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Miscellaneous - 34 TYLER ROAD 4/30/2018
N O 11/10/2013 Brian Leathe Town of North Andover 1600 Osgood Street Bldg 20 Suite 2-36 North Andover, MA 01845 RE: 34 Tyler Rd, North Andover PERMIT #880-13 Brain: On 6/26/2013 1 emailed you and advised that the owners of 34 Tyler Rd, changed scope of work contained in the permit I obtained. Based on that email, there would be no requirement for inspections by the building department. This letter is confirmation that Sterling Construction, Richard Arnone will need the permit #880-13 and hereby will no longer perform work at 34 Tyler St, North Andover. It is my understanding that the owner, Manny Raposa has contacted the building department and informed them of the status of work at this property. Ricydnone Sternstruction 285andnants Way Chelsea, MA 02150 Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......................................DA /.!......... .............................. has permission to perform ......... 5..... ;............................................ wiring in the building of .......................................... ..... #IC 51 o at ............. ...... .. ........................— ...................... . N rth Andover, Mass. 10 Lic. No....../u.% .......................... ................1......... hLEbMCAL INSPECTOR? 'check # 38-50 Official Use Only cc�� cc77Permit No. WEDM alJeParEnrent o��u+e �enrice3 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS .1/07](leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC , 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of.- /607,y 14To the Inspector of Wires. By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 3 41 2 �T Owner or Tenant 11211ey- ,moi ,ID Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 29 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity 4,/,pZ-L1—/ Location and ?6TF T ZJ, i. -o � i 4- Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters \ _ �m ftlraintln�ni.... f..Llo ... . L., . - .,.7 �:. rL- -rw;- No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans - - No. of -- _ -� Total Transformers KVA No. of I aminaire Outlets No. of Hot Tabs Generators KVA No. of Luminaires Above ❑ In- ❑ Swimming Pool grad. d. o. o Emergency Lighting Butte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS , No..of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No, of Air Cond. Total Tons Alerting No. of Ale Devices No. of Waste Disposers Heat Pump Totals: I Number Tons No. of Self -Contained Detection/AleDetection/Alerfift Devices I No. of Dishwashers SpacelAres Heating KW Local ❑ Municipal 11 Other No. of Dryers Heating Appliances KW Sec N of>es Systems:* or uivalent No. of Water KW Heaters o. of No. of Ballasts Data W No. o vices or uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or Equivalent OTHER attach adaltional detail 1 desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 such7B= force, and has exhibited proof of same to the permit issuing office.CHECK ONE: INSURANCE❑ OTHER ❑ (Specify:) FiCP . 3 -1 - I Li I certify, under the pains and penalties ofperjury, that the information on tilts ris true and conjplete FIRM NAME: 7A V I V I ILE"RI CAL CBN.T AC,-rqui i.l. LIC. NO.: Licensee. DAVID 4A64AA Signature �- LIC. NO.:14`I&5A (Ifapplicable, enter `exempt" in the license monber line) Address• Q� Fj)rLtr00 1' g_r 4AWyEf2 Im 01B1S Bus. Tel. No. -US- 57 -b73 Alt. Tel. Na:�f 1$ ' 375 513 *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'swent. Owner/Agent •�-� Signature Telephone No. PERMIT FEE. $ 'c ID-�'-1-3A�7 5� Z = 5/T lt3 c�a,"---- y f f UAy/Stak-! " rAUtcr rt FUMUUvt_rc, tuna M54bPhone - 978-682--6262 Are You :a 40111111ploye>? [hedk the appropriate twsw I.0 I am a ewpioyerwith 7 4- Q I an ageneral conuactorand I Type of project employees (fidl. mdkffi e)-� hwe hiked fie m 11 6- Q New construction 2.Q Iamasole, prgeetarcrpart w - ship and have no employees wodang for mein any rapacity_ [Nownds' camp msn�oe require&] 3. Q I am a howwwxw dniugaIl wodc myself [No wadme catnip, insmamoe regrmed j It listed an the anached sheeL Tie sub-contractms have employees and have wmkwe comp. jam+ 5- Q We ace a cwponation and its officers have exercised their riftofw=%Xanper MGL c- 152, §1(4), and we $ave no employees, [No workers' 7- Q Remodeling s_ Q Desolation 9 ❑ Buildingadddion I0-0 Electrical repairs or additions I1 -Q Plumbing irep or additions I2-0 Roofrepabs 13-Q ocher rr••• ••a� wan aaa omc�i mns[aISD nit om me section belowskowmg thew vwod me poiicv in&nu,, r t � who submit this affidavit ind�ng they are doing aU wow acid ten hhire outside cattractors must submita near affidavit mdwatmg sm L +"Cenb2daltthetcheck ambox must at an additional sheet stoarmgthe ofthe oswWAMwhether ortrotdwsee have emPtoYees.- Ifthe subl:atmacmrs have em0oycesy they an provide their wodam * comp- Pow menbed I f tra +player i/setiFs pnvvidmgworkeis'romp on hznwaneejor my enw0yem DWOw is file innmd om pnlrty andjoLsite Insurance Company Name. THE HARTFORD Policy # or self-ins_Lic. #: 08 WEC 618293 2 Expiration Date: MARCH A1, 20.1* 3 Job Site Address: � G� city/stat nix . ljaa* Attach a copy of the workers' compensation policy declaration page (showing the Failure to secure �, Pic}' number and expiration date}. erage as required under Section 25A of MGL c.152 cin lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year isprkonmeut, 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 m the Office of Investigations of the DIA for insures coverage verification. I do the ' ase DO&Otwrifeht&bmwa6toheconqdetedbycrtyartowjzoffichd Cky or Town; L mngAnthordy(cattleone): PerzowLicewe # is true and correct L Beard of Health 2- Builftg Depat6acot 3. Criyli'own ®erk 4- Electrical hmpecbt & Phrmbiog inspector CL Other CommaPetsm Phone The Cormmonwealth of Massachuseft Print Form D tofLwk% WAc - _ wr— - (lffuae aflim�s�g' nitons - =_' -_ - I Congress,&eek Suite 100 Bostou MA 02114-2017 wwwn=mgov1dw Workers' Compensation Insurance Affidavit; $m7derslCouftctors&lee#rieiaus/Plumbers Applicant Information Please Print !Aw'bly Name (0usinewOqpjfi.,jn&,idw). DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST UAy/Stak-! " rAUtcr rt FUMUUvt_rc, tuna M54bPhone - 978-682--6262 Are You :a 40111111ploye>? [hedk the appropriate twsw I.0 I am a ewpioyerwith 7 4- Q I an ageneral conuactorand I Type of project employees (fidl. mdkffi e)-� hwe hiked fie m 11 6- Q New construction 2.Q Iamasole, prgeetarcrpart w - ship and have no employees wodang for mein any rapacity_ [Nownds' camp msn�oe require&] 3. Q I am a howwwxw dniugaIl wodc myself [No wadme catnip, insmamoe regrmed j It listed an the anached sheeL Tie sub-contractms have employees and have wmkwe comp. jam+ 5- Q We ace a cwponation and its officers have exercised their riftofw=%Xanper MGL c- 152, §1(4), and we $ave no employees, [No workers' 7- Q Remodeling s_ Q Desolation 9 ❑ Buildingadddion I0-0 Electrical repairs or additions I1 -Q Plumbing irep or additions I2-0 Roofrepabs 13-Q ocher rr••• ••a� wan aaa omc�i mns[aISD nit om me section belowskowmg thew vwod me poiicv in&nu,, r t � who submit this affidavit ind�ng they are doing aU wow acid ten hhire outside cattractors must submita near affidavit mdwatmg sm L +"Cenb2daltthetcheck ambox must at an additional sheet stoarmgthe ofthe oswWAMwhether ortrotdwsee have emPtoYees.- Ifthe subl:atmacmrs have em0oycesy they an provide their wodam * comp- Pow menbed I f tra +player i/setiFs pnvvidmgworkeis'romp on hznwaneejor my enw0yem DWOw is file innmd om pnlrty andjoLsite Insurance Company Name. THE HARTFORD Policy # or self-ins_Lic. #: 08 WEC 618293 2 Expiration Date: MARCH A1, 20.1* 3 Job Site Address: � G� city/stat nix . ljaa* Attach a copy of the workers' compensation policy declaration page (showing the Failure to secure �, Pic}' number and expiration date}. erage as required under Section 25A of MGL c.152 cin lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year isprkonmeut, 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 m the Office of Investigations of the DIA for insures coverage verification. I do the ' ase DO&Otwrifeht&bmwa6toheconqdetedbycrtyartowjzoffichd Cky or Town; L mngAnthordy(cattleone): PerzowLicewe # is true and correct L Beard of Health 2- Builftg Depat6acot 3. Criyli'own ®erk 4- Electrical hmpecbt & Phrmbiog inspector CL Other CommaPetsm Phone 4- A This certifies that ...I ... "Q r' �� ' �' eN Q— has permission to perform ...=!��'`�... !-� L ............... plumbing in the buildings of. tI P!� ! N 0 at ..... ,� .. , North Andover, Mass. 11 Fee Lie. No.... . PLUMBING INSPECTOR �7 Check # � 6 -�I 1 ® MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK UTCITY POWNER TYPE OR PRINT CLEARLY dJ _� MA DATE PERMIT # 10 171 JOBSITE ADDRESS ,3 �_ _ - _ OWNER'S NAME ADDRESS I TEL=__. FAX _ f OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Q RESIDENTIAL NEW: 0 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NO© FIXTURES'l FLOOR --r BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ��E .._....__.....,I S .-_____►- _._._„� ... __...,� __ . __..,_ ._.._._._i ._-___( ___..__1 ,.....,1 .._..._._! —__i DEDICATED GREASE SYSTEM —1 I �- DEDICATED GRAY WATER SYSTEM I __.J .I_ -,___I ___-__. I ! ! _..._! _.._.___I ._._J ____I (.___.._._IDEDICATED WATER RECYCLE SYSTEMDISHWASHER..I W--jr- _....... - - ._...— �__� .___..._I �._—{_f ..-:_—� ..._._.. _---1 _—»_1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (I NTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINALI ._...__.._! _____1 __...._-.►---_-._! __...._..I ..__.__.-1 _..____-.----____! ._._...._ `-._._...__ .___-_._t :......_._f ._.._.....! ._-_._-; WASHING MACHINE CONNECTION r WATER HEATER ALL TYPES F-7 -.771 VOTER PIPING OTHER I P INSURANCE COVERAGE: B have a current liability insurance policy or its s bstantial equivalent which meets the requirements of MGL Ch. 142. YES NO Mi IF YOU CHECKED YES, PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Jo LIABILITY INSURANCE POLICY ,. OTHER TYPE OF INDEMNITY ! BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER .i 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 ac urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wyh t provision of the Massachusetts State Plumbing C de and Chap r 142 of the General Laws. PLUMBER'S NAME .- V .�_ _ s LICENSE # SI NATURE MPR( JP Q CORPORATION # r PARTNERSHIP_I # LLC EJ# E COMPANY NAME Vh2 ADDRESS Cn r- CITY uC j STATEZIP' � TEL FAX ��% _E CELL ( EMAIL �r OL a .r, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Phone #:_ 976 eJ7dVt> Are yoq.A employer? Check the appropriate box: 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ Ne construction 7. J21emodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other `Any applicant that checks box #1 must also fill out the section below showing their workers' 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. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy # or Self -ins. Lie. #: K7P Expiration Date: T J� ob Site Address:_ eh y �v//P i� City/State/Zip: Uttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of rivestigations of the DIA for insurance coverage verification. do hereby certify under 11 i aid Zenaes ofperjciry that the information provided above is true and correct. / t 7 b --nature: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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 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 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 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia �> COMMONWEALTH OF MASSACHUSETTS`. ,� . ERSA > GAS -I r S LICENSED AS A 111ASTER ('-LUMBER ISSUES THE ABOVE LICENSE TO: WILLIAM M KANNAN 10 B GRANDVIEW RD 17" METHUEN MA `.` 844-4 10286 05/01/14 147 Date....:S]-t ..�.�. /. .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.................................ja ............................................... has permission for gas i stallation ............................. in the buildings of ...... ............ffii!`:............................................................................ at ...............r 4-1 I-.&..... (i :......................... . North Andover, Mass. Fee '�.�`�..... Lic. No. Jo ....... J10 ....................................................... GASINSPECTOR Check # Z 6 1� ��Jf ", u ® •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY G MA DATE PERMIT # 0 0 CS JOBSITE ADDRESS OWNER'S NAME d, GOWNER - --- ADDRESS TEL TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL�__I EDUCATIONAL ® RESIDENTIAL !� CLEARLY NEW: Q RENOVATION:E] REPLACEMENT: 02ro� PLANS SUBMITTED: YESE-1 NOF APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER C COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE- FRYOLATOR FURNACE _ - . GENERATOR ._---- _ GRILLE GRILLE ._-- _ ___-- _ __-_-- _.-- _ __ v�__-.__- __ _-_-- 3 _ INFRARED HEATER -— LABORATORY COCKS �,_� (� _l __ �J r - I _.. IT_.. __ _�J Y I (✓, 1 ,� _ I I �- MAKEUP AIR UNIT OVEN _ - -- POOL HEATER �_ - [ - - ,I -^ _ I ROOM / SPACE HEATER ROOF TOP UNIT TEST 1 __-J ^! UNIT HEATER - UNVENTED ROOM HEATER �- �L I WATER HEATER OTHER F INSURANCE COVERAGE -�- have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1© NO Q 00 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,-__. OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �_fl AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to toe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance 't Pe Hent provision of the Massachusetts State Plumbing Code and Ch pter 142 oft General Laws. �j PLUM BER-GASFITTER NAME 'i��� LICENSE # SIGNATURE CC S MP JJMGF 0 JP Q JGF [] LPGI D CORPORATION PARTNERSHIP ©# LLC [3# COMPANY NAME: - f%'+� ADDRESS 5 _-- __-_--- _ -----_-.__� __ ._____ _t. --r--_�._.� - - - -- -- - - - -------- --_CITY CITYv STATE [�IP TEL "/__! �L� -_ ✓ -L .I _fl FAX CELL 11EMAIL s-- °z z o � H U � W �v w V o ❑ zCD O N W a Z U w a � m w a w CO a O � a w w d w N a d o a a c�c U M F� J a a a 1� �2 Lii x w H LL H z 0 F 0 The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:. Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: 1-t-, PSS 1 er S'� - - I City/State/Zip:_ 41 -GSL, . Phone Are yo n employer? Check the appropriate box: 1. bA ' am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ Ne onstruction 7. emodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ire 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. i Insurance Company Name:. Z4.I kew S C.� Policy # or Self -ins. Lic. #: /Vs 7t 7 Expiration Date: Job Site Address: _J i ?7"1 j/ Sk • 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 ynder the pains that the information providedaboveis true and correct. nate• Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other -- - - Contact Person: Phone #: 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.sucli employment be deemed to be an employer." MGL chapter 152, §25C(6)-als6 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this 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 �. A Please be sure that thd•,affidavit is complete and printed legibly. The Departhient 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, a& 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: Tho Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 61.7-727.7749 v tt-mass,gov/dia. Location No. ¢y Date54— 7575 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ sZo oti Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ IAO Building nspector Div. Public Works O ac O m r n m m m m r r V 0 I p p m> O O r` N; V r m C c C - > 0 ^wv D Z D Z r n = =4 m m A n D F -I A z Q vl W > D m � � m m m m N - 0 m m = r r m O 0 m -4 i y m m 0 0 N w N w amn m > i Z p Cf Q L°1 m 0 0 0 � 1 A m 8 °� Z N c 0 z N w m* y y m> 0 I p p m> O O r` N; A 0 r m C c C - > 0 D Z D Z D Z r n = =4 m m A n D Z O r p 2 p 2 Z mm m A n y y > z 0 >° 0 0 0 p A z 0 z to p > z m > N O 0 O r -" m p D a m f 3 O 3 -4 m; m m y m m m y n i0 0 � 0 z r m i Ul -a 1 Zr ; Z m y C 0 0 I _ z 0 -1 > Z < ID c ° m r < 0 m m VJ z m 1 4 z 0. 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PHOTO (BLASTING PPR ONLY) FEE: Tv w 4 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY 7 HEIGHT: STAMPED OR SIGNATURE OF THE COMMISSIONER DOB: Z' THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF 1 61 ATURE OF LICENSEE SIGN NAME IN FULL ABOVE SIGNATURE LINE THE HOLDER WHEN EN - OTHERS RIGHT THUMB PRINT GAGED IN THIS OCCUPATION. R—V. AI -17'H. rt j COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF 1010 COMMONWEALTH AVE. MASSACHUSETTS BOSTON, MA 02215 EXPIRATION DATE --- ---- --- CAUTION RESTRICTIONS EFFECTIVE DATE LIC—NO. FOR PROTECTION AGAINST THEFT, PUT RIGHT THUMB 0 Ca PRINT IN APPROPRIATE 0 BOX ON LICENSE. C BLASTING OPERATORS m .7 MUST INCLUDE PHOTO. PHOTO (BLASTING PPR ONLY) FEE: Tv w 4 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY 7 HEIGHT: STAMPED OR SIGNATURE OF THE COMMISSIONER DOB: Z' THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF 1 61 ATURE OF LICENSEE SIGN NAME IN FULL ABOVE SIGNATURE LINE THE HOLDER WHEN EN - OTHERS RIGHT THUMB PRINT GAGED IN THIS OCCUPATION. R—V. AI -17'H. 716 Lowell Street Methuen, MA 01844 (508) 687-7930 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home improvement contractors and subcontractors engaged in home improvement contract- ing, unless specifically exempt from registration by provisions of Chapter 142a of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. Designated Registrant's Name: 1 `c h _ e Registration Number: L' O 7 Salesperson's Name: This agreement is made on o; $ between J!J un : '15 -IC-t' ) C E'S too (DATE) (CONTRACTOR) of 6 L��) e_ (( S f • g`- 69"7- 7`1:3 0 (ADDRESS) (PHONE NUMBER) hereinafter called "Contractor" and (OWNER) of hereinafter called "Owner'. I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED (PHONE NUMBER) Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following: DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above described work consist of the following: i H. PRICE nn Contractor agrees to do all work described in Section I for the total price of $ d ate' o9 o III. PAYMENT Payment will be made as follows: 3[ 3 1/31 % (S TOO .00 ) upon signing Contract; a % ($ Jae �O) upon completion of ive, 33 � % ($ L-�) upon completion of� ; and the remaining I % (S ) upon verification of the work by Owner and Contractor as having been satisfactorily com- pleted, which verification shall take place promptly after completion. Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whichever amount is greater. IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or about 6;/(date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed byC (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that suc t delay hat are not avoidable by the Contractor shall not be considered as violations of this Agreement. V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in Section III (Payment) above for the reason that he deems himself or the payments to be insecure. If, however, he deems himself to be insecure, he may require, as a prerequisite to continuing the work described herein, that the balance of the payments under this contract that are in the control of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal. VI. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself, his employees or his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. 6. The following terms may be added, if desired, to clarify situations in which the Contractor will not be responsible for delays (for example, delays due to hidden conditions, etc.): VARIATIONS IN SCHEDULED START AND COMPLETION OF WORK The actual dates that construction will commence and be completed may vary due to: the time required to apply for and obtain necessary permits; delays caused due to necessary inspections; delays in the scheduling of work crew(s); the presence of hidden conditions or necessary additional work discovered during construction; or delays in the receipt of equipment and/or materials which must be ordered and/or delivered to the site. NOTICE OF SCHEDULE CHANGES The Contractor agrees that when any such delays become known to the Contractor, the Contractor will advise the Owner as soon as is reasonable. DELAYS IN COMPLETION DUE TO HIDDEN CONDITIONS The Owner hereby acknowledges and agrees that in certain remodeling work, the demolition of portions of the preexisting structure may reveal additional defects, conditions or the need for additional work, which must be repaired, altered or carred out in order to commence or to complete the work described under this contract. In such case(s) the Homeowner agrees that the duration of the work and the scheduled date of completion may differ from the date contained in Section IV, above, and that such variation which is not avoidable by the Contractor shall not be considered to be a violation of this Contract. 7. If the Contractor wants to provide leeway for adjusting the overall price when hidden conditions increase the amount of work required, the following term should be included: HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK Hidden conditions may require adjustment in the overall price of the necessary work related to this Agreement. In such case the Contractor shall inform the Owner of such conditions forthwith and where necessary a written amendment of this Agreement will be negotiated and executed by the Contractor and Owner. ENTER DATE OFTRANSACTION - NOTICE OF CANCELLATION You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the Contractor of your cancellation notice. And any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the Contractor at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may, if you wish, comply with the instructions of the.Contractor regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make goods available to the Contractor, or if you agree to return the goods to the Contractor and fail to do so, then you remain liable for performance of all obligations under the agreement. To cancel this transaction, mail or deliver a signed and dated copy of this Notice of Cancellation or any other written notice, or send a telegram to at (NAME OF CONTRACTOR) (ADDRESS OF CONTRACT'OR'S PLACE OF BUSINESS) NOT LATER THAN MIDNIGHT OF I HEREBY CANCEL THIS TRANSACTION. (DATE) (OWNER'S SIGNATURE) (DATE) (OWNER'S ADDRESS) [Two copies of this form to be attached to the Residential Contracting Agreement] H - GG 25M 6/92 VII. SUBCONTRACTING Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. VIII. CONSTRUCTION -RELATED PERMITS The following construction -related permits will be necessary in order to complete the scope of workincludedin this Agreement: C�1_ c T- , r o '�� ) C t o `r tP ( n ��( A f i'�C ►M The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction -related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit granting or inspectional agencies, authorities or individuals. Notice: If the homeowner obtains his own construction -related permits for the work described under this agreement, the homeowner is hereby advised that in the ^event of a dispute, judgment and nonpayment of the contractor, the homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter 142A, M.G.L. IX. MODIFICATION This Agreement, including the provisions relating to price (Section II) and payment schedule (Section III) cannot be changed except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed). X. WARRANTIES The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanshi or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect, in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such equipment. This warranty gives the owner specific legal rights, and owner may also have other rights which vary from state to state. Under Massachusetts law, sales of goods carry an implied warranty of merchantability and Fitness for a particular purpose. XI. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void, deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner of a copy thereof. Alkill 13 1 V k-A1Vk-r1L The owner may cancel this agreement if it has been signed by the owner at a place other than an address of the contractor which may be his main office or branch thereof, provided that the owner notifies the contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 4wner'satur Date Signed Cof/�4ictonaturc Da ign d H - GG 25M 6/92 OFFICES OF: AI'I'EALS BUILDING CONSERVATION HEALTH PLANNING IV °F "OR N Town of c a . ;..:; NORTH ANDOVER �saAcHuBE` DIVISION OF PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON. DIREC"I-OR 120 Main Street North Andover, Massachusetts o 1845 In accordancetyvith the provisions of MGL c 40, S 54, a condition of Building Permit Number 4� is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by N1GL c 111, S 150A. The debris will be disposed of in: u m r -� F�-T (Location of Facility) Signature of crmit Applicant ,0 3 `� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Ilome.j sp?Page=2&RecNo=21 3/23/2006 North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/SaveSearch.j sp 3/23/2006 North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/NandoverPubAcc/J*sp/Homejsp?Page=2&RecNo=1 1 3/23/2006 North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=2&RecNo=21 3/23/2006 North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/NandoverPubAcc/jsp/Home jsp?Page=2&RecNo=31 3/23/2006