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HomeMy WebLinkAboutMiscellaneous - 364 MAIN STREET 4/30/2018 (2)L 10643 Date... y� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .R( r ' t has permission to perform ......0 t, u> P � 4-�✓ ......... plumbing in the buildings of........ at.. FSA..... m.3t .................. Fee 3.5::x.. Lic. No. .9333 Check # 1 ..................9NG orth Andover, Mass. ..NS*..........................:...'PLINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK A A 4; D CITY ° MA DATE ,PERMIT # JOBSITE ADDRESS OWNER'S NAME Kai& I lftp-s P OWNER ADDRESS a TE 691FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _ EDUCATIONAL _ RESIDENTIAL 10 PRINT CLEARLY NEW: _ RENOVATION. _ REPLACEMENT: ,I� PLANS SUBMITTED: YES _ NO_ FIXTURES Z FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10_, 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM E� I Coo== DEDICATED GASIOIUSAND 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 I MOP SINK E TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabiloyinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, YES F'NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNI TY _ BOND _ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not: have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _ AGENT _ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application true and accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be�8 lance ith I eminent provisio f the Massachusetts State PI ing Code and Cha ter 142 of the General Laws. .KA0-.01MJ A- "4 9 PLUMBER'S NAME beEt LICENSE # NATURE MPR" JP _ CORPORATION PARTNERSHIP _# LLC �# COMPANY NAM ADDRESS &Ad CITY' t 1111 JUN STATE ZIP TEL FAX � CELL EMAI (,t, MM C 0� PLUMBERS W ?%S*FITTERS ISSUES THE FOLLOWING-LI.CIENSE LICENSED AS A JOURNEYMAN PL-UMB,ElR ROBERT A SAMMATA'RO 8 DUNRAVEN RD )R uj J - -7 WINDHAM NH 03o87 -12E3^ 18214 05/01/16. 226083 'xM � Q e �J PLUMBERS FITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM NH 03087-1263 p 9333 05/01/16 226o84 ccs a COMMONWEALTH OF N&SSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ROBERT A SAMMATARO ROBERT A SAMMATARO P&R, INC 8 DUNRAVEN RD WINDHAM NH 03087-1263 3373 05/01/l6 221168 w. Te" The Commonwealth of Massachusetts Department of IndustrialAccidents 91 OSIce of Investigations 0 1 Congress Street, Suite' Boston, MA 02114-2017 www;mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaiis/Plumbers *Any applicant that checks box 4 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site informadtom 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 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 and the information provided abpve Is 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 #: Name (Business/Organization/Individual): `f 1 O ,4 t 5i' i n ndo_-�a_n� &g.. Address: �� U ;q M Vf Yl Ci /State/Zi : Gti/VI W�.Phone #: �" J.3 ' c� Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4a❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ' 7, ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in anycapacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance reqs] mp. insurance.• 5.ewe are a corporation and its 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. [1 Other employees. [No workers' coma. insurance reouired.l *Any applicant that checks box 4 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site informadtom 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 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 and the information provided abpve Is 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 #: Location 3 4o `-) A /J '(� �- No. Date �aRTM TOWN OF NORTH ANDOVER a „ Certificate of Occupancy $ Building/Frame Permit Fee $ JACMUS� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL`` $ 3 4 2,1/99 13:50 Building Inspector 117.00 PAID Div. Public Works A '�-� tm'1 Z a r � .., � .. n � � •- C_ `r C Cd r 'nZ p z L Z m = CW-7� ? Z O z \ mp C d r nZ > z o O C fit a V c r m rl m v n W > p Im a -4 O p H m R Q m z 0 HO C l _n "V� a n � o o ~ m U C n ❑ n n n O o � � E5 z tY � c C a e m o n m z m m z o m p '° zr nn O O n O Z o°� 7 r n -' O H U) Z z Z z o c -1 ° z Oci O C C O m0 n o n O. y r .� C o c c n z n Z n E 'z H d .� y �� r n m m H n n n H M M p w o z t*f 0 0 0 O O O m Q a q u� > a (1a 1 C O � � r � H � m � m C o N z ^ ri n O z W a a n h North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number '4 6 G is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: F (Location of Facility) Sign , ure of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 4 4614 U DRIVE10'S LICENSEit; S88571006 D B MORETTI JOHN A 10 MOULfbN'ST GEORGETOWN MA 1833-1944 �� •✓>/LP. 100nt99tf1g7fvl,'fX(�/Z f�� F%Cd J:1fXTJt f(JCI�JI �l DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSEij Number: Expires: Birthdate: CS *008141 11/02/1999 11102/1942 Restricted To: 0 JOHN A MORETTI 10 MOULTON ST GEORGETOWN, MA 01833 0,pl 'KIll ROME IMPROVEMENT CONTRACtO9j Registration 108505-` TYPe - PRIVATE. CORPORATION.. Expiration 08%19!00 .MORETTIWN,ANC' .& John A. Moretti &44 oulton St/PO Box 119 ADMINISTRATOR Georgetown NA 01W - 4 4614 U DRIVE10'S LICENSEit; S88571006 D B MORETTI JOHN A 10 MOULfbN'ST GEORGETOWN MA 1833-1944 M=_ INSURER: RELIANCE INSURANCE COMPANY 1. INSURED: MORETTI, JOHN DBA MORETTI & SONS 10 MOULTON ST GEORGETOWN MA 01833 009622 WORKERS COMPENSATION. AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6R10UB-525X367-9-99) NEW -99 NCCI CO CODE: 80039 PRODUCER: COSTELLO INSURANCE AGCY 2 S KIMBALL STREET BRADFORD MA 01835 1 r0 is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05-28-99 to 05-28-00 12:01 A.M. at the insured's mailing address, 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compen- sation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 07-13-99 BL OFFICE: ORLANDO -RELIANCE 825 PRODUCER: COSTELLO INSURANCE AGCY 75RNF ST ASSIGN: MA 1124 6 D I SCP 34921727 02219772 150 1 0005449137-001-00002 ANNUAL BREINCH 19 ZURICH GROUP -HARTFORD ENDORSEMENT EFF 08/23/1999 SPECIALTY CONTRACTORS POLICYSM POLICY CHANGES THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. T'OklCY �FEIYE . :. PF3LIY. �IiANCS EFFEGT11/E :..;bMP}+NX . . ....... . FROM TO 05/04/1999 05/04/2000 08/23/1999 MARYLAND CASUALTY COMPANY . N,4MEt� iNS..UR�D AU f FIORIZE[] REf'RESE . ATiVE MORETTI &SON'S COSTELLO INSURANCE AGENCY, INC. —V::==A- COVERAGE PARTS AFFECTED COMMERCIAL UMBRELLA COVERAGE PART CHANGES ADDED UMBRELLA TO THE POLICY FULL TERM PREMIUM INCLUDING THIS TRANSACTION: $ 915.00 PREMIUM EFFECT OF THIS TRANSACTION: $ 174.00 Countersigned by 4C4 4 —. c � oL C"/ c Authorized Representative Date Copyright, Insurance Services Office, Inc., 1983. Copyright, ISO Commercial .Risk Services, Inc., 1983. 760018 Ed. 6-94 INSURED'S COPY 09/13/1999 C/) m m m Cl) m . c CA d — Ci CA Cl) CD n Z y CLO r c o.= c y n� -o O n O p CD CDCL O r� cr %<CD CDo CD E. C. O tH CD Q O y �O .0 El .l P} a c?�O y Q o m • VJ =-M-1 aO �•CD low y =: m O m C7 mc,n0 m ==dc y -1 ,,,� M m HT ?o. ..a m o y O y -1 �?g� a =Op: -1 z 0 �.Cj O VJ C.) Vl = C3== a. ^.. :0 O m y :e o m CD m� VJ xv m y CLC W a m�m c y C43 m m 03 V) CD o (gi ) CDo� 'o o CD :® .m. ED �CD c o � CD W: CCE: C3 o_. _C C/) C/) I ° " ° ° o o n °� � ^- N Cif w G � x w G K a o ° x a n 4J p. n• Q n a It yIt b I a � � y y ►z•3 z r R 0 c Location No. 62U Date f7 -l'-03 MO�,M TOWN OF NORTH ANDOVER ?.• • L ` Certificate of Occupancy P Y $ ,s •� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 Check # e r 6 4 9 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING "�i2.� ,- _,._.. ... ,s.:; w-, BUILDING PERMIT NUMBER: o DATE ISSUED: SIGNATURE: / C Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: X13 I Map Number Parcel Number n l • A/ � � V 0 / MAW 1.3Zoning Information: Zoning Dis—Uic—t Proposed Use 1.4. Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required, Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO 2ZOer of LRecord Name (Print) Addressfor Service: Signature Telephone 2.2 Owner of Record: Nacre Print Address for Service: J Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor _& Not Applicable ❑ 3 ' Company Name Address Registration Number Expiration Date Signature Telephone ■T ■.Y X z O J W z M M z^^ Y/ SECTION 4 - WORKERS COMPENSATION (Ai G.L. C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building 0 Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 1%r?� /i,y °t? 2 -AIS J i 9 %/ 711d /d /1 IEz- 1 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b rmit a licant Z3I+`FiCIAL USE _ 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction ��v 00 3 Plumbing Building Permit fee (8) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, As Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief zVlG % Print N - Signature of Owner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 RD 3 SPAN DIME7NSIONS OF SILLS DIMENSIONS.OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHII WEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4 Location J (o 4 No. L4 01 Cf MA A) � Date ---`-4- 3 `0Y NaRTN TOWN OF NORTH ANDOVER OG .. 9 > Certificate of Occupancy $ Building/Frame Permit Fee $ 3 r CHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # c;l, `7 17074 Building Inspector TON" OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING X �^ k }.# "� F� °a5"�9•- fSa `"�kY_ ;'F` -.'.n ♦ :ti` § °fi *8: ,"'2: "w 'a%kR': �flga�aem'3 BUILDING PERMIT NUMBER: , f n DATE ISSUED: SIGNATURE: Building Commissioner/Inyector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 3 1.2 Assessors Map and Parcel Number: 6ALL3/ J� I Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40: 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record f , I Name (P , t) IV Address for Service Signature Telephone ._ .2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licenyed Construction Supervisor: �d yr J, 7rnor"e . Licensed Construction upervisor: -7j r L�. LiJc=r��_ �- r4 /Cscn Oj9Y� Address �l70�7/ 1 --PGS Sig re Telephone Not Applicable ❑ LIS G( Z l 9 f License Number a Loy Expiration Date 3.; Registered Home Improvement Contract r pr naen e- Not Applicable ❑ D Company Name // % •�J1A fi �� �� /Gh 0 / �!� Registration Number `,I Address— �---- C17� Expiration Date Si natur Telephone k SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work- fr SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit a licant {IFFICA. USE ONLY 1. Building 22`x© (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing " Building Permit fee (e) X (b) 30 4 Mechanical HVAC -- — 5 Fire Protection ---- 6 Total1+2+3+4+5 e (/ •— Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT ID4 CONTRACTOR.APPLIES FOR BUILDING PERMIT 1, 7CTe 7,l I a �icl as Owner/Authorized Agent of subject property Hereby authorize f e4i ✓ !,-, to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b • WNER/AUTHORIZED AGENT DECLARATION I, J , 1 < 7 a Amn ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief J �.�-•---- Print Name Si ature caner/ ent NO. OF STORIES • - L 2 -2 3 Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND 3RD SPAN DMENSIONS OF SILLS DEVIENSIONS OF POSTS DIlVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE N_ '1. ��ir �!onrana�zu�ullir r�,..��,rr,�ztc�r�uve�i BOARD OF BUILDING REGULATIONS :ease: CONSTRUCTION SUPERVISOR r slumber: CS 062941 Irthdate: 06/06/1968 Expires: 06/06/2004 Tr. no: 26920 Restricted: 00 JOHN J TORNAME 74 LIBERTY ST MIDDLETON, MA 01949 Administrator ✓fes �a��x�nanufeallit a�./��/aaaticlzc��lly . Board of Building Regulations and Standards t- HOME IMPROVEMENT CONTRACTOR 3 Registration: 118789 Expiration: 4/21/2005 { Type: DBA TORNAME BUILDERS JOHN TORNAME 74 LIBERTY ST MIDDLETON, MA 01949 Administrator e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: c� �" 0 TO N 0-mex e_ Location: City P , A j �Ch-, Phone Fam a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F-1.1 am an employer providing. workers' compensation for my employees working on this job. Company name: City: Phone # Insurance Co. Policy Failure to secure coverage as required under Section 25A or MGL 152 can lead to the impositionof criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a. STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify urxlerlhe pains and penalties of perjury that the information provided above is true and correct v Print name , c>/Ha " Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: Phone #: FORM WORKMAN'S COMPENSATION _ 2 3 �UE/ 70ri�- ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall -be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: G , MA (Location of #acility) 0 /, 0 ignature of Permit Applicant Z 0 � Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector AGREEMENT February 23, 2004 Kathleen Phillips and Kathleen Schoonmaker of 364 Main Street, North Andover, MA 01845, agree as follows: That Torname Builders of 74 Liberty Street, Middleton, MA, 01949 shall undertake to replace the cedar roof on the round turret on the Main Street/Davis Street corner of the house; That we shall pay Torname Builders the amount of $2000 upon satisfactory completion of such work; That such completion shall occur on or before March 15, 2004. In witness whereof, we/I set our hand and seal Kathleen J. Phillips Accepted: y 'fl C •C O CO)CD n Z y E; O 0• r o C. y > to O ® CD CD CL �. O CD o CD CD y. CD C. v y CD I v CA O 1 CD O o CD 3 CD C cs�O =r 010 _ EL- c a y O ® Lf 7 m cc col n Z CA cli CD =r -S 01 d N Er CD y O -4p ON O N ?m' m 2 a.a o CD U2 --ft so n O 0 OLD. a9 O m . c lig � d„��,�,:, O• � VJ ® fA o Mb 0 CD ..a yi �^ a mcr O O. CA 17 C -CD tOJ co) N a1 aco: go Coo:CD co ® 0 o �0. t n z ..44 C/) ;,.-Dr 0 �10 0: CD c m J. �- p'yCD 0 �• CD �Z o ro O O Cl) O C/) o w G a C) (n r 7d 'z w 0 ''� w � 0- ro aq G a 0' fz 'ti "n, CA O a 1-1 w Q 0 c O 00 z=LL Q ' ® o� OW I > w J �-' Qw�o I oM z i uj < Y LoZ I ,a El NOTICE OF ASSIGNMENT EMPLOYER: MICHAEL KEDHAN DBA KEDHAN ROOFING 54 ELM ST NORTH ANDOVER, MA 01845 The Waiver of Our Right to Recover from Others Fndorsement is available on Pool policies. Contact your agent for details. AGENT T F WARD INS AGCY INC OR 403 FRANKLIN ST PRODUCER: MELROSE, MA 02176 AGENCY FEIN: 042895924 CLASSIFICATION OF OPERATION -------------------------------------- ROOFING-NOC-& DR EMPLOYERS LIABILITY 100/100/500 LOSS CONSTANT STANDARD PREMIUM EXPENSE CONSTANT RISK MINIMUM PREMIUM ESTIMATED ANNUAL PREMIUM DIA ASSESS. 4.5% OF STANDARD PREM. EST. ANNUAL PREM. PLUS ASSESSMENT' INSTALLMENT BASIS: Annual COMMENTS Coverage effective 12:01 AM on 02/26/03 COMBO I.D. 000004064 COVERAGE GROUP 0004064 STATUS OF EMPLOYER Individual Coverage under this assignment applies to Massachusetts operations only. For coverage outside of Massachusetts, contact the appropriate Pool or Plan for that state. INSURANCE COMPANY: TRAVELERS INDEMNITY CO MS JACKIE DENNIS. P 0 BOX 3556 ORLANDO, FL 32802 (800) 443-4404 CLASS ESTIMATED RATE ESTIMATED CODE .TOTAL ANNUAL PREMIUM REMUNERATION ----- -------------- ---------- ---------- 5545 $0 33.29 $0 984 0032 $50 $50 0900 $122 0990 $500 $500 $17 $517 REQUIRED DEPOSIT PREMIUM $517 DATE OF NOTICE: 02/27/03 PREPARED BY: Jeanne Shea EXT 530 LETTER ID: 378353 COPY: EMPLOYER The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street : Boston, MA 02110 R IFIC.- Q INS.!V-� LL 1$$UE DAiC (MM/IJI11v Y1. -LC. 1 9'11 ' 9.G .. .. . . . 05/21/c uce THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANv • CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICA (E WARD INSURANCE AGENC INC DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY 711E POLICIES BELOW. j FRANKLIN S.TR.EET COMPANIES AFFORDING COVERAGE Ei ROSE NLA 02176 ! COMPANY A HE.tMITAGE INS.' CO. COMPANY B _--� LCTYF•R U -H.AEL KEOITAN COrMPANY , ' LETTER r ELM ST COMPANY (J LETTCA _)ZTH AAIDOVER MA 01045 COMPANY LETTER E r ERAGEbi .. •:7: t; <i':Jn': "-1•�-��SJ17. F'_._ _.'i:i.°.I v.'.�a :':.. :.a�..,:;il:'i= '• - '3 i .-iIS IS TO CERTIFY THAT THE POLICIES OF INSl1%:AN: _;CTEw - HLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD raDICATED. NOTWITHSTANDING ANY. REQUIRCME r1 . ; Er rL'. OR C ONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS _RTIFICATE MAY BE ISSUED OR MAY PERTAIN. HE 1N.­,jaANr ., AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL,mr; TERMS. '_ CLUS'ONS AND CONDITIONS OF SUCH POLICic.3. LIMITS : r - :N MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE Of INSURANCE POL _Y I,UM E^. IPOLICY EFFECTIVE POLICY EXPIRATION " DATE (MWDD/YY) DATE IMM/DD/YY) LIMITS °NERAL LIABILITYj GENERAL AGGREGATE 51 '000, 0 00 `r7COAIM CRCIAL GENERAL LIAHIL I I'Y HGL4 3 16 6 10 5/ 2 0/ 03 , 05/20/0 q I PltouuGTS•CO MPIOP AcG.' s], 000, 000 _. ICLAIrtS MADE a OCCUFT. PERSONAL b ADV. INJUnY '. S500 , O O O ICNNER'S b CON1AaCTOH'S PROT. EACH OCCURRENCE $500,000 r.5 0 000 J ^ FIRE DAMAGE [Any ona Iva) MED. EXPENSE (Any Ona r)CrOn) L ] 0 00 AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AI;T l A—ALL LIMI1 OWNTD AUTOS - BODILY INJURY S ._SCHEDULED AUTOS (Por pnrsan) I1111ACU AU IUS BODILY INJURY' (Pcr acc10an() �^ L _ I INON-OWNCD AUTOS lG AFiAG E LIAVIL1 I PROF'EHTY DAMAGES `-E SS LIABILITY EACH OCCURRENCE T UMORLLLAFORM AGGREGATE s 10IHER 1HAN UMBRELLA FORM �{±:f,� k'':S« _rc .:_I . . .1 _r.• . WORKER'S COMPENSATION STATUTORY LIMITS ':`?t•C:`5;;�1:!^'�;.••;: ', EACH ACCIDENT S - AND s EMPLOYERS' LIABILITY DISEASE—POLICY LIMIT - ) DISEASE—EACII EMPLOYGG S } r A I .j. -APTION OF OP ERATIONSILOCATIONSIVEHIOLES/SPECIAL ITEP: JFING - COMMERCIAL TIFICATE-HOLDER_ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE yj LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALT_ IMPOSE.NO.OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES. _ -•4 Yi. . AUTHORIZED REPRESENTATIVE .. . _ )'1+:._'l: ' : a�:4+t :'+:� '-n:.a:...:• :r A• v a, • o '. til . ' I N::; �,.� «,>��c:«.��::-,.:4�:'�. '' ;.�:' 1` .. 1. • � .. _.-... r. i'yy F:i'a:.'' • �G; 25•S (7/9O1 _ + `+ � 1`"_ =: °� � ,� r TOTAL P.01 Ll1 W cd A O U � o w a cn 0 H z C .s o u. tic o c4 C :.c U G ci w" 0 a ADD p w' ib q (i. a o W W X00 o w v U Cl)fJ4 id r o rZ z �bD o rx G L% H w w w G 90 u V) o cn •a m I CC C.— IMM •— pM O :— H O O .g m m CD 0 CD CD L 3� O � CD C O M O d a- cmQ O civ Cc D C Z CD CL �.i CO) c C C C _c 0. COD 0 CO U) Ir W w VJ c� o g� c o � • oca O vv CL. Cc ev D o ' :cea CD y: N �. :Ea �• o c. EN E . 0 m o 3 0 • :mom �M:ate • �mm a + N Mot O r„ cm m�a� •5 a = c c Ncc Ca E cc o-C.,� ` m N O. 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