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HomeMy WebLinkAboutMiscellaneous - 37 MIFFLIN DRIVE 4/30/2018N 0 Nw � V Q S T W r - Z �� O Date...., ...... I ......................... f TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION f l V �'��•1 �'�i� This certifies that ................................... L �� `Cx J ........................................................................ has permission for gasnstallation ...1.,1..:..::x......... �:..'-......�.......�.................. in the buildings pf ....-- � .r ..................................................................... at.. I ......... .........:...........�:�.:.�-- .................... North Andover, Mass. < j � .may .. ......................................................... GASINSPECTOR Check #_ +�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover I MA DATE 41112014 PERMIT # JOBSITE ADDRESSI 37 Mifflin Rd OWNER'S NAMEp GOWNER ADDRESS I Same j TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL[] PRINT CLEARLY NEW: RENOVATION: [] REPLACEMENT: PLANS SUBMITTED: YES® NO[] APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ;; a CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER a _ FIREPLACE b. . FRYOLATOR FURNACE GENERATOR t GRILLE _ INFRARED HEATER -- - LABORATORY COCKS _ _ - MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER—� ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace Gas Meter and Pipin as Needed It VE-- A ........... =I[ -- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITYF-1 BOND Q 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 0 AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i mpliance with all rti a provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Joseph Marino LICENSE # 8736 SIG A URE MP El MGF Q JPEI JGF [] LPGI ® CORPORATION Q# 3285C PART RSHIP©#LLC 0#0 COMPANY NAM El RH White Construction Co ADDRESS 1,41, Central St CITY I Auburn STATE L_YLJ ZIP 01501 TEL 508) 832-3295 FAX 508-926-4347 j CELL 508-832-4614 JEMAILI JMarino@RHWhite.com mi LU LLI <Z .()' CDW.;3 LL ..Lu H 0 H. , ZU) H LU U) = LU MW Uj< LU n oll sa -j mi 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 !7C ® CERTIFICATEF08/29/2013 DATE(MMlDDNM) •F LIABILITY INSURANCE page l of z ThIS CERTIFICATE Is iSSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. A B C D D IMPORTANT: If the certificate holder is nn ADDITIONAL INSURED, the poliey(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conferrights to the certificate holder in lieu of such endorsement(s), ?villi* of Massachuaette, Inc. c/o 26 CO-Atury Blvd. P. 0. Box 805191 Nalghville, TN 37230-5141 R. H. White Construction Company, Inc. 41 Cmntral Street P. 0. Box 257 Auburn, MA 01501 �L•LT -MAIL - _ i ram-NO).000—A P !_- E 3/ d .DORESS ce.rtificate�pwillis.c_om INSURER(S)AFFORDING COVERAGE NAIC 6 INSURERA: The Chartor Oak giro Ineurancg Company 25615-001 INSURERS:Trdvo3,AxD property Casualty Cotgpany of Am 25674-003 INSURERC:Nati0AA1 Union Fire) 7:neuranca Company of 19445-001 INSURERD; Travelers Indemnity Company 25658 -Dal INSURER F,; oYLRAGE$ CERTIFICATE NUMBER: 20267680 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURI INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ 3 TYPE 09 INSURANCE ADwL susk,vuvn POLICY NUMBER EACNOCCURRENCE S 2,000,000 pM GENERAL LIABILITY BTOeT51rl 300.040 'VTC2000 977X9948-13 X COMMP,RCIALGENERAL LIABII.ITY PERSONAL&ADV INJURY S 2 000, 000 GE_NERALAGGREGATE CLAIMS -MADE OCCUR PRODUCTS-COMPIOPAGG $ 000,000 M51-1) iiccrEDSINGLELIMIT GEN'LAGGRewe LIMITAPPLIES PER; POLICY PRO LOG BODILY INJURY(Peramidonl) $ AUTOMOBILE LIABILITY S VTJCAP 977KSSSA-13 X ANYAUTO 000 AGGREGATE ALI,QWNED SCWP.DULED AUT08 AUT08 E.L.EACHACCIDENT 16 1.00 000 S HIREDAUTOS X NON -OWNED 1,000,000 E,L,DIBEASE-POLICvLIMIT 8 1,000,000 AUTOS X Co Dad X Coll ped 00 1- UMBRELLALIAS OCCUR BE8766140 < X EXCESS LIAR CLAIMS -MADE DED X RETENTION S l0 , O D 0 WORKERS COMPENSATION V�ggj1F3 8205A185-13 AND EMPLOYERS' LIABILITY - ANY PROPMETOWPARTNRRIFXECUTIVE NIA VTC2XUB A203A71A-13 <_ OFFICER/MEMBEREXCLUDED? Mendetoary In NH) u�C�rdceil iiUN OF QPURATIONS below TE Evidence Of IIIIpUZAnce )/1/2013 '9/1/2014 /1/2013 9/1/2014 /1/21113 19/1/2014 /1/2013 19/l/2014 9/1/2014 /1/2013 UMBER; :D NAMED ,ABOVE FOR THE POLICY PERIOD IOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS EACNOCCURRENCE S 2,000,000 pM BTOeT51rl 300.040 .s MED EXP(Any one arson $ 101000 PERSONAL&ADV INJURY S 2 000, 000 GE_NERALAGGREGATE 4, 000 000 PRODUCTS-COMPIOPAGG $ 000,000 M51-1) iiccrEDSINGLELIMIT 2,000,000 BODILY INJURY(Perperson) S BODILY INJURY(Peramidonl) $ eracddent $ S EACH OCCURRENCE 1--5,_000, 000 AGGREGATE X 0 TAriY,l,l E.L.EACHACCIDENT 16 1.00 000 E.L.DI8EA9E-EAEMPLOYP_E S 1,000,000 E,L,DIBEASE-POLICvLIMIT 8 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDAePRE8ENTATNE Col1:4197604 Tp1:1694012 Cert::20287680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SQLocation No. -1 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # $ / "0 I Building Inspector SIGNATURE: Building Cowdnissioner/IEU22tor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) 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) Public 0 Private 0 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT liisiOric UIStCICt: Yes NO 2.1 Owner of Record SAL' i= I V -F Name (Print) Address for Service G� Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: _ License Number Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ f�,)jv",4t2J()-"S G(-fV P-141 edNtRi?e-Hy� oS ompany Name /J (/ �� Registration Number q1 R/q A dress rr O o G f ILC—Al C— M* l� 1 L� /C� E pirraation Date Si nature Tel hone N SECTION 4 - WORKERS COMPENSATION (M.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 ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �% k ( L, ac 4--1i 1 I SF.CTTON 6 - RSTTMATF.D CONCTRITf TInN Vn4ZTc 1 Item Estimated Cost (Dollar) to be Com leted by permit applicant OFFICIAL USE ONLY 1. Building (� (� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number btc.11uN is uWNEK AU TriUKILALION 'TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 i Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/, Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS OT 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHR NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Dimitrios General Contracting 91 High Street Lawrence, MA 01841 1(978) 685-7573 (978)618-8085 MA Contractor Registration ID: 136105 April 2, 2004 Proposal To: Sal Sergi 37 Mifflin Drive North Andover, MA (978) 686-9385 For work to be performed at: Same We hereby propose to furnish materials and labor for the completion for the following work. Specifications • 46 squares of roof will be stripped. • Roof will be prepared with 6 feet of ice and water shield on eves and vallies. • 30 pound felt paper will be applied to remaining roof. • 8" aluminum white dripedge will be installed • 35 year Organic Architectural IKO shingles will be installed. • Roof ridge vent will be installed. Contractor will dispose of all debris. Customer is responsible for protecting any items in the attic from fallen dust and debris as roof is stripped. If chimney's flashing needs to be replaced it will cost an extra $500 that is not included in this contract. This contract is based on a one layer roof. If there are any additional layers, there will be a charge of $30 per square per layer. If roof deck needs to be prepared with plywood it will cost an additional $45 per sheet of plywood. This is not included in the original contract price. Sal Sergi Roof doc Pagel of 2 Dimitrios General Contracting 91 High Street Lawrence, MA 01841 1(978) 685-7573 (978) 618-8085 All material is guaranteed to be as specified. All workmanship is guaranteed to be for a period of 5 years from date of completion. All work areas are to be kept clean by contractor. All insurances are to be carried by contractor. Contractor is responsible for obtaining necessary permits. Cost of all materials and labor is $ 10,000. $1,000 is due upon signed contract. $4,500 is due upon starting. $4,500 is due upon completion of the roof Respectfully Submitted, Dimitrios Karagiorgos Acceptance of Proposal The above prices, specifications, and conditions are satisfactory and are accepted. Dimitrios General Contracting is aut orized to do work as speci red. Payment terms are accepted and will be made as outlined abov Signature Date Customer Signature Date IU lnzJr�-J- Dirilrios General Contracting Sal Sergi Roof.doc Page 2 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: , (4 <�, E LC I ) Location: n-1 1,( L, oz (� Q� 11 V 4- M1 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F7 I am an employer providing workers' compensation for my employees working on this job. Company name:w1 '-i-IZ1 O's G-6 AJ e � L COD'►' fi -4 ( NC_ Company name: Address City: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as welLas_civil,penatties in iheform -of -a_STOP WORK ORDER..and.a fine_of (.$100.0.0).a -lay 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 hereby certify under the pains pnd penalties ofp0wy44atJbe information provided above is true and correct. Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing El Building Dept ❑Check if immediate response is required I] Licensing Board p Selectman's Office Contact person: Phone #. ❑ 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: w E14 c�- WA 8 w C,- wi E/AJ 6K /V (Location of Facility) Signature of Permit Applicant CD 2-6 (Q y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector CO) m X m m X CO) CA m CO) 10 � z CD O CL r �=r CL O 0 0 CL c �G CCD O 5: C= cc CD CO) 'O CD a 0 7 O CO) n� O y IM d CD 0 CD .yam CD CO) 0 CD 0 CD C W =r-, o —1 O C• NN O C go = EL O S O10C/2 �.g O C'7 Z h O QO =r -c H CL .* d O O m y C y o i?o: , O = O ? _00:4.3 o U2 , _ : .. 0 n o Z5.CDD3 qtr W o'C Ap : r a CA a to O r n m o y a � ►�.� rr ^^ d C CO V J O CD CD cn N Q V ^^ n O0 z �a CD 0 cn MW Cn a o CD vq �, � o r: S CD: : o _ a.� O: nn ro r.r 9 Coz r• cn y M H a'- o aGn ? Y � °'- �' o CY7 H :v w 7° ::F,"`� � y :v '� n �*IrlC/) cc =b a' or 0- dj 41 H H n O. n fD O O omi 0 y O C P e 0