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North Andover Board of Assessors Public Access
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North Andover Board of Assessors
roperty Record Card
Location: 353 ABBOTT STREET
Owner Name: CONNOLLY, JAMES M.
ROSEMARIE CONNOLLY
Owner Address: 353 ABBOTT STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6 - 6 Land Area: 0.47 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2454 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 483,800 468,700
Building Value: 294,200 274,700
Land Value: 189,600 194,000
Market Land Value: 189,600
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=2252411 &town=NandoverPubAcc 3/18/2013
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Date ...... 1.1 ... rdo ............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
HU
This
certifies that ......
............... .................................................................................. ......
has permission to perform...b.C�.-t.x*;—,V7t:!A C-efvl�clsa
....... .... .... ... *......w.,!......
*0- i ... -- ... ** .................................
.... **"**"'*'****** ... *****"
wiring in the building of.T.- UrJ.N. I.-.1 ........................................
at ..... ........ ........ . North Andover, Mass.
......... . ..........
Fee .............................. Lic. No
........................
Z,
Check # (<2 oA 1 '9 4) ELECTRICAL INSPECTOR
n
U n 0�9
.1/1 76K .14 1)
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. b
Occupancy and Fee Checked
119ev-1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cod(MC), 527 CMR 12.00
(PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date:.SV0\ 11
City or Town of: NORTH ANDOVER To the Inspe for f Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) —11�— 3
Owner or Tenant r Telephone No.932 --X11- 19
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Us I tett 1 C:!; Utility Authorization No.
- Existing Service'1&,,,\ Amps � 1�Volts Overhead.. Undgrd ❑ No. of Meters _
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work:
0Z h L —�
No. of Recessed Luminaires "�tN
vu 'J— on vJ tt'"UttuWtn
f Ceil: Susp. (Paddle) Fans
ratite may tie walvea oy the inspector of wires.
Total
Transformers KVA
No. of Luminaire Outlets
f Hot Tubs
Generators KVA
No. of Luminaires
ming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
Batter Units
No. of Receptacle Outlets $f
Oil Burners
FIRE ALARMS No, of Zones
No. of Switches
f Gas Burners
No. of Detection and
Initiatin Devices
No. of Ranges
f Air Cond. TonTots
No. of Alerting Devices
No. of Waste Disposers
Heat Pump Number Tons...._ KW
Totals: ................
No. of Self -Contained
Detection/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
LocaI ❑ Municipal ❑ Other
Connection
No. of Dryers
No. of WaterNo.
Heaters KW
Heating Appliances KW
of No, of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
No' of
or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
hrracn aaamonal detail if desired, or as required by the Inspector of Wires.
Estimated Value El ctrical Work: y a b (When required by municipal policy.)
%
Work to Start;y (s \ N':1 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURA-NCE BOND ❑ OTHER ❑ (Specify:)
I"ceriify, ,in(ler the pains and penalties ofperjury, that the information on Otis application is true and complete.
FIRMNAME: LIC. NO.:
Licensee: ��Cl�gSz. L .p kj j� a h"43;Z� Signature LIC. No..:)
(If applicable, enter "exempt" in the license number line)
Address: 4 O .) Bus. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of PublicIVEafety "S" License: Alt. Lec. No.: rNo.an—Cl o —3 y
OWNER'S INSURANCE WAR: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMITFEE. $
The Commonwealth oflVlassachusetts -
Department oflndustriglAceldents
Office of Investigations
IN 600 Washington Street
Boston, MA. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NaMe(Busiuess/Organization/individual):
Address:
01 �7
City/State/Zip:e, 4a,c Z a.'� `1tro�r►� ��l 1,.) 4 Phone #:
Are you an employer? Check the appropriate box: -
Type of project (required):
1. ❑ 1 am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
��� Remodeling
2.F3 I am a sole proprietor or partner-
// ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10. F1 Electrical repairs or additions
required.]
3.01 am a homeowner, doing all work
officers have exercised their
right of exemption per MGL
11.❑Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance . re uired
required.) i
employees. [No workers'
13.❑Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they Ale doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name ofthe 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 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 maybe forwarded to the Office of
Investigations of the DTA- for insurance coverage verification.
I do hereby certify un r t e pains aardpenalties ofperjury that the information provided above is true and correct. -
Si ature• A6 Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/I,icense N.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other - -
Contact Person:
__ Phone
Location J %3 �
Check #
r• 1 r;
�uui 5
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ dy
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Permit
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
I If IMPORTANT: Applicant must complete all items on this page
LOCATION zq i)7 ®,/ L T
A A Print
PROPERTY OWNER N'Y'C-{Ylt- C.Ot/y
Print 100 Year Old Structure
MAP N0F)k-PARCEL.3Jk ZONING DISTRICT: Historic District
Machine Shop Villa
yes
yes n
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
-s'One family
❑ Addition
❑ Two or more family
❑ Industrial
; -Alteration
No. of units:
❑ Commercial
4ot Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
eOther
❑ Septic []Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
,eWater/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
lU1> li r 5 N 6 u x/ �E-v-` s7/pm J&�/11/(3;
Ax , �Am
�,
]Identification Please Type or Print Clearly) ���� �d�
OWNER: Name: • /4 ��S G C)AIA `OLL y Phone r 6
Address:
67- S 7"
CONTRACTOR Name: ,#44— '522k4c:i- Phone:4%%y� Rye
Address:W000 -57 e2fL;V 4 IL14 0/ 7`-9
Supervisor's Construction License: C,3— O?H 0,316 Exp. Date: S
Home Improvement License: /6_
ARCHITECT/ENGINEER
Address:
Date: /0////
Phone:
Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CT BASED ON $125.00 PER S.F.
S
Total Project Cost: $ Q �, D FEE: $ PINT?i
Check No.: Receipt No.:
NOTE: Persons contracting wi unregistere contractors do not have acgtad
gu ranty fund
Signature of Agent/Ovvner Signature. of contracto
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Plans 11
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE_ OF. SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
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
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW To -vv _.]Engineer: Signature:
Located 384 Osgood Street
FIRE -DEPARTMENT - Temp Dumpster on site yes no
Located -at 124 Mair Street
Fire Department signaturb/date
COMMENTS
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 16,020.00
m
$ -
$
192.24
Plumbing Fee
$
24.03
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
24.03
Total fees collected
$
340.30
353 Abbott Street
208-14 on 9/6/13
Finish Basement
Massachusetts Department of Public Safety
L7J Board of Building Regulations and Standards
Construction Supervisor i
License: CS -074036
CHARLES R SCHI3LER { I
153 WOOD ST ;" u '
HOPKINTON MA 01748!
Expiration
Commissioner 02/11/2015
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR Type.
R
Registration: '.,--M,,61236
Expiration: 1�f�14 Individual
CH LES R SCHUE— c F— f
CHARLES SCHU6-0 >> ,
153 WOOD ST��
HOPKINTON, MA 01748,` = <;." Undersecretary
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A & D MILLWORK
42 ERIK STREET
MERRIMACK, NH 03054
603-765-7020
FIXED PRICE AGREEMENT
DATE: 8/27/13
OWNER'S NAME: Mr. & Mrs. Jim and Connolly
ADDRESS: 353 Abbot Street
N. Andover, MA
PHONE: 978-764-9619
PROJECT NUMBER: #762
I. PARTIES
This contract (hereinafter referred to as "agreement") is made and
entered into on this 29rd day of August, by and between Mr & Mrs. Jim
Connolly, (hereinafter referred to as "owner"); and A & D Millwork,
(hereinafter referred to as "contractor"). In consideration of the mutual
promises contained herein, contractor agrees to perform the following
work:
II. GENERAL SCOPE OF WORK DESCRIPTION:
BASEMENT RENOVATION
DEMOLITION:
OPEN UP WALL UNDER STAIRWAY.
FRAMING:
FRAME PARTITION WALLS AND SOFFITTS WITH 2X4 LUMBER. SEE
DRAWING.
FRAMING TO MEET MASS. STATE CODE.
ELECTRICAL:
INSTALL THE FOLLOWING: OUTLETS AND SWITCHES TO CODE.
ONE (1) COMBINATION SMOKE DETECTOR/CARBON MONOXIDE
DETECTOR.
ONE (1) CABLE LINE.
EIGHT (8) RECESSED LIGHTS.
TWO (2) 6 FT. SECTIONS OF ELECTRIC BASEBOARD HEAT WITH ONE
THERMOSTAT.
INSULATION:
INSTALL FIBERGLASS INSTALLATION WHERE NEEDED TO MEET MASS.
STATE CODE.
DRYWALL:
INSTALL Y2 INCH DRYWALL ON WALLS AND CEILINGS.
APPLY 3 COATS OF SPACKLE.
SANDED, READY FOR PAINT.
FLOORING:
TO BE DONE BY CUSTOMER.
INTERIOR TRIM:
INSTALL 2 '/i INCH COLONIAL CASING ON ALL NEW DOORS,
MATCHING EXISTING.
INSTALL 3 V2 INCH COLONIAL BASEBOARD MOULDING.
INSTALL THREE INTERIOR DOORS. SEE DRAWING ATTACHED.
BUILT-IN - INSTALL CUSTOM BUILT-IN ENTERTAINMENT UNIT,
RECESSED ALONG STAIR WALL. (SEE DRAWING).
BUILT-IN ONLY, TO BE PREPPED AND PRIMED, READY FOR PAINT.
HARDWARE - INSTALL SCHLAGE BRIGHT BRASS LOCKSETS.
STAIRWAY - INSTALL OAK HANDRAIL WITH BRIGHT BRASS BRACKETS.
INSTALL CARPET ON STAIRS. (A & D MILLWORK WILL PROVIDE
SAMPLES)
INTERIOR PAINTING:
TO BE COMPLETED BY CUSTOMER.
CLEAN-UP:
DISPOSE OF ALL WASTE GENERATED BY JOB.
CLEAN UP EACH NIGHT AND LEAVE JOB SITE 1N A CLEAN "BROOM
SWEPT" MANNER.
ADDITIONAL SCOPE OF WORK PAGE(S) ATTACHED NO
TOTAL LUMP SUM PRICE FOR ALL WORK ABOVE: $16,020.00
III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE
A. EXCLUSIONS
THIS AGREEMENT DOES NOT INCLUDE LABOR OR MATERIALS FOR THE
FOLLOWING WORK AT THIS TIME:
1. STANDARD EXCLUSIONS: UNLESS SPECIFICALLY INCLUDED IN THE
"GENERAL SCOPE OF WORK" SECTION ABOVE, THIS AGREEMENT
DOES NOT INCLUDE LABOR OR MATERIALS FOR THE FOLLOWING
WORK: PLANS, LEGAL FEES, ENGINEERING FEES, OR GOVERNMENTAL
PERMITS AND FEES OF ANY KIND. TESTING, REMOVAL AND DISPOSAL
OF ANY MATERIALS CONTAINING ASBESTOS (OR ANY OTHER
HAZARDOUS MATERIAL AS DEFINED BY THE EPA). CUSTOM MILLING
OF ANY WOOD FOR USE IN PROJECT. MOVING OWNER'S PROPERTY
AROUND THE SITE. LABOR OR MATERIALS REQUIRED TO REPAIR OR
REPLACE ANY OWNER -SUPPLIED MATERIALS. REPAIR OF CONCEALED
UNDERGROUND UTILITIES NOT LOCATED ON PRINTS OR PHYSICALLY
STAKED OUT BY OWNER, WHICH ARE DAMAGED DURING
CONSTRUCTION. SURVEYING THAT MAY BE REQUIRED TO ESTABLISH
ACCURATE PROPERTY BOUNDARIES FOR SETBACK PURPOSES (FENCES
AND OLD STAKES MAY NOT BE LOCATED ON ACTUAL PROPERTY
LINES). FINAL CONSTRUCTION CLEANING (CONTRACTOR WILL LEAVE
SITE IN "BROOM SWEPT" CONDITION). LANDSCAPING AND
IRRIGATION, PAVING, OR STREET WORK OF ANY KIND. TEMPORARY
SANITATION, POWER, OR FENCING. REMOVAL OF SOILS UNDER HOUSE
IN ORDER TO OBTAIN 18 INCHES (OR CODE -REQUIRED HEIGHT) OF
CLEAR SPACE BETWEEN BOTTOM OF JOISTS AND SOIL. REMOVAL OF
FILLED GROUND OR ROCK OR ANY OTHER MATERIALS NOT
REMOVABLE BY ORDINARY HAND TOOLS (UNLESS HEAVY EQUIPMENT
1S SPECIFIED IN SCOPE OF WORK SECTION ABOVE), CORRECTION OF
EXISTING OUT -OF -PLUMB OR OUT -OF -LEVEL CONDITIONS IN EXISTING
STRUCTURE. CORRECTION OF CONCEALED SUBSTANDARD FRAMING.
REROUTING/REMOVAL OF VENTS, PIPES, DUCTS, STRUCTURAL
MEMBERS, WIRING OR CONDUITS, STEEL MESH, WHICH MAY BE
DISCOVERED IN THE REMOVAL OF WALLS OR THE CUTTING OF
OPENINGS IN WALLS. REMOVAL AND REPLACEMENT OF EXISTING ROT
OR INSECT INFESTATION. FAILURE OF SURROUNDING PART OF
EXISTING STRUCTURE, DESPITE CONTRACTOR'S GOOD FAITH EFFORTS
TO MINIMIZE DAMAGE, SUCH AS PLASTER OR DRYWALL CRACKING
AND POPPED NAILS IN ADJACENT ROOMS OR BLOCKAGE OF PIPES OR
PLUMBING FIXTURES CAUSED BY LOOSENED RUST WITHIN PIPES;
CONSTRUCTION OF A CONTINUOUSLY LEVEL FOUNDATION AROUND
STRUCTURE (IF LOT IS SLOPED MORE THAN 6 INCHES FROM FRONT
TO BACK OR SIDE TO SIDE, CONTRACTOR WILL STEP THE
FOUNDATION IN ACCORDANCE WITH THE SLOPE OF THE LOT). EXACT
MATCHING OF EXISTING FINISHES. PUBLIC OR PRIVATE UTILITY
CONNECTION FEES. REPAIR OF DAMAGE TO ROADWAYS, DRIVEWAYS,
OR SIDEWALKS THAT COULD OCCUR WHEN CONSTRUCTION
EQUIPMENT AND VEHICLES ARE BEING USED IN THE NORMAL COURSE
OF CONSTRUCTION.
ADDITIONAL AND/ OR JOB SPECIFIC EXCLUSIONS:
ABOVE PRICE DOES NOT INCLUDE COST OF BUILDING PERMIT.
TO BE PAID BY OWNER ONCE COST IS DETERMINED.
DOES NOT INCLUDE ANY PAINT OR FLOORING.
B. ALLOWANCES: NONE
C. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION
COMMENCE WORK: WITHIN TWO (Z ) WEEKS OF BUILDING PERMIT
APPROVAL. CONSTRUCTION TIME THROUGH SUBSTANTIAL COMPLETION:
APPROXIMATELY (4) WEEKS, NOT INCLUDING DELAYS AND ADJUSTMENTS
FOR DELAYS CAUSED BY: INCLEMENT WEATHER, ADDITIONAL TIME
REQUIRED FOR CHANGE ORDER WORK, AND OTHER DELAYS UNAVOIDABLE
OR BEYOND THE CONTROL OF THE CONTRACTOR.
D. CHANGE ORDERS: CONCEALED CONDITIONS AND ADDITIONAL WORK
1. CONCEALED CONDITIONS: THIS AGREEMENT IS BASED SOLELY ON
THE OBSERVATIONS CONTRACTOR WAS ABLE TO MAKE WITH THE
STRUCTURE IN ITS CURRENT CONDITION AT THE TIME THIS
AGREEMENT WAS BID. IF ADDITIONAL CONCEALED CONDITIONS ARE
DISCOVERED ONCE WORK HAS COMMENCED WHICH WERE NOT
VISIBLE AT THE TIME THIS PROPOSAL WAS BID, CONTRACTOR WILL
STOP WORK AND POINT OUT THESE UNFORESEEN CONCEALED
CONDITIONS TO OWNER SO THAT OWNER AND CONTRACTOR CAN
EXECUTE A CHANGE ORDER FOR ANY ADDITIONAL WORK.
2. DEVIATION FROM SCOPE OF WORK: ANY ALTERATION OR DEVIATION
FROM THE SCOPE OF WORK REFERRED TO IN THIS AGREEMENT
INVOLVING EXTRA COSTS OF MATERIALS OR LABOR (INCLUDING ANY
OVERAGE ON ALLOWANCE WORK AND ANY CHANGES IN THE SCOPE OF
WORK REQUIRED BY GOVERNMENTAL PLAN CHECKERS OR FIELD
BUILDING INSPECTORS) WILL BE EXECUTED UPON A WRITTEN CHANGE
ORDER ISSUED BY CONTRACTOR AND SHOULD BE SIGNED BY
CONTRACTOR AND OWNER PRIOR TO THE COMMENCEMENT OF
ADDITIONAL WORK BY THE CONTRACTOR.
CONTRACTOR TO SUPERVISE, COORDINATE, AND CHARGE 25% PROFIT
AND OVERHEAD ON OWNER'S SEPARATE SUBCONTRACTORS WHO ARE
WORKING ON SITE AT SAME TIME AS CONTRACTOR. CONTRACTOR'S
PROFIT. AND OVERHEAD, AND ANY SUPERVISORY LABOR WILL NOT BE
CREDITED BACK TO OWNER WITH ANY DEDUCTIVE CHANGE ORDERS
(WORK DELETED FROM AGREEMENT BY OWNER) THROUGH THE CURRENT
PAYMENT PERIOD.
E. PAYMENT SCHEDULE AND PAYMENT TERMS
1. PAYMENT SCHEDULE:
PAYMENTS DUE UPON SUBSTANTIAL COMPLETION OF THE FOLLOWING
JOB PHASES. DUE TO THE DYNAMIC NATURE OF RENOVATIING,
PAYMENTS MAY NOT ALWAYS FALL IN THE ORDER THEY APPEAR
BELOW.
$ 800.00 DUE UPON SIGNING OF CONTRACT.
$3,000.00 DUE UPON START.
$3,000.00 DUE UPON COMPLETION OF ROUGH ELECTRIC.
$4,000.00 DUE UPON COMPLETION OF DRYWALL.
$3,000.00 DUE UPON COMPLETION OF TRIM.
$2,220.00 DUE UPON COMPLETION OF JOB.
2. PAYMENT OF CHANGE ORDERS: PAYMENT FOR EACH CHANGE ORDER
IS DUE WHEN THE WORK IS AUTHORIZED BY OWNER AND
CONTRACTOR SUBMITS INVOICE.
3. ADDITIONAL PAYMENTS FOR ALLOWANCE WORK AND RELATED
CREDITS: PAYMENT FOR WORK DESIGNATED IN THE AGREEMENT AS
ALLOWANCE WORK HAS BEEN INITIALLY FACTORED INTO THE LUMP
SUM PRICE AND PAYMENT SCHEDULE SET FORTH IN THIS AGREEMENT. IF
THE ACTUAL COST OF THE ALLOWANCE WORK EXCEEDS THE LINE ITEM
ALLOWANCE AMOUNT IN THE AGREEMENT, THE DIFFERENCE BETWEEN
THE COST AND THE LINE ITEM ALLOWANCE AMOUNT STATED IN THE
AGREEMENT WILL BE WRITTEN UP BY CONTRACTOR AS A CHANGE
ORDER SUBJECT TO CONTRACTOR'S PROFIT AND OVERHEAD AT THE
RATE OF 25%.
IF THE COST OF THE ALLOWANCE WORK IS LESS THAN THE
ALLOWANCE LINE ITEM AMOUNT LISTED IN THE AGREEMENT, A CREDIT
WILL BE ISSUED TO OWNER AFTER ALL BILLINGS RELATED TO THIS
PARTICULAR LINE ITEM ALLOWANCE WORK HAVE BEEN RECEIVED BY
CONTRACTOR. THIS CREDIT WILL BE APPLIED TOWARD THE FINAL
PAYMENT OWING UNDER THE AGREEMENT. CONTRACTOR PROFIT AND
OVERHEAD AND ANY SUPERVISORY LABOR WILL NOT BE CREDITED
BACK TO OWNER FOR ALLOWANCE WORK.
F. WARRANTY
CONTRACTOR PROVIDES A LIMITED WARRANTY ON ALL CONTRACTOR -
AND SUBCONTRACTOR -SUPPLIED LABOR AND MATERIALS USED IN THIS
PROJECT FOR A PERIOD OF TWELVE MONTHS FOLLOWING SUBSTANTIAL
COMPLETION OF ALL WORK.
NO WARRANTY IS PROVIDED BY CONTRACTOR ON ANY MATERIALS
FURNISHED BY THE OWNER FOR INSTALLATION. NO WARRANTY IS
PROVIDED ON ANY EXISTING MATERIALS THAT ARE MOVED AND/OR
REINSTALLED BY THE CONTRACTOR WITHIN THE DWELLING (INCLUDING
ANY WARRANTY THAT EXISTING/USED MATERIALS WILL NOT BE DAMAGED
DURING THE REMOVAL AND REINSTALLATION PROCESS). ONE YEAR AFTER
SUBSTANTIAL COMPLETION OF THE PROJECT, THE OWNER'S SOLE REMEDY
(FOR MATERIALS AND LABOR) ON ALL MATERIALS THAT ARE COVERED BY
A MANUFACTURER'S WARRANTY IS STRICTLY WITH THE MANUFACTURER,
NOT WITH THE CONTRACTOR.
REPAIR OF THE FOLLOWING ITEMS IS SPECIFICALLY EXCLUDED FROM
CONTRACTOR'S WARRANTY: DAMAGES RESULTING FROM LACK OF OWNER
MAINTENANCE; DAMAGES RESULTING FROM OWNER ABUSE OR ORDINARY
WEAR AND TEAR; DEVIATIONS THAT ARISE SUCH AS THE MINOR CRACKING
OF CONCRETE, STUCCO AND PLASTER; MINOR STRESS FRACTURES IN
DRYWALL DUE TO THE CURING OF LUMBER; WARPING AND DEFLECTION OF
WOOD; SHRINKING/CRACKING OF GROUTS AND CAULKING; FADING OF
PAINTS AND FINISHES EXPOSED TO SUNLIGHT.
THE EXPRESS WARRANTIES CONTAINED HEREIN ARE IN LIEU OF ALL OTHER
WARRANTIES, EXCEPT WARRANTY OF HABITABILITY EXPRESS OR IMPLIED,
INCLUDING ANY WARRANTIES OF MERCHANTABILITY, OR FITNESS FOR A
PARTICULAR USE OR PURPOSE. THIS LIMITED WARRANTY EXCLUDES
CONSEQUENTIAL AND INCIDENTAL DAMAGES AND LIMITS THE DURATION
OF IMPLIED WARRANTIES TO THE FULLEST EXTENT PERMISSIBLE UNDER
STATE AND FEDERAL LAW.
G. WORK STOPPAGE, TERMINATION OF CONTRACT FOR DEFAULT, AND
INTEREST
CONTRACTOR SHALL HAVE THE RIGHT TO STOP ALL WORK ON THE
PROJECT AND KEEP THE JOB IDLE IF PAYMENTS ARE NOT MADE TO
CONTRACTOR IN ACCORDANCE WITH THE PAYMENT SCHEDULE IN THIS
AGREEMENT, OR IF OWNER REPEATEDLY FAILS OR REFUSES TO FURNISH
CONTRACTOR WITH ACCESS TO THE JOB SITE AND/OR PRODUCT
SELECTIONS OR INFORMATION NECESSARY FOR THE ADVANCEMENT OF
CONTRACTOR'S WORK. SIMULTANEOUS WITH STOPPING WORK ON THE
PROJECT, THE CONTRACTOR MUST GIVE OWNER WRITTEN NOTICE OF THE
NATURE OF OWNER'S DEFAULT AND MUST ALSO GIVE THE OWNER A 14 -
DAY PERIOD IN WHICH TO CURE THIS DEFAULT.
IF WORK IS STOPPED DUE TO ANY OF THE ABOVE REASONS (OR FOR ANY
OTHER MATERIAL BREACH OF CONTRACT BY OWNER) FOR A PERIOD OF 14
DAYS, AND THE OWNER HAS FAILED TO TAKE SIGNIFICANT STEPS TO CURE
HIS DEFAULT, THEN CONTRACTOR MAY, WITHOUT PREJUDICING ANY
OTHER REMEDIES CONTRACTOR MAY HAVE, GIVE WRITTEN NOTICE OF
TERMINATION OF THE AGREEMENT TO OWNER AND DEMAND PAYMENT FOR
ALL COMPLETED WORK AND MATERIALS ORDERED THROUGH THE DATE OF
WORK STOPPAGE, AND ANY OTHER LOSS SUSTAINED BY CONTRACTOR,
INCLUDING CONTRACTOR'S PROFIT AND OVERHEAD AT THE RATE OF 25%
ON THE BALANCE OF THE PAYMENT PERIOD UNDER THE AGREEMENT.
THEREAFTER, CONTRACTOR IS RELIEVED FROM ALL OTHER CONTRACTUAL
DUTIES, INCLUDING ALL PUNCH LIST AND WARRANTY WORK.
H. DISPUTE RESOLUTION AND ATTORNEY'S FEES
ANY CONTROVERSY OR CLAIM ARISING OUT OF OR RELATED TO THIS
AGREEMENT INVOLVING AN AMOUNT OF LESS THAN $5,000 (OR THE
MAXIMUM LIMIT OF THE COURT) MUST BE HEARD IN THE SMALL CLAIMS
DIVISION OF THE MUNICIPAL COURT IN THE COUNTY WHERE THE
CONTRACTOR'S OFFICE IS LOCATED. ANY CONTROVERSY OR CLAIM
ARISING OUT OF OR RELATED TO THIS AGREEMENT WHICH IS OVER THE
DOLLAR LIMIT OF THE SMALL CLAIMS COURT MUST BE SETTLED BY
BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION
ASSOCIATION IN ACCORDANCE WITH THE CONSTRUCTION INDUSTRY
ARBITRATION RULES. JUDGMENT UPON THE AWARD MAY BE ENTERED IN
ANY COURT HAVING JURISDICTION THEREOF.
THE PREVAILING PARTY IN ANY LEGAL PROCEEDING RELATED TO THIS
AGREEMENT SHALL BE ENTITLED TO PAYMENT OF REASONABLE
ATTORNEY'S FEES, COSTS, AND EXPENSES.
THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN
ADVANCE THAT IN THE EVENT THE CONTRACTOR HAS A DISPUTE
CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH
DISPUTE TO PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED
BY THE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND
THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
PROVIDED IN MGL. I42A.
OWNE 'S SIGNATURE:
CONTRACTOR'S SIGNATURE:
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO
AGREEMENT OF THE PARTIES ALTERNATE DISPUTE RESOLUTION INITIATED
BY CONTRACTOR. THE OWNER MAY INITIATE ALTERNATE DISPUTE
RESOLUTION EVEN WHERE THIS SECTION IS NOT SIGNED BY THE PARTIES.
1. EXPIRATION OF THIS AGREEMENT
THIS AGREEMENT WILL EXPIRE 30 DAYS AFTER THE DATE AT THE TOP OF
PAGE ONE OF THIS AGREEMENT IF NOT FIRST ACCEPTED IN WRITING BY
OWNER.
J. ENTIRE AGREEMENT
THIS AGREEMENT REPRESENTS AND CONTAINS THE ENTIRE AGREEMENT
BETWEEN THE PARTIES. PRIOR DISCUSSIONS OR VERBAL
REPRESENTATIONS BY THE PARTIES THAT ARE NOT CONTAINED IN THIS
AGREEMENT ARE NOT A PART OF THIS AGREEMENT.
I HAVE READ AND UNDERSTOOD, AND I AGREE TO, ALL THE TERMS AND
CONDITIONS CONTAINED IN THE AGREEMENT ABOVE.
S -1,3o)
DAT CONTRRCT S SIGNATURE
DATt OWNER'S SIGNATURE
21
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): AU AA 1 Lb Wo 21(. U,C..
Address:
City/State/Zip: /1A h 9-t Il/l6-GK - Ald _ v�t2S hone #: (&0J3 26-5---70a,(),
Are you an employer? Check the appropriate box:
1. ❑ I 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. I
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
3111 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. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I L ❑ Plumbing repairs or additions
12. ❑ Roof repairs
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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 thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: City/state/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as 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.
Ido hereby certyiy undeA the pains andpenalties ofperjury 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 #
3
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 #:
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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 21A -F and G min.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
. The foll"Swing is -a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
u Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
u Floor Plan Or Proposed Interior Work
o 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
Li Workers Comp Affidavit
L3 Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
L3 Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 al)W-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be sul)Wted with the building application
Doc: Doc.Bui?,3ing Permit Revised 2012
� I GUIVI1VItIV�'�_
Date.. �G......
NOR7ly
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
SSACNUSEI
This certifies that
has permission for gas installation . !.�. .... �../.�.�y....... .
in the buildings of � . x .......................
at ................ , North Andover, Mass.
Fee..7 ...... Lic.-�a.�- ........
I GAS INSPECTI;
Check #
r -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER Mass. Date APRIL 16 2010
Building Location 353 ABBOTT ST.
Owner Tel# 978-686-5860
Permit #
Owner's Name JAMES CONNOLLY
Type of Occupancy RESIDENTIAL
New a Renovation❑ Replacement
FIXTURES
Plan Submitted: Yes❑ NoEl
Installing Company Name Eastern Propane & Oil, Inc
Address 131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter JACK COOMBS
Check one: Certificate
Corporation
Partnership
Firm/Co.
INSURANCE COVERAGE:
I have acur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No F,If you have'''c ecked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy✓D 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Age
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in abov appli ti aretru accur he b of my
knowledge and that all plumbing work and installations performed under the permit issued licati I be in lian th all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La
By Type f License:
lumber f Licensed Plumber or Gas Fitter
Title Gas fitter ! n�
•
-Master Z:n/atur
mber L�""
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
Date ........... ..d!..... .
I
Of H0RT4
or �
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
f SA HUS
i This certifies that ...
*�.
has permission for gas installation_.. I '� .. '' ....- .. .
in the buildings of.
:.:..: �- n .................
at ......... �
-- .... , North Andover, Mass.
Fee'�- 00.. Lic. No..
���1n .. ..
GAS INSPECTOR/
Check # 1.
Ti 73
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS G
(Type or print) Date 3
NORTH ANDOVER, MASSACHUSETTS � � �/ 7-3
Building Locationsy v a✓ Permit #
Amount $
����i �� � Owner's ame
New ❑ Renovation ❑ Replacement Plans Submitted ❑
(Print or type)
Name T', IV), Check one: Certificate Installing Company
, V b �� ��--��ss
.� / El Corp.
Address �✓ �� 1 //
V � � Partner.
usrness a ep one .� ) Firm/Co.
10
Name of Licensed Plumber or Gas Fitter 1 JAI 1 < "n AptnI 1 1
INSURANCE COVERAGE Check ode:
f have a current liability Insur a policy or it's substantial equivalent. Yes No[J
If you have checked des, pleas indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
El
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 Agent
1 herehv certifv that all T L ---- --- -
---- _____..-. _ .. .. kvl ouncicu) m aoove application are true and accurate to the
best of my knowledge and that all plumbing work anin ations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassacHflettl State Gas Yb'
e and Chapt2 of the General Laws.
i
ICity/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber Ho' o v
Gas Fitter 1-icerise Number
Master
Journeyman
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S�JB-BASEM ENT
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o
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A
4
F
O
BASEMEN T
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7 T H. F L O O R
-
8.TH. FLO 24
(Print or type)
Name T', IV), Check one: Certificate Installing Company
, V b �� ��--��ss
.� / El Corp.
Address �✓ �� 1 //
V � � Partner.
usrness a ep one .� ) Firm/Co.
10
Name of Licensed Plumber or Gas Fitter 1 JAI 1 < "n AptnI 1 1
INSURANCE COVERAGE Check ode:
f have a current liability Insur a policy or it's substantial equivalent. Yes No[J
If you have checked des, pleas indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
El
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 Agent
1 herehv certifv that all T L ---- --- -
---- _____..-. _ .. .. kvl ouncicu) m aoove application are true and accurate to the
best of my knowledge and that all plumbing work anin ations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassacHflettl State Gas Yb'
e and Chapt2 of the General Laws.
i
ICity/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber Ho' o v
Gas Fitter 1-icerise Number
Master
Journeyman
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/O/rganiization/Individual):it7i,WfIL7,
✓t4'►Address: L . &t1f1 ✓Id1a,0,
City/State/Zip:
Are you an employer? Check thee appr
1. ❑ I am a employer with
I employees (full and/or part-time).*
® I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
S. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Phone #: L.
riate box:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet I
These sub -contractors have
workers' comp. insurance.
5. ❑ We area 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_)
! A -Y applicant that checks box #i
pP mut also fill out the section beiew shot b t:-_:.,.ves' comrsatronpolicy :nfo.Wawon.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a
#Contractors that check this box must attached an additional sheet showing new affidavit indicating such.
the name of the sub -contractors and their workers' comp policy information.
I an employer that is providing workers' compensation insur
inffoormaance for my employees. Below is the policy and job site
tion.
Type of project (required):
6. New construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Insurance Company Name:
Policy # or Self -ins. Lic. #:
2 Expiration Date:
Job Site Address: j
City/State/Zip: /V
Attach a copyof the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.0O,zday against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th DIA for insurance coverage verification.
I do hereby ce u�Cder the pa' Is penalties of perjury that the information provided above is true and correct
/ f.,e
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 #:
Of MORTq ,�
O F
SS'q US�
Date..:
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...... :. .................. .
has permission to perform ...-s .` ..."....::..... ......... .
x
plumbing in the buildings of ..
at. ... . .... ........ ........ . North Andover, Mass.
1
Fee -�� ..... Lic. No...... .�� �._. �� f -d? .4-.......... .
PLUh 551 GGNVSPECTOR
Check #
6566
MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building LocationDate V11-3ho
kbvtl �a 4.4��iZ� Permit # 4�
Amount �3G_
Owner Ji (,'Z'f (�J �� �
New Renovation Replacement Plans Submitted Yes No
FIXTUR F.0
- (Print or type)
Installing Company
Id Address
EM' • 1 -
`1 7 'A
Name of Licensed Plumber:
Insurance Coverage: Indicate th of insurance coverage by cheekft the appropriate box:
Liability insurance policy Other type of indemnity 11 Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature I
Owner ❑
I hereby certify that all of the details and informati I ve submitted
best of my knowledge and that all plumbing work d ' Uations a
compliance with all pertinent provisions of the Mass h etts State un
By:Signa 01 LicenspaL
Agent F
.red) in above application are true and accurate to the
under Permit Issued for this application will be in
Codd Chapter 142 of the General Laws.
Type
Title of plum1hg License
��
City/Town kens um er Master Journeyman
APPROVED tonics usE ONLY EIr13
._t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
1 l! 1 �1✓s
Name (Business/Organization/Individual): V
M
Address: �% l,/r ll V'1& ila, ILI r 1I Qty/ * I,�
City/State/Zip:
Phone #: Lao -5 f!5 --k)&#
Are you an employer? Check the appropriate boa:
I . ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
24 1 am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ElWe 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. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
I
+=-y applicant that checks box #1 must also iili out the section below shet Wd their workers' compensation I poLcy 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. po3icy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:_ J� rf7�r?1' S� City/State/Zip: V
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the // fol insurance cov9p1ge verification.
I do hereby certify un�er fie pains
the information provided
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 Z. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ove is Ir a and correct.
Z
`3
Contact Person:
Phone
Location J S g5y27 S?.
No. Date
f NORTIy ,
41 9
a
�ACMUS t�
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
0
Building/Frame Permit Fee
$
Z�
Foundation Permit Fee
$
Ot-hef Permit Fee
$
5
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
q
�.� Z /
%CK �(z 7
y 93 j196 14:39
_O
Building Inspector
1,158.29 PAID
Div. Public Works
LocationY
No.
Date
341— %
40RTOI
'TOWN OF NORTH ANDOVER
c.
p
•
Certificate of Occupancy $
N
Building/Frame Permit Fee $
�
r ,ssACMUSEt
Foundation Permit Fee $
Other Permit Fee $
AL /03l
Sewer Connection Fee $
000,6
oAU0 sS7
Water Connection Fee $
/07 7, Sl
TOTAL $
G% jq 2
o
Bufld!'prg Ins ect r
03/27/96 14:409 0 3 077.5o PAID Div. u
is works
PERMIT NO.Y
r
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. (/ " PAGE 1
MAP 440. 38
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK PAGE
I
ZONE R_ ?)
I SUB DIV. LOT NO. a
1/
AA`ve r� / yZ
$ani
LOCATION J,� 6Ti s
✓UepQrU/c
PURPOSE OF BUILDING �'� f e
OWNER'S NAME is o&,V/,r
�D MPS
NO. OF STORIES a SIZE % X3Q�J
�G
J6x�6 AA,`I�
OWNER'S ADDRESS Q �jQ X S3I /%- ND6 l�l�,
BASEMENT OR SLAB j.�A>!'��MP
ARCHITECT'S NAME ,geeo/ /2e 5-, /V)'
SIZE OF FLOOR TIMBERS IST 2X) Q 2ND ax/a
3RD ;?X
BUILDER'S NAME eoeee,c
rl til Lo,,,
I- OM P5
SPAN MI
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET q 6
POSTS
DISTANCE FROM LOT LINES - SIDES 3 f l REAR
Li al
"' "" GIRDERS X/ J
I `
AREA OF LOT 2S, ooQ s f FRONTAGE
01
HEIGHT OF FOUNDATION / I� THICKNESS
IS BUILDING NEW e.5 c
SIZE OF FOOTING ���X a 6 �� x
IS BUILDING ADDITION I /V 6
MATERIAL OF CHIMNEY Berc c
IS BUILDING ALTERATION N O
IS BUILDING ON SOLID OR FILLED LAND so/,6
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE /
e-5
IS BUILDING CONNECTED TO TOWN WATER es
i
BOARD OF APPEALS ACTION. IF ANY /v /i
V
IS BUILDING CONNECTED TO TOWN SEWER ye S
IS BUILDING CONNECTED TO NATURAL GAS LINE /U O
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
i
DATE FILED � //`r
SIGNATURE OF OWNER OR AUTHORIZED AGENT
FEE
PERMIT GRANTED
T cif 19 6,
PERMIT FOR FRAME/BUILDING
5130 DATE: 37`� FEE PAID: / ,Z
3 PROPERTY INFORMATION
LAND COST �(,� BOO
EST. BLDG. COST
si0lo `'
EST. BLDG. COST PER SQa.. FT
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSPECTOR
OWNER TEL. M
CONTR. TEL. M
CONTR. LIC. #
H.I.C. #
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FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*********�i**********
APPLICANT: X o ��req% eOUnJI e�/ �bMeS Phone ( o �- vssg,
LOCATION: Assessor's Map Number 8 Parcel �d-_57
Subdivision ��7' Lot(s) C7
Street �"/�J J 6 //77—S / St. Number 35.3
************************Official
RECO DATIONS OF TO AGENTS:
Conservation Administrator
Comments
Town
Planner
Comments
Food Ins ector-Health
S spector-Health
Comments
Use Only************************
AY4_Date Approved Y11
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections
- driveway perm i t �� u')
Fire Department I 64 64WN/
d/96
Received by Building Inspector Date
Ae %a»Urrearuuea�. c`'" `�aasac�cc ell3
.`s
OEPARTMENT OF PUBLIC SAFETY
-� CONSTRUCTION SUPERVISOR LICENSE
Number: Expires: Birthdate:
CS 005693 01/13/1998 01/13/1954
Restricted To: 00
OAVID A KINORED
x 40 MARBLERIOGE RD POSOX531
N ANDOVER, MA 01845
Restricted To: 00 17650
00 - None
1A - Masonry only
IG - 1 S 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Buiildiny Code
is cause for revocation of this license.
. — A
r
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number _ Date
THIS CERTIFIES THAT
THE BUILDING LOCATED ON �4e -7r -�7 4
MAY BE OCCUPIED AS Z4 ��� IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
MORT o CERTIFICATE ISSUED TO
i s
ADDRESS
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