Loading...
HomeMy WebLinkAboutMiscellaneous - 37 COURT STREET 4/30/2018a, 11107 Date. .............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ..1.... ...... has permission to perform .barlix-s ....... . . ........... plumbing in the buildi gs of .............. ............................... e, Fee,37,,S.Q ... Lic. NoPz�i.Y, Check .......................................................................... ................... I orth Andover, Mass. . PLUMBING INSPECTOR v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �j MA DATE PERMIT # CITY �' / OWNER'S NAME e lug JOBSITE ADDRESS TEL FAX POWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL �I RESIDENTIAL �] PRINT PLANS SUBMITTED: YES © NO® CLEARLY NEW: 0 RENOVATION: ® REPLACEMENT: [0 --> BSM 1 2 3 4 5 6 78 9 10 11 12 13 14 FIXTURES FLOOR E c III Ili III r— BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION " WATER HEATER ALL TYPES WATER PIPING OTHER Ce INSURANCE COVERAGE, 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES�NO �1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW OTHER TYPE OF INDEMNITY El BOND 0 LIABILITY INSURANCE POLICY 0 - OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the on insurance n ur this over ege required by Chapter 142 of the Massachusetts General Laws, and that my signature on t p pp CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of t e cieinstallad and information I hunder the Ittedoi permit issuedaor has aing tl ationplic be inare true pl anan e with rate eotine be: and that aall plumbing work Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � SIGNATURE PLUMBER'S NAME LICENSE # I �r IVIP © JP COMPANY NAME CITY FAX CORPORATION Q#PARTNERSHIP]#®LLC ATE VM ZIP of the o z y ❑ } f wr r The Commonwealth ofMassachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): o� .�' • l/ Address: 4 /­ aA C City/State/Zip: Q1 /o t, -,) / U Are you an employer? CKieck the appropriate box: Phone #: 1!�D 1.❑ I am employer with .:...1 employees (full and/or part-time).* 2. in as sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ 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.] 78'o w � Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is pr' ovidiyeg workers' compensation insurance for my employees.' Below is the policy and job site information. / Insurance Company Name: AV / —I le 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 required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 ldie�pains and penalties of perjury that the information provided at above is true and correct. SiLynature: I / �/1// y C Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 7 � s Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested; not the Department of Industrial Accidents._ Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1 -877 -MAS SAFE Fax # 617-727-7749 Revised 02-23-15 yvww.mass.gov/dia Date. �!. %/..... ....... � Of NO oTh 1ti D— 3j �` �� TOWN OF NORTH ANDOVER r o A 41 PERMIT FOR GAS INSTALLATION This certifies that ............................. has permission for gas installation .... R.!40?.7. - .............. in the buildings of .... .~ at ...rj!� :. f-� :4... ....... , North Andover, Mass. Fee. 4 3 k - Lic. No.. e1. .... :. � 1 ...... . GASINSPECTOR Check # 71 '2 L/ 5949 i pyo MASSACHUSETTS UNIFORM APPUCATON FOR PERM TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations r" l cow' , Owner's Name New D Renovation 11 Replacement D Date q -J-0-7 or type) Name Address CQt1'e,;- 7 Business Telephone Name of Licensed Plumber or Gas Fitter Ck one: Certificate Installing Company heU Corp. Partner. La Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes 0 No13 If you have checked Les, please indicate the type coverage by checking the appropriate box. Lability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: 1 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 13 Agent 1 harPMi narhi A, fL.ot nil ..F♦he ,J..�..:1,..._J :_c_____.� _, ____ ___ _. -.._ .,... ,.,,, ,,,,u.,,,,, , „Qv%; ,,,,,, itwu kur emerea) In aoove application are true and accurate to the best of my knowledge and that all plumbing work and install tions perform nder Permi ued for is application will be in compliance with all pertinent provisions of the Massachusettsst j� as Cde nd Chapt h of the G neral laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Permit # ® Amount $ Plans Submitted G ta-Master or type) Name Address CQt1'e,;- 7 Business Telephone Name of Licensed Plumber or Gas Fitter Ck one: Certificate Installing Company heU Corp. Partner. La Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes 0 No13 If you have checked Les, please indicate the type coverage by checking the appropriate box. Lability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: 1 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 13 Agent 1 harPMi narhi A, fL.ot nil ..F♦he ,J..�..:1,..._J :_c_____.� _, ____ ___ _. -.._ .,... ,.,,, ,,,,u.,,,,, , „Qv%; ,,,,,, itwu kur emerea) In aoove application are true and accurate to the best of my knowledge and that all plumbing work and install tions perform nder Permi ued for is application will be in compliance with all pertinent provisions of the Massachusettsst j� as Cde nd Chapt h of the G neral laws. By: Title City/Town APPROVED (OFFICE USE ONLY) SiUmbeer ® PID G ta-Master Journeyman � a z `�' z F � � o Z z v,x V U w x z d� o a > d tw7 F z F z x w w U a w I- w U x z w Q a o x z x o> x 3 a a o u o a> w SUB -BASEMENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR ,7T H. FLOOR lit 18T H. FLOOR or type) Name Address CQt1'e,;- 7 Business Telephone Name of Licensed Plumber or Gas Fitter Ck one: Certificate Installing Company heU Corp. Partner. La Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes 0 No13 If you have checked Les, please indicate the type coverage by checking the appropriate box. Lability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: 1 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 13 Agent 1 harPMi narhi A, fL.ot nil ..F♦he ,J..�..:1,..._J :_c_____.� _, ____ ___ _. -.._ .,... ,.,,, ,,,,u.,,,,, , „Qv%; ,,,,,, itwu kur emerea) In aoove application are true and accurate to the best of my knowledge and that all plumbing work and install tions perform nder Permi ued for is application will be in compliance with all pertinent provisions of the Massachusettsst j� as Cde nd Chapt h of the G neral laws. By: Title City/Town APPROVED (OFFICE USE ONLY) sed Plumber Or Gas Fitter n�177 License Number ``� SiUmbeer ® PID G ta-Master Journeyman sed Plumber Or Gas Fitter n�177 License Number ``� I Date.11/11�-`/`*��` "SRT" Ttj TOWN OF NORTH ANDOVER PER IT FOR PLUMBING 1P This certifies that ........................... has permission to perform ...T .c'k: 40- .................. plumbing in the buildings of ... 1. - - P- ................. at ... 1.7... rC,. L - P1 ........ North Andover, Mass. Fee Li c. No. f . ....... ./. .......... PLUMBING INOECTOR Check # 7339 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS � Date �1 4 -07 Building Location "31 � � Owners Name Amount Type of Occupancy New 0 Renovation 0 Replacement EL Plans Submitted Yes No FIXTURES (Print or type)j [� E Check one: Installing Company Name I 01-i JC L t V'Q;L - CS Corp. fpj Address l `t 0 Partner WFirm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insur#nce coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity Bond ❑ Certificate 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 , Owner I hereby certify that all of the details and information I have submitted (or ea best of my knowledge and that all plumbing work arl installati s perfo ed compliance with all pertinent provisions of the Massa to lu By: Nign,gnuv�q&ucensea ri nef ype f Plumbing License Agent 11 in above application are true and accurate to the r P it Issued for this application will be in andptei'142 of the General Laws. 101Z,4- a Title CiVrown r=737umner Master M\/ Journeyman ❑ APPROVED (OFFICE USE ONLY .n 6 Date ................ NORTH °�<��`�:•�"o TOWN OF NORTH ANDOVER .fir � � -.• '• OL p PERMIT FOR WIRING This certifies that ...........:S r 4 ✓�� A t� Tl► I �— .......................................................................... has permission to perform .r? t, t, ....ke.n'... .......................................................... wiring in the building of . Wl'l41-e ' ............................................................. .5r ................................ North Andover, Mass. Fee . ...... ..... Lic. No. �� � J .. �............... ........... q EL CTRICALINSPECTOR Check o�39d 7284 Commonwealth of Massachusetts Department of Fire Services w BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �7 Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME 527 LMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)_ Owner or Tenant , J O h n� Owner's Address 3 Telephone No. Is this permit in conjunctior with a buil mg permit? Yes �JNo ❑ (Check Appropriate Box) Purpose of Building I � �S ( 27i�7 L Utility Authorization No. Existing Service /00 Amps j-�)c) IP 5(J 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 Electrical Work:j Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig ing Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers ea Totals: Number Tonss KW No. o elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. o Water KW Heaters No. o No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: N- of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under lite 'ns and penalties of perjury, that the information on this application is true and complete. FIRM NAME:p /,4,c, G L LIC. NO.: Licensee: dcsi,J,�J Signature LIC. NO.: (If applicable, enter "ex pt" rn�t h� l�ice� se number line.) Bus. Tel. No.: Address: �G� �Y cV`<%1/tiC /� J� /�/� r! �, Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 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. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ '� ,�- -, 3w `9W-d� G*e. 4 The Commonwealth of Massachusetts Department of Industrial Accidents -- Office of Investigations ' a 600 Washington Street Boston, MA 02111 s� www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor and I e loyees (full and/or part-time).* have hired the sub -contractors ?.LIXam a sole proprietor or partner- listed on the attached sheet. 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.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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 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 c, h under th s a penalties of perjury that the information provided abov is tr a and correct. Si nature: Date: �. '3107 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 #: Permit NO: y_ Y 7 - Date Issued: r),` ( L- a -q - TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received a- 12- - d "'-' IMPORTANT: Applicant must complete all items on this page I LOCATION 37 LU (+ �f PA..# PROPERTY OWNER 5-1)W tkk v (i MAP NO.: P IrVP A1%M iJg1F nF RiTiT.niNV. k` ZONING DISTRICT: MgTnRir niSTRiCT VFS ❑ TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building ❑ Addition ❑ Alteration Obne, family ❑ Two or more �family No. of units: ❑ industrial epair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving relocation Other ❑ Others: ❑ Foundation only OWNER: TION OF WORK TO E PREFORMED XT 7( T6 gev­l on/ lease Type or Print Clearly) I Jd N,1; 144Jc( Address: �76 /,it)l l 66 e- f 3-7 C_Ov rt :�;f. ;(z -7 'fir/S� CONTRACTOR Name: Phone• ,29 ~4J 049 3 Address: '76 MGNC&L 57T Supervisor's Construction License: OC3 2-20 Exp. Date: Home Improvement License: J 1 Z Exp. Date: ' O ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT.• $12.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED ON S125.00 PERS F: Total Project Cost :$ f 33� 4? :f °a FEE:$ q0 Z Check No.: Receipt No.: oq'/�'6 Page 1 oP 4 TYPE OF SEWERAGE DISPOSAL Art E]g Swimming Pools ❑ Public Sewer El Well � ❑i Tobacco Sales ❑ Food Packaging/ Sales ❑ ❑ Permanent Dumpster on Site El (septic tank, etc. Electric Meteirlocation to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty Jund e Signature of Agent/Ov ner LSignature of contractor Plans Submitted ❑ #PansWaiv ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED U DATE REJECTED DATE APPROVED HEALTH COMMENTS. U IN FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments r � , Water & Sewer Connection/sstare_hc Date Driveway Permit Building Setback ft. Front Yard Side Yard Rear Yard Required Provided R wired Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 o Building Permit Application o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Addition Or Decks o Building Permit Application o Surveyed Plot Plan o Workers Comp Affidavit o 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) New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 In all cases if a variance or special permit was required the Town Clerks oMce must stamp the decision from the Board of Appeals that the appeal period h 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 Dee: INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS Page 4 of 4 Location �� C'y✓icT 5r— No. 5 Z2- Datet,)- (2. - 0 opMQ"T+I �TOWN OF NORTH ANDOVER t.... ,� tio S Certificate of Occupancy $ sus Building/Frame Permit Fee $ 4� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 31(1::7 19985 �. Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents JOffice of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _09i'1 i,; ; ( Ma -4c Address: JD Muiui%t 57 City/State/Zip: I,lg_(h< <( M4, Phone #: 50 %S-/ -��` Are you an employer? Check the appropriate bog: 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. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no 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.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. 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 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 c�err�tify under the p 'ns and nalties of perjury that the information provided above is true and correct Signature: /(1t�il� Date: 2/7/D % Phone #: S-6 OttoIV I use City or Town: not write in this area, to or town of}icia[ 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 #: 1 W W !c z w Q � o w x w x a 5 aa U to C a Av Ct G3 �;.Q o w a c9i o w o w U o w" oC w w W o c� C9 lz o w w rA c. o cn LU am Cn O E R c A Z O c 0 5"3-� k 0 z O U CO a O O E ai ■ L O z o. O y Q O I Ccm 0.— 0O3 Q •E m CIO CD 0 CD a 3.0 CD Q 0 CL CK CL c Q Co � c cc ca -� ■v CL. O }; c Z CD CL V y O C ■ C c CO2 0 U) W W Lc W U) 50 c �a O to C Ct G3 �;.Q C C W W O Z y.r roe m :z raa :.. O O. �v�om y 3ps :acm te • mm cp r" 3 GO cm co m CD m 3 CC.3m _mm C3, ao A y m O L 1C.32 CA m Qmo O = m •ai�c F- '� CL*12 y m $ CIO W CO �A me •LAA A dt C LU a y d m� Off_ Z M 7 CL.. Cc Cn O E R c A Z O c 0 5"3-� k 0 z O U CO a O O E ai ■ L O z o. O y Q O I Ccm 0.— 0O3 Q •E m CIO CD 0 CD a 3.0 CD Q 0 CL CK CL c Q Co � c cc ca -� ■v CL. O }; c Z CD CL V y O C ■ C c CO2 0 U) W W Lc W U) OCT 05 2000 12:21PM HP i-nsi:RJET 0200 ®aiD.D 06; A"RD 00 D CERTIFICATE OF LIABILITY INSURANCE Spiel Gobei` Munroe Street Haverhill MA 01830 ANN RFOJ+R-EhIENT TEW C't CVr'4f 1 -ION OF ANY COKrii%.CT 0R _;?EN GOSO Z.MODUCER � NAIC THIS GrimrwiCATE 15 IQSUED AS A MATTER OF INFORMATION 14 23 ONLY AND COFFERS NO RIGHTS UPON THE CERTIFICATE Dave , Davits & Moody HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 40 Kenoaa Avenue If ALTER THE CUVERAGE AFFORDED 9Y THE POLICIES BELOW. Haverhill MA 01830 Era're:978-373-1347 rax:978-558-0285-"- INSURERS AFFORDING COVERAGE snstiraen ---"- iftnWIRAnKS SpIINSUP,FR ANN RFOJ+R-EhIENT TEW C't CVr'4f 1 -ION OF ANY COKrii%.CT 0R _;?EN VVTH FLS -ti -.,T 7O WHI:; , T`!!:. CERTIFf,ATE MA" RE ISSUED OR � NAIC INSUReR.A.T:Bl ua 14 23 -;ytrons Fr: ------ -- v-- .i _ - _- r•---T-----POLI . PLlmm-ER TYPE OF I rSURAIXE �� .1CYEPFE+..'T'.'v ��'9P��iI�I$T�___-�.—_ GdT):IVMfDD!YYj pjliDDrY" i LIMITS '1 GENERAL LIABILITY I _AT_�r - � L-G0.CMCCCLIRiiENCE N3(AERf1ECJ -- IN—ER E: �►:, FX _ COLh1FACl.al_GENEF?�L:Adt? T5' I �_`Ti�DCG�=a5d 1 - -! POLLEES C; INSURANCE I ;SIF r0 EEI CV.' HAVE SEEN ISS i- D T7 "im,F, i SUR O `dA!"_C., AS -JE FOR THE PD - Y PERIOD NDICAFEU. IvCi'vViTHS'+41V6'tdu ANN RFOJ+R-EhIENT TEW C't CVr'4f 1 -ION OF ANY COKrii%.CT 0R _;?EN VVTH FLS -ti -.,T 7O WHI:; , T`!!:. CERTIFf,ATE MA" RE ISSUED OR 114AY FERTAIiv Tri: !NSURAtiCE A.Fr.)RDcD EY "K.; IS 3L'EJ C' TO Ai:. -HE TERMS, EXCLUSN'Na ANC CONt:I`)CN$ Df SUCH iOUCIES AGGMGATE UIVI'£ iHOY.Rd 1�?A7' HAVE EEEtd 4EDUf,F'v 1`.` ??:10 .^,LAI tS- �...--_ LTR IN RV� - _- r•---T-----POLI . PLlmm-ER TYPE OF I rSURAIXE �� .1CYEPFE+..'T'.'v ��'9P��iI�I$T�___-�.—_ GdT):IVMfDD!YYj pjliDDrY" i LIMITS '1 GENERAL LIABILITY I _AT_�r - � L-G0.CMCCCLIRiiENCE N3(AERf1ECJ -- - —`- — $ SCDDDD �►:, FX _ COLh1FACl.al_GENEF?�L:Adt? T5' I �_`Ti�DCG�=a5d 1 - -! o7t�E ilf2$j'D5 � 11J24/DE Pr~=fd+sFs(Ezoec::re�:F� 1$50000 _._—_-' �- CL?dV,,S WIDE ! G- :UR UED FXP (Any ere pw-53 is PERSONAL& ADV INJURY $ 55000 $ 540000 '----- ------------------_.— f GFNF7A.LAGGREGATE I $ 1000000 ! =GENT A3'3rTFGAT.E LA?IT AFPL 25 PER- j POLILY -�� I PRDDUCTS - CC`v?PIC? AC -C- ����• s :.000000 ALTOMO4ILE LIABILITY { C3M1?CiINED 3iNCiE LIMI , (Ea ecoiaw4) I $ AL'YAUTO Pd.L tJ4'UNEJ A.UTJS + BODILY INJURY � 3CHEDULEC.IAUTg9 , (Per Iperson) HIRED AU7C8 ! � � BCDILI' INJURY (Per llrJ_t76�M) $ m.uYN NoO'ED AUTOS --- -- ! I $ j I PROPERTY GA'dAi9E (Per aaideit) + i i GAkAGi UASILITY AUTO ONLY - EA ACCtDEA1T 5 -- ----------- ANY AUTO FJ, ACC !-$ EA AC OTHER THAN I EXCE VVIVISRELLA LIAWLITY i - --_..— + AUTDONI_`r` AGG EACH. QCCURREN^E 6 �- CCC'JR f CLAIMS IMACE � T AG NEGATE $ L DEDI;CTISLE I Ir E �_ `.---�-- $ - RerewnON S I� WGRKCASCCWPE4SATIONAND – EMPLOYERSLWMI.JTY ANY PROPRIETORIPARTNEF(!EXI_CUT!'JE TOR_ ,T-1 "ER" +------ � E.L. EACH ACCIOLNT 1 li _--.— Et. OSEA3E - FA E!UPL'JYEE: ---t--- DF�iCERfiAEI#HEkE:t^...UDED? I, li •)fas, E -se bB + .Ln.der opECIP� PP.JVISIONS Feovr ' : E.L D:SEASE - POLICY LImr $ OTHER II CESCRIPTION OF OPERATIONS i LOCATIONS I VEhrt: ?3 ; EXCLUSiON1 ADDED BY 13PECIAL AROIASIONE cERI IFIGATE F1OLLIEIs CANCELLATION _ BOBPALI 5HCU�.7 ANY OF THE ABOVE 0E3C.ED POUCI€S RE CANCELLED SCIOITE THE EIF"ATM ''aA'TETH@Rw7F,7MEISSUiNaiN$t,RkR:ALLEtdCIEAYC;fSTO,YlAil 1.0 DAYSWRnTEN BOB PALING YCI%'Il TO Tr,E GERTIFICA s 1-K)LD9R NA^RED TO THE LEFT, BUT FAILURE TO 00 411, SHALL 21 CRICKET KIT -]G 6F31 dGATtON 0R UABIL+TY OF ANY Y.iND UPON fiGR, tT3 AGF�acta EAST KINGSTON NII 03848 �ZWESE TAI iv LIS. ,..a -- -�_1-- ACCORD 26 {20151 J8) //— CACORD CORPORATiON'INS 780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS THE MASSACHUSETTS'STATE BUILDING CODE TABLE 3605.2.3.3a ALLOWABLE SPAN FOR GIRDERS SUPPORTING ONE FLOOR ONLY SIZE OF WOOD GIRDER' FLOOR LIVE LOAD (p SPACING BETWEEN GIRDERS OR BETWEEN GIRDERS AND LOAD BEARING WALLS' 4 feet 6 feet 8 feet 10 feet 16 feet 4x4 - 30 5'6" 4'6" 3'6" 3'0" 2'6" 40 510" 4'0" 3'6" 3'0" 2'6" 4 x 6 0 8-5 20x20* 6-3 23x23 5-3 30 8'0" 6'6" 5'6" 57 4'6" 40 76" 67 5'6" 4'6" 4'0" 4 x 8 6 x 6 30 11'0" 910" 8'0" 70" 5'6" 40 10'0" 8'6' 7'6" 6'6" 5'0" 4 x 10 k6 x 8 30 147 11'6" IV0" 8'6" 67 40 13'0" 10'6" 9'6" 8'6" 5'6" 4 x 12 6x.10 30 166" 14'0" 12'0" 11'0" 910" 40 160" 12'6" 11'0" 1010" 8'0" 26x26 4-2x10 9-0 20x20 6-9 25x25 5-7 For SI: I inch = 25.4 mm, l foot = 304.8 mm, I pound per square foot = 0.0479 kN/m2. 1. Allowable spans may be interpolated between tributary loads shown in table. Spans and girder sizes may be computed independently of the above table in accordance with accepted engineering practice. 2. Spans are based on No. 2 lumber. 3. The spacing is the tributary load to the girder. It is found by adding the -spans of the floor structure on each side which are supported by the girder and dividing by 2. TABLE 3605.2.3.3b ALLOWABLE SPANS FOR BUILT-UP WOOD CENTER GIRDERS . AND FOOTING SIZES FOR GIRDER SUPPORT COLUMNS WIDTH OF STRUCTURE (feet) GIRDER SIZE (inches) ONE STORY Maximum Span Footing Size 3 feet -inches) (inches) TWO STORY THREE STORY Maximum Span Footing Size 3 Maximum Span Footing Size 3' (feet-mches) (inches) (feet -inches) (inches) 24 6-7 17x17* 4-11 20x20 4-1 22x22 4-2x8 7-8 19x19* 5-8 21x21 4-9 24x24 0 8-5 20x20* 6-3 23x23 5-3 25x25 4-2x10 9-9 21x21 7-3 24x24 6-1 27x27 3-2x12 10-3 22x22 7-8 25x25 6-4 27x27 4-2x12 11-10 23x23 8-10 27x27 7-4. 29x29 26 3-2x8 64 17x17* 4-9 20x20 3-11 22x22 4-2x8 7-4 18x18* 5-6 22x22 4-7 24x24 3-2x10 8-1 1909 6-1 23x23 5-0 25x25 4-2x10 94 21x21 7-0 24x24 5-10 27x27 3-2x12. 9-10 21x21 74 25x25 6-1 28x28 4-2x12 11-5 23x23 8-6 27x27 7-1 3000 28 3-2x8 6-2 17x17* 4-7 21x21 3-10 23x23 4-2x8 7-1 18x18* 5-3 22x22 4-5 24x24 3-2x10 7-10 19x19 5-10 23x23 4-10 26x26 4-2x10 9-0 20x20 6-9 25x25 5-7 28x28 3-2x12 9-6 21x21 7-1 26x26 5-11 28x28 4-2x12 11-0 22x22 8-2 28x28 1 6-10 3000 32 3-2x8 5-9 16x16* 4-3 21x21 3-7 24x24 4-2x8 6-7 17x17 4-11 23x23 4-1 25x25 3-2x10 74 18x18 5-5 24x24 4-6 27x27 4-2x10 8-5 20x20 6-3 26x26 5-3 28x28 3-2xI2 8-11 20x20 6-8 27x27 5-6 29x29 4-2x12 1 10-3 22x22 7-8 29x29 6-4 1 3101 For SI: 1 inch = 25.4 nun, 1 foot = 304.8 mm, 1 psf = 0.0479 kN/m2, 1 psi = 6.895 kPa. 1. Values shown are for a clear -span trussed roof, a load bearing center wall on the first floor in a two-story construction, and a load-bearing center wall on the fust and second floors in three-story construction. 2. Spans based on allowable stress in bending Fb - 1,000 pounds per square inch (psi) for repetitive members. See Table 3605.2.3.1d 3. Footing size based on 2,000 psf soil -bearing capacity; footing thickness shall be one-half (minimim) the width of the footing, or ten inches, whichever is greater. 4. 4x4 posts may be used at these (*) locations, 6x6 posts, or 4x4 posts or three-inch diameter steel columns with bearing plates or equivalent area, are acceptable in all locations. 524 780 CMR - Sixth Edition corrected - 9/19/97 (Effective 2/28/97) BOARD OF BUILDING REGULATIONS " License: CONSTRUCTION SUPERVISOR Number: CS 063220 Birthdate: 01131/1966 Expires: 01/31/2006 Restricted: 00 DANIEL L GOBEIL 80 MONROE ST HAVERHILL, MA 01830 p� ex- Board Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 132182 Expiration: 11130/2008 Type: DAN GOBEIL CONTRACTING DANIEL GOBEIL 80 MONROE ST.� HAVERHILL, MA 01830 - Administrator Tr, no: 13112 commissioner License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 &U-C-40-md- a__- - Not valid without signature PAGE 2OF2 AGREED TO & ACCEPTED BY.- Daniel Y: Daniel Gobeit DATE: 2--2-07 R6gin esser DATE: 2--7-67 • CLEAN .AND REMOVE ALL DEBRIS • ENGITNIEERINIG MATERIAL AND LABOR FOR 8" OPENING $1850.00 � • PELT j $250.00 • DDWSTER $750.00 • MATERIAL $1,488.00 • LABOR $8,265.00 • GAS $275.00 + PL LING $3600.00 + ELECTRICAL $4000.00 • TOTALMATERIA-1 SND LABOR $20,478.00 • PA SCHEDULE One third down at Contract sigmt1g, then one quarter p#yments at intervals during the 'ob. Initiala _ cnt due at contract singing v $6836.00..4p& Second payment due at cornnieticn of rc ught . $3410.50 Third pay itnL v,- all, Vom i'V6ion o-wa 1, trim, linin paint. Ip T I V. Forth payment due at completion of plumbing, electrical, and cabinets. $3410.50 Fifth payment due at completion of file and pupch list. $3410.50 AGREED TO & ACCEPTED BY.- Daniel Y: Daniel Gobeit DATE: 2--2-07 R6gin esser DATE: 2--7-67 Dan Golbeil Dome Improvement 80 Munroe Street Haverhill, MA 01830 508 451-0493 CONTRACT i CUSTOMER: Regina Jesser DATE: January 29, 2007 37 Court St. North Andover, 01845 PLAN: Remodel kitchen THE JOB WILL INCLUDE THE FOLLOWING: PRICE • DEMO: Disconnect all plumbing and electrical that will interfere with the removal of cabinets. Remove all cabinets in kitchen area. Remove all flooring down to sub -floor In kitchen area. Build temporary wails, one in kitchen area and one in dining area to suprt ceilings, Create ars Hing ap roxiniateiy 8a -sk de to gain direct access from kitchen to dinin area. Remove anyLaster needed to accommodate the plumber and the ° { electrician. Remove any trim in kitchen area. • FLOOR. Apply Ia" hardy backer -board to entire kitchen area.. • PLUIviBING: Remove radiators in kitchen and in dining room-, and rough in for new baseboard beat, toe -space beater, and sink. € ' ® ELIC $ RICAL. Rough in for three recessed lights over sink, three over stove, and two over, pantg area, under cabinet li titinS in same areas and light over table area and over new opening in kitchen. Move switch from sink -base cabinet to counter area for dis sal. Install proper switches In mud- room area. EXTERIOR: install new outlet on front of house and one on side of house • DRYWALL: Patch and drywall any areas needed. IVIud,to pe and sand. + TRIM: Apply trim to kitchen windows. PAWT: Faint kitchen, dining room and mud room. + CABINETS: Install cabinets. To be supplied by homeowner • COUNTER: Ap2lied by others and su lied by homeowner. NEED TO ORDER $ FLOOR: Install tile, - out and seal. PLUMBING: Install new baseboard heat to kitchen and dinin_g area and a toe -space heater in kitchen to accommodate the removal of one old heater. install sink, faucet and disposal. Sink and faucet and disposal to be..supplied.by homeowner. • ELECTRICAL: Install all new outlets and switches, li tits, and connect di$ sal and ' toe -space heater. 'fable and entry fixture to be nMlied by homeowner. • GAS HOOK UP: Move gas line to new stove location. + PUNCH LIST., install an remaining trim and an other touehu s. Re Aaoe sill on Mead room window and move dryer vent to front of house. o ALOWANCES; Tile $4.50 a square foot l • Anything above and beyond said work will be done on a time and material basis at a rate of $40.00 per man hour CONTITINUD Location J Cv N 1? f ST c No. Date TOWN OF NORTH ANDOVER 0�...o ,•1h •OOw O?• n a � • Certificate of Occupancy $ Building/Frame Permit Fee $ a e� swcHU Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3� Building Inspector 7 �9/�9/98 09:34 136.00 PAID Ln ! Div. Public Works 0 Location No. , +— Date T NaRT� TOWN OF NORTH ANDOVER `•O I•,MO moi° F?O•'t Certificate of Occupancy $ I -�(• } ; Building/Frame Permit Fee $ -1 cmus6 Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �� \ Building Inspector! 09/09/98 09:30 136.00 PAID i Div. Public Works 6 - XI S \ V 1S = C C^. a Q f 50 C Y U :J O N C n/1 l�`�� X X X weir Z C Z = Q L Q � C n Z L — N Z Z rr 9 C 9 r y fn N ye r v Z 0 Z 'Z 7 7C z Q :n Vl :n F d' C7- x Tq;?n" �' `; Z Z Z z W T �, �/'[ G v.l r 000 Z Z 4� 7 rj J j ,ZLU — .. v u] C l:: L•l 6 - XI a S \ S 1S = C C^. f 50 .^ U :J :J . z n/1 l�`�� X X X weir Z C Z = Q L N {� C n Z L — N Z Z Z 9 C 9 r y fn ye v Z 1. Z 'Z 7 7C Q :n Vl :n F d' C7- x Tq;?n" �' `; Z Z Z z W LL) �, �/'[ G v.l r 000 Z Z _ 7 rj J j ,ZLU — .. v u] Z l:: L•l 0 � F � d � U Q .. i. LU z W ¢ S N a LLI Z ` z UJ LU LLI 1 F Z a a Z w vl z Z_ Z_ C 1 Z Z . Q 4 W CA a S 1S f 50 z n/1 l�`�� to = v OFV" C- N C- J >� d' C7- v.l r LLI 7 rj J j ,ZLU a ml z O SIR * cm J o O C s W C* a O c •` 3 o cc cc A m o � cc CD CA � ma � H Do �t Al l :L CD C 0 CL 0 4D • E c O • 0 0 t; c ti �1 Y H m3 cn O H U �j c _m L z ! � • m oH w c c 0 y � U cm h ; C c� o � t0.7 y Z O Os CDc c. o c Q i m C O = m 42D N H O gy p !0 m COD �.+ O = r.+ 0 w W p 'p �' C .� .y :ZZ A C z °c 'E C :� CO2LU C3 OF= y o cmL30-0 Cos CD 5 H .0 O y= O c b O O a co E O a� C O CL H O .Q H G O V O �G cc CO)CL is CDco•c co cc 3 s' CL L C. C Q cc � C '0 O Z s CDCLy G d C �V. .\Y. S v v 9 O[ w Aa G O O O XC U cz x 19 O U w ow ADO O c� id G w C4 a W O O a u cx ro G w I a O � O 0 u: I icf C w I H w a r.r FL C , 7 M O .~ C/)cf) 0 E cm J o O C s W C* a O c •` 3 o cc cc A m o � cc CD CA � ma � H Do �t Al l :L CD C 0 CL 0 4D • E c O • 0 0 t; c ti �1 Y H m3 cn O H U �j c _m L z ! � • m oH w c c 0 y � U cm h ; C c� o � t0.7 y Z O Os CDc c. o c Q i m C O = m 42D N H O gy p !0 m COD �.+ O = r.+ 0 w W p 'p �' C .� .y :ZZ A C z °c 'E C :� CO2LU C3 OF= y o cmL30-0 Cos CD 5 H .0 O y= O c b O O a co E O a� C O CL H O .Q H G O V O �G cc CO)CL is CDco•c co cc 3 s' CL L C. C Q cc � C '0 O Z s CDCLy G d 0 I am a homeowner performing all work myself. [:] I am a sole proprietor and have no one working in any capacity C] I am an employer providing workers' compensation for my employees working on this job. �k address- s(� 0 I am a -sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: Failure to secure coverage as required under Section 25A of NIG L 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and e)orrem SignaturDate / g� e Print name lvPhone # 603 e7 official use only do not write in this area to be completed by city or town official city or town: permit/license # r-1 Building Department 0Licensing Board check if immediate response is required ❑Selectmen's Office (31-lealth Department contact person: phone #; I71Other (revised 1/95 PIA) •