HomeMy WebLinkAboutMiscellaneous - 29 BALDWIN STREET 4/30/2018� �
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Date-AA-i�--fiSk .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .......................................................................
has permission to performbl.w"Iw .... tsx�-A . ................................................
plumbino, in the building of .............................................................................................
....................................... Andover, Mass.
FeeJQ.S? ... Lic. NotP.4/e.ff.
SPECTOR
Check # NO 6
L
OR A PERMIT TO PERFORM PLUMBING WORK
MASSACH SETTS UNIFORM.APPLIGA I 1UN r
--------------------
MA DATE PERMIT
CITY 4a7x-
OWNER'S NAME /V- wcy�c��'
JOBSITE ADDRESS
POWNER ADDRESS TEL RESIDENTIAL FAX
OCCUPANCY TYPE COMMERCIAL;0 EDUCATIONAL El
4
TYPE OR PLANS SUBMITTED: YES Eo- NOO
PRINT
CLEARLY NEW: Mi RENOVATION: REPLACEMENT: 01 10 12 . .13 14
F[kFU-RES --I
BATHTUB
CE
b-E—DICATED SPECIAL WASTE SYS I tM
SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
VLO—OR1 AREA DRAIN
KITCHEN SINK
1-7AVATORY
ROOF DRAIN
SHOWER STALL
sL�kV—JCE /MOP SINK
URINAL
WASHING MACHINE CONNECTION
�O—ATER HEATER ALL TYPES
WATER PIPING
ZT2
'- -53r.
--FN—SURANCE COVERAGE: ments of MGL Ch. 142. YES NO
1 have a current liabilitY.insurance policy or its substant I ial equivalent which meets the require BOX BELOW
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE
OTHER TYPE OF INDEMNITY D BOND Ell
LIABILITY INSURANCE POLICY 6
OWNER'S INSURANCE WAIVER: I am aware that the licensee does no have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application Wghm this requirement.
CHECKONEONLY: OWNER [] AGENT
e
SIGNATURE OF OWNER OR AGENT -j�ccurate to the best of my knowl age
on I hav- sUU1 I 1ILLUa oi ei ite ed i eigai di t ig tili s app. cation are true at id t . . n of the
I hereby certify that all of the details and ImOrIfIdU r the permit issued for this application Vill be in compli ce with I Pertinen provisl
and that all plumbing work and installations performed unde
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE
LICENSE#
PLUMBER'S NAME
ERSHIPD#�LLCU�[:=
MP E5 AT", CORPORATION 0J #=PARTN
ADDRESS
COMPANY NAME.
TEL
ST -h A
CITY ZIP
CELL ff?��EIMAIL
FAX E=
19-1
LU
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LLJ
LL.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
B oston, MA 02114-2017
. . . . . . . . . . . . . . . www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu.mbers.
TO BE FILED WITH TIRE PERMITTING AUTHORITY.
Name (Business/Organization/bdividtial):
� 5— JJ/L 4P
Address:
City/State/Zip: /&/z Phone #: 9,2F _-3 7— 63rZ;�--_
Are you n employer? Ch eck t6e appiopriaie box:
Type of project (jr�4uirM):
am a employer with 7. E]New construction
I wi, (full and/or part-time).*
2.FJ I am a sole proprietor or partnership and have no employees workirrg for me in 8. E I Remodeling
any capacity. [No workers' comp. insurance required.] 9. Demolition
3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.) t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition
ensure that all contractors either have workers' compensation insurance or are sole ll.FJ Electrical repairs or additions
pr6p"rietors -with no employ�Ts.
12., E]Plumbing repairs or additions
5.F_J I arn a general contractor and I have fiired the sub -contractors listed on the attached sheet. If. n Roof iepairs
thes'e s�b-contractors h6e employees and have workers comp. insurance.
14.El Other
6.FJ We are a coiporatio. nand its officershave exercised their right of 'exemption per MGL c.
152, § 1 (4), and We h?iye nQ �pployeqs., V9 workers' comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing ffieir workers' compensation policy information.
Homeowners who subtrift 0�s af6davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors Pat check this box must -attached an additional sheet showing thqna�pp of the sub -contractors and state whether or not those entities have
o' " � " I h. ' "i — I-' " ili , ide their workers' comp. policy number.'
employees. If the sub -c ritractors ave emp oyees, ey must pro -v
i am an employer t1i at is piov I idbig workers' compensation insurancefor my employees.' Below is thepolicy and)ob site
information.
e,
Insurance Company Name: /4-"o-1 'r—Ar
Policy # or Self -ins, Lic. #: Expiration Date:
W, A 31 City/State/Zip:
Job Site Address�ol
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do h ereby certify un der th e pains an dpenalties ofperjury th at th e information provided above is true an d correct.
Signature: Date:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one): i
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I
Contact Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
' V , .
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrab't of hire,
expres's or implied, oral or written."
An employer is defined as "an individual, partnersWp, 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 ibree 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 bd deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the W�ance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Pl6se fill' out -the workers' compensation affidavit completely, by checking - the, boxes that apply to your situation and, if
necessary, supply sub-contractoi(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 employdes 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 Depaitment of hidustrial
Accidents fbi confirmation of insurance coverage. Also be suire to sign and date the affidavit. The affidavit should
be returned to the city.or town that the application for the permi� or license is, being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law if you are
or requ�red to obtain a workers'
compensatiodpolicy, please call the Department at the number listed below. Self-ftisur6d companies sh,ould'enter-their
self-insurance license number on the appropriate line.
City or Town Officials I
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be prov—ided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15
www.mass.gov/dia
4
N
11 207
Date.1001-Y./f . .....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
P -
.......... .....................................
has permission to perform... ........... S7 ......................................
plumb;jn... ain he buildipgs f ................ I .............................................................................
a6 .. ...... ... . W .. ............... ...... .......... .. No h Andover, Mass.
91 . ............
Fee,��.O .... Lic. Nd.;�IP �. .. ..... .. ..........................................
LUMBI IN
Check# SPECTOR
WATER HEATER ALL TYPES
WATER PIPING
6T -H —ER F -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ca" 'NO M-1
IF YOU CHECKED YES, PLEASE INDICATE THE TY E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERF-11 AGENT IR -1
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application Vill be in compliance with all rtinent provis' f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 X X
PLUMBER'S NAME [ �� �� � �le- __'*T1rF6 , LICENSE# � ------ /��S I G N �AT 6Rt
I I
MP 01 ip CORPORATION MJ PARTNERSHIP DI #L__J1 LLC
COMPANY NAME ADDRESS
CITY 414046'm STATE ZIP TEL[_
FAX CELL I EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
MA DATE /J�JPERMIT# 11PI
k1- I �J�
JOBSITE ADDRESS
I
0 W N E R'S N A M E
POWNER
ADDRESS
t?5A-l'
&#:Lee� TEL ____JIFAX
-
TYPE OR
OCCUPANCYTYPE
W
COMMERCIAL EO EDUCATIONAL D RESIDENTIAL,�
PRINT
CLEARLY
N E W: FJ RENOVATION:P/"' REPLACEMENT: Ell
PLANS SUBMITTED: YES - NOD!
FIXTURES'l FLOOR-
BSM 1 2 3 4
5
6 7 8 9 10
11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
F ---J
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR (INTERIOR�
KITCHEN SINK
LAVATORY
R,OOF DRAIN
SHOWER STALL
S�RVICE / MOP SINK
TJILET
I
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
6T -H —ER F -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ca" 'NO M-1
IF YOU CHECKED YES, PLEASE INDICATE THE TY E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERF-11 AGENT IR -1
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application Vill be in compliance with all rtinent provis' f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 X X
PLUMBER'S NAME [ �� �� � �le- __'*T1rF6 , LICENSE# � ------ /��S I G N �AT 6Rt
I I
MP 01 ip CORPORATION MJ PARTNERSHIP DI #L__J1 LLC
COMPANY NAME ADDRESS
CITY 414046'm STATE ZIP TEL[_
FAX CELL I EMAIL
LLJ
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The Commonwealth Of Massachusetts
Department ofIndustrialAccidents
4
I Congress Street, Suite 100
Boston, AM 02114-2017
www.massgov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information Please Print Lellib
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone#:
Are you an employer? Check the appirl'opria . te box:
Type of project (Tequired):
l.FJ I am.a. employer with employees (full and/or part-time).*
7. []New construction
�2.Fl I am a sole proprietor or partnership and have no employees working for me in
8. Remodeling
any capacity. [No workers' comp. insurance required.]
§. Demolition
3Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
1 0 EJ Building addition
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
'
11.0 Electrical repairs or additions
proprietors -with no employees.
12. E] Plumbing repairs or additions
5. 1 am a general contractor and I have hired flip sub -contractors listed on the attached sheet.
I
13. [J Roof repairs
Thes'e s�b-contractors fiaV� employees and have wo rkers'comp. insurance.1
6. We are a corporati ' on ' and its officers.have exercised their right of 'exemption per MGL c.
14. E] Other
152, § 1(4), and we have nQ �18vees. [No workers' comp. insurance required.]
7
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit Ws affi�davit indicating they arc 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 state whether or not those entities have
employees. if the sub-coritractors have employees, �the� must provide their workers' comp. policy number.
lam an employer that is providing workers I compensation insurancefor my employees.' Below is thepolicy andjob 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 cove . rage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
rif
coverage ve ication.
I do It ereby certify under thepains andpenalties ofperjury that th e information provided above is true and correct.
Simature: .. Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
Information an d 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`6i hire,
express or implied, oral or written."
An employer is defined as "an individual, partnersl�ip, association. corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 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
.ppplicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall -
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out -the workers' compensation affidavit completely, by checking - the'boxes that apply to your situation and, if
necessary, supply sub-contractoi(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 Depaftment of Industrial
Accidents fb� confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the citypr 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 re'quired to obtain a workers'
compensatioii'policy, please call the Department at the number listed below. Self-iiisur6d companies sh.ould'enter their
self-insuran*ce license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
G)Iumt�L Gas -
of Masskhusetts
A NiSource Company
995 Belmont Street
Brockton, MA 02301
January 7, 2013
Daneth Chhoeuy
31A Baldwin Street
North Andover, MA 01845
Dear Customer:
During a recent visit, our service technician detected a safety problem with your gas
conversion burner at 31A Baldwin St., North Andover, MA 01845 — high carbon
monoxide reads and giving off carbon monoxide odor. Accordingly, we have issued a
Warning Tag because of this situation.
Under the circumstances, we strongly urge you to correct the code violation. In addition,
the Massachusetts code pertaining to the installation of gas appliances and gas piping,
established under Chapter 737, Acts of 1960, requires that the condition be remedied.
If you have any questions, please call our Service Department at 1-800-677-5052 and ask to
speak with the Service Supervisor.
Please disregard this notice if the condition has been corrected.
Sincerely,
Customer Service Department
Columbia Gas of Massachusetts
/I /�
Locationd, ZE
No. Date 12�4z=-ld
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CHO* Building/Frame Permit Fee $ z
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
23812 Building Inspector
MAP NO: 1 PARCEL: afo ZONING DISTRICT: I-Estoric District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
D.One family
0 Addition
XTwo or more family
11 Industrial
0 Alteration
No. of units:
0 Commercial
KRepair, replacement
0 Assessory Bldg
0 Others:
11 Demolition
o bther
PRIN, 2 1
RIM,,
F1b5dp-1aJ
§ff &TI)i§
N�F
Sol 9-1, W x M-21,11
J-)ENUKW 1 WIN UP W UX& I U bt� rt�rcv
,-% � � \,-, -,� /, C n
Type or Print Clearly)
Address:
CONTRACTOR Name:
Phone:
Address:--';�',
C�
Supervisor's Construction License: Exp. Date:
Home Improvement License: __j3xp. Date: IA. v -
ARCH ITECTIEN G I NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT.- $12. 00 PER $1000. 00 OF THE TOTAL ESTIMA TED COST Br ON $125. 00 PER S.F.
Total Project Cost: FEE:.
Check No.: Receipt No.:
'th registered contract, irs
NOTF,� Perso ntracting wi ®rro n tot h! access to the guarantyfund
Av�
f
1 0
Uri o
TYPE OF SEWERAGE DISPOSAL
F7 .0
Public Sewer
Tanning/Massagefflo I dy Art El
Swimming Pools
well TY
well
Tobacco Sall El
es
Food Packaging/Sales El
Private (septic tant�, etc.. El
Permanent Dumpster on Sit e
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT El El
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMM��NTS,
Reviewed on Simature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
-Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer ConnectioniSignature & Da(te Drive fay Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTA/MNT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire 'Department sigriature/date
COMIvENTS
WE -
Low -Income Multifamily Retrofit Program
9/26/10
Administered by LEAN
North
Andover - DRAFT
Overall. Work Order
For Program Approval Only
North Andover HA
Job 10-123-0
Multiple
NORTH ANDOVER 01845
Joanne Crawford
(978) 862-3432
Section
Measure Installed
Unit Price
Price
Attic
*Unfloored
R-20 open/u n restricted Cellulose 11700
$1.23
$14,391.00
Sub Total 11700
$14,391.00
Wall
*All Walls
Clapbd/wood/vinyl R-1 3 18720
$31,824.00
Sub Total 18720
$31,824.00
Floor
Floor Insulation
Basement Overhead - R30 11700
$1.73
$20,241.00
Sub Total 11700
$20,241.00
Infiltration
Airsealing w two-part foam 26
$75.00
$1,950.00
Sub,Total 26
$1,950.00
Distribution
Duct insulation R-5 520
$2.95
$1,534.00
Sub7otal 520
$1,534.00
Grand Total
$69 , 940.00
AQ,
Attic & Wall insulation savings estimates are based on audit limited access evaluation of need. initial vendor
walkthrou2ii �vjll
determine the ability to install these measures and estimates will be updated at that time.
4
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111.
s www.mass.gov1dia
Workers'* Compensation Instrance Affidavit: Builders/Contractors/Electricians/Plumbers
Ai�ijlicant Information Please Print LeObly
Name (Bus*mess/Orgmizationgndividual):-, r1,C_
-Address:
City/State/Zip: r(,\A Phone.#: -
Are you an employer? Check the appropriate box:
1. [A.I am a e4loyer with �6
4. 1 am a general con ' tractor and I
. . employees (fall and/or part-time).*
have hired the'sub-contractors
2. El I am a �ole proprietor or partner-
listed on the -attached sheet�
ship and have no employees
These sub -contractors have
worldng for me in any capaoity.
employees and ha-ve workers'—.—
[No worke.rs' comp, insurance
required.]
comp. insurance.t'
5. We area corporation and its
'3. F-1 I am a homeowner doing all work
officers have exercised. their
myself. [No 7orkers, co,mp.
right of exemption per MGL
insurance required.] t
jc. 152, § 1(4), and we have no
employees. [Nb workers'
qomp. insurance requiredL]
*Any applicant that checks box #1 must also HE out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they aTc doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors th�t check this box must attached. an additional sheet showing the name of the sub-cofitractors and state whether or not those entities have
employees. If the sub-contractDrs baie employees, they must provide their workers' cpmp. policy number.
I am an employer,that is providing workers'compensation insurancefor my employees. Below is thepolicy andjob site
informadon.
Insurance Company Name: -
Policy # or Self-ifis. Lic. M �M\aqc)\C�� E)q)iration Date: U_\Zc,� LS3\\
en,_%.
.Job Site, Address aq-cl_ wn City;/State/zip:__D
Attach a copy of theworkers9 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 tol$1,500.00 and/or one-year ii . nprisonmen� as well as civil penalties in the forin. 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 2f the DIA for insurance coveraze verification.
I - do hereby certift under the pains-andpenalties of er' that theinformation pniQded above is true and correct
J
Phone "2;)
Official use only. Do not write in thbajea, to be completed by 3—ty 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 Inqpector 5. Plumbing Inspector
6. Other
Contact Person: Phone-#:
ACORDDATE
. CERTIFICATE OF LIABILITY INSURANCE
(MM1DDfYYYY)
1 04/23/2010
PRODUCER (800) 225-1965
Fred C. Church, Inc.
41 WeUman Street
Lowell, MA 0 185 1
800-225-1865
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE,
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
—ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC
INSURED
Advantage Weatherization, Inc.
Two Adams Place, Suite 100
Quincy, MA 02169
INSURERA: Citation Insurance Company
ER B: National Union Fire Insurance C
INSUR ompany of Pittsburgh
INSURER C- Selective Insurance Company of America
INSURER D.,
INSURER E:
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 BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
ADO'
INSP
TYPE OF INSURANCE
POLICY NUMBER
POLICYEFFECTtVE
POLICY EXPIRATION
DATEIMM/DD I
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1,000,000
COM MERCIAL GENERAL LIABILITY
CLAIMS MA DE OCCUR
DAMAGE _NTED
PREMgSl 0 RF S 100,000
(Es Gccurence)
MED EXP (Anyane perion) S 10,000
C
I
S1928883
412/2010
4/2/201 1
PERSONAL& ADV INJURY � 1,000,000
GENERAL AGGREGATE S 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PEP-,
_�
PRODUCTS - COMP/Op AGG $ 3.000,000
PRO-
7 POLICY F JECT F� LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
A
X
7
X
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED ALrros
BBNT98
4/212010
4/2/2011
BODILY INJURY $
(Per person)
BODILYINJURY
(Per eccIdent) $
PROPERTY DAMAGE $
(Per accident)
GARAGELIASILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC $
AUTO ONLY: AGG S
RANY AUTO
EXCESSIUMBRELLALLABILITY
_R1 Or -CUR FICLAIMSMADE
EACH OCCURRENCE $ 15,000,000
AGGREGATE 15,000,000
B
BE1223010
6/20/2010
6(20/2011
$
�DEDUCTIBLE
X RETENTION $10,000
S
WORKERS COMPENSATION AND
x -70—TH-
I ;:R
FMPLOYERS'LIABILITY
E -L EACH ACCIDENT S 1,000,000
B
ANY PROPMETORIPARTNEWEXECUTIVE
OFFICERIMEMBER EXCLUDED?
'S'XeE.'dl'AuLsPO'R'bl"lulnlld0a'NI bLI.
WC001290194.
0/20/2010
6120/2011
E.L. DISEASE - EA EMPLOY Ed'$ 1,000,000
E.L. DISEASE - POLICY LIMIT s 1,000,000
OTHER
L
DESCRIP71ON OF OPERATIONS LOCA71ONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate is Issued as evidence of coverage.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO'MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
[AUTHORIZED REPRESENTATIVE
WFuJ4014vulluo) Client# 17Ar I Mst# 20I0GL,Auto,WC,Umb Ccrt# IPACORD CORPORATION 1981
4
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11
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRI I CAL: Movement of Meter location,- mast or service drop requires approval of
Electrical Inspector Yes No
7nN1= I ITERATURE: Yes No
DAN
MGL Chapter 166 section 21A-1- and G min.$10041000,fne
F
Building Department
The following is a list Of the required forms to be filled out for the appropriate permit to be obtained.
Roofing., Siding, I interkor Rehabilitation Permits
Building Permit. Application,
Workers'Comp Affidavit
Photo c
opy Of H.I.C. And/Or C.-S.L. Licenses
COPY of Contract
Floor Plan Or Proposed Interior Work
Engineerin Affidavits
9 for Engineered -products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Co
PY of H. I. C. And C. S. L. Licenses
Copy Of Contract
FloOr/Crossection/Elevation Plan Of Proposed. Work With Sprinkler Plan And
Hydra ulic'Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
NeW Construction (Single and Two Family)
Building Permit Application
Certi
fied Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
13 Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic. Calculations (if Applicable)
COPY of Contract
• Mass check Energy Compliance Report.
• Engineering Affidavits for -Engineered products
40TE: All dump
ster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special per
mit was required the Town clerks office must stamp the decision from the Board of Appeals
bat the appeal period is over. The Pplicant must then get this recorded at the Registry of Deeds. On co,
.'Ust be submitted with the building2application e copy and proof of re rding
Doe: Doc.,BuildingPermit Revised 2009mi
Date ... ...
V,ORTk
.6
TOWN 0 ORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .............
" - , /C �:_ �
has permission for gas installation 10-111f. .............
in the buildings of r��. ............
:7k.
North Andover, Mass.
Fee./ Lic. No..3
V..
SINSPECTOR
Check #
6222
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT 0 0 G SFITTifirl.
(Print or Type)
L)Ok:Ch Mass. Date — IJ /6 Permit #
—LL --
Building Location .29..9�A; 51 31,q &,LV�)j Owners NameA/VkTH A1VQ0LfC--L 11;6.&t-Tk1
AU06V6L4 LA Type of occupanc eCS1DEkJ71 t� L -Al U A) 1 7-<
New E] Renovation [] Replacement [] Plans Submitted: Yes[] No []
Installing Company Name - BAY STATE GAS COMPANY
Addr�ss. 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7!B-68.7-'1105
Name of I-Icensed Plumber or Gas Fitter Francis X. Corkery
Check one:
)CI Corporation
0 Partnership
El Firm/Co.
certificate #
1862
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No El
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy D< Other type of Indemnity 11 Bond El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent OwnerO Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�pte to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
T f U
R.T rri;�rnse:
Title Gasfitter �ignature of Licensed Plumber or Gas amv
Master License Number 374-5
City/Town Aourneyman
APPPOVF�O FIC�SF �O�
MEN
0
NONNI
0
SEEN]
RON
NONNI
soon
0
on
MENEM
NONE
men
son
MEN
0
NONNI
MENNEN
ON
0
Installing Company Name - BAY STATE GAS COMPANY
Addr�ss. 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7!B-68.7-'1105
Name of I-Icensed Plumber or Gas Fitter Francis X. Corkery
Check one:
)CI Corporation
0 Partnership
El Firm/Co.
certificate #
1862
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No El
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy D< Other type of Indemnity 11 Bond El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent OwnerO Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�pte to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
T f U
R.T rri;�rnse:
Title Gasfitter �ignature of Licensed Plumber or Gas amv
Master License Number 374-5
City/Town Aourneyman
APPPOVF�O FIC�SF �O�
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