BSM 5 6 7 10 11 12 13 14
BOILER I ---7 --7
t4
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE 1777-7
GENERATOR
GRILLE 77-1
INFRARED HEATER
LABORATORY COCKS
--kA—KEUPAIR
UNIT
—6V- E —N
--�OOL —HEATER
ROOM/ SPACE HEATER —Al
ROOF TOP UNIT'
TEST
UNIT HEATER f
L�ji
UNVENTED ROOM HEATER . . . . . . . . . . .
WATER HEATER
:O=T=HER—.. .... . ...
I
r
INSURANCE COVERAGE
I have a current liabilh insurance policy "0
or its substantial equivalent which m eets the requirements of MGL. Ch. 142 YES
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO�VE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIC _: OTHER TYPE INDEMNITY [' j BOND
_�
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not hav . e the insurance coverage required by Chapter 142 of the
C4 -
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT[—.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application , are tr
I ue and a cur e to st of my knowiedge
and that all plumbing work and installations performed under the perrin t issued for this application will be in co ia ce Ith I P provision of the
Massachusetts
state Plumbing Code and Chapter 142 of the General Laws.
PLUMBE ER NAME LICENSE #a
W11rG'AS1ITT SIGNATURE
P
M __ MG F JPn JGFE] LPGI[:] CORPORATION PARTNERSHIP LLC #
COMPANY NAME: 014- FH- E -
ADDRESS
r
CITY STATEV-0- ZIP 3_]TEL
FAX CELL[3
X\41`1-
kit
Die Commonwealth ofMassadiffsetts
Department of InditstrialAccidents
Office ofinvestigations
I Congress Stree4 Suite 100
Boston, M4 02114-2017
wjvjv.ntass.gov1dia
NVorkers'Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers
Name (Biziness/Orgmization4ndivid-mD:
Address:
CitylStatelZip:6e6gfe;�Ui4
�T
44 0/phone#: S— 7 —
Are you an employer? Check the appropriate box:
Type of project (required):
L r_1 . 4.
L—J I a eirployer
4amin
general contractor and 1
E] I amai
6. NL%-.-- coristruction
loyees (fiffl and/or part-tirm)
�l
have hired the sub -contractors
2. a sole proprietor or partne-r-
listed on the attached sheet.
7. Rernodeling
ship and lmve no enployees
These sub -contractors have
S. E] Demolition
working for nr in arry capacity.
employees and have workers'
9. Building addition
[No workers* comp. insurance
required.] 5.
comp. itwurance.-
F� We are a corporation and its
10. Electrical repairs or additions
3.Ej I am a homeowrier doing all work
officers have exercised their
11. P lunbing repairs or additions
myself. [No Amrkers, comp.
right ofexeniption per MGL
12.[] Roofrepairs
insivance required.]
c. 152, § 1(4),. and we haw no
13. [P16t e_#iWe&
employees. [No workers'
conw. insurance reouired.1
qA-r A/10/0710
*Any applicantthatcheck-s box 4"1 must also fill out the section below showing their workers' compensationpolicy information.
I Horneowner, who submit this affidavit indicating they are doing allwork and thenhire outside contractorstriustsubnair anew affidavitindicating such,
1clonTractors that check this box rmstattached an additionalsbeet showing thenatne ofthe sub -contractors and state whether or not those entities baw
ernployees. Ifthe sub -contractors hm-e employees, they must pr(mide their workers' comp- polic�y number -
lam an eWImertliatisprovidbigivorkers'conzpensationbisitraiteefornt- emplm7ee& Beloit., is fliepolkIv andjob sile
information.
Insurance Company Name;
Policy L' or Self -ins. Lic. ExTirationDate:
Job Site Address: A&W 11111112op A/-
Wdatel&
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failre to secure coverage as required under Section 25A ofMGL c. 152 can lead to the inVosition of crinninal penalties of a
fine up to$ 1,500.00 and/or one-year irrqirisonment. as well as civilperialties in the form ofa STOP WORK ORDER and a fine
of -Lip to S250.00 a day against the violator. Be advised that a copy ofthis statement rmy be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification
IdoherebjcerVfi/,n.'Yertl pai a at the informationprovided aboi,e iy true an)( correct.
$1 4��% 1111,1113
imnture: 1/4 Date:
-70- -
Phone #: ?,ra FS_Z—SU�vl
Offlclaluseon4v, Do noturite in this area, to be completedlq? city, orion7t ojflciaL
Cih. or Tomm:
Perruit/Ucense #
Issuing Authority (circle one):
1. Board ofHealth 2. Building Department 3. Cityffov-m Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone#:
0
1%
COMMONWEALTH.OF MASSACHUSETTS
"'P UM-13ERS AND GASFITTERS
NSED AS AWASITER PLUMBER
IS ' SUESTHE ABOVE.P.CENSE TO:
�RPBERT G
I'K;EMMER
�A59 NOOTH 'ST
GEORGETOWN MA,01833-1240
-.15405 J
05/01/14 283948
- -- � I ': --7
It6MMONWEALTH OF MASSACHUSE��j-
ERS AND GASFlfT;R
P bW s
. -LldENSED AS A,JOURNEYMAN PLUM B E
18SUES,THE ABOVE LICENSE TO:
B E XEMMER
:-45'9�'-.N0.RTHJST
EORIGEtOWN,, -1240
_��O 18 3 3
Z-2052 05/01/14 -.283947
FA
-TT
's
COMMONWEALTH -OF MASSACHUSE
-Pt-OMbERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
SUES -THE ABOVE LICENSE TO:
ROBtRT K�MMER
: -.-09 NORTH, ST.
i�-'GEORGETOWN M A 0 18 3 3 - 1124144 0
u
u 'L 0 0
839
..15405 �05/01/14 283948
Le 6,
�;ddMMONWEALTH OF MASSACHUSETFTS-`��-,!
I BILTMisliffel a wits
PLUMBERS AND GASFITTERS
LICENSEGAS A JOURNEYMAN PLUMBIE
I SSUESTHE ABOVE LICE NSE TO:
ROBERT KEMMER
1.4.59 NORTH 'ST
:,-,�,-'�OLOR,GET-OWN' -MA,,61833-1240
59
22952 05/01/14 283947
LICENSEIN.O.' *XPIRATIONPATE: SE0l,A'L_N0!
li
GENERATOR APPLICATION
DATE: 13
P/"/
LOCATION: c?, (f L/ S&q /Z
OWNERS NAME: Av.,�� /c)"e 0
.")o/
GENERATOR kw , Z,
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR: -12 6 -IZP14 R 111?X / 17 �715 o (v
PHONE NUMBER: � 7op-- e5-7- S-36 /
ELECTRICAL
RESIDENTIAL
6D
COMMERCIAL TEMPORARY
LOCATION OF GENERATOR:
*ZONING DISTRICT: �Q A—
*PLANNING APPROVAL (IF IN WATERSHED)
*CONSERVATION APPROVAL
North Andover MIMAP
November 18, 2013
viecdo
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MA -012
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065.0-0108
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- Rail Line Wetlands
Zoning
Interstates (I Exempt Lands
- In enstate
. . Bu in
a n.
13 13..i .
s 1 District
s 2 District
Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83,
Major Roads
13 Busirn"
0 B sine!
a 3 District
a 4 Distdct
A01111i
Metem Data Sources: The data for this map was produced by Merrimack
Valley Planning Commission (MVPC) using data provided by the Town of
Roads
C'i Easements
0 G.nera
C3 Plannei!
n Couido
Business District
Commercial Dev
Development Dist
+
North Andover. Additional data provided by the Executive Office of
Environmental Affaim/MassGIS. The information depicted on this map is
C3 MVPC Boundary
C3 Municipal Boundary
0 Corrido
0 Corrido
Develol Dist
Dist
Development 1Z
VIM
for planning purposes only. It may not be adequate for legal boundary
definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
Zoning 0 erlay
E3 Adull Entertainment
Ind s�,t
u:r
I" Ind s n
u
1 DD!st�n.t
n'
Distrl
t ' DZ6
THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
C3 D ntown Overlay District
0 Indu n:�31)itnll
'
4-
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
0 H ist.d. District
E3 Water Protection
InclZri
Reside
Resideice
S . a ri cl
ce 1 District
2 District
THIS INFORMATION
0 Parcels
A= R-ideice
3 District
I Hydrographic Features
de�;ce
4 Di �nt
l
218 ft
de
ce 5 rit
Stne.nns
District
,dte.6
ge
esidential District
D at e . t
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . . . . I ... ..........
has permission for gas installation. U./� al i.0
in the buildings of. C.)V\. -P ------
at ... 0,.J. i .... &!c�J. hkk. . �,. j .* .* ' N'*o*rt*h' A**n*d*o*v'e*r,* M'' a' ss*.
Fee. .2.0, 0.0Lic. No. 7WS� ... ......
GASINSPECTOR
Check # SUZ)
8401
4
It
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
& '-j" /) , "
in Mass.
City, Town
Building
AT: Location -99)
New El Renovation
Plans Submitted Yes El Nol
Date Ik- A — -
Permit #
Owner ' s
Name cloke A,nJore
Type of Occupancy:
Replacement 0
(Print or Type)
Installing Company Name T0=.qP-nd Oil Co, , Tnr-
Address 27 Cherry Street
nnnyers, MA 01923
Check One:
ff] Corp. —
0 Partnership
0 Firm/Company
Business Telephone 979-777-0701 Name of Licensed Plumber or Gasfitter
Certificate
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 all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertincnt
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signai ure of Owner � Agent
I have a current liability insurance policy to include completed operations coverage. 0
By
Title
City/Town
APPROVED (OFFICE USE
Lgi 4wl � -0 4'�� t -7 -
TYPE LICENSE:
0 Plumber
El Gasfitter
C3 Master
0 Journeyman
,Wature! of`Xk�ised
Plumber or Gasfitter
License Number/��
MIR".
(Print or Type)
Installing Company Name T0=.qP-nd Oil Co, , Tnr-
Address 27 Cherry Street
nnnyers, MA 01923
Check One:
ff] Corp. —
0 Partnership
0 Firm/Company
Business Telephone 979-777-0701 Name of Licensed Plumber or Gasfitter
Certificate
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 all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertincnt
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signai ure of Owner � Agent
I have a current liability insurance policy to include completed operations coverage. 0
By
Title
City/Town
APPROVED (OFFICE USE
Lgi 4wl � -0 4'�� t -7 -
TYPE LICENSE:
0 Plumber
El Gasfitter
C3 Master
0 Journeyman
,Wature! of`Xk�ised
Plumber or Gasfitter
License Number/��
I
F
-4%
TOWNSEND OUPROPANE Fax 19787779008
The Comynonwealth of Massuchic5etts
Departinen t of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Nov 26 2012 05;54am P003/003
F-PrintForm--i
wwiv.nzasS.gov1dia
Workers' Compensation Insurance Affidavit: )Builders/Contractors/Electriciaus/Plumbers
Narne (Busint,5-,,'Organizaticii,'Individual):_
Address: 9-7 C �
city/state/71,
Qj Er�vg--O_
Phonc� #: �O 19 4? �—
Are you an employer? Check the appropriate box -
I I an -L a employer with 50
- 1�
4. E I arn a general contractor and I
_
employee5, (full and/or
have hired the sub -contractors
part-time).*
2. E] I am a sole proprietor or partner-
listed on the attacbed sbeet.
ship and have no employees
These sub -contractors have
working for iric in any capacity.
employees and have workers'
comp. iusuTance.t
[No workers* comp. insurance
5. we are a corporation and its
'quiied.]
I am a homeowner doing all work
3. ElL
officers have exercised their
myself. [No workers' corrip.
right of exemption per M.GL
insurance required.]
c. 15 2, § 1(4), and we have 110
employees. [No workers'
comp. instirance required.)
Type of projert (required):
6. New construction
7. KRomodeling
S. Demolition
9. Building additioi)
1O.E] Electrical repairs or additions
ll.Ej Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
*Anyapplicant thatchecksbox NI MWts1so rill Qutthesection bclow s1lowingtheir workers' compensatio"PolicY information.
t Homeowners who submit This affidovit indicating they arm, doing all work and then hire outside contoctors must subMit a new affidaviz indicating sucL
*Contractors that tbcck this box must 211tacbed an additional slicot showing the nanie of the sub -contractors and state whether or not those etitities have
employees. if the sub-conincLors; have employees, they niu5t providc tlicir workers' Comp. Policy nuMeT.
I am an employer that i.5 providing workees I compensation insuran ce for MY einployees. Below is the policy andjob site
information- r� I
Insurance CornpanyName:
ISN
Policy # or Self -ins. Lic. #-. Expiration Da:te: OILIII
Job Site Address: City/State/zip. 0
Attach 2 copy of the workers' compensation policy declaration page (showing the policy n i u ' wber 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 S 1,500,00 andfor one-year imprisonment, m well as civil penalties in the form of a STOP WORY, ORDER and a fine
of up to $250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fot insurance coverage verification.
I do hereby certify 44er the paiq5 and dnalties 9fperjury that the lizLornzati I on provided above is true and correct.
�ignaturel Ik Date
Phme _#_ L
0 ff
le -al u '-e
fficial use only. Do not write in this area, to be conipleted by city or town officiaL.
C or
ity or Town: Permit/License
it� TOWI
Issuing Authority (circle one): In$ c
g Utl I S ctor 5. Plumbing pe tOr
ssuin -3. City/Town. Clerk 4. Electrica In pe
1. Board lot Health 2. Building Department
r
oth r
16 LOtlier
Contact Phone #:
Contact Person:
TOWNSEND OIL&PROPANE Fax 19787779008
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Nov 26 2012 05:53am P002/003
TOWNSEND OIL&PROPANE Fax 19787779008
R. CHARLES R ANNALORO ACCT 41d!:1;2 iax iype i
81 BEAR HILL ROAD Company 7 Product 8
ORTR ANDOVER MA 01845 Tax zone A
Pay INSTANT
fel:617-510-6098 Anniv 10/11 00000000000
BURNER INFORMATION
Burner # 1 PROPANF 1023337 Make/Model
Calls Profit Next Tune
Nov 26 2012 05:53am P001/003
%,UZn. LYIJW V
Salesman 023 *COM*
Price A4 3.00000
Deviation N .00000
Terms 2
Contract
5 Ytd $691.01- Last Tune POOL HEAT/FP
0 Last
.00 Last W/O 10/29/12
Renew No
0 Prior
.00 Last Call 10/24/12
SERVICE HISTORY
Date
Call# Billed
Sale Cost Rsn Tec Hours
Part
W/P
Oty
10/29/12
473975 10/30/12
72.06 39 082 1.0
Remarks�:-
VERIFIED SER#1023337
10/25/12
473786 10/29/12
303.03 30 095 1.3
Remarks>
RAN GAS LINE
Parts>
ELBOW FLARE 1/2"FL X 3/4"FIP
37-412
4
1
Parts>
CONNECTOR FL 1/2" FL X 3/4"MIP
37-411
4
1
Parts>
POLY PIPE 1" IPS(500' COIL)
97-360
4
15
Parts>
POLY PIPE 3/4 IPS SOR11 PER FT
97-355.4
11
Parts�-
RISER FLEX 3/4'IPS X 3/4MPT
97-056
4
1
Parts>
RISER 36" 3/4IPSX3/4MPT SWIVEL
97-055
4
1
Next Page ? Y
h(\4L4-C'qq C --e- f) ajo-e-f,:4
G,4.
',%, This certifies that
Dat�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
..............
has permission to perform .... 13 �.�A% �4 k�'.
plumbing in the buildings of ...................
at. f ........... North Andover, Mass.
Fee.� Lic. No../ 7.)� -7
. ... ...........
PLUMBING INSPECTOR
Check c'
7662
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date
-1 k A 10 no- IQU) Permi7# z
Building Location I?d, O,nersName Amount—
Type of Occupancy
New 1:1 Renovation El Replacement 1:1 Plans Submitted Yes. 0 No 11
(Print or type)
Installing Company Name 141(in yr-cle-yM',
Check one: Certificate
E] Corp.
Partner.
Firm/Co.
Name of Licensed Plumber: AIQ r) �7-e& VWP1
Insurance Coverage: Indicate the Vpe of insurance coverage by checking the appropriate box:
Liability insurance policy ET Other type of indemnity E3 Bond
Iff
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature I Owner n Agent 0
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 all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass4z!114 State,�bing Code and Chapter 142 of the General Laws.
B y.- 4 / -4 r a., �_-
WgHffLUTe OFEICeI14CU rIUMDer
Title Type of Plumbing License
City/Town 1-3-3Y7 I
Eicense iNumoer Master Journeyman
APPROVED (OFFICE USE ONLY La
I I I
Date-cr-Fl..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
--2
This certifies that ..................................... : .......................................................
has permission to r-/. -
................... ............................
wiring in the building of .................. ..........................................
at .,-:9XZ ......... I( North Andover, Mass.
O -V
Fee�� ... Lic. Noj!��7
. . . . . . . . . . . . . . . . . . . . . . . . .
LECTRICAL INSPECTOR
Check# / 6 P, 620
Los=
338.24 ARnCLE 340 - UNDERGROUND FEEDERI
U40 s colobo
0
-71 mm tu Ell
rwML -10M
-.4 M11", `MV
g
A V
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
6�7/1
Permit No. 7
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEA SE PRINT fN INK OR TYPE ALL 17VFORALI TION) Date: 2-1 Z- a-! 0
City or Town of- NORTH ANDOVER
TO the Inspel ctor 2� Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 7,,S -k tC-A-v<,_ "Iu- �
Owner or Tenant - CNAA K -L -C- !�-- A v Telephone No.
Owner's Address 15 A -V -k 6
Is this permit in conjunction with a building permit? Yes 2� No El (Check Appropriate Box)
Purpose of Building LIV-� I k�M,� �iA-L-- Utility Authorization No.
Existing Service Amps Volts OverheadF� Undgrd 0 No. of Meters
New Service Amps Volts Overhead 0 Undgrd 0 No. of Meters
Number of Feeders and Arnpacity
Location and Nature of Proposed Electrical Work:
- 9
r� I"f;- IL
No. of Recessed Luminaires
EJO&I—rix
No. of Ceil.-Susp. (Paddle) Fans
uum may ve waivea oy ine inspector of Wir
No. of — Total
Transformers KVA
No. of Luminaire Outlets z-
No. of Hot Tubs
Generators KV A
No. of Luminaires Z-
Swimming Pool Above Ei In- - El
grnd. grnd.
No.—Of Emergenc-ylEign g
BatteEy Units
No. of Receptacle Outlets
No. of Oil B urners
FIRE 41LARMS
Zones
No. of Switches
No. of Gas Burners
No. —of Detectio- n-- and
Initiatina Devices
No. of Ranges
otal
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pu
T-
N timber
I Tons
r
--y0---0fSeFf--Contained
......................
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [-] Municipal
Connection 0 Other
No. of Dryers
Heating Appliances KW
becurity §_vstems:*
No.
No. of Water
Heaters KW
No. of �Noof
Signs Ballasts
of Devices or Equivalent
Data Wiring:
No. of Devices, or Eguivalent
No. Hydromassage Bathtubs
I—Telecommunecations
No. of Motors Tota HP
Wiring:
No. of Devices or Equivalent
OTHER: --I
19 o( Arrach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: ) '�- 0, OD (When required by municipal policy.)
Work to Start: Z- I Z-SrAb'�-, _ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCEE] BOND 0 OTHER E] (Specify:)
I cerdfy, under f;hpiuns andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAA C LA� LIC. NO.:
Licensee: /�AkWAk- Signature -T� LIC. NO.:
11 - --� (,
(Iftipplicable, ent "exempt in the licenAe number line) V
Address: LLL_,5 IS v fJA--, �(� Bus. Tel. No.: 4o.S V 7 -
Alt. Tel. No.:ct-)-&
*Per M.G.L c. 147, s. 57-61, secthity work requires Department of Public Safety "S" License: Lic. No.
OWNERIS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) E] owner E] owner's agent.
Owner/Agent
Signature Telephone No.
"'�' A
g044�
jt�W al Lo k- 3 - J4 - ob? Pje
" 0
4 1*
The Commonwealik of Massachusetts
Department of Industrittl Accidents
mir I QJf1ce of Investigations
600 Washington Street
Bostoiz, MA 02111
V�i 1, . www.nutss.go v1dia
Workers' Compensation Insitrance Affidavit: Bailders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nairie (Business/Organization/indi vidual):
Address:
City/State/Zip: Phone #: -
Are you an employer? Check the appropriate box:
1. 1 am a employer with
4. F1 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. 1 am asole proprietor or partner-
listed on. the attached sheet I
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp. 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
myself [No-worke'rs'comp.
c, 1,52, 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.)
Type of project (required):
6. D New construction
7. Remodel Ing
8. Demol ition
9. 0 Building addition
10 -El Electrical repairs or additions
I I - 0 Plumbing repairs or additions
12.[] Roof repairs
13.M Other
ATIY applicant that checks bo)C,# I must also fill out the section below showing their workers' bOMPMEation 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.
$Contractors ti;at check this box must attached an additional sheet showing, the name of the sub -contractors and their workers' comp. policy informajion.
I am an employer that isprpriding workers' compensation insuranceformW eMP10yees. Below is the policy andjob site
information. I
Insurance Company Name:
Policy 9 or Self -ins. Lie. #:
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).
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 $t,500.00 andJor 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 under the pains andpenaities ofperjury that the information provided above is true -and correct.
Signature: Date:
Phone
Officiat use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
I nformation 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, assodiation, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enter�rise, and including the legal representatives of a deceased employer, or the
receiver or trustee4 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."
MOL 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.te construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance I 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 compliaince with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Acciants 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 am 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 ap'plicant
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 firture 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 lnvestip,�tions 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 Investiggations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 6xt 406 or 1-8.77-MASSAFF,
Revised 5-26-05 Fax 4 617-727-7744
www.mass.gov/dia
- ------ ----
90,4WOFFREPREVEMONRWMTIOM527CjlWRl2.W Occupancy & Fees Checked
VAppUCATION FOR pERNff To PEUORM ELECTRICU RK
,4 ALL wORKTO BE PERFORMED IN ACCORDANCE WITH TliE MASSACHUSSTS ELECIWCAL CODE, 527 cmR 12:00
CLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
r4
'Me undersigned applies for a permit to perfbrrn the electrical work described below.
Location (Street & Number) 6EA& "Cu—
OwnerorTenant
owner's Address -,-�> /A—vl-'U-,
is this permit in conjunction with a building permit: Yes [3No (Check Appropriate Box)
Purpose of Building ---b e Utility Authorization No.
Existing Service Amps Volts overhead r7 Underground F] No. of Meters
New _Servicc Amps Volts overhead M Underground =3 No. of Meters
Number of Feeders and Ampacity I
ir --+; - ..A Vatimp nf Pmntised Electrical Work -) V\ -t,
7'
No, ofLighting Outlets
to
No. ofHat Tubs
No. afTransformers
Total
KVA
No, of Lighting Fixtures
Swimming Pool Above
[D
Below
Generators
KVA
2--
ground
Pround
No. of Oil Burners
No. of Emergency Lighting Battery
Units
No. of Receptacle Outlets
No. of Switch OutletS
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Air Cond. Total
No. of Ranges
Tons
No. of Detection and
Devices
\110. of Disposals
No. of Heat Total Total
Purmis
Tons
KW
Wtiating
No. of Sounding Devices
No. of Self Contained
No. of Dishwashers
Space Area Heating KW
Detection/Sounding Devices
Local Municipal
ElConnections
Other
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No. of No. of
Sign
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
0
ks==COMW Lam
limeaa=tLnWkmr&=POkYni&gCaqO*OPMMM—COD—Wcrgss1 dovalent YES
IIMeWhr[&dM&pwd,0fSa=1ote0ffi= YES ff�mba%edniodyESpkmmdcatetArofamsaWbydmdmgtbe
06-TTIOV77
Iq 1, 1 Ro*c*d
FRM NAME 4)g- .4-, c - 7%-U LA-4—�
MEMOIR,_
E '�V"dBid"Wdk S
-7
Rc* Firw
LixnseNdL
B -;i=T
t d No.
I 0`21��TdNcL
,hwWeqmWatasmpmdbyMm3d�G=i9La%s
�dimunysignutwonfisparnit va%afismp,mmat
(Please check one) Owner Agent
E] Telephone No. PERMIT FEE S
96(ow Ok . 7- /.a s- A�
10
Eo
m
0
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...........................................................
has permission to perform
wiring in the building of ..(z ....... .................................
at ... ....... . North Andover, Mass.
Fee.A. � ............ Lic. N0�5;'Z&-� ... (."z ..... ..................
ELEcrRic f INSPEaMR
Check # (!�r
5b79
DEPARTAffiWOMBLICS4FETY Pern-ut No. 60
BOA . RD OFFDZEPREVEMONREGULATIOAN527CHR 12.00 --d,-'
Occupancy & Fees Checked
IVA
UAPPUCATION FOR PERNff TO PEUORM aE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE wITH THE MAssAcliussis ELECTRICAL CODE, 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Datg-
Town of North Andover nspector of Wires:
ne undersigned applies for a permit to perfbrm the electrical work described below.
Location (Street & Number) Z-�5- k 6 6 A
Owner or Tenant C�,-CAA_L—E<,
Owner's Address -D-1r1-1kZ
is this permit in conjunction with a building permit: Yes [3"No M (Check Appropriate Box)
Purpose of Building "-5 45 Utility Authorization No.
Existing Service Amps Volts Overhead Underground No. of Meters
New Servi Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. ofLighting Outlets
I'a
No. ofHot Tubs
No. ofTransfonners
Total
KVA
No, of Lighting Fixtures
Swinuning Pool Above
ground E]
Below
ground
Generators
KVA
No. ofReceptacle Outlets
No. ofOil Burners
No. ofErnergency Lighting Battery Units
No. of Switch Outlets
No. . of Gas Burners
FIRE ALARMS
No. of Detection and
Irtitiating Devices
No. ofSounding Devices
No. ofSelfContained
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Disposals
No. of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space Area Heating KW
Detection/Sounding Devices
Local Municipal
E3 Connections
Other
No. of Dryers
k
Heating Devices KW
No. of Water Heaters kw
No. of No. of
Signs Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
0 1 17HER -
inraxecavaagm pjsmttDtrm*ianmsoDAwsadwgftGmiewLzm —
ItmeammtLj*khmm=PokYmAxkgCarqi*OPUaf'Kmc-D3=WcritsskswrtWa*ivakit YES 0 ----NO
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(Please check one) Owner Agent
M 1:1 Telephone No. PERMIT FEE $
Date.',� .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
This certifies that . !(1-1 ..... .................
has permission to perforT ............. .......................
plumbing int-�e buildings ofi�2.. .: ...... = ......................
at ...... .. ..... North Andover, Mass.
............
F e e 7"'/ ...... Lic. N0:9��?.q"I. .
('Z/ '�;�LUIVI N. INSPECTOR
Check ff
6517
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO
G
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date ('q - c;9 -o -;—
Building Location 121 Owners Name R rk no- Lo r4o Permit #
Amount be,
Type of Occup2ncy Re S'
New Renovation Replacement Plans Submitted Yes . El No 1:1
FIXTURES
(Print or type)
installing Company Name A \C1 n
Check one: Certificate
Corp.
Partner.
0 Firm/Co.
Name of Licensed Plumber Pr\av) Vireemao
insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy [a Other type of indemnity 0 Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent 0
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 all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas;s4pou tts State P mbing Code and Chapter 142 of the General Laws.
P-1 ;� 4jZ
By: �4 - 2P __ 44A Afi
31gnaHlre 01 IAMISCU rIUMVer
Type of Plumbing License
Title Lf I — M . aster Journeyman
City/Town I-1cense IN uInver
APPROVED (oma uSE ONLY Li
Location
No. 7 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
8 3 4
uilding Inspector
Of
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
2VA�M OR
APPLICATION TO CONSTRUCT Ep DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMrr NUMBEEL DATE ISSUED:
0.0 - -
ro,
SIGNATURE: AL4&� A��a44.�
BWlchng CommissionerTn-spector of BWlchngs Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
HI'd 1U
1.2 Assessors Map and
0�� —
Map Number
Parcel Number-
0() je)
Parcel Number
1.3 Zoning Information:
Zoningl3isuict Proposed Use
1 1.4 Property Dimensions:
Lot Area (sf) Frontago (il)
1.6 BUflDE4G SETBACKS (ft)
Front Yard Side Yard
Rear Yard
ReqWred Provide Reqmjj:= Prm&d
Reqwmd Pmi&d
1.7 Water Supply MC -1-C-40. 34) I.S. Flood Zone Infounation: 1.8 Sewerage Dispoul Sywteur
public 0 Privau 0 zow . Onande Flood Zone 0 Municipal 0 On Site Disposal Sydetu D
SECTION 2 - pRopERTY OWNERSH[P/AUTHORMD AGENT
L)i��trfct: yes —mo
2.1 Owner of Record
C" c',ar
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Sianature e ep one
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
MAZ-fi,- (Mag,
Licensed Construction Supervisor:
Address
)11�4 " t� 6 v
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 egistered Home Improvement Contractor
Company 14ame
252 k)kAM
Not Applicable 0
Registration Number
lcb6(o�,
Address
fkzalll?
E*ration Deb
Signature Telephone
ou
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0
SECTION 4 - WORKERS COMPENSATIO14 (KG.L C 152 § 25c-(-6)-----J�
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
SECTIONS Description PIroposed Work (check appleable)
New Construction 0 Existing Building 0 Repair(s) 0-- terations(s) Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
IIZZL441 11WARA.
I SECTION 6 - RSTIMATRn CONRT121TVT1rnM Vnelre I i
Item Estimated Cost (Dollar) to be
OMCL4L USE ONLY
Completed by permit applicant
"�a;
I . Building 0, 00
Building Permit Fee
Multiplier
2 Electrical 5"000,00
(b) Estimated Total Cost of
Construction
3 Plumbing 13763,vo
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
VVA�Vlrd%M PT. I%ILWW'01M A
Check Number
"'nVJLVJL'JM JL zu W rMIN
A,-G-EN,,T-,O--R- C--O-N-T--RA—CT—O,R,-A"PP,L-IE"S�FOR 19MMING PERMIT
1, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature ot*Owiier Date
SECTION7b OWNER/AUTHORIZED AGENT DECLUUTION — I
,,— n1dA IT27" 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
BASENIENT OR SLAB
SIZE OF FLOOR TIIVIBFRS
SPAN 2 ND 3
DMIENSIONS OF SILLS
DRAENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHDANEY
IS BUILDING ON SOLID UR- FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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REGULATIONS
BOARD OF BUILDIN
I.License: CONSTRUCTION SUPERVISOR
Number:tbS 043865
-'- \
Tr.mo 14235
01
MARK S |
RATTE ,
*moovsn MA al
commissioner-_-
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din ftcPlzti�
Beard of Bull 9 I
AOME IMPROVE
RagistMtjor'C. 117532
.612006
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MARK-R*l/E
—'252b pLEASAN
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Ratte' Construction Co., Inc.
252B Pleasant Street
Methuen, MA 01844
Tel. 978-6824982
RESIDENTIAL CONTRACT 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.
Note: All home improvement contractors and subcontractors engaged in
home improvement contracting, unless specifically exempt from
registration provisions of Chapter 142a of the General Laws, must be
registered with The Commonwealth of Massachusetts. Inquires about
registration and status should be made to the Director, Home
Improvement Contract Registration, One Ashburton Place, Room
1301, Boston, MA 02108.
This Agreement is made on 6/13/05 between Ratte' Construction Co., Inc. of
252B Pleasant Street, Methuen, MA 01844 (978) 682-4982, hereinafter called
"Contractor" and Charlie and Heather Annaloro, 281 Bear Hill Road, North
Andover, MA (978) 688-4189, hereinafter called "Owner".
L &TAILED DESCRIPTION OF WORK TO BE PERFORMED
CoAh* ' 46r agrees to perform in a good and workmanlike manner all work
detailed -below. Such work consists of the following:
Reftid4dAdichen and half bath as per specifications provided by "owneel.
IL DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the
following:
,,§W,Aftched provided by "owner". Owner to supply all ldtchen cabinetry,
"nity with top and faucet and under cabinet lighting. Contractor to supply
all other materials.
111. PRICE
Contractor agrees to do all work described on a cost-plus basis.
Materials at contractoes cost. Subcontractors at contractor's cost.
Carpenter's labor at S45.00/hr. Totat of all above plus 21 % overhead and fee.
Projected cost approximately $45,150.00.
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HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK
Hidden conditions may require adjustments to the contract price. In such a,
case the contractor will inform the homeowner of such condition forthwith
and where necessary a written amendment of this contract will be negotiated
and executed by the parties.
IV. PAYMENT
Payment will be made as follows:
$15,000.00 deposit due at signing of contract;
Progress payments will be periodically billed. $15,000.00 deposit will be
credited toward final invoice.
Notice: No agreement for home improvement contracting work shall require
a down payment (advance deposit) of more than one-third 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
delivery materials, and equipment, whichever amount is
V. COMMIENCEMENT AND COM[PLETION OF WORK
Contractor will not being the work or order the materials used before the third day
following the signing of the Agreement, unless specified here in writing.
Contractor will begin work on or about June 22, 2005. Barring delay caused by
circumstances beyond Contractor's control, the work will be completed by August
5, 2005. 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.
VL NO ACCELERATION OF PAYMENTS BY ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of times specified
in Section IV (Payment) above for reason that he deems himself or the payments
to be insecure. If however, he deems himself to be insecure, he may require as a
prerequisite to contmumg the work described herem, that the balance of the
payments under this Contract that are m the control of the Owner, shall be placed
in a joint escrow account that requires the signature of both the Contractor and the
Owner for withdrawal.
VILL INSURANCE
Contractor will be responsible to Owner or any third party for any property
damage or bodily injury caused by himselt his employees or his subcontractors mi
the performance of, or as a result of, the work under this Agreement. Contractor
agrees to carry insurance to cover such damage or injury.
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VIIL 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.
IDL CONSTRUCTION -RELATED PERMITS
The following construction -related permits will be necessary in order to complete
the scope of work included in this Agreement:
Town of North Andover budding 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: N 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, XG.L.
X. MODMCATION
This Agreement, including the provisions relating to Price (Sedion HI) and
Payment Schedule (Section M, cannot be changed except by written
statement signed by both Contractor and Owner. However, cancellation by
Owner is allowed in accordance with the Notice of Cancellation (annexed).
XL WARRANTUS
The Contractor warrants that the work fin-nished hereunder shall be free ftom
defects in materials and workmanship for a period of I Year following completion
and shall comply with the requirements of this Agreement. In the event any defect
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 agreed-.
upon work.
All warranties for equipment supplied by the Contractor under this Agreement
shall be those given by the manufacturers of such equipment, which shall be and
are hereby passed through directly to the Owner Under such manufacturers'
warranties, the Owner may be required to register or mail in a warranty card or
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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.
XIDL COWLETENESS OF AGREEMENT FOR EXECMON
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 or referenced documents that are incorporated
herem are attached hereto.
XIIIL 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.
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.
Note: This proposal may be withdrawn by us if not accepted within 30 days.
HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES
Owner's Signature -Date Si ed
Owner's Signature Ja Date Signed 13 &.5 -
Contractor's Signature )'04A Date Si ed � Of
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Kitchen Renovation Specification
Permits
Obtain the necessary Town of North Andover building and plumbing permits.
Demolition
Remove and dispose existing cabinets, refrigerator, wall oven, dishwasher,
stovetop, downdraft, flooring, ceiling and lighting fixtures. (Tall utility cabinet and
trash cabinet to be retained for client use.)
Cabinets
Install Woodmode cabinets, molding and associated hardware/fixtures (supplied
by client) as specified by design plan provided by Jackson Lumber.
Counters
Install counters—Verde Butterfly granite tagged at Boston Granite Exchange
Haverhill warehouse. Lot 11137, slabs 19 - 20. Pencil edge style.
Backsplash
• Source and install tile backsplash from counter to cabinets right of the
refrigerator through cabinets just left of the slider– Ferrazoli (Jerusalem gold)
3X6 tiles from counter to cabinets in a brick pattern. Fabricate and install
edging/ molding as a termination point on the backsplash closest to slider.
• Install and paiWb65db5`a-rAbackspIash underneath wine rack.,._.
Appliances
install the following appliances (supplied by client) with appropriate electrical,
venting and plumbing hookups:
Kitchen Aid Counter Depth Refrigerator in Stainless Steel KSCS25INSS
Wolf 30" Electric Cooktop with Stainless Steel Trim CT30E/S
Faber 30" Scirocco Downdraft Blower system in stainless steel 6058028
Kitchen Aid 30" combination Microwave/Convection oven KEMC308KSS
Kitchen Aid Dishwasher with Stainless Steel Front Panel KUDS01 FLSS
Flooring
Demolish exiting flooring to sub -floor.
Source and install tile flooring–Happy Floors, Cross Cut dark (1 7X1 7) in a
straight pattern. Same tile throughout—kitchen, powder room, kitchen
hallway to basement stairs and front hallway.
0 s wooden thresho transition areas to adjoining rooms (family
a 0 s'
aA-:� ra c kAr
room en�tranceVa , iningtroom, living room and library).
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Revision E 6/13/2006
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Note: Trim, door and wall colors to be determined.
Walls
• Strip existing wall paper.
• Prep and paint walls. Color and technique to be determined.
OtA
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Revision E 6/13/2005
Front Haltway Renovation Specification
Flooring
Demolish exiting flooring to sub -floor.
Source and install tile flooring --Happy Floors, Cross Cut dark (1 M 7) in a
straight pattern.
Install wooden thresholds in transition areas to adjoining rooms.
Baseboard Molding
Replace baseboard molding with wider (?) molding and paint to match
existing trim color.
Doors/ /Moldinci/Trim
Prep and paint doorway jambs and trims kitchen. Jamb to be painted to
match front hall trim color.
Revision E 6/13/2005
Kitchen Bath (Powder Room) Specification
Permits
Obtain the necessary Town of North Andover building and plumbing permits.
Demolition
Remove and dispose of existing vanity, sink, toilet, flooring, ceiling and lighting
fixtures.
Vanity
Install vanity and counter supplied by client. Affix backsplash to vanity
countertop.
Plumbing/Toilet
• Connect sink plumbing.
• Source and install new toilet—Kohler Memoirs, comfort height 1pc toilet (color
= sandbar)
Flooring
• Demolish exiting flooring to sub -floor.
• Source and install flooring. Source and install tile flooring --Happy Floors,
Cross Cut dark (1 7X1 7) in a straight pattern.
Ceiling
Re -plaster exiting ceiling with smooth plaster. NOTE: While ceiling is "open"
investigate potential leakage problems from above. Report any repair work
required to client. Make repairs as agreed upon with client.
Hardware
Install toilet paper dispenser and towel bar supplied by client.
Install mirror, supplied by client, on wall over vanity.
Li-ghtin-q
Install two wall sconces supplied by client.
Electrical
Bring electrical outlets to code.
Install exhaust fan with integrated light.
Install two swiftches--one for wall sconces and one for exhaust fanAight.
Heating
Remove current baseboard heating. Install baseboard heating component
beneath the window. CA4
Revision E 6/13/2005
r.
DoorNVindow
• Re -trim window casing and sill. Repaint with trim color TBD.
• Paint (or replace?) existing door. Inside of door to match powder room trim
color. Outside of door to match kitchen trim color.
Tirm/Molding
a Replace baseboard molding with wider molding and paint with trim color.
Painting/136co
• Paint trim. Color to be determined.
• Paint walls. Color to be determined.
Other
Renovate enclosure for pool equipment. Cut down comer posts. Cap.
Revision E 6/13/2005
Ceiling
Re -plaster exiting ceiling with smooth plaster. NOTE: While ceiling is "open",
investigate potential leakage problems from family bath (above). Report any
repair work required to client. Make repairs as agreed upon with client.
Plumbing and Fixtures
• Source and install new faucet- rohe Alira anfid - t inless steel.
6ii�?n eBlanko 510-78�j2>
• Source and install new unden-noun si
• Re -install existing disposal.
Lighting
• Suuply and nstall 4" can lighting in ceiling (with dimmers)
• Install Kirchler under cabinet lighting modules (supplied by client)
Electrical
• Connect ceiling lighting and all appliances as required.
• Bring all existing reused electrical to code.
• Install new electdcal outlets and switches as required to code, including an
outlet in the island. (Switching configurations to be determined by client.)
• Cable and phone outlets to remain as is.
Heating
0 Install heating unit in toe kick beneath the sink.
DoorsNVindows/MoldinqrTrim
z Slider and window to remain as is. Prep and paint in kitchen trim color.
E Replace, prep and paint doorway jambs and trims (into family room, dining
room, bathroom, to cellar and library). All trim to be kitchen trim color. All
jams as specified below:
Door Jamb
Paint Color
Kitchen to Family Room-
Kitchen trim
Kitchen to Dining Room
Dining Room trim
Front Hall to Kitchen Hall
Front Hall trim
Kitchen to Library (where stain currently exists)
Kitchen trim
Kitchen to Powder Room (1 /2 of doorjamb)
Kitchen trim
• Replace baseboard molding with wider molding and paint with kitchen trim
color. C/0-
• Prep and paint library door to kitchen trim'color. oil
Revision E 6/13/2005
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N -I tie Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston., MA 02111
www-mas&gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electticians/Plumbers
Applicant Information t Please Print LeWbly
Name (Business/Organization/Individual): RAPS CWT RUC�Al
Address: e �'(� 8
5f.
City/State/Zip: Phone #:
Aerey, in an employer? Check the- appropriate box:
12
1 1 am a employer with -
4. El I am a general Contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
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. 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,
conip. insurance required.]
Type of project (required):
6. Dlew construction
7. [2 Remodeling
8. El Demolition
9. E] Building addition
10. [:1 Electrical repairs or additions
I I - El Plumbing repairs or additions
12.0 Roof repairs
13.[:] Other
bV L11i Uut t e I i)elow showing their rkers' compensation policy information:
' cl on
Be '
t Homeowners who su;;Zjt this affidavit indicating they are doing all work and then hire outside contractors must subInit a new affidavit irAcating suclL
tContractors that check this box must attached an additional sheet showing the name of the sub—tractors and their workers, comp. policy inforrriation.
I am an employer that is providing workers " Compensation insurancefor my employee& Below is the polky andiob site
information.
Insurance Company Name: 0+ M/+ MW
Policy # or Self -ins. Lic. Vvi ( (000J ST 00 1 ?_ coLf Expiration Date:
Job Site Address:— 2�b I �w 1-�, 1( W # City/State/Zip: Al. 446Vcr M4
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as require# under Section 25A of MGL c. I . 52 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year'Irnprisonment, 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 under the painsAnd enaties
OfPeriurY that the information provided above is true and correct.
Signature: Date:
'211)? Coe�-Ltt,7
Oricial use only. Do not write in this area, to be completed by chy or town official"
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. BuildingDepartment
6. Other
Contact Person:
Permlt/License #
3. CitY/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone #:
1[nformation and Instruc ions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pur . suant 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 writtm."
An employer is defined as "an individual, Partnership, association, corporation 6T 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 aln 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."
chapter 152, §25C(7) states "Neither the conmionwealth nor any of its political subdivisions shall
Additionally, MGL mp u th th ins
enter into any contract for the performance of public work until acceptable evidence of co lia ce wi e urance
requirements of this chapter have been presented to the contracting authority."
Applicants sation affidavit completely, by checking the boxes that apply to your situation and, if
Please fill out the workers' conVeB
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 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 Tequira Be advised that this affidavit may be subn-dtted 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 hive 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-inmed 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 subinit 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 affidivit 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 pen . nit 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
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts
(80) 876-2765 NCCI NO 26158
POLICY NO. I VWC 6004MWI2004
ITEM PRIOR NO. I VWC 6004650012003
1. The Insured Ratio Construction Co
Mailing Address: 252 B Pleasant St Methuen MA 018"
ft Stled Tom or City courdy State Zp Code
C] Individual 0 Partnership Q Corporation 0 Other FEIN 04-3247039
Other workplaces not shown above:
2. The policy pariod lsftm1(XW20N to 101M005 12:01 ain. standard time at the insureds mailing address.
3. A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the states listed We;
MA
B. Employers Liability Insurance: Part Two of the policy Opplites to work In each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident$ 100,000 eachaccident
Bodily InJury by Disease $ 500,60-0 policytimil
Bodily I" by Disease $ 100,000 eaMemployee
C- Other States Insurance. See Endorsement WC 20 03 06 A
0. This poricy inchides these endorsements and schedules: SEE SCHEDULE
4. The prernfurn for Oft poky will be determined by our Manuals of Rules, Ciasaifaca*M Rates and Rating
AN Information required balm is sul4ect to verification and change by aud[L
Classifications Premium Basis Rates
code
Estimated
Per $100
EsOftated
No.
TOWAnnual
Of
Mwal
P_
IM
Rarmumatim
Pmrium
DITRA 177476
SEE EXr"NSION
OF INFORI
4ATION PAGE
Minimum premium $ 600.00
As indicated, interim adjustmentis of premium shall be made:
(2 Annually 0 Semi Annually 0 Quarterly [] Monthly
i ow tsurnam Annual Premium s 2,701.00
Deposit Premium $ 2,819.00
MA Assessment Chg.
$2,415.85 x 4.WWA $118.00
This policy, including all endorsements, is hereby countersigned by 09101/2004
Av hAwrizati sitinattge
GOV
STATE
GOV
CLASS
I KIND
AUDIT
1PLACING1
OFFICE
CLAIM
I OFFICE
I NAME
I CHECK
SAFETY
GROUP]
MA _
15506 �
P_
IM
I
WC 00 00 01 A (11-88)
includes capriOW material of Me National Cotowl on CmWermom kaurame,
am %VM its
MacDonald & Pangione Ins Agcy
P 0 Box 428
No Andover, MA 01845
,�
�.. ,.
...
.„
r
,;
3 6 4
Date.. /=,2-. � .....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that Vli d� A ..................
has permission for gas installation ..... V ....................
in the buildings of .................................
at North Andover, Mass.
.... Lic. No..
Fee. .......
,�GAS INSPECTOR'
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO CzASFITTINEi
(Print o , T Permit #
M /% mass. Date- j/)/o
Building Location Owner's N Iq cen
vi ofo 5(Ao,/U��
New Renovation C] Replace[nent Plans Submitted: * Yes[] No 0
(i
r
Instalikv Company Name
Address
I
Check onw.
56 Corporation
0 Partnership
Business Telephone, 2 7 P -- -7 7 5/- -1 763 0 Fkm/Co.
Name of Licensed Plumber or Gas Filter /-7 Y�&Aj
Certftme
INSURANCE COVERAGE:
I have a 010 Insurance policy or Its substantial equtvalent W" meets " mqwrementsof MGL Ch. 142.
Yes TM*IY No 0
if you have checked Yes. please Indicate the type coverage by dmx*lng the appropriate b0X
I A liability Insurance policy t�, Other b" of Indernrilty 0 Bond 0
OVOIER'S INSURANCE WAPIER: I am aware UW the llce� does W haw the Irmirance ctwerage reqUired by
Chapter 142 of the Mass. General Laws. and that my signature an #6 permft application Waives this requirement.
Check one:
OwnerO Agent 0
Sig -nature of Oww or Owner s Agent
I tiereW cartify that all of the details and infaimation I have submitted (or entered) in a bove aplificatlim an true WW aCCurate to the best of my
knmWp and Dist d Om*ng work and mWiabons perWrmed under the for 11WAI Will! P!!�Twml an
pertinent provismns of tM Massadtusetts Slate Gas Code WW Chapter 142 0 the tAM. A
Two of Ucense, 7VI"
Plumber Skjwure if Lmensed Plumber or Gas FMw
r
Title fitter
ster License Number
*WS,.
Journeyman
1CM
r
Instalikv Company Name
Address
I
Check onw.
56 Corporation
0 Partnership
Business Telephone, 2 7 P -- -7 7 5/- -1 763 0 Fkm/Co.
Name of Licensed Plumber or Gas Filter /-7 Y�&Aj
Certftme
INSURANCE COVERAGE:
I have a 010 Insurance policy or Its substantial equtvalent W" meets " mqwrementsof MGL Ch. 142.
Yes TM*IY No 0
if you have checked Yes. please Indicate the type coverage by dmx*lng the appropriate b0X
I A liability Insurance policy t�, Other b" of Indernrilty 0 Bond 0
OVOIER'S INSURANCE WAPIER: I am aware UW the llce� does W haw the Irmirance ctwerage reqUired by
Chapter 142 of the Mass. General Laws. and that my signature an #6 permft application Waives this requirement.
Check one:
OwnerO Agent 0
Sig -nature of Oww or Owner s Agent
I tiereW cartify that all of the details and infaimation I have submitted (or entered) in a bove aplificatlim an true WW aCCurate to the best of my
knmWp and Dist d Om*ng work and mWiabons perWrmed under the for 11WAI Will! P!!�Twml an
pertinent provismns of tM Massadtusetts Slate Gas Code WW Chapter 142 0 the tAM. A
Two of Ucense, 7VI"
Plumber Skjwure if Lmensed Plumber or Gas FMw
r
Title fitter
ster License Number
*WS,.
Journeyman
N2 4 kC 3 0
Date. .�- .-./ Y. .- c.'
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... P., .......................
has permission to perform .... e14" ..................
plumbing in the buildings of ... .....................
a t ........... North Andover, Mass.
Fee. . Lic. No.. .,S—�� 3 .......... ......
PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETFS
Building Location .2- r I 6-.Pq & 1 /, ' / e
New 01- Renovation M
a INS F -I
.lers Name A,4-', 11, /,) ,
of
Replacement 0 -
FIXTURES
Plans Submitted Yes
J'-/ A
Date
-Permit
Amount
NO El
(Print or type) Check one: Certificate
I 1� I A4 444 r 17"- Corp.
Installing Company Name El
Addms &D k' -te /L- 5" F Partner.
Business Telephone 2— 0 0—Firm/Co.
Name ofLicensed Plumben
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity F1 Bond
Insurance Waiver L the undersigned, have been made aware that the licensee of this application does not have any one of 'the above
three insurance
Signature Owner F1 Agent
I hereby certify that all of the details and information I have submitted (or entered) ir above application are true and 'accurate to the
best of my knowledge and that all plumbing work and * tall ti performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the lumb(3, Code an
By: R95; , I
61g'natUre Ot.Lir-ensed ruimoer
Type of Plumbing License
Title T�) 3 ( .
City/Town License 1'qumoer Master Joumeyman
APPROVED(OFFICE USE ONLY Er'
2316
r
41 Date ....... /,.,;2 .... L10).
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... ......... ......................
has permission to perform ........ A �., ....... ................
... .. .. ......
wiring in the building of ...... .............................................
at ...... ....... �T��--R ....... ..... ...... .... I'dorth Andover ass.
. M ......
Fee ..... T.0 . ........ Lic. No..:�� 71 ........... . ....... . e . .. .. .. .... ...
LECTMRIC NSfPECTOR;
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
(9\ Office Use only
ThEG0W0NWE4L7H0FA14MC1ffJSE77S
N DEPARTAfflW0FPUBL1C&4FM Permit No.
BOAM 0FFREPREVE7M0NRWUL4770AS527CW 120 Occupancy & Fees Checked
VU44PPLJCATION FOR PERAff TO MFORM ELECMCAL WORK
1 ALL WORK TO BE PERFORMED IN ACCORDANCE VATH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 7.
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4
Town of North Andover
The undersigned applies for a permit to perfbrm the electrical work described below.
Location (Street & Number) *Z-'�- i
OwnerorTenant CV(A-.-L&,S A -A)+1 -00-(D
Owner's Address
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building (z: A -C-- Utility Authorization No.
Existing Service Amps Volts Overhead r7 Underground No. of Meters
New Service Amps Volts Overhead [=] Underground No. of Meters
Number of Feeders and Ampacity
Lolation and Nature of Proposed Electrical Work (-7,v 6/c—:::�.M 6 -
No. of Lighting Outlets
No. of Hot Tubs
No. ofTransformers
Total
1 10
KVA
F4o, ofLighting Fixtures
Swimming Pool Above
Below
Generators
KVA
60
ground
1:1
ground
No. ofReceptacle Outlets
No. of0il Burners
No. ofErnergency Lighting Battery
Units
7Z
No. of Switch Outlets
No. ofGas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. ofDetcction and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Inutiating Devices
No. ofSounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local Ol Municipal
Other
No. ofDryers
Heating Devices KW
Connections
kNo. ofWater Heaters KW
No. of No. of
Signs
Bailasis
,No. Hydro Massage Tubs
No. of Motors
Total HP
OTHE -
hwxa=Com� Laws
Tha%eamnatLmhltyhiu==PokynijhgCaypklclDpOerig-CmtrdWcrtsWistfftdmpv-dat YES NO
Iha%esibintedmMpmf,ofsamlottL-Offw- YES NO lf�cuha%edwdW YES, pkmhdc*thet
.qxofwmaWbydrddngthe
MmTd*bcx
INSURANCE �BOND MI -M ftweSpeffy) EViafimD*
Estim&dVahxcfEkcfi-2lWdk
Wdk1DStVt 0 1--) hEpecdwDabRaWesWd Ra* FmW
FIRMMME A-tMAY-
Li== -,� \ /,I 4r� �10 Sigl�
19 U, -i -I - Pst, -,-/-o -,J
--7
im Td Nh 4;D
Ak.TdNh
and*Aniysgn&waltmpemitappheebmw,n'msthismW'mnat
(Please check one) Owner M Agent M Telephone No. PERMIT FEE$ 60
V2 1842
Date..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... ............................................
has permission to perform .................... ........
wiring in the building of s�" ...................................
............... . North Andover, Mass.
..............................................
Fee.xl� ........... Lic. No?e�.7"/4 '--ELEcrRicAL INSPECTOR
WHITE: Applican 68/26/9§'ft48y: Building Q5p40 PAIMNIK: Treasurer
ne Commonwealth of Massachus
Department of Public Safety
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12M 13/90
Wiles U*4 oat
occ--p- Y & r., owb"W-4=
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AU work to be PCTIQCM*d In &CcOtdance with the Maa"chuseru ElectriCal Code. S27 CMR 12:00
(PI -EA E PRINT IN INK OR TrPE ALL INFORMATION) Date /9 L)6— clQ I Y P
City or Town of A�0�11 AAIDOVV_ To the Inspector of Wires:
1he undersigned applies for a permit to perforn the electrical work described below.
Location (Street& Number) ag I BlFfip'41 LL --
Owner or-Zeasut L( AW IQ I n P
Own*r's Address -S d M L -
Is this permit in conjunction with a building permit: Yes NOE] (Check Appropriate Box)
Purpose of Building DWS"--JAIJ -____YtLlity Authorization No.
Existing Service r--1
--17-740 AMPS— 4 -WO VOlt3 Overhead V& Undgrd NO. Of Haters
New . Service -Aaps Volts Overhead 0 Uodgrd NO. of Meters
Number of Feeders and Anoscity
Location and Nature of Proposed Electrical Work LJ(
No. of Lighting Outlets
No. of Hot Tubs co
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above M In-
grnd. L—J grnd.
Generators KVA
No. of Receptacle outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
NO. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Sol Contained
DetectionMunding Devices
Local C] Mm'c'P&l E:]Oth4r
Connection
No. of Ranges
Total
No. of Air Cond. tons
No. of Disposals
Heat Total Total
No. of Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters XW
No, NO. of
sum Ballasts
Low Voltage
wirine
No. Hydro Massage Tubs
No. of Motors Total HP
INSURANCE COVERAGEs Pursuant to the requirements of Massachusetts General Laws
I have a L biliM Insurance Policy including Completed Operations Coverage or its substantial
currm NO [J I have submitted valid proof of same to this office. YES(a NO 0
equivalent.
If you have checMEYES, please indicate the type of coverage by checking the appropriate box.
INSWU= pt som 0 OTHER 0 (Please Specify)
Estimated Value of Electrical Work S (Expiration Date)
Work to Start Inspection Date Requesteds Rough- 0"'l -Final P'w F//
Signed under the penalties of perjurys
FIRM NAME q //�� LIC. No.
Licens*0—b "V1 SAM PSOA) Signature V&a4 QA-Az� LIC. NO. T4,0114
Address wawr-lflo MA& 01&0 1hus. Tel. No.-
-Alt. Tel.* -
OWNER'S INSURANCE WAIVERt I ant aware that the License* does not have the insurance coverage or its sub-
stanti&I equivalent as required by Massachusetts General Laws, and that my sigmtury an this perwit
application waives this requirement. Owner Agent (Please check one)
(Signature of Owmr or AgentT— Telephone No. PERMIT FEE S /'-�
i
f
It
N2 1 Ur' 0 9
A 0 0 A
CHU
Date —.E.5 .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies th
. .... ..................... .... ... ---- --------
has permission to perform ......... ......................
................... Z� ........
wiring in the building of ............ ... j -r " .......................
at ... / Z),I? - ( .............................. North Andover, Mass.
Fee ..... S-0 ... . .... Lic. N? -Z1 J-A� ............. ......
ELEcrRicAL INSPECTOR
I
08/10/99 14:40 50-00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TIM COMMAWE4L771 OFAIASS4MUSEM Office Use only
DL7?4RTA1E7YT0FPVB0CSe4F= Permit No.
BOAROOFFB?EP)ZEYEMONREGLL4HONS527(3MIZ-00
Occupancy & Fees Checked
,4PPLICA17ONFORPEI?AlflTTOPEI?FORMELE=(�'AL WORK
ALL WORK TO BE PERFORNED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 cMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work, described below. [MAP PARCEL
Location (Street & Number) Z-? 66Ao'- �J(q—
Owner or Tenant CV�)k'-L-C S— A PJJJA-t-0A--C)
Owner's Address A-vAe
Is this permit in conjunction with a building permit: Yes [D --No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead Underground No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. ofHot Tubs
No. of Transformers
Total
9
KVA
No. of Lighting Fixtures L4
Swimming Pool Above
Below
Generators
KVA
ground
[p
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local M'J Murucip�l
M
Other
No. of Dryers
Heating Devices KW
Cormcctions
of Water Heaters KW
No. of No. of
1qN10-
Signs
Bailasis
No. Hydro Massage Tubs
No. ofMotors
Total IIP
OTEER-
buarceCowmWa
YES E3 -----No 0
IhawWmnth�dvabdrioofofsmmtothoOffim YES Y)Kuhmdmd<odYESPk=mdc&&tA)ecfmNwdWbydiedm�tlr
Fkase Sp,*)
lN9M*1C-E �BOND F-1 OR -IR FNxa6mDate
El,,�ValwdEbjfticalWcik $
Wcdctostatt 94 b kspe�DieRmp�kd Rougli Final
s*-cdunacrTepl4m�sofpc�w-
Fff ZMNAIVE a-) AA A --r- —X -rt C--(-� Lt-ir� 5 4/-- L==1,b
Lmlseq�L �,t Sigrmm -A
Bus�MTCII"b-
Adiuss—iL Li� LA-, S'4:, < — Alt Tel NTa
OV�T�S INKRAk-EWAIVER, I&naw&cdiatdieI-=m does nnt1uw1lrin==cu�aaWcri1s alsbrtoleqxvakriaswqxedbyN4asmdmgcttsCvniaiLa8As
ar)d#rtrrrysgikmcn�mpmTntTo'cat'mwd'r�Asths1eqm- al-iffit.
(Please check one) Owner ED Agent F7
Telephone No. PERMIT FEE $
Signature ot Uwner or Agent
Location
No.
".7 -
L
Check #
13761
I ,,, /" / �/-
Date
41- j", - , -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ r-/ 'A
Building Inspector I (--
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERNUT NUMBER: DATE ISSUED: Ay F
SIGNATURE: '0MAke c4l���
Building Commissionerflps
ZStor of Buildings Date
SECTION 1- SITE INFORMATION
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zonmightformation:
Zoning Diar idt Proposed Use
1.4 Property Dimensions:
Lot Area (st) Frontage (ft)
1.6 BUILDING SETBACKS 00
Front Yard Side Yard
Rear Yard
Required Provide �eqwred Provided
Requir=ed
Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Publi 0 Private 0 Zone Outside Flood Zone 11
1.8 Sewpage Disposal System:
municipal On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
C6,(� 3 Pe ,,r N
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed' Construction Supervisor:
"Ok R14M
Licensed COvstruction Supervisor:
Address
krk,�� IVA 0(6qq
Signature Telephone
TV14A Q4/
Not Applicable 0
License Number
SA (?60 1
Expiration Date
3.2 Registered Home Improvement Contractor
RAM Co WL
Not Applicable 0
I I ? S??
Company Name
?—R 8 -Pkfta11fS4
Registration Number
D lt�
Address
?Y" Ak—
Expiration Date
Signature Telephone
9,
0�7-'
ti
N
M
z
G)
I SECT -ION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (chec applicable
New Construction 0
Existing Building W
Repair(s) 0
Alterations(s) V
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Desciiption of Proposed Work:
f"Q -91404C,4- of 2-X4 P"�ftq wl Blwbaud/RN�r
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to
Completed by permit applicant
1. Building
10
'/000' 0
(a) Building Permit Fee
� Multiplier
2 Electrical
1,5'00,00
(b) Estimated Total Cost of
Construction
3 Plumbing
AZ' -)C' 0 o
Building Permit fee (a) x (b)
Mechanical (HVAC)
.4
5 Fire Protection
.6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLES FOR BUILDING PERAHT
T
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all, matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
iv'60C
Print Name 8(o o
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TEVIBERS iST 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TFUCKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
Ci!Y Phone
am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
E&�l am an employer providing workers� compensation for my employees working on this job.
Company name: RA -q? comrqucrw (c) mtt
Address plea,.J
Ci!Y: Phone #:
Insurance Co. -�VaV&Vs Poligy #
Corrigany name:
Address
Cily: Phone #:
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER a6d a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DLA for coverage verification.
I do herby certify under the pains and penalties of pedury that the information provided above is true and correct.
Signature )V�(� fa/4 Date 4h q20
- OATI Phone# 602-YC182
Print name m4Q E
Official use only do not write in this area to be completed by city or town official' 0 Building Dept
FlCheck dirnmediate response is requffed Building Dept [] Licensing Board
E] Selectman's Office
Contact person 7 Phone E] Health Department
I -I Other
FORM WORKMAN'S COMPENSATION
HOME IMPROVEMENT CONTRACTOR
Registration. 117532
T - PRIVATE CORPORATION
ype
Expiration 10/16/00
RATTE CONST CO INC.
S. RATTE
7 LAUREL AVE
ADMINISTRAMR
THUEN MA 01844
BOARD OF BUILDING REGULATIONS
I ERVISOR
License: CONSTRUCTION SUP
S 043865
Number: C
Birthdate: 05/08/1962
Expires: 05/08/2001 Tr.no: 9790
Restricted To: 00
MARKS RATTE
7 LAUREL AVE
METHUEN, MA 01844 Administrator
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No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
Sewer Connection Fee $
Water Connection Fee
TOTAL
t-/ 1,4 -2-�aj c/ Building Inspector
C' 008/04/99 11:50
78.00 TTI
Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*********-********************APPLIC.�NT FILLS OUT THIS
C,
APPLICANT C C-> -
PHONE
LOCATION: Assessor's Map Number (D(2
PARCEL—ac;L
SUBDIVISION
L 0 T (S)
STREET �,Xyi �54�
ST. NUMBER
USE
Pbqcle- 0�
RECOMMENDATIONS OF TOWN AGENTS:
0 P -Et,-) c te"
rt(A'L —
CONSERVATION ADMINISTRATOR
COMMENTS 1\J b ��
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
. I 4U1.11- k-,�
SEPTRC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATEAPPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9\97 jrn
DATE
North Andover Building Dep2rtment
Tel: 978-688-9E45
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 5 54, a condition of Euilding Permit
Number is that the debris resultino from this work shall be
disposed of in 2 properly licensed solid waste disposal fac;il*-'Ly as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
,IVC)�WAJ JnA
lq)qd 67
- � O'D
A,1
(Location of Facility) 1�)Cle
_,o54111121r
-'��?'anatdre W"Permit Applicant
99
Date
NCTE: Demolition permit from the Town of North Andover must be obtained for
this project through the C-ffice of the Building Inspector
y.
's
The Commonwealth of Massachusett
7 Department of Industrial Accidents
Office of investiciations
Boston, Mass. 02'11
-davit
Workers' Compensation Insurance Affi
Name Re2se Prinz
Marne
^ korco
Lccgticn� 0 '?-) fS:�Fn g )�) I L Y -,"a
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I am a hcmecwner peri'crming all v�cir'k mysa!f.
I am a sole prcprietcr and have nc cne wcrking in any c=,;act/
am an ern,picycar prcviding wcrkers' c0m,pensaticn for my em,cicyees vvcr`1-inC ,:n '(1 -JS jcb.
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insurerce Co. Pofic/ ��
Failure to ccverzce -as requirej under Se,--:cn 25A or NIC -L I s-'7 czn le-�c �o tne irr.cos;ticn & of a "ne uo �c S!, ECO.00
ancic, cne years' r-,.cnscnr,-ief7: as -Ne!! as cvd penaitie-s in ute fcrm cr -� STCF I/VCRK CFCEF�' 2nc a a z v 2 rz , m e.
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Ratte' Construction Co., Inc.
291 Lowefl Street
Lawrence, AU 01841
Tel. 978-682-4982
USIDENTML CONTRACT 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.
Note: Ali home improvement contractors and subcontractors engaged in
home improvement contracting, unless specifically exempt from
registration provisions of Chapter 142a of the General Laws, must be
registered with The Commonwealth of Massachusetts. Inquires about
registration and status should be made to the Director, Rome
Improvement Contract Registration, One Ashburton Place, Room
1301, Boston, MA 02108.
This Agreement is made on 0/4/99 between Ratte' Construction Co., Inc. of 291
Lowell Street, Lawrence, MA 0 1841 (978) 682-4982, hereinafter called
Contractor" and Charlie Annaloro of 281 Bear Hill Road, North Andover, MA
0 1845 (978) 688-4189 hereinafter called "Owner".
L 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:
See attached specifications.
H. DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the
following:
See attached specifications.
III. PRICE
Contractor agrees to do all work described in Section I for the total price of
NINTEEN THOUSAND SEVEN HUNDRED AND NINETY FIVE
DOLLARS ($19795.00).
,.f 1
HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK
Hidden conditions may require adjustments to the contract price. In such a
case the contractor will inform the homeowner of such condition forthwith
and where necessary a written amendment of this contract will be negotiated
and executed by the parties.
IV. PAYMENT
Payment will be made as follows:
("W" wal"ro-
30% ($5938.50) apon completion of rough'plumbing;
30% ($5938.50) apon completion of carpentry and tile work;
10% ($1979.50) apon completion ofjob.
Notice: No agreement for home improvement contracting work shall require
a down payment (advance deposit) of more than one-third 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
delivery materials, and equipment, whichever amount is P.Leate
V. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not begin the work or order the materials used before the third day
following the signing of the Agreement, unless specified here in writing.
Contractor will begin work on or about July 19, 19". Barring delay caused by
circumstances beyond Contractor's control, the work will be completed by August
18, 1999. 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.
VI. NO ACCELERATION OF PAYMENTS BUT ESCROWING
ALLOWED
The Contractor may not require payments to be made in advance of times specified
in Section IV (Payment) above for reason that he deems himself or the payments
to be insecure. If however, he deems himself to be insecure, he may require as a
prerequisite to continuing the work described herein, that the balance of the
payments wider this Contract that are in the control of the Owner, shall be placed
in a joint escrow account that requires the signature of both the Contractor and the
Owner for withdrawal.
VH. INSURANCE
Contractor will be responsible to Owner or any third party for any property
damage or bodily injury c*used by himseK his employees or his subcontractors in
the performance ot or as a result of, the work under this Agreement. Contractor
agrees to carry insurance to cover such damage or koury.
� _ f
` -
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..
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VM. 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.
IX CONSTRUCTION -RELATED PERMITS
The following construction -related permits will be necessary in order to complete
the scope of work included in this Agreement.
Town of North Andover building, electrical and plumbing permits
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: If 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.
X. MODIFICATION
This Agreement, including the provisions relating to Price (Section III) and
Payment Schedule (Section IV), cannot be changed except by written
statement signed by both Contractor and Owner. However, cancellation by
Owner is allowed in accordance with the Notice of Cancellation (annexed).
XI. WARRANTIMS
The Contractor warrants that the work flirnished hereunder shall be fi= from
defects in materials and workmanship for a period of I Year following completion
and shall comply with the requirements of this Agreement. In the event any defect
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 agreed-
upon work.
All warranties for equipment supplied by the Contractor under this Agreement
shall be those given by the manufheturers of such equipment, which shall be and
are hereby passed through directly to the Owner. Under such manufacturers'
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 fidlure to mail in or register such documentation, which
fitilure voids the manufiwturer'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 gate to state under Massachusetts law, sales of goods carry
an implied warranty of merchantability and fitness for a particular purpose.
XII. COMPLETENESS OF AGREEMENT FOR EXECUTION
The owner is hereby advised that he should not sip this Agreement unless and
until all blank sections have been filled 'in or marked as void, deleted or not
applicable, and until all exhibits or referenced documents that are incorporated
herein are attached hereto,
XIII. COPY OF AGREEMENT TO HE 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
Agrement and transmittal.
RIGHTS TO CANCEL
The Owner way cancel this agreement if it has been signed by the Owner at a
place other than an address of the Contmetor which may be his main office
or bmuch thereof, provided that the Owner notifies the Contmctor in
writing at.his main office or bmuch 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.
Note: This proposal may be withdrawn by us if not accepted within 30 d
HOMEOWNER: DO NOT SIGN THIS CONTRACT IF
BLANK SPACE�J.
jp u
Owner'sS* at re Date Signed A A
Contractor's SiwuitureM44 fZ4k� Date Signed_�j �19 �
TERMS AND CONDITIONS
1. CHANGE ORDERS: During construction the Owner may order additional
work. The amount for such additional work shall be determined in advance if
possible, or may be charged for at cost of labor ($34.00/hr) and materials plus
21% of gross for Contractor's overhead and fee. All sums for change orders
shall be due and payable before commencement of work on each change order.
2. MATERIALS REMOVED - RUBBISH: AD materials removed from
structures in the course of alterations except Asbestos or similar hazardous
substances, shall be disposed of by Contractor except those items designated
by Owner prior to commencement of construction. All construction rubbish to
be removed by Contractor at termination of work and premises to be left in
neat broom -clean condition.
3. ASBESTOS & HAZARDOUS MATERIAL: Contractor shall not be held
ible f
responsf or the identification, detection, abatement, encapsulation or
removal of asbestos or similar hazardous substances. In the event that
Contractor encounters any such products or materials in the course of the
performing of the work, Contractor shall have the right to discontinue work
and remove employees from the project until no such materials or products nor
any hazard exist as the case may require, and Contractor shall receive an
extension of time to complete the work hereunder and compensation for delays
encountered as a result of such situation and correction.
4. ALLOWANCES: are included in most contracts. Those allowances are
shown at actual cost exclusive of the contractors overhead and profit. Upon
completion of the work the items charged to these categories will be
summarized and the result added to or subtracted from the contract amo-
Signed. Signed
(Colltractor) eir)
r
1 � � .
�
..
. l .
� . � .. a
�. � .. ` '
Ratt6 Construction Co., Inc.
291 Lowell Street
Lawrence, MA 01841 DATE
6/3/1999
I NAME/ADDRESS I
Mr. Charlie Annaloro
281 Bear Hill Road
N. Andover MA 0 1845
DESCRIPTION
Permits -
Obtain the necessary Town of North Andover building and plumbing permits.
Specifications
PROJECT
Masterbath2
Contents -
Homeowner to remove all contents from the bathroom, master bedroom, and closet. Contractor will move bed
and bureaus to another bedroom upstairs
Demofition-
Remove and dispose of the existing shower, tile floor, toilet, vanity and mirror. Remove wall separating toilet
from the vanity area.
Plumbing -
Supply and install the following. (1) Kohler Dynametrics 5 1/2'tub in white, (1) Kohler Highline toilet w/seat it,
white, (1) Moen Monticello 4572CP 97373 lav faucet, (1) Moen Monteceflo 3127CP 97463 shower valve with
tub and fill. Replace existing baseboard heat.
Electrical -
An allowance of $875.00 is included in this estimate for the following. Supply and install (2) recessed lights, (1)
shower fight, (1) Nutone Ultm-Quieffest Fan. Wire for medicine cabinet lights.
Framing -
Owner's Accep*ce 1
Date
Page 1
MR
0INq
Raft6 Construction Co., Inc.
291 Lowell Street
Lawrence, MA 01841
NAME/ADDRESS
Mr. Charlie Annaloro,
281 Bear Hill Road
N. Andover MA 0 1845
As per plans excluding pocket door.
DATE
6/3/1999
DESCRIPTION
Specifications
PROJECT
Masterbath2
Plaster -
Install 1/2" blueboard and skimcoat plaster on ceiling finished smooth. Install 1/2" blueboard and skimcoat
plaster on walls as necessary. Patch closet as necessary.
Mouldings -
Install crown moulding as per plans. Replace baseboard. Recase (1) window.
Door -
Reusing existing bathroom door change the swing to be a fight band swinging into bath against outside wall.
Patcbjamb.
Vanity -
Supply and install a Dover Woods Royal Premier vanity 57"x2 1 "04" w/fillers.
Corian-
Supply and install a 22"x6O" custom Corian vanity top in Rain Forest with (1) white bowl, backsplash and (2)
sidesplashes. Supply and install a piece of the same to cap the half walL
Tile underlayment-
Install a plywood underlayment on the floor. Install waterproof tile backerboard on the tub walls.
Tile surround -
Owner's
Date
Page 2
v,.. .. � ,.. .,
Raft6 ConstnActlon Co., Inc.
291 Lowell Street
Lawrences MA 01841
NAME/ADDRESS
Mr. Charlie Annaloro
281 Bear Hill Road
N. Andover MA 01845
DATE
6/3/1999
DESCRIPTION
U N
Specifications
PROJECT
Masterbath2
An allowance of $600.00 is included in this estimate to supply and install a white tile surround to match the
bathtub. Included are (2) soap dishes and (2) corner shelves.
Tile Floor -
An allowance of $550.00 to hustall a 12"xl2" slate look tile floor. Based on $6.55/square foot tile. Let me see if
I can match this sample for less money.
Painting -
Paint bathroom ceiling walls and woodwork complete. Paint walk-in closet as necessary after patching access
for plumbing.
Medicine Cabinet -
Supply and install (1) Robern B&C Series 2 door/inset center 60"x38" medicine cabinet w1halogen lighting
system.
Hardware -
Supply and install the following Moen Monticello accessories. (1) 24" towel bar, (1) toilet paper dispenser, (2)
robe hooks. Supply and install (1) chrome shower rod. Install owner supplied cabinet knobs or pulls.
.P . A
Ownere's �Ac �te IW/111- 77-
31-
D ! (difil
Page 3
• •L
3 8 L 0
-A,
Date....
, .........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .....
.......................................................................................
has permission to perform ...... ......
..............................
wiring in the building of ��� ..............................
....... .........................
. ......... North Andover, Mass.
at. .......
Fee ... ..... . ..... Lic. No . .............
.. ..... ..... .......
��i'L-;E�c-m ICAL INSP ECrOR
611'
Check #
utrictai use L).njy
Permit No__
'45.5
Occupancy & Fee Checked.. 04
BOARD OF FIRE PREVENTION REGULATIONS.527 CIVIR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AJI work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date to -
L Ln _T
To the Insoector of Wires:
Townof North Andover
The undersigned applies for a permit to perform the electrical work described below.
Locabon (Street & Number- 2-1� rA V, 1,-A (� 1,,(_ 01E!!�b -
OwnerorTenant A V,41 +I_p X_ 0
Owner's
Is this permit in conjunction with a building permit Yes &r No 0 (Check Appropriate Box)
Purpose orf Building Utility Authorization No.
Existing Service Amps - Voits Overhead 0 Undgmd 0 No. of Meters
New Service —Amps voits Overhead 0 Undgmd 0 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work 4 r=, A, 1t7&Z—_
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
'4 have a current Liability Insurance Policy includ!%I,"pleted Operations Coverage or its substantial equivalen 0
hgye_%ubn3JJt0 valid proof of same to the OffickXES Vo M.Zer. ecking the appropriate
�-' NO = If you have checked YES please indicate the type o co ge by ch box
IQRSURANC�� BOND = OTHER =. (Please Specify)
I ------- (Expiration Date)
Estimated Value 7f.Elelrical Work$ L-f�
Work to Sta f 07-- Inspection Date Resquested_V-&A �01_�—Rough Final
Signed und' m(je Penalties
FIRM NAME 2L%_i_AA A -r LIC. NO.
L ke n s e e VAA A.* -'L— eA,.,3 Signature NO.
Bus.TelNo. �C)�
Address R�<-(VUL, _A,4 Alt Tel. No.
OWNIER;S INSUR*CE WAIVER: I am aware that the Licenses does Aot have.the insurance coverage or its substantial equivalent as required by Mas�ac_husetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
—Telephone No. PERMITFEE $ "00
(Signature of Owner or Agent)
Total
No.qof Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 0 In 0
No, of Lighting Fixtures
Swimming Pool
grnd 0 grnd 0
Generators KVA
_f__
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIREALARMS No.ofZone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initialing Devices
Heat Total Total
No. of Diposal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Soace/Area Heating
KW
Detection/Sounding Devices
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No.. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
'4 have a current Liability Insurance Policy includ!%I,"pleted Operations Coverage or its substantial equivalen 0
hgye_%ubn3JJt0 valid proof of same to the OffickXES Vo M.Zer. ecking the appropriate
�-' NO = If you have checked YES please indicate the type o co ge by ch box
IQRSURANC�� BOND = OTHER =. (Please Specify)
I ------- (Expiration Date)
Estimated Value 7f.Elelrical Work$ L-f�
Work to Sta f 07-- Inspection Date Resquested_V-&A �01_�—Rough Final
Signed und' m(je Penalties
FIRM NAME 2L%_i_AA A -r LIC. NO.
L ke n s e e VAA A.* -'L— eA,.,3 Signature NO.
Bus.TelNo. �C)�
Address R�<-(VUL, _A,4 Alt Tel. No.
OWNIER;S INSUR*CE WAIVER: I am aware that the Licenses does Aot have.the insurance coverage or its substantial equivalent as required by Mas�ac_husetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
—Telephone No. PERMITFEE $ "00
(Signature of Owner or Agent)
Location
No. b a Date
TOWN OF NORTH ANDOVER
97 - .
jj"k
Certificate of Occupancy $
A Building/Frame Permit Fee $
.2 CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 0
Check # q i 93t
15571 Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_Nt-4
BMDING P ER M[I T NUMBER: !DATE ISSUED:
f—cp 5L
SIGNATURE: JVW
Building CommissioneLA�Ior ckfAuildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
r
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dis&id Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required I Provide Required Provided
Required Provided
J
1.7 Water Supply M.G.L.C.40. �1 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewene Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSIUP/AUTHORIZED AGENT
2.1 Ow�er of Record
Ou'rhi Nt"11 112V-1
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
W -K rzA
WA
Licensed Construction Supervisor:
I
8 -5 ?— "0 P1 PCx
Address
xi�
Signature Telephone
Not Applicable 0
04 3 966j—
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Ro"m I Zx
Not Applicable 0
Com�any Nan�e
2s,� 8
Registration Number
Address
Expirati...
Signature Telephone
00
M
z
0
0
z
M
90
0
ic
M
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Q
I SECTION 4 - WORKERS COMPENSATION (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 DescHiption o Proposed Work (check appUcable)
New Construction 0
Existing Building 0
Repair(s) EJ
Alterations(s)
Addition 11
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
5 tlQ G6��X W1 SC
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL ONLY
'USE
I . Building
Po/
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
—3 Plumbing
Building Permit fee (a) x (b)
.4 Mechanical (HVAC)
5 Fire Protection
.6 Total (1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLEED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
—SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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/A ent Date
OF STORIES SIZE
—NO.
—BASEMENT OR SLAB
iST ND
SIZE OF FLOOR TRVIBERS 2 31w
—SPAN
—DIMENSIONS OF SELLS
OF POSTS
—DIMENSIONS
_DMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
OF FOOTING X
—SIZE
—MATERIAL OF CHIMNEY
JS BUUDING ON SOLID OR FULED LAND
—IS BUILDING CONNECTED TO NATURAL GAS LINE
FORM U .-LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fro . m
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
******************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT 111M-zk Rftm I PHONE(9)�
LOCATION: Assessor's Map Number --Q PARCEL 01��
SUBDIVISION LOT (s) 3-ZA
STREET— ST. NUMBER
USE
I VECOWENDATIONS QF TOWN AGENTS:
ATION I
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
TOR
,-K /00 /
DATE APPROVE513
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
141
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 jm
DATE.
!- N A r.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
VI
CRY "�Inor Phone
am a homeowner performing all work myself
I am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensation for hly eMployees working on this job.
Company name,
CRY: 0,hone.*,. 9),V. W3,
insumac—e- QQ TRAv E LFej
poliev
Ad -dress
Phone 4 -
Failure to, Secure uIred under Section 25A or WL of criminall, penaltift of a fine up t-
0 $1 59M.00
STOF, VVORX=
as 71'well as ctvil penalties in the .52 can lead to and
0�
and/or one yeamlW form; or a AM Of ($106 * a day against
understand that a copy of this statement may be forwarded to the Of InVeStigations of to DIA for coverage verificatim.
I do herby certify under the pains and P&M!" Of PedulY Mat the k7fomation provA*d above is irue, and- conect
Signature t t-1
Date- 5
Print name ewTTVr Phone#
0fficial use only do not write in this area to be completed by city or town dflcial*
OCheck ifimmediale response is requked Builbirig Dept
Contact person: Phone
RM WORKMAN'S COMPENSATION
E] Building Dept
0 Licensing Board
0 Selectr�an Is office
0 Health Department
0 Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
I Pr / � -,1w A) k-�
(Location of Facility)
) I'Z66�
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
,�
a;' , .
. .
MORTGAGETI48PEO
ORAIM
SCALE i I logo
A nM NUTS ILA4.8-9.9- UAW
Mvent mows AW at In i
pious. "it PLAN is of nun he
...... ........ AM— Oftftlaa &=
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v
Am
Ratte' Construction Co., Inc.
252B Pleasant Street
Methuen, MA 01844
Tel. 978-682-4982
RESIDENTIAL CONTRACT 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.
Note: All home improvement �ontractors and subcontractors engaged in
home improvement contracting, unless specifically exempt from
registration provisions of Chapter 142a of the General Laws, must be
registered with The Commonwealth of Massachusetts. I . nquires about
registration and status should be made to the Director, Home
Improvement Contract Registration, One Ashburton Place, Room
1301, Boston, MA 02108.
This Agreement is made on 5/14/02 between Ratte' Construction Co., Inc. of
252B Pleasant Street, Methuen, MA 0 1844 (978) 6824982, hereinafter called
"Contractor" and Charlie and Heather Annaloro, 281 Bear Hill Road, North
Andover, MA (978) 688-4189, hereinafter called "Owner".
L 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:
Construct screen porch addition to your home at 281 Bear Hill Road, North
Andover, MA, as per plans drawn by Jane Griswold and attached
specifications.
ILL DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the
following:
As per plans drawn by Jane Griswold and attached specifications.
III. PRICE
Contractor agrees to do all work described on a cost-plus basis.
Slaterials at contractor's cost. Subcontractors at contractor's cost.
Carpenter's labor at $40.00/hr. Total of all above plus 21% overhead and fee.
Projected cost approximately $80,000.00.
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