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HomeMy WebLinkAboutMiscellaneous - 39 LONGWOOD AVENUE 4/30/2018N O_ O O N O O O O O /%� TEL: (603) 382-6166 =�' 'W'im w 0 m. an'�. = a * ��" September 10, 2008 Mr. Brian Leathe Building Inspector 1600 Osgood.Street - Ner dover, MA. 01845 RE: 39 LONGWOOD AVF\ ANDOVER MA. 8 WENMARK ROAD NEWTON, NH 03858 Please be advised that I have completed several inspections concerning the structural portion of the construction of the above-mentioned house and can certify that the new construction meets my design intent as specified on drawing S1, dated June 14, 2008. Also note that the new framing meets the seventh edition of the Massachusetts State Building Code. If you require any additional information please call me at my office. Very Truly Yours, Ronald J. Pica, P.E. R. J. PICA ENGINES G CO., INC. OF "foss o?� Ronald �c Pica e7 U Structural y Q 31369 �O ASO FGIStEP�k, �FSSrOW_ CIVIL & STRUCTURAL DESIGN • STRUCTURAL INVESTIGATION • TRAFFIC IMPACT STUDIES CONSTRUCTION MANAGEMENT • EXPERT TESTIMONY Date ...... 7-:-:�.d TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. bk.) ..... 4�1,<ArZ7 . ...... ............................. has permission t o perform ...... wiring in the building of .......................... ��?91-417-.x .. ............................. at ......... . ................. . North Andover, Mass. Fee ... Lic. N ��41.34W ............ I �. c�, �. 0 Check # f3 49 8 2-55. ' !L\ J Ott,. :It Only � The Commonwealth of Massachusetts r...lt b._ Deportment of Public Sofety Occupant) S Fef O.eeked u,p BOARD OF FIRE PREVENTION REGULATIONS S27 CMR MOO 3/90 ile-e slam: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All w wk to be performed in accordance with the Masaachusens EleetrIcal Code. S27 CMR 12:00 (PLEASE PRINT IN INR OR TYPE ALL INFORHATION) Date 'Dc) I. /,3-�P-0 a j City or Town of c ►? .Ove, To the Inspector o hires: The undersigned applies for a permit to perform the electrical work described below. Location (Stre Owner or Tenan Owner's Address a AV 77n Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) l Purpose of Buildin'eki.11/ ff /! Utility Authorization NO.—I-0 3 I-0 �Y'2 6 Existing Service OO Amps ARLD/027D Its Overhead CRe"Undgrd❑ N..-Vget'FeAs`8 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Eleettical Work Fe JCC'Z' 7e Serra e A- ers 9loAl / • CC Om - o e ro 4_uC404 O dk d 1c, a Y'. kc, W i /jrty �ad No. of Lighting Outlets No. of Not Tubs No. of Transformers ata1 � 5 No. of Li htin Flxturea No. Above In - Swimming Pool rnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of BatterX Units Emergency Lighting No. of Switch Outlets Q No. of Gas Burners FIRE ALARMS No. of Zones o. of Detection and Initiating Devices � . No. of Sounding Devices No. of Self Contained Detection Sounding Devices Local n echocipal Other Connection❑ No. of Ranges No. of Air Cond. TtNCAL ons No. of Disposals No. of Heats Total TotTonstaal No. of Dishwashers S ace/Area Heating KW P No. of Dryers y Heating Devices KW g No. of Water Heaters KW No, of No. of Si ns Ballasts Low Voltage Wiring✓r %� No. Hydro Massage Tubs No. of Motors- Total HP -779 27—A /30o6 OTHER: INSURANCE COVERAGE: Pursuan to the requirements of Massachusetts General Laws I have a current Liabilit s.rance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO I have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES) please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Expiration Date Estimated Value of Electrical Work S 200©! - Work to Start v �� Old-- Inspection Date Requested: Rough Final Signed under the penalties of perjury:// )- FIRM NAME�LJ F7 M a Y [7e- !v�/� � LIC. N0. 7e% 3 6 License k -e Jfi Waltham Electrical Permit No. Date: Electrician's Name: (print) A. . or company Signature: • ` , u , , , , Zip: _ Address: License No. Tel. No. - Owner or tenant: Tel. No. Address of Work: Nature of Electrical Work: Date to start work: Inspection Date: Fee: ' is there a building permit? Yes:_ no: b4� i� - (PIT 4y Xv6f �� Date. TOWN OF NORTWANDOVER t Z-01 PERMIT FOR PLUMBING This certifies that ..................................... has permission to perform ... P /L V ................................. plumbing in the buildings of ...................... at ... L�-e PA � ... ........ North'Andover, Mass. Fee. .... Lic. No. ...... .......... PLUM13ING lh(SPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date1'2 l2 Building Location -W L0064404 AVE Owners Name -7bR p,Q,4 Permit # "t % Amount S 7 k% Type of Occupancy - New 0 Renovation M Replacement 0 Plans Submitted Yes 0 No 0 WM FIXTURES (Print or type) ' Installing Company- Name —QMAR Q /^( Check one: Certificate Corp. Partner. 0 Firm/Co. Name of Licensed Plumber: Qo,t EA7- 1)24Z 67 - Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate boa: Liability insurance policy ® Other type of indemnity- 0 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 Owner [] Agent F] I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pa mit Issued for this application will be in compliance with all pertinent provisions of the M hu to Co Chapter 142 of the General Laws. Signature i m Type of P bmg Licen Title City/Town�- 1-31 Master Joumey'man PPROVED (OFFICE USE ONLY -- - - - :. (Print or type) ' Installing Company- Name —QMAR Q /^( Check one: Certificate Corp. Partner. 0 Firm/Co. Name of Licensed Plumber: Qo,t EA7- 1)24Z 67 - Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate boa: Liability insurance policy ® Other type of indemnity- 0 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 Owner [] Agent F] I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pa mit Issued for this application will be in compliance with all pertinent provisions of the M hu to Co Chapter 142 of the General Laws. Signature i m Type of P bmg Licen Title City/Town�- 1-31 Master Joumey'man PPROVED (OFFICE USE ONLY 4-� .. � < ^ `/, -� N � c -J � . �^ . . .. � ��� .. � < ^ `/, -� N � c -J � . �^ . . .. � ��� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t' ' i" www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): &,t. ,qR P1LW9'14)6W&47- Address: P6 &)X City/State/Zip: % 2y A)q 0.303* Phone #: 978 523 7VZ2 Are you an employer? Check the appropriate box: l . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. 1 am a sole proprietor or partner- ship 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 have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [V Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other •-y-PP-11u111 11— -1—b U.,n n I 111LLst. aisu L111uue me secnon oeiow snowing their workers' compensation policy information. + Homeowners who submit this a„idavii indicaiing they are doing all work and ihen hire outside contraciors must submit a new affidavit indicating such. $Contractors that check this 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. #: Job Site Address: Expiration Date: 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. / do hereby certify nler thA 77 pis and penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of 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. 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Sep 10 08 03:02p Ronald J. Pica 6033826476 p.2 TEL: (603) 382-6166 9 WENMARK ROAD NEWTON, NH 03858 September 10, 2008 Mr. Brian Leathe Building Inspector 1600 Osgood Street North Andover, MA. 01845 RE: 39 LONGWOOD AVE. ANDOVER MA. Dear Brian, please be advised that I have completed several inspections concerning the structural portion of the construction of the above-mentioned house and can certify that the new construction meets my design intent as specified on drawing S1, dated June 14, 2008. Also note that the new Beaming meets the seventh edition of the Massachusetts State Building Code. If you require any additional information please call me at my office. Very Truly Yours, Ronald J. Pica, P.E. R. J. PICA ENGINEERING CO., INC. pied 4u strudu-i y 31369 �O �GIST,�Q` F�SIONA��� i CIVIL & STRUCTURAL DESIGN • STRUCTURAL INVESTIGATION • TRAFFIC IMPACT STUDIES CONSTRUCTION MANAGEMENT • EXPERT TESTIMONY 00 \0 *%.0 \0 CD CK Z CD 0 m --4 o 0 > M m 0 OL w c CQ o m 0 z 3 0 — 0 -n 3 0 2 c -n z -n m CD n CD CD 0 fA 69 64 4A 49 > z a 0 m Z r- 0 ji 0 1 D 0 CD r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: V DATE ISSUED: �T d� C SIGNATURE: Building Commissioner/I or of Buildings Date SECTION 1- SITE INFORMATION 1.1 Pr ed Address: 1.2 Assessors Map and Parcel Number: C 6 Map Number Parcel Number 1110C J/C� 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lal Area Fronts R 1.6 BUILDING SETBACKS 11 Front Yard Side Yard Rear Yard ReqWred Provide ReqWred Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Sita Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT ' ;�l:�if lc: istriCt: �/es 2.1 Owner of Record as -,C � /,:" �JG�egr� 09 ���9W � ,�y E. Name (Print) Address for Service: i" L f-3 --,5-3 Signature( Telephone t,s 2.2 Ow er"of Record: Duval Roofing, LLC PO BOX 62:7 for Name Print No Reading, M �1 164Service: i ature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Duval Roofing, Company Name LLC Registration Number. PO Box 637 Address No. Reading, MA 01864 ��� Expiration Signature Telephone 11e, /v" SECTION 4 - WORKERS COMPENSATION f10LG.L C 152 & 25cf61 Workers Compensation Insurance affidavit mu be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi rmit. Signed affidavit Attached Yes ....... No SECTION 5 Descrip2tion of Propose Work check a®a ble New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS item Estimated Cost (Dollar) to be Completed 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 (+) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5) -- Check Number j SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I• as Owner/Authorized Agent of subject property eby authorize to act on My behalf, in all matters relative to work authorized by this buildnig permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1> as Owner/Authorized Agent of subject P rty Hereby declare that the statements and information onou gR"gq & Gare true and accurate, to the best of my knowledge and belief pp Box 637 No. Reading, MA 01864 Prin m ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1' 2 3RD SPAN DIMENSIONS OF SILLS DIIVIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by NIGL It, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: ation of Facility} Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date C/ %Luh—� � J� � tC b'. NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (vm) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD CT 06183 ADDRESS OF INSURANCE COMPANY (7POUB-7334880-A-06) 03-11-05 TO 03-11-06 POLICY NUMBER EFFECTIVE DATES ARGEROS INSURANCE AGCY 360 MAIN STREET m READING MA 01867 <= NAME OF INSURANCE AGENT ADDRESS PHONE # �i DUVAL ROOFING LLC 184 PARK ST o NORTH READING 0= MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT - �� The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the Q= provisions of the Workers' Compensation Act_ A copy of the First Report of Injury must be given to the �- injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •am i connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 010480 W20P1012. Page No. / of Pages Builders License # 58443 Home Construction Reg. # 109288 Ogznl (VUC01 102e 0 0 U,0,0 aac� (981) 944-1994 (998) 664-2559 "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 PROPOSAL SU WITTED 0 P / �� � �� •pdTE � ` e L � f STREET f 1 7 JOB NAME CITY, STATE AZIP CODE i D JOB LOCATION We hereby submit specifications and estimates for: Recommended (Included in price) Optional (Not included in -price). ✓ Rip & Remove all shingle debris from roof & job site: ❑ 1 layer 0 L layers ❑ 3 layers or more •�' Repair/or Replace any roof decking; not to exceed 50sq. ft. •.� Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill,4-Iifte'or brown + ✓ Install ICE & WATER underlayment along horizontal eaves, valleys, sidewalls and sky -lights & chimneys It/ Install premium base sheet underlayment between roof deck and roofing shingles Install 25yr CertainTeed/GAF/Tamko or Owens & Corning traditional 3 -tab roof shingles ❑ 30 year 1 • Install 30yr CertainTeed/GAF/Tamko or Owens & Corning architectural roof shingles ❑ 40 year ❑ 50 year ❑ Lifetime See manufacturer warranty policy for more details e Install new aluminum vent -pipe flange (s) V Chimney (s) -counter-flash and re -step existing flashing ❑ Cut & Install new lead flashing • Ridge-vent/exhaust vent with low profile design, hidden by shingle caps ❑ Soffit -ventilation ❑ Roof louver -vents • Seamless style aluminum gutters - custom fabricated at job site �. ❑ downspouts It/ Other " < `Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off Price includes all items above that are checked only / others may be priced separately upon request. 3ffiAe Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: - - Total price not including options. dollars ($ �, C ��� ), Payment to be made as follows: 30% deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of $50 per week for all outstanding bills due upon day of Authorized completion. Signature - Accepting proposal means agreeing to the terms of the enclosed binder Note: This proposal may be rontrart Plaaca Sinn rnntrar t R raft irn tnn rnn tte,hi+o1 %.,i+h r!o ,not+ ...:+t•..r.,... t......_ :c __. _-1- 11 ... .. —1-11 1 vy — a IIv QwcVPLVU vvntIII t _d Udyb JJ Y f e4ll �s a✓��t� a�ds� Board of Bwldlni; Regula 10 r.ONTRACTOR DUVAL Kennett 72 NOF N. REAvll— Administrator The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s+ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information pe Please Print Legibly Name (Business/Organization/Individual): Duval Roofing, LLC PO Box 637 Address: N6. Rdlb MA 01 City/State/Zip: Phone #: ? Are you a mployer? Check the appropriate box: /) 1. 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We 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. El Electrical repairs or additions 11. E] Plumbing repairs or additions 12. E 44t5of 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. _ /2 Insurance Company Policy # or Self -ins. Lic. #: *72A TU A _7,5, MMI VC —Expiration Date: Job Site Address:City/State/Zip: Attach a copy of the workers' compeigation 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 certify_ypdey the pains and penalties of perjury that the information provided above,is truy/and correct. 17,YG/J Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # V MA 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 # 1-4 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Ew Board of Building Regulations and Standards HOME Ino"EMENT CONTRACTOR Re ist109288 DUVAL ROOMtV # Kenneth Du:n! 72 NORTH ST N. READING, MA 01854 Administrator Board of Building Regulations and Standards HOME IMRRO\'EMENT CONTRACTOR RegistrAtion�> 109288 T1kXr1�a`IOl /C (),C l f u 7vna fYPa DUVAL RUOrI�G Kenneth Du:•a' 72 NORTH ST N. READING, MA 01854 `�-- Administrator m m m m N m mm v. CO) 'v co C d � d 'fl O c) Z CO) C-* O 'C � � C CL y a� � o o v CD CD o CrCL CD CD o CD C. `Y y CD d O y O �O O CD � v y O 'v Z CD O co 0 CD z r m tz n I O Q y dO O CO) o CDCO2m C7 >N �mH c1ea= Z = C4 4 O?m NT w� cL oyoCWe, CO O p O: m_ m�>A MO?A0 0 oy.S a �Go�00 :0 o.�^., . �c o ? CO O m H m ' O m CL 11, co, O y O.CL CA CD d C 1a o OD ^� V//JN ' , CD O *0072 "~ N 3 CTm Ch FW0 CD CD 1 33 moo: 0 o m cn a3 =CO) Mai � CD d d CL n C=* C O �� W W v I H 0 0 c ° b7 ~ d tr1 "ti z gz O b 'r1 (n qd O n �d n z PO O z v n a O O cn tz Cy O �� W W v I H 0 0 c n ul rA 0 z t7l Convnonwea o� ///al9ac/iude�! For Office Use Only (Rev. 11/99) cc�� cc77 Permit Number: ..LJaPa��sn1 a`.�`ire �irvicsa i�—". Occupancy & Fee BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:2�b 0 PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: (if City or Town of: 0 ANDOVER To the Inspector of Wires: By this application the undersigned gives notice f his or her intent* to pert the electrical work described below. Location: (Street & Number) Owner or Tenant: Owner's Address: Is this permit in conjunction with a Building Permit? Yes ❑ No (Check Appropriate Box) Purpose of Building:FUtility Authorization # . / / 7 / 26/ Existing Service: (40 Amps tv /240Volts Overhead Underground.❑ # of Meters_ New Service: Amps /Volts Overhead Underground.❑ # of Meters: Number of Feeders and Ampacity: T Location and Nature of Proposed Electrical Work:CI'L No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Transformers Total KVA No. Of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground ❑ In Ground a # of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of Zones # of Detection & Initiating Devices of Sounding Devices: # of Self Contained Detection/Sounding Devices Local ❑ Municipal Connection ❑ Other ❑ No. of Switches No. of Gas Burners# No. of Ranges No. of Air Conditioners TOTAL TONS: No. of Waste Disposals Heat Pump Totals: Number: TONS: KW: Security Systems: No. of Devices or Equivalent No. of Dishwashers Space Area Heating: KW Data Wiring, No. of Devices or Equivalent: No. of Dryers Heating Appliances KW Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydro Massage Tubs No. of MotorsTotal HP INSURANCE COVERAGE: Unless waived by the owner, /p�it for the performance of electrical work may issue unless the licensee provides proof of liability insurance including 'completed operation' coverage or its substantialent. The undersigned certifies that such coverage is in ff orrce,,andhhaxhibiteed proof of same toa permit issuing office. CHECK ONE: INSURANCEBOND ❑ OTHER 13Please Specify: C/1/� i Estimated Value of ElecV-29 Work $ (When required by municipal policy) Work to Start: /or Inspections to be requested in accordance with MEC Rule 10, and upon completion. l I ce , under the pains and penalties/of perjury, that the Information on this application Is true and complete. Firm Name: v L�G �C relc GO -•'y"vG LIC. # ^� ;s��3 Licensee: �`7 �y�� �� Signature: L 'y/� LIC. # /T �/ 3 Q (if applicable, enter " empppt" in the 10/nse numq r line) G Address: `i� % /1 iC�E///Q /� e� //� /%/y�/r/� U/��✓J Bus. Tel. # �d f-3 Address: Tel. # OWNER'S INSURANCE WAIVER: 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 c OR Agent ❑ Signature of Owner/Agent: Telephone # PERMIT FEE: S Ivo pe�(Sls S-to—og Ao/I