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HomeMy WebLinkAboutMiscellaneous - 346 WAVERLY ROAD 4/30/2018:�� I�7 <- S .� 04/08/2011 FRI 9:35 FAX 4 April 7, 2011 /2002/002 Paul M. Goldberg, P.E. 17 Chipping Norton Ln Bedford, NH 03110 • (603) 765-8650 Re: Paskalis Residence 349 Waverly Road North Andover, MA 01845 Dear Mr. Paskalis: At your request I have inspected the construction of the Second Floor Dormer addition to the above referenced residence. My Inspection indicated that the structural work was in accordance with the drawings that I approved earlier. The workmanship and materials meet all construction industry standards. If you have any questions or comments, please feel free to contact me. Paul Goldberg, P.E. Date.. -3/ . � �—//o -.1 ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that A ........................................ has permission for gas installation .!)X. in the buildings of f. k,� �/ ................................ at North Andover, Mass. Fee. -7P ... Lic. No.. r Check# Ir< =16 N (4 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New ❑ Renovation ❑ Replacement Plans Submitted Date Permit # Amount $ (Print or type) Name Address __ _ice C3 D J. ra i—a u �— Check one: Certificate Installing Company ❑ Corp. Partner. ['Firm/Co. Name of Licensed Plumber or Gas Fitters INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes IT- No rl If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy - Other type of indemnity ❑ Bond 13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 1 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus%!!�Iate GA Code and Ct apter 14V the GAeral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Wumber Or Gas Fitter Plumber .Y Gas Fitter License NUMDer -Master MJourneyman F vi a O CG H aaO O p cC vs w C p O z H zV w x it V F Z E.r a S z W W W z �" o W U x w w m o w a 3 0 o z c H x SUB -BASEM ENT a° > c° o B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR -,• .:.-.. E.TH. •FLOOR (Print or type) Name Address __ _ice C3 D J. ra i—a u �— Check one: Certificate Installing Company ❑ Corp. Partner. ['Firm/Co. Name of Licensed Plumber or Gas Fitters INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes IT- No rl If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy - Other type of indemnity ❑ Bond 13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 1 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus%!!�Iate GA Code and Ct apter 14V the GAeral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Wumber Or Gas Fitter Plumber .Y Gas Fitter License NUMDer -Master MJourneyman The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations -600 Washington Street Boston, MA 02111 ky www.mass govldia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Mlicant 1nfnrma1Nnn Naive (Business/Organization/Individual): Address: City/State/Zip: Phone #: mployer? Check the appropriate boa: mployer with 7E:11 4. ❑ I am a general contractor and I es (full and/or part-time).* ole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp, insuranCe workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption MGL myself. [No workers' comp, per C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] * •-nv applicant that check.- box #1 mus, also . t illi out the section below shoe:.^.^ �� w T , �> Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors musty 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. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declarationa e (showing P g ( wing 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 penalises of perjury that the information provided above is true and correct; Si ature: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town offic£aL 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 as d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the. owner of a dwelling house having 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 notbecause 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 coxnpliance 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future perinits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business, or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwuw.mass.-gov/dia Date..'&—. -'S— ........... ,ORTH 0 TOWN 0 `N�RZTH ANDOVER W, POW PERMIT FOR GAS INSTALLATION This certifies that ...... ................. has permission for gas installation in the buildings of .,,� . .................................. at . ... �-. I .. ). � ... North over, M ass. Fee�� .... Lic. No. Af— Check# / -/ q,�— 2, 6773 1 MASSACHUSETTS UNIFORM APPLICA'TON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations J W � � � 7,3Permit # Owner's Name r Amount $ New� Renovation Replacement Plans Submitted ❑ ,� �, F e � a z z ° �• X CA z d W Q C Fes- w G7 O > W W U z W o SU B -BASEM ENT VO �° o 0 F G _ B A S E M ENT 1ST. FLOOR 2N D. FLOOR 3RD. FLOOR 4TH. FL00R 5TH. FLOOR 6TH. FLOOR 7TH. .FLOOR . 8TH. FLOOR (Print or type) Name_ Check one: Certificate Installing Company Corp. Address (J� YC. A—�( 7-- �► U 1 ;✓aJ' ,1 El Partner. Business 'e ep one � �� ®� ,7 Firm/Co. Name of.Licensed Plumber'or Gas Fitter INSURANCE COVERAGE ! have a current liability Insurance' policy or it's substantial equivalent Check one:. lfyou have checked es please indicate the a cove y YCS � No[3 Liability insurance olic �-y type rage b checking the appropriate box. policy LJ — Other type of indemnity D❑ Bond Owner's Insurance Waiver. I.am aware that the licensee does not the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: wner i hereby certify that all of the details and information f have submitted (or e�Otered) in � application ion 3 a and accurate best of my knowledge and that all plumbing work and ins lations performed under Permit !s ued for this application will be in nate to the compliance with all pertinent provisions of the Massae s Stat as ode Chapter I of the Gen y BY ��ignature of License lumber Or Gas Fitter Title Plumber City/Town.. [3Gas Fitter3 (cense um er Master APPROVED (OFFICE USE ONLY) Journeyman The CornrnnRwealth of Massachusetts 1 [,K /(jDepartment of Industrial Accidents iirOffice of f�zvestiQ :i F 7u Wa a tZtlOnS ' 600 shinaton Street MA 02111 Workers' Compensation insurance Affiday.its Builders/Co n r'actors/Electric' applicant Information>ians/Piumbers Name (Business/OrganizationMdividual): Address: City/State/Zig: -7. o Are you an employer? Check the appropriate box: 1� P Phone #: F j r" J, - am a employer with 4. ❑ 1 am a general contra^tor and I 2. ❑employees (full and/or part-time).* , have hired the sub-contrac 1 am a tors sole proprietor or partner- listed ori the attached sheet i ship and have no employees These sttb_contractors have working for me in any capacity. workers' No workers' comp, insurance j Oor o• insurance. . P ❑ We are a corporation and its 3. ❑required.] officers have exercised.their I an a homeowner doing all work right of exemption per MGL myself. [No. workers' comp. c. 152 insurance required.] t , § 1(4), and we.have no PlaYees. [No .workers' Type of project (required), 6. ❑ New construction 7• ❑ Rem odeiing . 8• ❑ Demolition 9. ❑ Building addition 10:❑. Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 777— comp. insurance required ] I 13 ❑Other /�C /d �yc [---e,A 1Any a own p w1j t checks box # 1 .must also fill out the section below showing their workin, compensation policy mformatton. + iiomcuwoert wltu submit.{]tfs a�iidavit iftdicarittg &ley iu doing, 0 t=.:;,_} �� YConmu coca that check this box must attached an additional sheet showirm - �u tn_n n�re ou�i0e contrnc[urs rnuSi submit a now amdavir indiczzin , the name of fhe sus ccatraetors and their workets' camp. S = n I am an. em�layer that is providine workers' co enation P Poiie} inrannation. information.° assurance for m3' employees. Below is the poficy and job site Insurance Company Name: Policy # or Self -.ins. Lic. #: Expiration Date: Job Site Address:.2�,., C �(( Attach s copy City/State/Zip: � ,4-r of the workers' compensation poi y declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MC3L c. I52 can lead to the imposition of criminal penalties of a fine up to 511500.00 and/or one-year imprisonment as well as civil of up to .5250.00 a day against the violator. Be advised that a co penalties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. statement of this statement may be forwarded to the Office of .1 AI I ---- L., pauzc Z s of 73' r u ,that the information provided above is true and correct Official use onip. Do not write in this area, to be .completed by city or town off ciaL City or Town: Issuing Authority (circle one): PermitlLicense # 1. Board of Health 2. Building Department 3. C' /To 6. Other was Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 4" Type of project (required), 6. ❑ New construction 7• ❑ Rem odeiing . 8• ❑ Demolition 9. ❑ Building addition 10:❑. Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 777— comp. insurance required ] I 13 ❑Other /�C /d �yc [---e,A 1Any a own p w1j t checks box # 1 .must also fill out the section below showing their workin, compensation policy mformatton. + iiomcuwoert wltu submit.{]tfs a�iidavit iftdicarittg &ley iu doing, 0 t=.:;,_} �� YConmu coca that check this box must attached an additional sheet showirm - �u tn_n n�re ou�i0e contrnc[urs rnuSi submit a now amdavir indiczzin , the name of fhe sus ccatraetors and their workets' camp. S = n I am an. em�layer that is providine workers' co enation P Poiie} inrannation. information.° assurance for m3' employees. Below is the poficy and job site Insurance Company Name: Policy # or Self -.ins. Lic. #: Expiration Date: Job Site Address:.2�,., C �(( Attach s copy City/State/Zip: � ,4-r of the workers' compensation poi y declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MC3L c. I52 can lead to the imposition of criminal penalties of a fine up to 511500.00 and/or one-year imprisonment as well as civil of up to .5250.00 a day against the violator. Be advised that a co penalties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. statement of this statement may be forwarded to the Office of .1 AI I ---- L., pauzc Z s of 73' r u ,that the information provided above is true and correct Official use onip. Do not write in this area, to be .completed by city or town off ciaL City or Town: Issuing Authority (circle one): PermitlLicense # 1. Board of Health 2. Building Department 3. C' /To 6. Other was Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 4" Information C, nd 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 "..very person in the service of another under any contract ofhire, 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 appurttrrant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state a►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 o'f 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 worl< until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the coritrmcting 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-contractor(s) name(s), address(es) and phone number(s) along with their cerdficate(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 reser rdinv the Iaw or if you are required to obtain a workers' compensation policy;please call the Department at the nmsnber.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 legrbiy. 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 most submit multiple penmit/iicerise applications in any given year, need only submit one affidavit indicating currerrt policy information (if necessary) and under "Job Site Adcli-ress" 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. NWhere a home owner or citizen is obtaining a licenses 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 Departrnent's address, telephone and fay, number: The Comrnonweal.th of Massachusetts E)epartment of lmdustrial Accidents Office of Lavestigations 600 Washington Street Boston; lu1A 02111 Tel. # 617-727-4900 e= 406 or 1-977-MASSAFE Revised 5-26=05 Fax # 617-7-7-7749 wv^kmass.Dov/dia L Ee 9, Q � M h a M �n N v r 4 0 0 E o E 80 • C vOi O b oo c 3 Y .0 t ° x H U t: O O a y a °o d U CL O F a; 0 i A Q a L a C O T .0 U W' ° a i 73 a b G E� o ai w. C U ,a b O y � O d v '•�= a> U a� .� M O N O O C bD 4, Y p., w 3 U .b O OA U T O o x o 0> b �. � Cd 0 G y N cn ❑ __ Is cd 63 U M Q Q W �4 •� � +'O.+ R N, cCC .� V1 ..a •Vi � � d lu y bD s- O G o E � o u u E E a O "o ea .�: u y u O '� O U d A U C7 R4 A.. U 0 0 E i I U C y C O 7 O fU n U 2D .j m J y N LO O N 0 O a) C7 o E 80 • C vOi O E oo c 3 Y .0 t ° x H U a O O a y a °o d c F a; 0 i A Q i I U C y C O 7 O fU n U 2D .j m J y N LO O N 0 O a) C7 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: IMPORTANT: Apl �tLQCATION' 00nDCDTV« (l1A/nIRR 1 lA_ I MAPtNQ:� PARCEL: Date Received 41-11,1d�— ant must complete all items on this page �` O o � Residential Non- Residential New BuildingOne nO ey ELM G{DISTRICT -' Histor+ctD+strict yes .no _ Mach+ne ShoplV+llage ryes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New BuildingOne famil Addition w r more family Industrial AlteT!,=ep No. of units: Commercial Re cement ), Assessory Bldg Others: Demo i ion Other Se - 1Nell" 7"15 6o a Watershed,Disfr+ct` Y 'Water Sewer. J . v' ` i�— n DESCRIPTION OF 94 OWNER: Nam TO BE PREFORMED: Type or Print Clearly) Ph HU U re55. ..:y....._..- .� _. ,.-..s :.. #. ': .:,.,. C�-.v t ---{.. .., 1f -_.. .vim ...-. -.: _. .,.#.; .-'.1,. •f.'fi14F'� c±., U-wsr .-i.a»x - ���., ;.'i_ ac.. .4r._...�:.:...._.,,F.-.-.�.r fGONTRACTORe Name l i ck7 Phoneys �Acliiress ��`'%tc�°� � ��s N�� >.�-•�—_���. 'd��l��' ' r Supervlsor�stGonstruction License(;9`Exp +Date.-: _ ,. #Home lmprov4ement1License � �©C G /� �- a iExp Date Al ARCHITECT/E Address: Phone: . No. ---FEE--SCHEDULE. BOLDING P IT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASE ON $12W0 PER S.F. Total Project Cost: -$ F E: e a, Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to he guaranfund Signature of Agent/Ovvner: - Signature of contractor M Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Located s =Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. permanent Dumpster on Site � R � + THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS o HEALTH COMMENTS Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located s ood Street _ no-,uesite eIRE}DEP Lo `v etl1at,1245MaijSteet DepartmentTsignature/dated � ., a � R � + .�, .. .., COIVIM.ENTS, Yom. �. a''" ilia -Q 1'}'•` c��� t �. ., ,�,L t �?a..1_�iM+ :ICDA f,(�� 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 LITERATURE: Yes No MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine NOTES and DATA — (For de ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 nt use 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 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 NOTE: 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 that 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ Check # 25463 building Inspector • L� ZA fx• J W x U. 0 O m � C a) t `= Y O LLL E Ln f1 Ln OV a z Z m O 7 LL : = v U LL 0 LA Z Z m J a to 7 d' @ LL o CA Z V v J W 7 OC N u [ LA LL a V a CA Z N to 7 d' LL Z Q YI 5 U. i m O Z a) N O Ln clz% uj a; O � o Q. � cca c o ;0 E Q L N d O CD0 L ccc O O .N N <.i _: Q. L m 0 •a > Ccc c °) a) as o •r- 0o ED 0 U)CD .a � w- o L O Z N r- O O c, = :t• 3 i O O FL L CL CL d d 0� c cc 0rn o cc Q L L :6 CD 0 to d 2 m W = •a - O O LL .yV) c .Q O v v w v _ zi V Q O_ :d Cl) °'>w= c � .0O F=- . ao0 LV • N 1;7 0 w v 0 *1 C � O 00 O Q Q � Q .Cc Cc J -0 O d Z � U) r_ LU N U) W W C9 W U) a Z z 0 m 2 Z Ocr— • GZ Cl) X Z o O LJJ U W c W J . m 0 O N N t O z O Q J O a LV • N 1;7 0 w v 0 *1 C � O 00 O Q Q � Q .Cc Cc J -0 O d Z � U) r_ LU N U) W W C9 W U) JULES ROOFING CARPENTRY CO (Al Finish ftrklxnyt Wing OFMCE , /FAX (6 17) 567-2808 67 LUBEC STREET Cell Pit (617) 212-5612 EAST 8 "SN MA 021-28 Lic #067095/Reg A12008: TO JOB DFsc:4,H] Icv: NAWDLOCATION v . ts . . ........... ) a6 /v, . ........... . . . ........ ................. a, 7� c .... .... ..... . .... • > ................... A. ............ �le . ........ . . .... .... ... . ....... ............ L —7� THIS ESTIMATE IS FOFi C,(DIMPLETING, THEJOB kS DE SCRIBIED ABOVE.T I COr E D E D IT .S BASED ON OUR EVALUATION AND DOES NM INCLUDE MATERIAL a ST OST PRICE INCREASES OR ADDITIONAL LABOR ANE; 101ATERIALS WHICH MAY BE REOUIRED SHOULD UNFORESEEN PROM.E-'IVIS OR ADVERSEST IMIATED WEATHER CONDITIONS ARISE A,�FER 1-HEWC61K HAS STARTED, ,-.1- THIS-.1- JULES ROOFING & CARPENM'CO. JOB Roo OFFICE/FAX (611) 567-2808 67 1 - L)BEC STREU Cell Ph. (61Y) 212.5612 EASTSOST).N, MA 02128 Lic #067095/Ro8 #120081 1-0 JOP - 7qA F1 E , L. 0 C A" ON a JOB DESCRIPTM: 4:x - ... .. ..... . .. ....... .. .... . .. ..... Fa ...... .... .......... ........... 'f` ESTIMATED tivlkf� IT. ill-) r"Op T!NG THE JOB BFD ABOV[:` � � % "' , , I '. q PIA, T- ;Rm :i',jC',LUDE JOB co� AND NAIATEWALS 1NC1*-1EA$=-�I 0" ALCI "NAL Al E E D 14" 14 F O!"i L. 0- E1 1 01 R A. V F P ESTIMIAT ED W�' A T i 1F11'('1DNi^)1 R THE HAS S, IAM Ef, BY foa11.1ti�.tchii� fts D61JAt-tinent of•Ptiblic'Safet} r Boat dlof Building Re'aulatiofis and �Standard. i Constrpction 'S'upervisorh. License One 'and Two- family Dwellings License: CS 67095 JULIAN GRILLO r 67 LUBEC ST EAST BOSTON, MA 02128 Expiration: 8/30/2013 Commissioner Tr#: 20095 Y",✓µLQ'94CLGf2[IJP.b �, ,<rct c 7, �u< <er , ffrirs &c $usrness R *i s3nun ft c{OIYIF e,�# spa .r u e e `* r pROaJFtt ENT CCNTRA RACTOF Regiu4on120081 " ° Type: Expiron_ 10/=15/2013;' DBA JUL S; ROOFING- ND CARPENTR' CO: J�i LUIO G,RILLCS 67 LUBEC ST, EAST BOSTON, MA 5;1:28=" Q'f ._, Undersecretary _it'd- t -: D 1 , = in: 07101 IC'r•_ -HUE _ r To � -- „; - F', 4'.^ 4,5.,. :39 .11 •1 . !4 : �. _ i' _..._ _1lT_tl_I S,e : 1/1. p QO v DATE (MM1DDrYYYY) . '12 CER` IFICA ' F LIABILITY INSURANCE �/ i;'iIS CjERTIFICA`fE: IS ISSUED AS A MATTER OF iNFOIPMATION ONLY AMD CONT- a ry? R9�� T � UPON THE CERTIFICATE HOLDER. 7WI5 CERTIFICATE DOES NOY AFFIRMATIVELY OR NEGATIVEI-Y AMEND`, EXTEND OR :ALTER THE COVERAGE AFFORDED DY THE POLICIES BELOW: THIS CERTIFICATE OF INSURANCE DOES NO?COWITUTE A CONTRAC; RETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. !!V1I�ORTkNT: i€thE`r e tifl�ate holder is an ADDITIONAL INSURED, the � ;.IICY(Ias must b-- endowed. if $U19ROGATION IS WAIVED, Subject to the terrns and conditi+om of tho policy, certain FO�i; -.ay -.ay require an Cs,?or-serneilt. A a v t.R=e=nt on this cortlfleatc docs not confer rights to the certificate hoklar in lieu of such endorsetnent(s). r01:0,1140GxUE NAM ASTCandace RR1ey INS AGENC') TNC Iftir. (lel) 1546-9300 �F� (781)645-1545,,ii•r Not- _ 90 s;�=er St (aGt. EMAIL P.O. Box 181 R�W!NSURER'S), AFFORDING COVeRAGE NAIC 0 Arlington 1AA 02476 !NSUMM A:%+'.S' rf01'= r. Dedham INWRIr -- r�- -- INSURERs;A.I,X. Mutual Ing. -Ccs. --- Jules Carpentry IN-it+ReRC: T 67 Lubec St ;'(4SURER D; Easy', Eeoston � �. _ � MA. 02128 .R. 1 wsuRe=R r : I CCVERACSS _ CERTIFICATE NUMB R:Town of N Ar-doVer REVISION NUMBER,. THIS !S Tom, CFPTIF"Y' THAT THE POLICIES OP I^IUL!f�AN-CE z!,RT:[) BELOW _.. 4 -EEN i`i__C: ?`- THE: Ih! OREJ NAMED ABOVE FOR THE POLICY PERIOD INlJ!.ATED. N^vTWiTH°T •'=I `!� AhJY RE{�U!!?%ivlENT. -ERI OR CON -;IT! � . _ ,u iY ,�OPrirll .- _ OR iv T HET. rOCUINENT 1MTN RESPECT TO NIHICH THIS At.s i, a CERTIFICATE MAY t3f ISSUED OR MAY PFRTAI"v, THE !t; !1!;AN s. AF! l;R_T_r E`! THE P LITE LE' :=:n!L�e HEREIN IS SUBJECT TQ ALL THE TERMS, r:(r'I I)R/t'1N3? At4P ('11N"i-I--NA Car 2UCH P•^_'L!CIIES- LI PA ITS SH"CIVJ4 MAY HAfE BEE#J REDLIC. ED eY PAID CLAIM �. Tq P0�1CTS'�I}3 n.e.r. TYPE OF INSURANCE ClEkERALblABIL�t"s' �` rc^,LICY NUMRErt — � POLICY EF POLICY 4MIDD;"iYYY' EXP MMiD r m P ,------ -- LIMITS i � � 1 I EACH OCGLHr~tNC_ , ow, 04 ('.0 I' F,N RAL' ASILIT'( X ^NhIE.Pa nL� >: +` Ly--i I CS94$�2A 8/2!/209.1. !8/^25/2012 1- _ _ _ SEC�Ep -r��- - g, 50,00 T MED FXP IAn on -person+ X 5100 PERSON-ALR ADV INJURY - $ 1 r OOC , C0' GENERAL, A 3C. RIGATE 2,000,00 I I,.a .$ D c' + Tv"'1,OOC, OC G� UGT3 - C aMPlOP A _ G $ C T iF$ R: GEN'LA REGATE!_i; APPL K R0 .K P3LIG�1. _t y AUTOMOBILE LIABILITY AUTOMOBILE ANY AUTO ALL OWNED 1 - SCHEDULED AU IU5 AUTOS NpN•OwJED I-I'rtt,t) A,!Ti1,� �� A,UTOS � ! I 1 I i�JL [NIFgPb!N+iL�IMI� 'rnt) S BODILY INJURY (Pur purer) $-W-- 80DiL7 INJURY IPSt acci et tt! r PROPERTY DAh1It � Pfr arcidrtntl $ � EACH OCCURRENCE S �� LLA UAG ' I OCCUR II � AUL REGA11: a LEXCES5LIAR GLA'I.A ,-ivw;:+t F.TF.NTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANY PRCPRIFTCIRIPAFTNGR,'EXCCUTI4E OFFICERR'hiEMBER EX"l-VOE07 (M8:lltetOry !:1 NH) ifes, aeauiw under DESCRIPTION OF L;:.`ATPN$ below N 1 A � I I I ! I G'C,'v'bG$$07. 18/27/2011 I ` /27{""2012 �+ I _ 5 X WC ;TATU, DTH- I L. EACH ACCIDENT $ 100,00 1--- - [ E.L. DISEASE - EA EMPLOYEE $T_ 100,00 E.L. DISEASE - POLICY LIMIT u 500,00 I DESCRIPTION OF OP=P.A1ION5 i LOCATIONS t VEHICLES (Attach ACORD in', Addit;cnal Re, Iaeke Stheduk), Irrm}ra speca Is rujulree) TE HOLDER `own a:C North Andover Bui -inch Ia6pt 1600 Osgood St North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITA THE POLICY PROVISIONS. AUTHORIZED REPI:ES _r,TAYiVre Parrye9wa,7111�111 - - ACORD 26 (2014/05 (z) 988--2010 ACORD CORPORATION. AI; rights reserved INS025 pioas) 0t The AGGRO name and Ingo are registerad marks of ACORD The Commonwealth ofVlassachusetts • - Department oflndustriglAccidents Office of Investigations M. 600 Washington Street .Boston, lV1A 02111 www.massgov/d'ia Worker' Compensation Insurance Affidavit: Builders/Contractor/ElectriciansfPlumbex s Applicant Information Please Print Le>;ibly Name Addrei City/State/Zip:,'%'yt/1j„ Phone Are you a employer? Check the appropriate box: 1.19fam a employer with 4. ❑ I am a general contractor and I employees (full and/oxpart time) * have hiredthe sub -contractors 2. [] I am a sole proprietor or partner- ship and'have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. El am a homeowner doing all work myself. [No workers' comp. insurance required.] Ti listed on the attached sheet. x These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type ofproject (required): 6. [] New contraction 7. [1 Remodeling 8. ❑ Demolition 9. ❑ Building addition ME] Electrical repairs or additions 11.1] Plumbing repairs or additions U.Npiat repairs 13.1] Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submitthis affidavit indicatingthey ge doing all work and then hire outside contractors must submit anew affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. .1 am are employer that 1s providing workers' compensation insurance for my employees Below is thepolicy and job site information. , , A , , I i r _ Insurance Cc Policy # or S elf -ins. tic. #: �O U/S/9c>l� Expiration Date: Job Site Address: (�/�t //City/State/Zip: forp Attach a copy of the workers' compensation-policydeclarationpage (showing the policy number and expiration date).�3- 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 $250.0 0 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 cqt unrleifliepains rs.77/fia that the information provided above is true and correct. 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 )lealth 2. Building Department 3. City/Town Clerk 4. EIectrical 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 ofhire,- 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 shallnot 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 ofpublic 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), addresses) 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. Iran LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 pemilt/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. Anew affidavit must be filled out each year. More a home owner or citizen is obtaining a license o 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: `rho Commonw.oalth ofMassachusPtts - l3. apattment of fadustdal A.ccidepts 9l'lloe ofIuvestigation 600 Washing w Stwe"t Butw,MA02111 Tel, # 617-7.274900 ort 406 or 1-577,A%SSMB Revised 5-26-05 Fax # 617^727-7749