HomeMy WebLinkAboutMiscellaneous - 29 WAVERLY ROAD 4/30/2018J
Date. A
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . /' :T,. . . Y. `e .`P `P ../fly' 1-74
has permission for, gas installation ..�?q
in the buildings of ....v ... .......................
at .....1jAG:S
North Andover, Mass.
3V aJ�
Fee.... �.... Lic. No.. (�.�'...... ..� .IN PECTOR
Check j ��r% Lf
7297
MASSACHUSETTS LTSHORM APPLICATON FOR PERMIT TO DO GAS FLTTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Date `/�r/� 0
Permit #
Amount $
Owner's Name
New 13— Renovation Replacement Plans Submitted
(Print or type)v� Check one: Certificate Installing Company
Name- >� t �^ WilG�y f1c �f
�f ❑Corp.
Address 6 U /30 X r C /L -J- -7.1,/7�/"-� -,� Partner.
usmessTelephone 7 IF ce F Z,�• ` um/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [3-' No[3
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 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 Owner El Agent 0
...... vy , �,u�y WaL a« vi uic ua.aus anu miormarlon i nave
best of my knowledge and that all plumbing work and in al
compliance with all pertinent provisions of the Massa - set
By.
Title
City/Town
APPROVED (OMCE USE ONLY)
Signature of Li
El'&m.ber
�. Gas Fitter
0-iCdaster
MJourneyman
or entered) in above application are true and accurate to the
firmed under Permit I d for this a ication will be in
de and -`h-apter 14 of the G Laws.
sed,Rlumber Or Gas Fitter`
M 3
License Number
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8.TH.FLOOR
(Print or type)v� Check one: Certificate Installing Company
Name- >� t �^ WilG�y f1c �f
�f ❑Corp.
Address 6 U /30 X r C /L -J- -7.1,/7�/"-� -,� Partner.
usmessTelephone 7 IF ce F Z,�• ` um/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [3-' No[3
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 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 Owner El Agent 0
...... vy , �,u�y WaL a« vi uic ua.aus anu miormarlon i nave
best of my knowledge and that all plumbing work and in al
compliance with all pertinent provisions of the Massa - set
By.
Title
City/Town
APPROVED (OMCE USE ONLY)
Signature of Li
El'&m.ber
�. Gas Fitter
0-iCdaster
MJourneyman
or entered) in above application are true and accurate to the
firmed under Permit I d for this a ication will be in
de and -`h-apter 14 of the G Laws.
sed,Rlumber Or Gas Fitter`
M 3
License Number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizationAndividtW):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate boa:
L ❑ 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. ❑ I am a sole proprietor or partner- listed on the attached sheet t
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
• d n , .„nrin . el -..s -1.,._7_- 1. ___ u
workers' comp. insurance.
5. ❑ We are a corporation and its
Officers have exercised their
Tight of exemption per MGL
c. 152, § 1(4), and we have no
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
12.0 Roof repairs
13. ❑ Other
—_ -_- - ua: a:av a.n Vel lue Secuo", r1ciew anna.nw . Their work=, p=s' r..} ...f0. suQn.
t Homeowners who submit this arhdavit indicating they are doing all work and then hire outside ontr actors 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. Lie. M
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 c . erWft.under the pains and penalties of perjury that the information provided above is true and correct
Simare:
Date.:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
Permit/License #
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 of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or. other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having riot 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, §25CM states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (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
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retCuued to the ci y or town that the application for the per mitor license :s being requu,-sted, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition; an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future perinits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to�thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and fax number.
The Commonwealth cif Massachusetts
Department of Industrial Accidents
Office of Inwestig ations
600 Washington Street
Boston, MA. 021.11
Tel. # 617-727-4900. ext 4406 or 1-8 77-MASSAFE
Revised 5 -26 -OS Fax # 6.17-727-7749
www.mass.-govfdia
Date.../Z,..
3? '` TOWN OF NORTH ANDOVER
O D
•, o PERMIT FOR GAS INSTALLATION
This certifies that .. ......... .
has permission for gas installation ....7F U U P
in the buildings of .... ......
at ... Andover, Mass.
Fee.. U " Lic. Nolb .. IS'17,�-
SPECTOR
Check #
7109
y
A
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations tl%
Owner's Name
New1:1Renovation 1:1Replacement
Date / Z ��/ 0
Permit #
Amount $
�� dd
Plans Submitted ❑
(Print or type) I r Check one: Certificate Installing Company
Name .1 lla,-141- 44 � G� �tt� Corp.
Address 1.�� DOXi �v � d � � Partner.
`SLG) -i d jy��_ �L�
us�iness I e ep one �Firm/Co.
Name of Licensed Plumber or Gas Fitter P6/
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Ur 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
, ��. �..y uiall Va LIM ucLaita aiiu uiiuiulauun 1 nave suomineu kor entereo) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatio ormunder Per Issued fqf this app ' tion will be in
compliance with all pertinent provisions of the Massachusett tat as C e arid Cha to 142 of a Gen aws.
Title
City/Town
I AYYKU V L J (OFFICE USE ONLY) I
Signature of Licensed Plum" Ger Or G Fitter
Plumber
® Gas Fitter License Nurnuer
[a -Master
0 Journeyman
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SUB -BASEMENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8-TH. FLOOR
(Print or type) I r Check one: Certificate Installing Company
Name .1 lla,-141- 44 � G� �tt� Corp.
Address 1.�� DOXi �v � d � � Partner.
`SLG) -i d jy��_ �L�
us�iness I e ep one �Firm/Co.
Name of Licensed Plumber or Gas Fitter P6/
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Ur 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
, ��. �..y uiall Va LIM ucLaita aiiu uiiuiulauun 1 nave suomineu kor entereo) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatio ormunder Per Issued fqf this app ' tion will be in
compliance with all pertinent provisions of the Massachusett tat as C e arid Cha to 142 of a Gen aws.
Title
City/Town
I AYYKU V L J (OFFICE USE ONLY) I
Signature of Licensed Plum" Ger Or G Fitter
Plumber
® Gas Fitter License Nurnuer
[a -Master
0 Journeyman
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
IV 600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiza6on/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
�. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
'.. ❑ I 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.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp,
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
-A-
comp. Insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
.««....,......,Q.:.uu:.n Z.r, : iuui GCS'J uL UCL CCC 3eGnUC neiny,� c'n!T{{'CCb _^.e:,* work=' compensation policy.... information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the. name of the sub -contractors and their workers' comp, policy information.
lam 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
Signature: 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. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
v
Information and Instructions
Massachusetts -General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or.written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25CM 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 -contractors) 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 affidavitmay 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 permait or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the.
applicant as proof that a valid affidavit is on file for future perinits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investiagaiions
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
-1
Location 0-7c% VIA tA2 RL 9
No. '3 Date
TOWN OF NORTH ANDOVER
` Check # 068 1
18t,59 Building Inspector
Certificate of Occupancy $
o •,
ACNUS
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
` Check # 068 1
18t,59 Building Inspector
1.1 Property Address:r
VWlC-
1 ❑ U l Stu ! Ct:
1.2 Assessors Map and Parcel
� l D
Map Number
Number:
D
Parcel Number
P.
,1
V
1.3 Zoning Information:
Zoning DiWc—t Proposed Use
1.4 Property Dimensions:
Lot Area
Fronts ft
1.6 BUILDING SETBACKS ft
S'gnature
Telephone
Front Yard
Side Yard
Rear Yard
Required Provide
ReqWred Provided
ReqWred
Provided
Expiration Date
;gegisterdd' Ho a Improvement
r
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private 0
1.3. Flood Zone Information:
Zone Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System:
0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1 ❑ U l Stu ! Ct:
2.1 Own �oecord
Name (Print)
1
r
Address for Service :
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
S'gnature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature
Telephone
Not Applicable ❑
License Number
Expiration Date
;gegisterdd' Ho a Improvement
r
Not Applicable 0
�` 7
Registr tion Number
4�off,�any ane
Addres
7 - '�/�
7 77J a � U
Expiration Date
Si nature
Telephone
r
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will
in the denial of the issuance of the building it.
Si ed affidavit Attached Yes .......0 No ....... 0
SECTION S Description of Proposed Work check afl applicable)
New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition ❑
Accessory Bldg. 0 Demolition ❑ Other 0 Specify
Brief Description of Proposed Work:
CJ
a�rw c veTil►RATVT !`ANCTQii!'TiAN !'(1CTC 1
Item
_
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1.
Building
(a) Building Permit Fee
Multiplier
2
Electrical
(b) Estimated Total Cost of
Construction
S�
3
Plurnbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6
Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AU HURLZATIUN ru BE c:umrLz rry wnzlr
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as (honer/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application. '
Si nature of Owner Date
M .n A\171�TL•D / A 7T7`II/AD77Ti T% A d' V XTT r%V /''r A D A Trl1N
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements anq information on the foregoing application are true and accurate, to the best of my knowledge
and beli�t
Print Nanf
Si lure of Owner/ARent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST 2 NU 3
RD
SPAN
DIN ENSIONS OF SILLS
DINIENSIONS OF POSTS
DM ENSIGNS OF GMDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CH MNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Norm»
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofte of Invudgadons
Boston, Mass. 02111
Worlrers' Car,penwUw Insunme Alyda t
0 I am a homeowner performing all work myself.
0 1 am a sole proprietor avid have no one working in any c apadty
Please Print
�f, XJ �4-1
I am an employer providing workers' compensation for rry employees worldng on this job.
rmmum Co. -M PO&W *
Fdk" to swam, coverW • ro*drad wdr Section 25A arMOL 152 can had to du krpmklon d,,h,dI ps WVw d,a fina up to $1,500.00
andfaromyesn'imprkam-w.wd.nAd43wofta Jobe fmdABTCPNOW ORDER.aodafkwd.W1WAW-aAgrapakdMEL I
wxWstmd that a copy of this etstono may be farwwtW to do Of e of InvMtlpatlone d the DIA for coverage verMcdon.
I do hereby =* roma mrd
Nie k1formeft provided abow Is true and aarrsot
Print nam----, v Phora3 C yszf-V
Of wd use only do not write in this area to be comphted by dty or town oNkdal'
City or Town
O Buk ft D90
[3Chwk II Immediate response la requied 13 LkwLskW BOeid
p Selectmen's Oliit O
Contsd person: Phone tth I] Hoeft Department
13. Other
1
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL 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 MGL
c 11, S 150 A.
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
RightFax Hartford 1/24/2005 7:46 PAGE 004/004 Fax Server
;: DATE(MWDD%YYI
I�1/® +,RTtFIT iSUR►iGE
�►!
MATTER OF INFORMATION
THIS CERTIFICATE IS ISSUED AS A
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COVERAGESPOLICY RED NAMED FOP, THE PERIOD
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THIS IS TO' CtRTIFY THAT THE ?OL(CIES 0 INSURANCE LIST DBE
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EXCLUSIONS
PCLICYEFFECTIVE �POLIG'YEXPIRATION .LIMITS
^n rvofl OF NSUR4NCE POLICY NUMBER
DATE (NRMDD\YY) ' GATE imm'DD".YY)
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T 1C E ER GANCEEATIOt*
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXP'RATION ]ATE THERECF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL-
-'G DAYS WRITTEN NOTICE TO TIME CERTFiCATEHOLDER NAMED TOTHE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION CR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
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A\, Board of Building Regulati4v and Standar8s ;
HOME IMPROVEMENT CONTRACTOR
Registration: 108424 * 4
_ Expiratiom- 8/18/2005
{ : Type: DESA t -
' ABCO ROOFING i£ CONSTRUCTION
JosephGys
10 MEGHANN LANE
LOWELL, MA 01852
�,Y - A(lm�mstrator
No. / of
ABCO ROOFING & CONSTRUCTION CO. PROPOSAL AND
LOWELL, MA 01852 ACCEPTANCE
978-937-5840 or 978-957-8212
PROPO% UBMCT'TEOTQ// '
PHONE `7� f
q7j � f
DATE
a
/
STREET f:'
JOB NAME
STATS A�JD ZIP/,CODE
I! ����
T
10B LOCAT
�,
i 1
i 1
R HITE
DATE OF PLANS
JOB PHONE
We her by submit specifications and estimates for:
f 12
r
lj(�CJ . 1p_ Lq'" /r') '- (6,&- �X411
IIA
t 1J
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We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars ($ ).
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workman-
like manner according to standard practices. Any alteration or deviation from above Authorized
specifications involving extra costs will be executed only upon written orders, and Signature
will become an extra charge over and above the estimate. All agreements contingent
upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: This proposal may be
and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted days.
gensation Insurance. within
Acceptance of Proposal -The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment will be made as outlined above.., Signature
Date of Acceptance Signature
No. IC>of
ABCO ROOFING & CONSTRUCTION CO. PROPOSAL AND
LOWELL, ISA 01852 ACCEPTANCE
978-937-5840 or 978-957-8212
PROPOSAL SUBMITTED JTOf /
PHONE
DATE
STREET / /
JOB NAME
CITY, STA%t, AND CODE/1_ `
JOB LOCATION
ARCHITECT'
DATE OF PLANS
JOB PHONE
W hereby submit specif'c Ikons and estimates for:
f r
G
BCW
` 61
F ,
t(
,2
We Propose hereby to furnish material and labor — complete in accordance with above specifications, f the sum of:
2 dollars (S ).
Payment to be made as follows: /
r'
All material is guaranteed to be as specified. All work to be completed in a workman-
like manner according to standard practices. Any alteration or deviation from above Authorized I f%f iq
specifications involving extra costs will be executed only upon written orders, and Signature ?�
will become an extra charge over and above the estimate. All agreements contingent
upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: T propa'sal may be
Com -
on other necessary insurance. Our workers are fully covered by Workmen's Com• withdrawn by s not accepted days.
ponsation Insurance. within
Acceptance of Proposal -The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment willbemade as outlined above. Signature
Date of Acceptance^-�� t � Signature
f
r_9526 ...
Date.�
............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
14 U Let q� 6,(, SVYV
This certifies that .....
has permission to perform .......................................
wiring in the building ofZ.4. .... TPM ..................................................
at. .... (/VaR-AX.-L .... 14.e ................... � Andover, Mass.
Fee .�.Q.�.. Lic. No..J.�.� �-� .............
C[ R1CAL INSPECT O
Check #
�� �.V►IU►IV►IWCQI6,I1 W I'IQJJQ�.IIUJCl.{.J � -'
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: °7 - I La _ bo
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his
"a
or her intention to perform the electrical work described below.
Location (Street & Number) -Z q LA A� wt z (Z
�Owner or Tenant 64 7a � � Telephone No.
Owner's Address 2q W w ecky V4_
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (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
Location and Nature of Proposed Electrical Work:SerFY
Completion of the following table may be waived by the Inspector 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- Elo.
rnd. rnd.
o mergency 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
Heat Pump
Totals:
I.N!l
ITons
KW
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Dryers
Heating Appliances KW
Security f Devices or Equivalent
No. of Water KW
Heaters
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 Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: '-?—I (o - [ a 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 ® BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains tend penalties of perjury, that toinformation on this application is true and complete.
FIRM NAME: 41 Pk n c. I uF.r . c -44 e. Brat C- �-- jo LIC. NO.: %4 I5q 2 -
Licensee:
Licensee: o"k % Signature LIC. NO.: Sy2
(If applicable, enter "exempt"r in the lic s numbe ine. Bus. Tel. No.: (a03— 54,2^ 41'o
Address: I �ecr'Coc\I - �r� .t 1J 4 7-'0 1 S' Alt. Tel. No.: &Q-1-233--15 5
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. a (S�
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.
r
The Commonwealth of Massachusetts
DI Department of Industrial Accidents
fB Office of Investigations
600 Washington Street
Boston, MA 02111
swww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): le I/ic— 1L (C -S-. - IC.AI � ----V`(, L- J-
Address: 7 ��,e « �-c-
City/State/Zip: QC
Or,CkN I /l1 �-{ Phone #: C't S 2-- 45"
Are you an employer? Check the appropriate box:
1. E� I am a employer with 1 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 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.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors 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.
fInsurance Company Name:_ 5300 c � �ovct-s J�AS .
Policy # or Self -ins. Lic. #: W CL St (3 (,p c(03 O' 12_ Expiration Date:
Job Site Address: 25 W 'Po `,ty City/State/Zip: k) - 4v-, �O jts.._..
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 certff")rnder tlfepains andpenalties ofperjury that the information provided above is true and correct.
Phone #: (a03 rid 2- —
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: