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Miscellaneous - 325 APPLETON STREET 4/30/2018
325 APPLUON STREET 210/065.0-0147-0000.0 i Location �� No. s Date NORTIy TOWN OF NORTH ANDOVER 0 0 s A i • - }�o Certificate of Occupancy $ CH E�� Building/Frame Permit Fee $ s.� us - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # - 2 3 J 4 9 Building Inspector i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ' Date Issued: IMPORTANT:Applicant must complete all items on this page _ �Jl%LaWan Am>-ytic /Y)A O 6 gy� LOCATION I Y Print PROPERTY OWNER.AAM�S iA Print MAP NO: _PARCEL: Jq!7 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family Addition ❑Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: I� ❑ Demolition ❑ Other fill e tick" Well[ g, ®9Flo odpla� Wetland (ei y��/ r� �1-iuF, a'4..t� ,.�1' ®Wat DESCRIPTION OF WORK TO BE PERFORMED: b Rest- P-WE CA- 406P16-5 �7A fa&& 51 k &JrV2�I Identification Please Type or Print Clearly) ' OWNER: Name '► .�'1�y7r� �2 Ari 6&IN � . Cki-1-1 TO.J Phone: 5172 t`�5 7,3)(� � Address: L OIJ � 1^ �Jyn H AluDoy�L 4414. i T . 5 CONTRACTOR Name: �--� C `�-' Phone:'''79 352- 6319f Address: 3 150A J LDI, f;i f �� ��66e o-yy, 114 A v l g?a3 Supervisor's Construction License: S 7 9 I y Exp. Date: 0\5© 20 6 Z $ ` Home Improvement License: 15- _Exp. Date: ct 17-4 l -210"1 i L. ARRCHCH Irt•EE CT/154 �. >G- Phone: 4&�fd'� • Address: j ,4vL�,�6. Ap-, 66o0d uio, M1. 01333 Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I`f FEE: $ Check No.: f' y Receipt No.: I 3iVl NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �Signature_of?A" ent/Ovvner Si nature_of contracO .;•.°:,..._ y Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits _ b ❑ Building Permit Application ' ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits 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 o n ❑ Certified Surveyed Plot Plan - - ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses -- - ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) 1 ❑ Mass check Energy Compliance Report (If Applicable) - M ❑ 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 ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a 211 cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals at the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application a Doc: Doc.Building Permit Revised 2008mi Dimension Number of Stories: i _Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 4132919 ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—Fan G min.$10041000 fine ' NOTES and DATA— For department use I I I _ ® Notified forp ickup - Date Doc:.Building Permit Revised 2008 _ I * - i' Plans Submitted Plans Waived ❑ Certified Plot Plan ElStamped Plans El TYPE OF SEWERAGE DISPOSAL ' t. `» 3`�; �•. � . Public Sewer Tanning/MassageBody Art ❑ Swimming Pool's* -� Well ❑ To Sales ❑ Food Packaging/Sales ❑ j Private(septic tank,'etc. . ❑ Permanent Dumpster on Site ❑ I - i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I+ DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ - ❑ COMMENTS CONSERVATION Reviewed on Signature + COMMENTS HEALTH Reviewed on Signature COMMENTS + t Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes x Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Vngineer: Signature: r4.k Wit" Located 3 84-Osgood,Street FIRE DEPARTMENT T mp Dumpster on site yes __ no ` `i-, �► Located at 124 Main Street I Fire Department signature/date ! COMMENTS NORTF1 Town of' 6 over z o dover, Mass. O .LAK 1 COCKICKEWICK\V �ADRATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT u/VIGJ C.....e. �, �. ...... .............. . ....................... ..... ..... .. .... ....... ... ................................................................. Foundation has permission to erect...........:. .... buildings on ........� ... . ..... .............. Rough ..........? nn II to be occupied as �� �-�L / t In s /VL Chimney �. it �......,5......................... t,s�.l.... provided that the person accepting this pe shall in everlrespect conform to the terms of the application on fil in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. ® Now PLUMBING INSPECTOR VIOLATION of-the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU O STARTS ELECTRICAL INSPECTOR Rough ......... . .............................................::::.:»......... .. .,..................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR, Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ��at� ,l�,� '✓'T i�II11,�pp4�33�7Y9��'��5.S �.a Thi� �;, ,5� a ��_ Al E 1 y > M Ili V kl ,� W-01't ti �d nx i13�E _ _ _ c vT S `# •-K i�t,�1f. id[{i°ix9 �' A 1 t VA- I i `^+ pxr •vI ,-sKr� 5 �(:"r .._ y e r AM, ^cF FOY V. A t • r ' 4 �• 4y5i 5 �ry r u g 4 dF ?� t�,tr�,n► 3 i i t - , The Commonwealth of Massachusetts r 1 Department oflndustrialAccidents jn Office of Investigations �r' 600 Washington Street _41. j1EBoston,MA 02111 �., www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): Address: SPAvL©jwG. �� b City/State/Zip: (9-�o�Ca�l t1t,+ul , 01$03 Phone#: 97 3 Z l Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor end I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2, # E] Remodeling I ani,a sole proprietor or partner- listed on the attached sheet. These sub-contractors have 8. Demolition ship and have no employees ❑ working for me in any capacity. workers'comp.insurance. 9. F1 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I ain a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.Puf VsL Other(2-oQF CAOJA aV64L comp.insurance required.] *Any applicant that checks box 91 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. $Coniractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andiob 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(showin 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 verificat'on. Ido hereby certify under thepmfls and enalties peilmy that the information provided above is true and correct.' Signature: Date: M lA-n&4 2011 Phone#• °7 �� 3 f9 Official use only. Do not write in this area,to be completed by city or town offccial. 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#: 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, §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 numbers)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 confinnation 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 pen-nit 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 pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit 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 Massachusetts Department of Industrial Aaeidents Office of Investigations 600 Washington Street Boston,MA 02 111 Tel.#617-727-4404 ext 4.06 or 1-877-NUSSAFB Revised 5-26-05 Fax#617-727-7744 www.inass.gov/dia Craig Residential Improvements Lee C. Craig 3 Spaulding Road Georgetown,MA 01833-2215 Tel: (978)352.6319 March 3,2011 E-mail:ellcee39@verizon.net James A_ Clayton,Jr. Licensed Builder Betty LaVerne Clayton 325 Appleton Street North Andover,MA 0 1845 PROPOSAL FOR FRONT AND SIDE FNTRY ,ANOPY CONSTR_UCTTON This proposal is for the construction of new exterior front and side entry canopies at the dwelling located 325 Appleton Street,North Andover,MA in accordance with discussions and sketches reviewed prior to this proposal. In Site Preparation,we agree to prepare the site for the work to be done, including removal of snow and ice. i In Construction, we agree to obtain the materials necessary and to construct the proposed exterior canopies in accordance with the sketches we have provided, and in keeping with the discussions we have had about the project. In Supervision, we agree to manage the project to the satisfaction of the property owners, including obtaining the necessary permits and inspections with the Town of North Andover,and with other trades on the site, if any. In Landscaping, at a later date and not part of this agreement,we agree to create a finished landscape, including hardscape, plant materials, and accessories which will be in accordance with sketches and approvals by the property owners at that time... We estimate the front and side entry canopy work, as proposed, considering favorable weather conditions,and timely material deliveries, to take about 30 days from beginning to completion. We propose that work and materials needed to construct the front and side entry roof canopies, will be FOURTEEN THOUSAND FOUR HUNDRED SEVENTY- FIVE DOLLARS ($14,475.00), subject to cost restrictions and discounts anticipated and previously discussed. Payment is to be made per invoices or estimated as follows: y At the signing of this agreement $ 4,475.00 At roof shingles in place $ 5,000.00 At trim work in place $3,000.00 On last day $ 2,000.00 The above amount represents an estimate,which is an appropriate cost of the job. Any alteration or deviation from the above specifications involving extra costs will become an extra charge over and above the estimate. If the cost of an estimated joh is expected to exceed 10%, we will discuss any additional charges with you prior to continuing the work. All unused materials will be returned for a credit which will belong to the owner. Any material pricing amount savings will be passed along to the owner. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. All agreements contingent upon strikes, accidents or delays are beyond our conirol. Owner to carry fire, windstorm, liability and other j necessary insurance. This proposal may be withdrawn if not accepted within 10 days. Respectfully submitted: Date: af ACCEPTANCE OF PROPOSAL: The above prices, specification, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signatures) / , 1 Dater ' Date: f f z 694Z :#Jl r ZIOZ/9/6 :u6l;endx3 CEO L'bVVV,'NM013Jb03J �,GVQ2J 0Nlal(1`ddS ' £ Y^ �': `x.. ria. _. . r �� t� �s� c.• �„ Ff 93 9b16L SO :3SU931�, p I� 1 asuaol.-.1 josWadnS uot;ona}suo0 rV ':COMMONWEALTH OF MASS HUSETTS AC -' s�Sar.pums pur. suoilr.ln,�� uiplin8 J.pai�og d AI?ijl '�tlynd,lo ;uaiui n�I�Q 5;;�sny�r55r,1N nc �rx,•. _ s LANDSCAPE ARCHITECTS ASA REGISTERED LANDSCAPE ARCHI ISSUES THE A50VE`L�CENSE TQ = j�s „ UEE C CRAIG � . NG 'R'D-- 3 GE O,R:G E T.:O W f-190.raas.aap° D I= N MA 01833 221=5 - .. n m s8oyw' fi£F NAA01396030 u t :211 01/31/12 950072 I°p � 08 E)Nlainbds c I } 0 331 Fold,Then Detach AlongAll Perforations _le�ptntPUl — . . 6 WOL #J1 v 1 iLOZ1�9Z/6 u.a'Iejldx3 {. 21010SLItiE� of;ej;sl6aa < g sae1N0O W3A021d 1N3 WI3W0H . 1� T sa1e,13�7�0 J3°aaoJO m ` T �RI Ij 1 Roo r- CLAI TON fZE6(bENCE- ` Date .. .. 7......... NOR71f .� I.o '"0 TOWN OF NORTH ANDOVER a !e o PERMIT FOR WIRING ,SSACMUS� s J 1 This certifies that ...... !��rC?......�� ... ..' ............ .......�..:/.............�.f......I .......i ' w .. I r// L'� 4 has permission to perform .... ',!`'y`' 1/....:..; ....................................... wiring in the building of 'll• ° c. at............. .. ............................................... ,North Andover,Mass. ?� '. Fee..................... Lic.No.............. ............. QLECTM�RICALINSPECf Check # 1 8 ' 98 x Commonwealth of Massachusetts Official Use Only •�` ~ Department of Fire Services Permit No.- � BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod ( EC 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:by V('f City or Town of: NORTH ANDOVER TO the By this application the undersigned gives notice of is r her' ntion to perform the el�electrical work ector of ies described below. Location(Street&Number) �� ' Owner or Tenant d h Telephone No. ( Owner's Address 5'(Z Y) F Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building S/n�1 C XG�ml�y Utility Authorization No. s 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: Q tf /3f?lc°Sst /� b1,1. lnl le fc, L �i ' i e "t Completion of the ollowin table may be waived b the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total . Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA 4. No.of Luminaires Swimming Pool Above in o. o mergency ►g g d. d• attety Units --, No,of Receptacle Outlets No.of Oil Buriaers. FIRE ALARMS No of hones No.of Switches No.of Gas Burners No..of Detection and No.of Ranges No.of Air Cond. otal Indtiating Devices Tons No. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW__ No.of Self-Contained Totals: __.._.._._......_...... _._. Detection/Alertin or Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal " Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* + No.of water No.of No.of Devices or E uivalent Heaters KW o.of Data Wiring: Signs Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Estimated Valueof Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Stark l9 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 wns and enalties ofperjury,that the information on this application is true and complete. FIRM NAME: � C LIC.NO.: /91/'lf 6 Licensee: Signature (If applicable, enter "exe t"int a license neinline. LIC.NO.: er Address: D/S f [ Bus.TeL No.: O ' f 3 - *Per M.G.L c 147,s.57-61,security work requires Department of Public Safety"S"License: ��L ci No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner El owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. S 35� <.... �, M 3 s t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ilil;! 600 *ashington Street Boston MA 02111 www.nzassgov/dia . Workers' Compensation Im ilirance Affidavit.davit: BuilderslCoatractor slEle ctricians/Pfnmbers Applicant Information Please Print Legibly Name (Business/OrganizatioMndividual): Address: City/State/Zip: Phone#: . Are you an employer?Check-the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. employees(full and/or part-time).* have hired the sub-contract New construction P ) ors 2.❑ i am asole ries 7. prop or or partner_ listed ori the attached sheet # ❑Remodeling ship and d have no employees These sub-contactors have S. Q Demolition working for mein any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required-] 10. Electrical�1 ] offic ciricat officers have exercised their ❑ repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself[No-workers'comp, c. 152, §1(4),and we have no insurance required.]t .employees, [Yo worke - 12. Roof repairs comp. insurance required_] 13.❑Outer *Any aPpi1Cant that checks bob tk l must also fill out the section below showing their workers'compensationmust submit a new affidavit indicating such. p tractors olicy information, f Homeowners who submit this affidavit indicating they ale doing all work and then hue outside con tContractors that check this box must attached an additional sheet showing the name of the sub•connactom and their workers'comp.policy infornm6on. f am an employer that is providing workers'compensation insurance for mV employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Daze: Job Site Address: City/State/Zip: Attach a co +' copy of the workers',compensation policy declaration page(showing the policy number and expiration date). x Failure to secure coverage Y o erage asuired under Section ectron 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 cert y under the pains and penalties of perjury that the information provided above is true and carred Si tures Date. Phone#: ficial use only. Do not write in this area,to be completed by city or town officio[ 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#: Information o and Instructions �. MassachusettsGeneral Laws chapter 152 requires all employers to provide workers' compensation for their employees. P 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." xP 'An employer is defined as"an individual,partnership,assooiation,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,associatiohn 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 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, MOL 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 Y 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),addresses)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised.that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not`the Department of Industrial Accidents. Should you have any questions regar-ding 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 ygw heed only submit one affidavit indicating-current policy information(if necessary)and under"Job Site Address"the applicant shouldwrite"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 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 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 Mee of Investigations 600 Washington Street Boston, MA 02111 Tel#617-7274900 ext 406 or 1-8.77-MASSAFE Revised s-26-05 Fax#617-727-774 www.nzass.govIdle �. Date.....d:/...'. . NORTH O�t.�ao ia,tiO '' TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACMUS� This certifies that ......:............:.............:..............:-...............:......................... �. S" has permission to perform .. wiring in the building of....! ....................................... p.�1....?}:.........._<-c5. .......... .. .. .North Andover Mass. Fee. '............. Lic.No.�S!ti 1 .............. r LECCRICALINSPECTO Check # 8726 ` Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank f APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance.with the Massachusetts Electrical Code(WC),527 CMR 12.00 (PLEASE PRINT IN OR TYPE ALL INFORMATION Date: `7`1,:;,2( �(,J9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location(Street&Number) � �� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No E] (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: fy ilLr� /)BUJ UA R� 4eZe Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires /3 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 Poold. rnd. oo gncy jig ge Batte Units -- No.of Receptacle Outlets /Q No.of Oil Burners FIRE AT—ARMS N®.€:f Zones No.of Switches No,of Gas Burners / No.of Detection and Initiating Devices No.of Ranges TotalEEEd g No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW -No.of Self-Contained Totals: ""' Detection/Alerting Devices No.of Dishwashers Space/Area Heading KW Municipal g Local❑ Connection Other No.of Dryers Heating Appliances KW Security Systems:* _ No.of Water No.of Devices or Equivalent No.of No.of Heaters KW Data Wiring: Si BzRsE Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ectrical Work: (When required by municipal policy.) Work to Start: Q Inspections to be requested in accordance with MEC Rule 10,and upon completion. ` INSURANCE CO GE: 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 cove ge 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 and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: 3 V 43 Licensee: Signature LIC.NO.: (If applicable, enter"exempt"in the license number line.) Address: Qi/<Q ,�i�'L 1/L'� v�l�r� �J,�. () !,/� Bus.Tel.No.:—UM74 a F Alt.Tel.No.: f It gr 3 S-7 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 1 A� • '' `;` E'er ����L�'I�i����� rte, i F J]J]YY//////ll�� I/ �}} 1 �1 - �� ,, �� The Commonwealth of Massachusetts k; ! Department of Industrial Accidents 7 Office of Investigations 600 Washington Street J��r .�a i Boston MA 02111 { www_mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr'icians/pinmbers Aaplicant Information Please Print Legibly Name(Business/oigmization/IndividuaI Z2 Address: 3 City/5taxe/Zip: � _ Phone#: . Are you an employer?Check.the appropriate box: Type of project(required): 1.❑ I am a employer with 4, ❑ l am a genera[contractor and I ,,��..,,���� employees(full and/or part-time).* have hired the sub-contractors 6. 1�-►vew construction 2. am asole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and have no employees These sub-contractors have 8. C7 Demolition . working for me.in any capacity. workers' comp.insurance. q, ❑ >�Buildi addition [No workers comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I-❑ Plumbing repairs or additions ' myself. [No-worke'rs'comp. c. 152, §1(4),and we have no insurance required.]t employees. [No workers' 12.❑ Roof repairs comp. insurance required_] 1317 Other 'Any applicant that checks boz�lt l must also fill out th t e section below showing their workets''compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tonttactors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' policy comp. information. I am an employer that is providing:workerscompensation insurance,for my employees: Below information. is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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 pen of perjurythat the information provided above is tate and correct r � Signature: � 1---- Date: �- d J Phone#: 22r-- `- FOtheer only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: 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 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,§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 requiremertts 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. Ifan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also'be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not'the Department of Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the'appropriate line. City or Town Officials 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 applicam 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext"406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-QS www,mass.gov/dia .. Date. . ."�a��� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� - - –T his certifies that . �. ss- . . .t . . . . . . . . . . . . . . _ ��-�'"- has permission to perform . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . � . . . . . . .Al. . . . . . .;. . . .; North Andover,-Mass. a 1 Fe i .Li o.. . . . . ..f. . . �. . . . . . . P'L"U`MBING�INSPECTOR Check Hd �l U 8087 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location 3a�S— 9PPle�>^S Owners Name `t3 $' ��G �e .t Permit# Q Amount Type of Occupancy CC' iJ New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES Q z cc a W tn x a c H xa z Z x w Ex- p a O. SBM BSEEvr O M FLOOR MFLOOR M FLOOR 3WM 7H-/�(� / . F 6M1. AOM 7M l� oM MOCIR (Print or type) Check o Certificate Installing Company Name l e C_ Corp. Address 116 'CSSF_..f! s✓ Partner. s-o e usmess Te ephone 7691rC- s1900 Firm/Co. Name of Licensed Plumber: //UJ k e- F T# c -e—:./p e Insurance Coverage: Indicate the type of insurance coverage bV checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St lumbin e and Chapter 142 of the General Laws. By: igna ure 01 1#ZMseGum er Type of Plumbing License Title d S .7 City/Town icense um er Master Journeyman . APPROVED(OFFICE USE ONLY 4 " The Commonwealth of Massachusetts kj J1 Department of Industrial Accidents Office of Investigations 600 FN=hington Street Boston, MA 02111 www_nzasxgov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Pittmbers Applicant Information Please Print Le—vibty Name (Business/Orgenizadon/individual):_ 6 Address: F SS2X <s>L City/State/Zip: �l_ e.1roses lr ty h 17, Phone#: . 'Z�' X65- o _ Are y�an employer?Check the appropriate box: t.at am a employer with 4. Type of project(required): — _ ❑ I am a general contractor and I O ew construction employees(W and/or part-time).* have hired the sub-contractors G. N 2.❑ I am.a:so}e proprietor or partner- listed on the attached sheet.= 7. ❑Remodeling ship and have no employees These su&contractors have 8. 0 Demolition for me in any capacity. workers' comp.insurance. [No workers'comp. insurance 5. 9• ❑Building addition p ❑ We are a corporation and its required.) officers have exercised their I0•❑Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No•workers'comp, c. 152, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs 9 ] .employees. [No workers' comp. insurance required-1 13.D-0 erAOr ter ,ZeBI�c.ae� 'Any applicant that checks bcrZ#t must also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Coonaators that check this box_must attached an add:'tionrd sheet showkg the name of the sub-contractors and their workers'com .pclic;irfnnnatian. t am an employer that is provfding,:workerx'compensation insurance for my employees; Below is the policy and job site information. Insurance Company Name: C CA"I J . Policy#or Self-ins.Lie.#: Expiration Date: j !bc( Sob Site Address: 3 City/Statelzip:IJ/1`14cid,e,� ,c1r 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. Ido hereby certify nder the pains and penalties of perjury that the information provided above is true and correct Si tttre: Date: -S/;� t�9 Phone#: [[I. Board l use only. Do not write in this area,to be completed by city or town of iciaL r Town: Permit/License# Authority(circle one): of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector rt Person: Phone#• I A vv Information and Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 ormore of the'foregoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the 3� 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 ,1 dwelling house of another who employs persons to do mai-ntenance,constriction or repair work on such dwelling house 7 `7 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 evident e,of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither t3he 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 compiertely,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'cos npensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also.be sure to sign and-date the affidavit. The affidavit should be returned to the city or town that the application for.the permit or license is being requested,notthe Department of Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' compensation policy;please caU the Department at the number listed below. Self.-insured companies should enter their self-insuiance'lieense 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 A-ilI 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 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 DepartMont of Industrial Accidents Office of Investigations 600 Washington Street Basion, MA 02111 TeL # 617-727-4900 ext 406 or 1-9.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia " Date.. . . .. . ... .. . . . . . . 3� TOWN OF"NORTH A OVER o rx ; � PERMIT FOR GAS STALLATION . 9 r�9SS4CMUSEt< This certifies that . . . . . . . . . . . . . . . . . . has permission for gas installation_,-(,'-'.,-,-. . . . . . . . in the buildings of . .+._. . . . at . . . . . . . c . ., North Andover, Mass. Fee. .—?P.,. . . . . Lic. N/o..,//.z�, ?. . . 4�1 . . . . . . . . . R Check# l / 6791 r /r MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS RrnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date -r/0 Building Logations 3, Sfst- Permit# Owner's Name ` Amount$ + S C- IGt New❑ Renovation Replacement -------Plans Submitted p W H m m W W p O C Z F w e VV F z d S a w q F w C p C z C Z p Z w C F W L� 3 a c7 �. m > x [suB -BASEM ENT p F 0 SEM ENT T. FLOOR D . FLOOR D • FLOOR H . FLOOR H . FLOOR H . FLOORH . .FLOOR 8TH . FLOOR (Print or type) Name_ /�ca C CA it(— Check o ertifrcate Installing Company Corp. Address C5 e ro nal 7 Partner. Business 1 a ep one Firm/Co. Name of Licensed Plumber'or Gas Fitter r� cmc .e "INSURANCE COVERAGE' 41 have a current liability Insurance policy or it's substantial equivalent. Check one: If you have checked Les,please indicate the a cove Yes LJ No� Liability insurance policy type rage by checking the appropriate box. P cy Other type of indemnity D1 Bond Owner's Insurance Waiver. lArn aware that the licensee does not h the Insurance coverage required by Chapter 142 of he Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of Owner Or Owner's Agent Check one: I herebyOwner13 A certify that all of the details and information I have submitted gent 1 or entered) best of my knowledge and that all plumbing ( ered)in above application are g p mbmg work and installations performed under P true and accurate to the compliance with all Permitissu pertinent provisions ed for this P p ons of the Massachusetts State Gas Co e d Chapter.142 of the General Laws.application will be m Title. D Signature Licensed Plumber Or Gas Fitter Title Plumber City/Town. Gas Fitter , �/ 3 ' ' Lice 1'��um er ^er. APPROVED(OFFICE USE ONLY) D Journeyman ] �22 \ The Commgrzwe.jth of Massachusetts Department o Ind A cidents. .f ustrial " ;g Dffce Of Investigations r� 600 Washin ton Street Bostoft ATA 02111 r H'►t'►�'.rnass.goj�/dia Workers, Compensation Insurance.Affitdavit. guilderslCoutractors/Electricians/piumbers Aw licant Information Pease, Print Le6ibiF� . Name (Business/Organization/Individual : Gt 1 Ctic:� � Address: City/state/zip: ,tet Cha 1? Phone #: Are you an employer?Check the appropriate box: 1•�1'am a employer with 4. ❑ I am a M'eneral contractor and I T7wn ect(required): employees(full and/or part-time).* have hired the s 6•. construction ctio conn ❑ I am a sole proprietor or partner- listed ozi0 the attached sheet x 7. eIinor.ship and have a employees These sul>-contractors haveworf:ingforme in any capacity. workers' g itioncomp. insurance.[No workers'. comp. insurance 5. ❑ We are a corporation and its 9' g ad.difionrequired] officers have exercised.their 10al repam oradditiansI am a homeowner doing all work right of exemption per MGL l 1g r. repairs myself. [No workers' comp. c. 152 a ep rs or additions insurance required.] t errs la e 1(4)'and or have no 12, P Yes• [No workers 12,E] Roof repairs comp. insurance required.] 13-[U-Other 5b, '`PPj'ue *Any app}icant.that checks box#1.must atso'fili out the section below showiteg their workers'compensation oli +iiomcowners witu submit.t]ii.el;tdavit indicating uiej;are;doing,En rrr,..:„.,L} fen him cutsiaempenu;iios rnusi submit a now am' zConttactota that chcc};this box must attached an additional sheet showi j �+ P cS'inforrnation. rm the A ua.tt indicating such. n.nte.off3:e s;tb-cortlactors and their wormers'com 1 am an.employer that is providing workers'co ensation i P.Policy information. information assurance for my employeeS. Below iS the poficy and job site Insurance y Com an Name: � \\ P Policy#or Self-.ins. Lic. Expiration Date. Job Site Address: ads Attach a copy of the workers' compensation policy declaration page(showiva the po icy number aexpiration� Failure to secure coverage as required under Section 25A of date). fine up to 51,500.00 and/or one-year imprisonment. as well as civi)penalties in ad o thee imposition a STDP WORK ORDER penalties of a of up to Z250.00 a day against the violator. Be advised that a copy of this statement may ER and a fine Investigations of the DIA for insurance coverage verification. ) be forwarded to the Office of I do hereby certify under the paint and penalties of Perjurf'rhe the informnLnrr provides move is trueSi_nature: and correct Date Phone#: Oficial use only- Das not write M this area to be cnmpleted.bj,cit),or town official Cite or Town: Issuing Authority(circle one): PermitlLicense ------------- 1. Board of Health 2. Building Department 3. City/Town 6. Other perk 4. Electrical Inspector S. PlumbirzQ Inspector Contact Person: Phone tlltut ti1dLlULI ;:ana instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined.as"._every person in the service of another under any contract ofhire, express or implied;oral or written." An employer is denied as an individual,partnership;association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and inclucdi-nu 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 ap artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maint=ance,constriction 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 o r local licensing agency shall withhold the issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence cif compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its potrtical 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 compi-etely,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 nr LLP does have_. employees, a policy is required_ Be advised that this of c'Lavit may.be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also lbe sure to sign and date the.affidavit. The affidavit shouid be returned to thecity or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have.any questions regi,-ding the laza,or.if you are required to obtain a workers' compensation policy;please call the Department at the naasnber.listed below. Self insured companies should enter their self-insurance license number on the,approprate line. City or Town Officials i Please be sure that the affidavit.is complete andprinted 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 p=itAicense number which will be used as a reference number. In addition, an applicant that must submit multiple permittiicense applications in arty given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Addix-ess"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 Iicenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a licensct 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 Phis affidavit. The Office of Investigations would tike to thank you.in advance for your coop,.;ation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fay, number: The Commonwealth of Massachusetts Department of lradustrial Accidents Office of Lavesfigatioas 600 WashLington Street BQsmn; MA G2111 Tel 4 617-727-4900 e=4.06 c r 1-977-MASSAFE Revised 5-2645 Fax 4 617-7-7-7749 VtVrK'.IrI ass.g ov/dia Paul W. Young P. E. + P. O. BOX 164 + West Newbury, Ma 01985 Date: 5/08/09 'To: Town of North Andover Code Enforcement Dept. North Andover, Ma 01845 subject: Clayton Addition at 325 Appleton Street On February 25, 2009, I visited the addition at the address above to inspect the installation and to see if it complied with the design as given in the report of November 18, 2008. I am satisfied that the installation of the framing conforms to the design. Best regards, IktX'" �j�•� tN of a, o Paul W. Young P.E. P L. ou 9-28 57 �Ss�(3P1AL P.O. BOX 164 WEST NEWBURY, MA. 01985 TEL (978) 363-5836 AEROSPACE CRYOGENICS HIGH VACUUM ELECTRONICS STRUCTURAL OPTICAL .� � .�7. Paul W. Young P. E. P. 0. BOX 164 West Newbury, Ma 01985 Date: 5/08/09 To: Town of North Andover Code Enforcement Dept. North,Andover, Ma 01845 Subject: Clayton Additio ' at 325 Appleton Street P On February 25, 2009, visited the dition at the address.above to inspect the installation and to see if com with the design as given in the report of November 18, 2008. I am satisfied that the installation of the framing conforms to the design. Best regards, OF�fAs P = j TI Paul W. Young P.E. -N 28257 FS61ONAL E%0 P.O. BOX 164 WEST NEWBURY, MA. 01985 TEL (978) 363-5836 AEROSPACE CRYOGENICS HIGH VACUUM ELECTRONICS STRUCTURAL OPTICAL '� _ :. _ v `_.", .. e c I` r l� . I. .. r -- Paul W. Young P.E. P. O. BOX 164 West Newbury, Ma 01985 Date: 2/25/09 To: Town of.North Andover Code Enforcement Dept. North Andover, Ma.01845 Subject: Clayton Addition at 325 Appletoh Street On February 25, 2009, I visited the addition at the address above to inspect the installation and to see if it complied with the design as given in the report of November ,18, 2008, I am satisfied that the installation of the framing conforms to the design. Best regards, s Paul W. Young P.E: P.O. BOX 164 WEST NEWBURY, MA. 01985 TEL (978)363-5836 AEROSPACE CRYOGENICS HIGH VACUUM ELECTRONICS STRUCTURAL OPTICAL ,�. � L` 1 i� PER111T NO.-0 /3> APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. c PAGE 1 MAP NO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE ONE I SUB DIV. LOT NO. I �I OWNER'S --&C—AT ION 3a PURPOSE O!.B14LD4N6 VQ O WNER'S NAME ' lb/J NO. OF STORIES SIZE l/L Cf�L BASEMENT OR SLAB -- ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /a�� 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 MATERIAL 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 INSTRUCTIONS 3 PROPERTY INFORMATION SEE BOTH SIDES LAND COSTEST. BLDG. COST -7 PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLA MUST BE FILED AND APPROVED BY BUILDING INSPECTOR ATE FILED BOARD OF HEALTH SIGNATURE F OWNER OR AtifHORIZED AGENT vvvC� / PLANNING 130ARD PERMIT GRANTE 1 19 BOARD OF SELECTMEN i BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES 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 ES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY VJALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'TAREA _ '/. 1/1 3/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I—� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.( _ FLAT SHED 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 I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS '7 NO. OF ROOMS Oil B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING Nlassachu-setts- Dep:irttncnt of 1'ultfic Safo,. CS/ Roard of Ruilt.lirig Regouiation,s and Slatwdat-d6.. UVJ Construction Supervisor License License: C9 79146 Restricted to: 00 ti LEE C CRAIG 3 SPAULDING ROAD GEORGETOWN, MA 01833 Expiration: 9/5/2010 uu(iriv+hrni r TO2378 .� Irlrsi'ttOrrr rlrnrtfrrrarl� til..1(.C7,iJrr�Jru.N+,lt✓4 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 134115 Expiration:. 9/26/2009 Tr# 132799 Type: Individual LEE C.CRAIG LEE CRIAG 3 SPAULDING RD. GEORGETOWN,MA 01833 Administrator COMMONWEALTH OF MASSACHUS TTS IN LANDSCAPE ARCHITECTS A REGISTERED LANDSCAPE ARC IT, [SSUES THIS LICEN-SE TO LEE C CRAIG fI 3 SPAULDING RD ; GEORGETOWN MA 01833-2�1 }i 211 01/31/09 394878 lave- The Commonwealth of Massachusetts ;X r Department of Industrial Accidents Office of Investigations sts.?A 600 Washington Street tttlt: i . Boston, MA 62111 e ww>*.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Lembly Name(Business/Organization/Individual): Address:_--3 0 u LD, ' i�u w D ' of P:3-1a City/State/Zip: 6Or2(f.€Zowoi MA. Phone #: . 97C- 36-2- 63/4 Are you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4; ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.D(I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These soli-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. gBuilding addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10❑Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.)t .employees. [No workers' 13.0 Other comp.insurance required.] "Any applicant that checks boz#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. tContraetors 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.#: 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 pai penal,�tt'es f perju that the information provided above is true and correct Si L -Date: OI LLO Phone#: O ficial use only. Do not write in this area,to be coni pleted 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#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t i1 Y'r 600 Washington Street ru' r Boston, MA 42111 c www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aunlicant Information Please Print Legibly Name(Business/Organization/individual): Address: IhG City/State/Zip: Phone -35-7-- ?q Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. New construction - ~- employees(full and/or part-time),* have hired the sub-contractors 2.9YI am a sole proprietor or partner- listed on the attached sheet.t 7, Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers' comp.insurance. g• t] Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its required., officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.]t .employees. [No workers' 11M Other comp.insurance required.] "Any applicant that checks boz*i must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees, Below is the policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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. !da hereA�ceunder the pains and pe 's of perjury that the information provided above is true and correct. Si tatureDa : 1!S Phone d QfJ`lcial use only. Do not write in this area,to be completed by city or town ofcial 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 b.Other Contact Person: Phone#• XCAV147o The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i •i r 600 Washington Street Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Alwlicant Information Please Print Legibly Name(Business/Organization/Individual): �� �u ���f�� �e Address:- City/State/Zip- / Phone #: . Are you an employer?Check the appropriate bore: Type of project(required): 1.El I am a employer with 4. El am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.R I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. q. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees. [No workers' 13.❑Other l comp.insurance required.] J *Any applicant that checks bon*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. tt on(ractors 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 informadom Insurance Company Name: '/'Llt ry GZC`3 573 7tr` �cJi ✓ _ Policy#or Self-ins.Lie.#: lu r—y Expiration Date: L L 1U9 jar .lob 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 pen ' s pe that the information provided above is true and correct Signature: ' Date: Poems Of)`icial nse 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#• Craig Residential Improvements Lee C.Craig 3 Spaulding Road Georgetown,MA 01833-2215 Tel:(978)352-6319 September 10,2008 E-mail:eQcee39®verizon.net James A.Clayton,Jr. Licensed Builder Betty LaVerne Clayton 325 Appleton Street North Andover,MA 01845 PROPOSAL FOR CONSTRUCTIoN OF ADDITION This proposal is for the construction of a one story addition,with exterior deck,to the dwelling at 325 Appleton Street,North Andover,MA in accordance with plans and sketches submitted with this proposal. In addition to this work,some site preparation and finished landscape treatment will be done. In Site Preparation,we agree to supervise removal of trees, shrubs and other plants that will be in the line of work. We agree to install and maintain silt barriers around the excavation area. We agree to provide a dumpster on the site during construction. In Construction,we agree to obtain the materials necessary and to construct the proposed addition and exterior deck in accordance with the plans we have provided,and in keeping with the discussions we have had about the project. i In.Supervision,we agree to manage the project to the satisfaction of the property owners, including obtaining the necessary permits and inspections with the Town of North Andover,and with other trades on the site, if any. In Landscaping,we agree to create a finished landscape, including hardscape,plant materials,and accessories which will be in accordance with sketches and approvals by the property owners as the work is done. We estimate the entire project as proposed, considering favorable weather conditions, and timely material deliveries,to take about 30 weeks from beginning to completion. We propose to furnish material,as needed,and labor in accordance with the above specification,not to exceed one hundred seven thousand,three hundred fifty-four dollars ($107,354.00),subject to cost restrictions and discounts anticipated and previously discussed. The breakdown of costs are as follows: Design,Site,Permits,and Landscaping$20,865.00 Addition and Deck construction .$86489.00 Payment is to be made per monthiv invoices.or estimated as follows: At the signing of this agreement $ 3,000.00 September 30,2008 $36,310.00 October 30,2008 $16,146.00 November 30,2008 $ 9,071.00 December 30,2008 $12,652.00 January 30,2009 $ 6,835.00 February 28,2009 $ 9,076.00 Completion of the work $14,264.00 The above amount represents an estimate,which is an appropriate cost of the job. Any alteration or deviation from the above specifications involving extra costs will become an extra charge over and above the estimate. If the cost of an estimated job is expected to exceed 10%, we will discuss any additional charges with you prior to continuing the work. All unused materials will be returned for a credit which will belong to the owner. Any material pricing amount savings will be passed along to the owner. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. All agreements contingent upon strikes,accidents or delays are beyond our control. Owner to carry fire,windstorm, liability and other necessary insurance. This propo may be withdrawn if not accepted within 10 days. Respectfully submitted: .cam. Date: y 0 ACCEPTANCE OF PROPOSAL: The above prices,specification,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(s)_a � �i Date: Date: