HomeMy WebLinkAboutMiscellaneous - 292 SALEM STREET 4/30/2018Ap
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10803
................. .......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifiesthat .......... I.P�!.L ....... Ofe_..�J.l b
............. ... ..... . .... .....
has permi .....
ssion to perform ..... . .....
plumbing in the buildings of .... ........................ ..................................... . .
at. ..... ........... ....................................................................... North Andover, Mass.
I-- . . ........ M.A . . .......................................................
Fee.��6 ..... ...... Lic. 'No.
PLUMBING, INSPECTOR
Check (10i -
fly
is. mul-in
IN
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY -de MA DATE &F PERMIT#
JOBSITE ADDRESS
OWNER'S NAME
OWNER ADDRESS L TEL i(:k-tSU3a.S�JJFAX
2a _-I- - I 5a -t -
OCCUPANCY TYPE COMMERCIAL EO EDUCATIONAL
NEW: 0 RENOVATION: D REPLACEMENT: Ell
FIXTURES -1 FLOOR- BSM
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIALWASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ON DRAIN
SHOWER STALL
/ MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES '2111
WATER
OTHER
2 1 3 1 4 1 5 1 6 1 7 1 8
RESIDENTIAL 0-"
PLANS SUBMITTED: YES 0 NO F -J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO MI
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND 0
OWNER'S INSURANCE WAIVER: I agypvvare that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts GqWal jAs, aDeffo*y signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F-11 AGENT 0"'
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 01 My Knowiecige
and that all plumbing work and installations performed under the permit issued for this application will be in complia ce with all Paftment provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LICENSE# SIGNATURE
PLUMBER'S NAME
ral--,
MP ip L-71 CORPORATION FJ # PARTNERSHIP Ej# LLC
i
COMPANY NAME 'ADDRESS
CITY TEL
ISTATE ZIP T5
FAX CELL -;�.(��IEMAIL
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The Commonwealth ofMassachusefis
Department of IndustrialAccidiks
Office of Investigations
600 Washington Street
Boston., MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders[Contractors/EIectriciansfplumbers
Applicant Information Please Print Le2iblv
NaMe (Business/OrganizatiorAndividual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. Q I am a employer with
4. El I am a general contractor and 1
6. 0 New construction
employees (fuli and/or part-time).*
have hired the sub -contractors
7. E] Remodeling
2. El I am a sole proprietor or partner-
listed on the attached sheet. I
ship and'have no employees
These sub -contractors have
8. F1 Demolition
working for me in any capacity.
workers' comp. insurance.
I
9. 0 Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10. F1 Electrical repairs or additions
required.]
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
ILEI Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.F] Roof repairs
insurance required.]
employees. [No workers'
13.[� Other
comp. insurance required.]
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
-1 Homeowners who submit this affidavit indicating they aire doingall work and then hire outside contractors must submit anew 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.
lam an employer that isproviding workerscompensation insuranceformy employees. Below is thepolicy andjoh site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: Citv/State/Zi-o:
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, a's 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.
IT do h ereby certify under th e pains andp en alfies ofperjury th at th e information pro vided above is true and correct.
Simature: Date:
Phone#:
OfJ71clal use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License 9
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#:
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 impli4 oral or written."
An employer Is defined as "an individual, partnership, association, corporation or other legal entity, or any two or.more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a -deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an I enaployer."
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 reqi�ired."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that Us affidavit maybe submitted to the Department of Industrial
Accidents for confirm�ationof insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed- legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the, Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
niit one, affidavit indicating current
that must submit multiple permit/license applications in any given year, need only sub
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
flleA out each
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be f
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 burn 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 M-ossachusetts
Department of Jndustrial Accidents
Office of Invesfig#4011S
600 Wasbington fted
Boston, M& 02111
TQL 4 617-727-4900 ext 406 or 1-877-MASSAFF,
Fax # 617-727-7749
Revised 5-26-05 wwwmass.,gWc
Ra
Date...
. .. ...... ....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
.� A-0�JL- 0�)e
iat . .... . .. ............ ........................ ; ......
. ............................... ........ . ........ . . ......
has permission for gas installation
in the Ifuildings of De P,�- D
. ........... ..... ............ ...... ..... ....... ... . .......... .. .................. . ..... .... . .
at ... v- Nort h Andove r M as s
Fee.... 10 ......... Lic. No. .....................................................
Check # GASINSPECTOR
9584
\ U'V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY jAlij MA DATE apr-r RMIT#
JOBSITE ADDRESS �,;OWNER'S NAME
OWNERADDRESS !SkaVh TEL JFAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARILY
NEWT.1 RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES NOD
APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8, 9 10 11 12 13 14
BOILER E:j E:J
NBSM
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE an
FRYOLATOR
FURNACE f j J
GENERATOR I I I i
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATER
ROOF TOP UNIT I
TEST
UNIT HEATER
U,N)ZNTED ROOM HEATER
Ri
07MNE R
........ .. . .............. ......
-1
t F=D __j I-
INSU GE COVERAGE
I have a current liabifty nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES[] NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITY INSURANCE POLICY E3 OTHER TYPE INDEMNITY [j BOND 0J
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts no La d that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 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 true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia a wl��all , �Dent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I D
I LICENSE SIGNATURE
MP [711 MGF Ejl JP O'JGF [] LPGI [I CORPORATION D1# PARTNERSHIP [j# LLC E3#
COMPANY NAME:L----- ------ ADDRESS Q ta\A 4
_!LA�t
CITY E STATE ZIP
FAX CELL 11 EMAIL
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The Commonwealth ofMassachusefts
Department of lndustrialAccldi�ts
ice o nves tions
600 Washington Street
Boston., MA 02111
www.massxov1V1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NaMe (Business/Organizatiordfndividual):
Address:
City/State/Zip: ,
Phone #:
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
employees (fuli and/or part-time).*
have hired the sub -contractors
2.1] 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. El I am a homeowner do' all work
Ing
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. F1 New con.struction.
7. E] Remodeling
8. E] Demolition
9. 0 Building addition
10. El Electrical repairs or additions
11. El Plumbing repairs or additions
12. E] Roof repairs
13. Ei Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they aire doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an idditional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company Name;
Policy # or Solf-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 requiredunder 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 thepains andpenalties ofperjury thatthe information provided above is true and correct.
Simature: Date:
Phone#:
Official use only. Do not write in this areato he 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
a
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. left
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 employdis defined as "an individual, partnership, association, corporation or other legal entity, or any two or.more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, Partnership, association or other legal entity, employing employees. However the,
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an . employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who.has not p . roduced -acceptable evidence of compliance with the insurance coverage requ ' ired."
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 tc . k 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 maybe submitted to the Department.of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the, permit or license is being requested, not the Department Of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town officials
Please be sure that the affidavit is complete and printed' legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number wl-dch 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 AddressP 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
ffi e llle�d out each
applicant as proof that a valid affidavit is on file for future permits or licenses. A new a davit must b f
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.
'would like to thank you in advance for your cooperation and should you have any questions,
The Office of Investigations
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho Commonwoalth of Mbssadhusetts
Dopartm ent of Jndustrial Accidents
Office of Investigations
600 WasbingtOn Stre(-,t
Boston,MA02111
Tel, 4 617-727-4900 ext 406 or 1-877,:MASSAFE
Fax # 617-727-7749
Revised 5-26-05 WWW.Mass,govIdia
v
Location -A- F,�- S77-'-��?z- /
No. —4/3 Date
I
TOWN OF NORTH ANDOVER
I p .
Certificate of Occupancy
$
Building/Frame Permit Fee
$
CH Foundation Permit Fee
$
o PAYtAM*r Permit Fee
REr,EIVE-
$
Sewer Connection Fee
$
SEP 4 -!Water Connection Fee
$
�,ndover G0jjej%rIL
$
Building lns�e`ctor
Div. Public Works
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
�V PPMA%ler Permit Fee $
IRSCSGEN
Sewer Connection Fee $
SEP Water Connection Fee $
Nndrixiet $
No.
f --
Building Inspector
Div. Public Works
PEIRtIf IT NO.
MAP NO.
c
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE I
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
INSTRUCTIONS
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
VIDATE FnEDA
AIA t' fi�--ft
\J-1WA '95'
bZU flR 'AUTHORIZED AGENT
SIGNATLbkE 16W
FEE -/[0,:2
PERMIT GRANTED OWNER TEL.
CONTR. TEL.
CONTR. LIC. #--2f7Z96-_
0 0 8 2- 2—
sh/ Z-71'
-7-11 7 L�--
Is s- If -3
3 PROPERTY INFORMATION
LAND COST
,Y.ST. BLDG. COST lo.000
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF WEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILMING IN5PECTOR
2 RECORD OF OWNERSHIP iDATE
BOOK '.PAGE
ZONE
SUB DIV. OT NO.
F
E6CATION
URPOSE OF BUILDINGV/t��K 5
OWNER'S NAME 8 ob 0 I-Qf\ I o
NO. OF STORIES sizif
OWNER'S ADDRESS
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
PIJILDER-S NAME 6o,
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
.IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
INSTRUCTIONS
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
VIDATE FnEDA
AIA t' fi�--ft
\J-1WA '95'
bZU flR 'AUTHORIZED AGENT
SIGNATLbkE 16W
FEE -/[0,:2
PERMIT GRANTED OWNER TEL.
CONTR. TEL.
CONTR. LIC. #--2f7Z96-_
0 0 8 2- 2—
sh/ Z-71'
-7-11 7 L�--
Is s- If -3
3 PROPERTY INFORMATION
LAND COST
,Y.ST. BLDG. COST lo.000
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF WEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILMING IN5PECTOR
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY f_ CRIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY______] OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION
8 INTERIOR
FINISH
CONCRETE
2
13
CONCRETE BL K.
FINE
BRICK OR STONE
HARDW D
PIERS
PLASTER
JIN F I _N
3 BASEMENT
AREA FULL
FIN. B M T AREA
V, '/� 1/1
NO BMT
FIN. ATTIC AREA
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
CONCRETE
EARTH
HARDW'D
COMMON
ASPH I—ILE
B
1
—1
2
—1
3
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MAi_0NRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STIRS. & FLOOR
f
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME.
SUPERIOR
ADEQUATE 1__� PNo0oNlH_
5 RO_F
10 PLUMBING
GA E
GAM BREL
FLAT
, T
HIP
MANSARD
SHED
BATH (3 FIX.)
TOILET RM. (2 FIX.)
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
HEATING
WOOD JOIST
_11
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER EMS. & com
STEAM —
STEEL EMS. & COLS.
HOT W*T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
B'M'T 2nd
Ist I 3rd
AS
OIL
ELECTRIC
NO HEATING
Suggested Affidavit for Home Improvement Contractor Permit Application
For Offlce Use Only NAME OF CITY/TOWN
Permit No. 413
Date 5-- 14,41 z
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLc. 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, inprovement, removal. demolition
or construction of an addition to any pre-existing owner -occupied building containing at least one but not more than four dwelling units or
to structures which are adiacent to such residence or building" be done by registered contractors, with certain exceptions, along with ot
requirements.
Type of Work: N/I/JA-C 0- wattwQ,' .0, 15�,e 4) Vezv&?LAO�1_ St. CostZA1 A"
I
AddressofWork
Owner Name: Fwee-xl avxj7i J"0
Date of Permit Application: 1,99Y
I hereby certify that:
Registration is not required for the following reason(s):
— Work excluded by law
—Job under $1,000
—Building not owner -occupied
—Owner pulling own permit
k�.
Y,Other (specify) / :—IWbv �y
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Y Vv Contrddt4r Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
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