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Miscellaneous - 340 WAVERLY ROAD 4/30/2018
C- (3 A P�U"'V' 4 - This certifies that ............... 1. . ; t'��.Cj . . has permission for ga stallation .............................. �� P'-< \-PC, --) in the buildings of ........... Pi ........................ at Ck)�.j eve �P North Andover, Mass. Fee......... Lic. No ...... ... ........................ ... GASINSPECTOR Check Perri—, "610-11k3- Building 610vl1 lr Building 'type of Occumcy: Commsed L v EdttCdtic ro j..,{ "I'Li fi-- Near_ Q Alteration: 0 Renovation: Q Replacement GK Plans Submitted: yes ❑ No O rl Abdldelta# FDffURES t6 U1 tu Fre � � Ju D re P W FIIx O> WO _ M aa Q 0. U) U1 2.. tt! 0 u3 W p D te R 0 'ju lu � Z� fA X W [— � 2 w U1 ju BQQ! tetEU fit [� u! p ]z Q! W mlu ? O d u Z tail Q H U Q O uw LS 2 Z 4 !t. X0 >>? S 0 I # i SUS JBSmr_ BASEMH�+i1' # � i FLOOR 2 FLOOR 3 FLOOOR # # I # I. OOR 1 E?OR j7FLOR OR OR Check One Onty Cerl:fsrcate a Installing Company Name-* 0 colRoradon d�a �'LL1 P'% SfaW: � hi P fftnem t]i� f C ( � � 1 Acidress~,.� - -j C I .J {-7 d a Fac[WWCompafly Business Te!_ f � Name of u ;ensedd Pltinll�ed�Gw F = K INSURANCE (�VERAGI~ or its subsiaaSal equivalentwhich meeis the muirernen s of MGL Ch_ 142 Yes Er -NO ^[ {1{>urance <GY I have a current If you have checked Yes Please indicate the type of (:overage by checkirfg the aPP�Anate box below_ insurance Policy Outer, We of indemnity ❑ Band ❑ A i'lWRY � fired by Chapter't42 of the VMVIt I on aware drat tite VCMLgee does not l ave the irhsurance coverage recti O1tVIwfER'S iNSURMCE aed thea my m an this €/era m on fwrahres this anent. Massachusei#s General taws, Check One Only Owner Q Agent: 0 r�� �- $' Ol ONmer or S t 1 havesubfniiied {a� errteredi rBgaTdtn9 fibs appUea6on 3� f>ue gy chefs this box ; I hes eb3f c�iythat a0 of the detaUs � � undfw the permit issued for thus awuc2#on will be a and t�apLer i42 of Ls- acwrafe to the best of ny Kno�dge and ami aII of the eenw compitance wnh art pegtineot pra.risfon of fate � S'� Phnabhtg i rte. v Plrgrrber �` Q Gas f7it� Signature of PlumberlGas Fttief r i4)t °umeyman License Number- ---eQ- APpR OFFICE USE ohm O LP lns#altsr 1.� r Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING C bA A This certifies that ................ uk has permission to perform k,/,- ......... plumbing in the buildings of. C --1 at . . . ....... North Andover, Mass. Fee Lic. No. Check # A PLUMBING INSPECTOR LL, i M FOR t Building Locatlow . ']'�J iC.l lO�`i Owners Name Type OcctrParrcy: Corrirrierciaf Educadiona)�Enl Industrial New: ❑ Alteration: ❑ Renovation: ❑ Replacernent: ❑ TO DO PLUMBING Pemiif# ❑ in6tuttonal ❑ Residen6af (i�r' Plans Submitted: Yes ❑ No ❑ lLV*tJt+ P,NE;E GOV RAGE;: �= I have a current liablIlty insurance PORGY 'Or Its substanflal eilunralentwhich meets the requirements of ML Ch. 142 Yesa---N--a ❑ If you have checked Yes, please indite the type of coverage by checking the appropriate box below. A liability insurance policy Q--� Other type of indemnity © Bond a QWNER'S INSURANCE ililAlifER:1 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 wars alis regumement Check One Only SigmatureorOwnerorOwneesAgent Owner Q Agent ❑ 1 hereby cerfify that an of -the dWft and hdarntaunn i crave submitted (or entered} regarding fills application are tree and accurate to the best of my Knowledge and that all plumbingwork and h�iaiiatlans Pertinent provision of the Massachusetts State Pt C d ander the permit issued %r Etas appttraf3on will be In compliance with all z(4 umbing chapter 142 of Via General ianr--, l l By Type of Lam; C14lurzlber Sigrratum Of Lice ed Pfumber CtylTown ❑ Master APPROVED FFiCE iiSE ONLY)License httrrrtber: f 113 U) 0 Co 45i 2Uj �( W W G a.�� V3 ? W too ¢ 0 tQ - Z tY Co �„ ti! 93 Z ? [L !Y Q 1— Q CL Q Q p} Fx O W _t iiC Q 0 Z Z fJ? i— F LU x m m a a IL 0_ to A fl SUB BSMT, BASEMENT 151 FLOOR FLUOR 3 FLOOR f 4 FL8{3R 5 FLOOR 6 FLOOR 7 FLOOR c 8 FLOOR lnstalfing Company Name- Check One Only Certificate # Address: ��iL�am $tatBak Q Corporation _ Ld Business Tei: 7 ,19'-112Wen: Zip Dade: t31 ❑ ParEnership _ Fa � x G()FnPany m Nae of Licensed Phnmbm-. lLV*tJt+ P,NE;E GOV RAGE;: �= I have a current liablIlty insurance PORGY 'Or Its substanflal eilunralentwhich meets the requirements of ML Ch. 142 Yesa---N--a ❑ If you have checked Yes, please indite the type of coverage by checking the appropriate box below. A liability insurance policy Q--� Other type of indemnity © Bond a QWNER'S INSURANCE ililAlifER:1 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 wars alis regumement Check One Only SigmatureorOwnerorOwneesAgent Owner Q Agent ❑ 1 hereby cerfify that an of -the dWft and hdarntaunn i crave submitted (or entered} regarding fills application are tree and accurate to the best of my Knowledge and that all plumbingwork and h�iaiiatlans Pertinent provision of the Massachusetts State Pt C d ander the permit issued %r Etas appttraf3on will be In compliance with all z(4 umbing chapter 142 of Via General ianr--, l l By Type of Lam; C14lurzlber Sigrratum Of Lice ed Pfumber CtylTown ❑ Master APPROVED FFiCE iiSE ONLY)License httrrrtber: A 0 I e. I N2 9586 Date. 9 - �� -. N."Z- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that FI, ............. has permission to perform plumbing in the buildings of ... vx�. at. . —34 P ... North Andover, Mass. Fee.5?.-��. . Lic. No. . ...... . ......... P�LLBING �IN�PEC�� Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �aN- , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kv�wYCITY POWNER TYPE OR PRINT CLEARLY NORTH ANDOVER MA DATE�— jf lag. PERMIT # JOBSITE ADDRESS -34/0 &1411e -R! y fO OWNER'S NAME ej,+Sjo^q /V�C_'ZeV,41 ADDRESS S 14 t--' TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL El NEW: E RENOVATION: E] REPLACEMENT: ] PLANS SUBMITTED: YESE] NO FIXTURES Z FLOOR— BSM 1 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. C SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �71 � PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MP JP I CORPORATIONS# PARTNERSHIP# LLC[# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE M tl' ZIP 01845 TEL 978-685-9504 \� v FAX CELL EMAIL \ 51 " o c 0 r c W z 0 z -v m C-) --I O z z 0 m cn m 2 m CO) u r_ 0 co m O r z 0 r CO) D m T z < 0 Du mm < X � O T m ?� -i T m c-) M -um O � cn 3 m m m N O Z ❑ y r ❑ o T Z D r z cn m m —I O z z 0 m cn Date. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......................... ............... C�C.A- Ock6-- 4 has pennission for gas installation. �k �'P� ........................ in the buildings of. C- L^— ........................... at . 0 V-) c' .-C ...... , North Andover, Mass. Fee.� ....... Lic. No .. ...... ..... 0 GASINSPECTOR Check # � �':�-S- 8332 4DI\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATEPERMIT # JOBSITE ADDRESS 3110 ����'/�jr� ,-E)-4 OWNER'S NAME OWNER ADDRESS S,44 G' TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL El CLEARLY NEW: El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESO NOD APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY C] 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: OWNERAGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE # 02 q SIGNATURE MP 0 MGF [j JP [:] JGF LPGI 0 CORPORATIONE]# PARTNERSHIP 0# LLC'# COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 5 -7Y -6'i;57` FAX 978-208-0840 CELL EMAIL % p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION S Permit NO: Date Received 1, V P -t , Date Issued IMPORTANT: Applicant must complete all items on this page LOCATION , aD- D«„tet /�� I Print MAP NO:—Z�-"'" PARCEL: 6) ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residenti Non- Residential 0 New Building ❑ O family ❑ t�afion wo or more family ❑ Industrial ❑ No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: 0 Demolition 11 Other T_ ®S ptic O Well ` Flo d an _ m Wetlands ®W shed Distrie f ® Water/S,ewer..:.s L L_�_ �� �-d-- � DESCRIPTION OF WORK TO BE PERFORMED: Address: A VO CONTRACTOR Name: Address: Type or Print 501 -Vce-a �C�Gr�eVbtic CcnAAv&, c te, I- C Phone: �j Supervisor's Construction License: 7 225- Exp. Date:—lo- Home o Home Improvement License: Exp. Date: G 2- A2Wl Z ARCHITECT/ENGINEER Phone: Address: / I 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: $—!.X71 O — FEE: $ Check No.:Receipt No.: d 161810 NOTE: Persons contracting with ynrM#t5Hd contractors do not have access to t"qty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pool$` `.r ❑ Well ❑ ` Tobacco Sales ❑ Food Packaging/Sales 0 Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH r COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: -Signature: FIRE DEPARTMENT Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS 'a,J V\4 -V c -K Located 384 Osgood no no Dimension Number of Stories:__ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE I-ITERATURE: Yes No MGL Chapter 166 section 21A-1- and G min.$100-$1000 fine Doc:.Building Permit Revised 2008 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 ❑ 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 ❑ 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) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products OTE: 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 o 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 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals t:lhat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc -Building permit Revised 2008mi Location 3Vd zd,? No. a --? Z= Date TOWN OF NORTH ANDOVER 0 0 0 $ Certificate of Occupancy C Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 24220 Building Inspector ri M s.� *3 N Q i !!° E Q �C y= p s = F r0+ O. k o Lc 1�e1 ° Q i E o m G m C N to CD L oc�?—% 3 N CD CO ccl ., m N O 2:2 N mcoo o.v N 4D O CoItQ V y O :cvo� C oc.o Q o �mc CD ui -N -d t O C N V •m y a m -O -o x o :aoLA= t- t :0 o.$ m O z E CDL N L N O i N C O cc cmm oc os C _ m 0 cm c -c N CD t O Z O J CD z Q u CD O CD _O co O ca C C W CO2 O CD O �O Co Co CL CD L O O Q o- CMa ca o �"0 c ea ev CO O C Z O 0 CL LD y O O d CO2 0 0O �o O U rx Z �o a o� v Lwa C N O o ¢ C a w v W u � O 'c w z o C o w° V)w° a�' U w a°' w n r � N Q i !!° E Q �C y= p s = F r0+ O. k o Lc 1�e1 ° Q i E o m G m C N to CD L oc�?—% 3 N CD CO ccl ., m N O 2:2 N mcoo o.v N 4D O CoItQ V y O :cvo� C oc.o Q o �mc CD ui -N -d t O C N V •m y a m -O -o x o :aoLA= t- t :0 o.$ m O z E CDL N L N O i N C O cc cmm oc os C _ m 0 cm c -c N CD t O Z O J CD z Q u CD O CD _O co O ca C C W CO2 O CD O �O Co Co CL CD L O O Q o- CMa ca o �"0 c ea ev CO O C Z O 0 CL LD y O O d CO2 0 �o m c �o o� Lwa C N O C V V •per � C RM wow"p� O A c mCc O b - m N Q i !!° E Q �C y= p s = F r0+ O. k o Lc 1�e1 ° Q i E o m G m C N to CD L oc�?—% 3 N CD CO ccl ., m N O 2:2 N mcoo o.v N 4D O CoItQ V y O :cvo� C oc.o Q o �mc CD ui -N -d t O C N V •m y a m -O -o x o :aoLA= t- t :0 o.$ m O z E CDL N L N O i N C O cc cmm oc os C _ m 0 cm c -c N CD t O Z O J CD z Q u CD O CD _O co O ca C C W CO2 O CD O �O Co Co CL CD L O O Q o- CMa ca o �"0 c ea ev CO O C Z O 0 CL LD y O O d CO2 0 2The Commonwealth of 1Ylassachuseits -Auk Department oflndustrial.Accidents A ._,; (: Office of Investigations hin 600 Washington Street g. Boston, MA 02111 " = " www.mass govldica Workers' Compensation insurance Affidavit: Puiiders/Contractors/JElectricians/Fllumbers Applicant Information . Please Print ]f e*b1v Name (Business/Organization/Tndividual):��,.�,o��,l City/State/Zip: {-i(,, �A _ Phone i#: G S .--7 7 3 �- Are you ali employer? Check the appropriate 1. am a employer with ''S box- 4. ElI ain a general contractor and I Type of project (required):❑New employees (full and/or part-time).* have hired the sub -contractors 6. construction 2. ❑ Iain a sole proprietor or partner- listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g. Building addition required.] officers have exercised their I0.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL . 11.0 Plumbing repairs or additions inyself. [No workers' comp, c. 1,52, § 1(4), and we have no 12.❑ Roofrepairs - insurance required.] T employees. [No workers' 13.0 Other comp. insurance required.] *Any Applicant that checks box #1 must also fill out the section below showingtheir 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors aiid their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L� '` iy , At-/ frV,-i Policy # or Self -ins. Lic. #: � �/ S ci 7 �'Z o2� Expiration Date: ZC Zo%z Job Site Address: City/State/Zip: oLA,� Attach a copy of the workers' compensationpolicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Sedtion 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 ofthis statement maybe forwarded to the Office of Investigations of the DIAfQ,r inmr9eTcovprage verification. .Ido hereby ofpesjury that the information provided above is true and collect.' V7 -- Lone #: � 6 Official use only. Do .otF*11q.th1s area, to be completed by city or town offrcr'al. 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 Inst°ncti®ns 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 ofthe foregoing engaged in a joint enterprise, and including the legal representatives ofa 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 ba deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local Iicensing agency shall withhold the issuance or renewal of a license or hermit 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 ofpublic work until acceptable evidenceof compliance with the insurance' requirements of this chapter have been presented to the contracting authority." , Applicants Please fill out the workers' compensation Iaffidavit 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 cany workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any.questions regarding the law or ifyou 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 PIease 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 pennit/lieense 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 ofthe 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 ventur'e (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 lndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext406 or 1-87. MA.SSAFT Revised 5-26-05 Fax # 617-727,7749- www.mass.gov/dia w 1 (h yr c o co a CL J .,, q Q x J' G � C o Nor: J, 1 •Q � � 0 U d M r p �V H Q N= m ' .2 m - Fully Licensed and Insured • Member of MA Better Business Bureau 'PrIOP 0.5ar Member of NH Better Business Bureau .s GAF Cert. ME # 20212 IV➢ 1 HIC Reg # 166661 EIN # 26-1081508 r„—, n4A rSl re ma79A -�— & Nuo fi—JL� Genera/ Contracting, LLc �� m0 51 S. Broadway #2214 Salem, NH 03079 (603) 890-0084 110 Stevens Street #141 Andover, MA 01810 (978) 475-0095 P� ,OPAOSAL SUB ITTED TO IVLr PHONE I DATE 02.0 STREET ,4—` E-MAIL CITY, STATE, AND ZIP CODE I/� JOB LOCATION 4 Completely protect the home with tarps to catch falling debris. Respect and protect shrubbery, and flower beds. Strip off _!;�_ layers of roofing material down to the bare roof deck. -Inspect-the roof deck for structural defects. Determine the condition of the underlying plywood or boards, and repair and replace as necessary*. Inspect roof ridge for proper 11/2" g acing on either side of ridge for maximum exhaust ventilation. Cut in if necessary. Install new heavy gauge (color) A4 QM drip edge at roof eaves. Installice and water shield to meet manufacturer's specifications (i.e. 6 feet from roof edge, 3 feet centered in valleys, around all skylights, chimney bases, roof penetrations and at all sidewall transitions). Install Dwicptr breathable roof deckrotection to remainder'of the roof deck. Install new heavy auge Ukt (color) A0� drip edge at roof rakes. Install starter strip at roof eaves and rakes. Install GAE'C'`E nn Inc,r\ire. L --i jrtt - 44 D desired color. -t-1 (color) Install new flashings to meet manufacturer's specifications. (i.e. sidewalls, chimneys, skylights and roof penetrations). Install �9_ (feet) of �5 ' VI-t'y`l� ridge vent at roof ridge to allow max rnum ventilation. Hand nail to ensure proper fastening. Install ! o (feet) of7�A,�-k distinctive hip and ridge cap. Hand nail to ensure proper fastening. Thoroughly clean up and dispose of all roofing debris on property. Magnetically sweep property for nails. Notes: - �[ fr C90 11 C14 fiv?K e �. s e GGj z�T'tG�L. / Oyi SOLI. Edmunds General Contracting will: • Obtain all necessary construction -related permits to complete this project. • Perform work as efficiently as possible without sacrificing quality. • Furnish and install all necessary materials to complete the project. • Provide a thorough clean-up and disposal of all debris generated during project. Edmunds General Contracting LLC agrees to commence work on/or about 6 / Z / � and described work will be completed in about I days. 0 Product Upgrade 1: GAF ( GAF yD - ��— Prnrli v+ I Inr,rorlo 'T Contractor's employees are fully covered by en's compensation and liability insurance. Upon completion of the above work, all undersigned agree to execute and deliver to the contractor, their joint note in accordance with his (their) above obligations as requested, by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees, and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by the contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. Edmunds General Contracting LLC guarantees all workmanship performed for years. We will register factory enhanced warranty providing 5V ye material defect coverage and _X years of workmanship def t coverage through GAF Materials Corporation for: 7o charge. —_e- the additional cost of X 'Edmunds General Contracting LLC will provide the materials, labor and d i s osal to replace up to 64 sq. ft. of r of decking and 20 ft of fascia at no additional cast. Any additional materials including labor and disposal will -- replaced at 1;15 per sheet or _ linear foot. Edmunds General Contracting, LLC agrees to furnish the material and labor complete in accordance with th above ecifi ations, for the sum of 5' ars ($ 6'7 10 ) Payment Terms: • A deposit of _�_ (no to exceed 1/3 of the total contract) is due upon start of work. The balance of � is due when work is completed to the satisfaction of all parties. • For your convenience we offer financing and accept all major credit cards. If you elect one of these options we will add anditional 5% to the contract price stated above to cover dealer/merchant fee(. -N4> C- <.-- l., (� • A finance charge of 1.5% per month 118% per year) will be charged on p�astd e accounts over 30 days 01CCEptance of PTOpo5al - The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. M, Date of acceptance: ► ,A Y a- 6, � U 11 All material is guaranteed as specified. All work to be completed in a workmanlike manner according to standard practice. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the stated contract price. Contractor is not responsible for damage due to high winds, tornadoes, hurricanes, fire or other hazards. Owners) agree to carry fire tornado and other necessary insurance. Contractor is considerate of ovrner's landscaping and but due to the nature of the roofing installation some damage may occur. We attempt to minimize any damage, and will not be held responsible if any damage occurs. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (I.e. water stains, crumbling plaster, exposed nails) -or conditions resulting from application of materials as specified above. Items in the attic may need to be covered by the ntractor is not responsible for damage caused by ice dam build-up. All agreements are contin, n s ccid nts, or delays beyond our control. Authorized Signature: jl Edmu s Gene I Contracting LLC of This pro�o�aSre(ay be withdrawn y us if not accepted within 20 days. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Authorized Signature: &&5Au4 �D. ,.. Authorized Signature: All home improvement contractors shall be registered. Any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation, 10 Park Plaza, Suite 5170, Boston, MA 02116 (Phone: 617-973-8700). Owners who secure their own construction -related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund provisions of MGL.c.142A The owner will receive a signed copy of this contract before work will commence. The owner has three (3) business days to cancel this contract and incur no penalty. Correspondence should be directed to Edirunds General Contracting LLC at the above address. Rev. 04111