HomeMy WebLinkAboutMiscellaneous - 281 WAVERLY ROAD 4/30/20189 6-5
Date..................................
AORTPI
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
A op
This certifies that ....
........................ . .... .. .......
has permission to perform ....... 2-42:904
A25;04�7 .............................................
wiring in the building of .............. . ..........................................
at ....... )11 ....... k1l ....... ........ North Andover, Mass.
Fee... Lic. No.Y5�0114 ......... i�ica�..� ....
... ZI r P':�O�
Check 4,
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Permit No.
Department of Fire Services
�� 32
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O q- d 7 1'0
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
2-LOwLocation (Street & Number) oZ V e 12-1-
Owner
ner or Tenant C k4- y 1 egi4A1_ff F 9 co Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No. 9 6
Existing Service 410 Amps 12 iq Volts Overhead �[ Undgrd ❑ No. of Meters
New Service 6� Amps /)_.P"/c;2 dVolts Overhead Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 57
Completion ofthefollowing table maybe waived by the In ector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
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 Ran
Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
p
Heat Pump
Totals:
Number
�• � �•
Tons
KW
.........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Sectio. uritof Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications
No. of Devices or E u valent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: loyd d - X Q (When required by municipal policy.)
Work to Start: f7 -t (_ Jv Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: f0 LIC. NO.:
Licensee: Signature (i(%EJ
LIC. NO.:
(Ifapplicable, ent r "exempt" in the h nseber line.) Bus. Tel. No.
Address: / n 4 Alt. Tel. No.:Qn 7, •Sv8 -I qw)
*Per M.G.L c. 147, s. 5 -61 securitfwork requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's
Owner/Agent PERMIT FEE. $
Signature Telephone No.
'k,
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
4 s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual):
Address: A/ 4VA t' 2�' /-/0 ,
City/State/Zip: VW e904 Phone #: 6 O 3 ' 6 � s_- 7i�9 5
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.M I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
d,3 - (� _C
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
—/-le)
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
LContact Person: Phone #: II
Location ,�"<Iel
No. Date
(*--I - - *'N
AP - 0- 1
& +4 z
Check # 2,31)
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
13596 2�a�
Building Inspector
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BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL -c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a property licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
Location of Facility
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
'Q DAVID CASTRICONE
ROOFING, SIDING & REMODELING
REPLACEMENT WINDOWS FREE ESTIMATES
HOME IMPROVEMENT CONTRACTORS REGISTRATION NUMBER 104569
In Kingston 603-642-5990 In Haverhill 978-374-7314
In North Andover 978-688-9638 In Boxford 978-887-6147
7 Hillside Road, Boxford, MA. 01921
231 R Sutton St., No. Andover, MA. 01845
I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below described:
Owner's Name..........nC.....s�OS D G�►�.. C�.... JJ`16.?...h...Y......... .
......................................
........................................
Job Address .... r�?l.................................................City:..Yt........ State ..... .................................
J.......1-.1 J�-4 ....... .ts..at.S..�......... A/0
........S�r..,. ........ .l..s....�. 5...�...
. ........J ..��.:......... ,•.:.�..�......
:d.'....... .......0
1..�..�..G..,... . ........ 1P...�
. ........ �.. 3.'.........�`
......... ). y.�......... ,;;,.. .;-WA .......r
..............................................................................................
ft
SPECIFICATIONS
.........:�.1�.... fi..`.CJ.1........Ga.�i.. I...�A........................
......... ..�..,.............
...�...... 7Q .....................
do ..s,........./V.C-"j.. �.�.,. _. L 1�Lir-
............. .....s ................ �..
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.......................... ..................... ......tai..►Q...1.I................................................
/
- —ARM •► rs�t�11���I!!��,If�
........................................................................................................................................................................ .......... ......
Materials and labor to cost
$ ........... �.!P.V. D.Q......................... Payable ...1.,�....�.n...:�� ........... ..,,C� = .. ..cn
Contractor will do all of said work in a good workmanlike manner.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligati completionas s requested
by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if
permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, In addition to the amount due and unpaid, that shall be Incurred in enforcing the
terms and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, If any, nor any agreements collateral hereto, nor is this contract dependent upon or
subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof
understood and that no representation or agreement not herein contained shall be binding upon the parties and thrat all of the agreements and understandings of said parties are contained
herald. ,
'owner or Owners are not responsible for Property Damage or liability while job is in operation.
3
IN WITN SS WHEREOF, the parties have hereunto sj ned their names this ........ ... ..... day of..V.sc.�..t t, to ... cr7.a.0 L�
Accepted:":. y t.a,1. W a j`I�c l^h r Lfj 1
PJ . 9:T*—
Per..- .-9� . • ....... .. .. ... .......
Representative
Signed ... k.,.:G.
Owner
Signed......................................................................................
Owner
G.Jiie Liammaoouur¢�!% a�✓�aau�ci+uar,Cra i
HOME IMPROVEMENT CONTRACTOR
Registration 104569
Type - PRIVATE CORPORATION
Expiration 07/14/00
DAVID CASTRICONE ROOFING, SID
David T. Cas,tricone
illside Road -
ADMINISTRATOR.
Boxford MA 01921 ,
DA
AC 28P- CERTIFICATE 4F LIABILITY INSURANCE 10T 12-1999
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INTERN$T INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE W
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
522 CHICKERING ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NORTH ANDOVER, MA 01845
INSURERS AFFORDING COVERAGE
INSURED INSURER A: TRUST ASSURANC&
DAVID CASTRICONE INSURER S: EASTERN CASUALTY
ROOFING AND SIDING INC INSURER C: M
7 HILLSIDE ROAD INSURER D: y
BOXSORD HA 01921-� -
INSURER E:
nMVFRAAFC
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS.
IN$R
TYPE OF INSURANCE
POLICY NUMBGR
POLICY EFFECTIVE
POLICDATEY EXPIRAn N
LIMITS
GENERAL LIABILITY
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EACH OCCURRENCE i 1,000,000
AIK
COMMERCIAL GENERAL LIABILITY
TCP 1012811
08/06/1999
08/06/2000
FIRE DA_MAOE�Aronelin a� 50,000
CLAIMS MADE La OCCUR
MED EXP An oneperson) S _ 5" 000
❑
PERSONAL 1F ADV INJURY i 1,000,000
GENERAL AGGREGATE $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGO $ _ 1,000,000
jECT FM POLICY ❑ PRO- LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Es soClOent)
ALL OWNED AUTOS
ILY INJURY
SCHEDULED AUTOS
E(ZI)pennon) $
HIRED AUTOS
BODILY INJURY
NON -OWNED AUTOS
(Per accI09M) i
PROPERTY DAMAGE $
(Per eccl0ern)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
(�ANY AUTO
AUTO ONLY: AGG $
EXCESS LIABILITY
EACH OCCURRENCE 6
07OCCUa CLAIMS MADE
AGGREGATE i M1
i
S
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT i 100,000
- .-_-
B
99 A24009
09/23/1999
09/23/2000
E.L. DISEASE - EA EMPLOYE i 500,000
E.L. DISEASE -POLICY LIMIT 3 200,000
OTHER
DESCRIPTION OF OPERATIONSAOCATIONSNEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ROOFING AND SIDING
j rumAIIVIV ivou
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OF CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN
'
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENT
AUTHORIZED" E
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Location
No. �16 B Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
U5. FoundationPgrit Fee $
' p V
%tt!1 $
Fee
Sewer Copption Fee $
Oter GoNnection Fee $
TOTAL 0\\edk13, rl
3�r Building Inspector
Div. Public Works
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