HomeMy WebLinkAboutMiscellaneous - 407 WOOD LANE 4/30/2018i�
11061
Date-�/
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Thiscertifies that .......................................................................................................................
has permission to perform .......
... ............................................ ........
plumbingnthe buildings of..
7� /J� - � �,;j ......................................................................................
at...................................................................................................... North Andover, Mass.
Fee ..�,..h. Lic. No. . ..... &&—
...............................................................
PLUMBING INSPECTOR
Check #
11024
...........
This certifies that...� .... &-V1 ....................................................
U-' ...r V,,A , -Ul
has permission to perform ..... ............... . .. ...............................................
................................
plumbing in the buildings of A, of4-1- -t�, n -
.......................................................................................
at .....40....... . ...................................... North Andover, Mass.
IV . ...... 0. M
Fee!!� ......... Lic. N ..... .......... k .............................. ................................
'S�Z-k k -
Date.
..................................
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
PLUMBING INSPECTOR
Check , . A ZZ
dy) 31W,11-
WASHING MACHINE CONNECTION
WATER HEATER ALCTYPES
WATER PIPING
OTHER F—
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES F�l NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY D BOND M
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts 9e�l Laws, 99d that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER R AGENT
/ SIGNATURU OWNER OR AGENT
I hereby certify that all of the dWils 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 in QgMyliance with a I Pertinent rovisio of the
(Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE #F lI SIGNATOR
MP Pr' JP UI CORPORATION jJ #PARTNERSHIPP#®LLC M j
COMPANY NAME 1�jyYc ► f�tz, �; �� ADDRESS
CITY �^Pfi� __..._.._..._1 STATE a ZIP 0 69 TEL
FAX CELL �) EMAIL
MASSACHUSETTS
UNIFORM APPLICATION
FOR A PERMIT TO PERFORM PLUMBING WORK
'
CITY
MA DATE 319 _jj PERMIT # 11, SCD I
JOBSITE ADDRESS
%c
OWNER'S NAME
POWNER
ADDRESS
TEL =� IFAX
TYPE OR
OCCUPANCY TYPE
COMMERCIAL
EDUCATIONAL Q RESIDENTIAL
PRINT
CLEARLY
NEW: - RENOVATION: REPLACEMENT: Q
PLANS SUBMITTED: YES 0 N0 Ell
FIXTURES 7 FLOOR-
BSM
1 2
3 4
5
6
7
8
9
10
11 12 13
14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEMI
I; _ [
[
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
I 1 ._._
____I ._----_{
__ E ._____. __-__I ___J _.__.__( ..._-___
FOOD DISPOSER
( __1
FLOOR/AREA DRAIN
l —__-�
--_.j _.___1
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
__..'1
—31 __-._j _.—J
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALCTYPES
WATER PIPING
OTHER F—
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES F�l NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY D BOND M
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts 9e�l Laws, 99d that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER R AGENT
/ SIGNATURU OWNER OR AGENT
I hereby certify that all of the dWils 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 in QgMyliance with a I Pertinent rovisio of the
(Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE #F lI SIGNATOR
MP Pr' JP UI CORPORATION jJ #PARTNERSHIPP#®LLC M j
COMPANY NAME 1�jyYc ► f�tz, �; �� ADDRESS
CITY �^Pfi� __..._.._..._1 STATE a ZIP 0 69 TEL
FAX CELL �) EMAIL
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The Commonwealth of Massa chusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
` Boston, MA 021142017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbly
Name (Business/OrganizatioxAndividual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with : employees (full and/or part-time).*
I ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Q 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.]
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12.0 Plumbing repairs or additions
13.0 Roof repairs
14. ❑ Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not. those entities have
employees. If the sub-coniraciors 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 thepolicy andjob site
information.
Insurance Company
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 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 the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
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 noemployees 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' -
compensatioii'policy, please call the Department at the number listed below. Self-iinsur6d 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-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY l' T�t�� /'�.s� I MA DATE PERMIT #
JOBSITEADDRESS 1-107 &.10od' 4A,--G OWNER'S NAME i
POWNER
ADDRESS �y. %ice"d TEL 6/ 77/ ��1( FAXii
TYPE OR
OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL LN
PRINT
CLEARLY
NEW: � RENOVATION: M REPLACEMENT: Q PLANS SUBMITTED: YES Q NO�(
FIXTURES 7 FLOOR- BSM 1
2 3 4 5 6 7 8 9 10 11 12 13
14
BATHTUB _{ =1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM _ i ( (I _ _.1 1 _ _- _I E—A I
DEDICATED GREASE SYSTEM.-....-....E I _[
I
DEDICATED GRAY WATER SYSTEM I - .- _a l —_ -� , _. I ( ! w_ - _-Jr-77I _- f _ 1 .... ..I I I
DEDICATED WATER RECYCLE SYSTEM I _._.___..1 .. _ . I � _—_J .__.._1 I f. ! —7
DISHWASHER _ ? ._..._I _.._. _I _ I .. _1 I W� _ _� __..J _-. _ i
DRINKING FOUNTAIN _ _1 ( ..__--- - I ._—._ (----_._f ___---' •---.--._I .-. - _- I .-----' - - .--1
FOOD DISPOSER _ _ I ... _ _.1 _ ._ i I (_ ..._1 . _ _ l ._ I -_ I [- I ._ _ I f ._---
FLOOR / AREA DRAIN
-_
INTERCEPTOR (INTERIOR) - i I ._ .__.T I I _..__._I _-� _ _ !i f . _.-.1 = _ I
KITCHEN SINK
LAVATORY'__.._I ____. ( f I
ROOF DRAIN I _ _-_j _..._-_! f I f
SHOWER STALL
SERVICE / MOP SINK
____I f
URII\IAL
KAj�,HING MACHINE CONNECTION
WATER HEATER ALL TYPES _^_ �y _ . I--- `___ =_-,
WATER PIPING
OTHER__.
i INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES .._i NO EI
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
4441
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Q BOND F1f
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gener.@1 Laws, an that my ignature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERf AGENT
SIGNATURE OFAM.OR AGENT
I hereby certify that all of the deta Is 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 'pliance with all Pertinent ovision he
(Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
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PLUMBER'S NAME2t�✓! LICENSE # SIGNATURE
(VIP 21"1P E CORPORATION n.#=PARTNERSHIP -i PARTNERSHIP O# ; LLC
COMPANY NAME v V 1 vt� ; ADDRESS m u V
CITY �`FL1V-P ti =STATE ZIP 0 JR-TEL �S-�'' %
FAX L CELL ;EMAILNIV
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The Commonwealth of Massachusetts
Department oflndustriglAceldenis
Office ofln•vesiigations
600 Washington Street
Boston, MA 02111
www.massgov/!iia
Workers' Compensation Insurance Affidavit: Builders/Cony°actors/Electricians/Pliumbers
Applicant Information Please Print Legibly
Name (Business/Organhation/1ndividual):
Address:
City/State/Zip:
Phone
Are you an employer? Check the appropriate box:
1. ❑ 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. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [1 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing, repairs or additions
12.❑ Roofrepairs
13.❑ Other
, Any applicant that checks box#1 must also fill out the section bel6w showing their workers' compensation policy information.
t'Homeowners who submit this affidavit indicating they aie 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
Policy # or Self ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under the pains andpenalties ofperjury that the information provided above is true and correct
Simature: Date:
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 Instruction's
Massachusetts General Laws chapter 1.52 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 orimplied, 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 notmore 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 -contractors) name(s), addresses) 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 maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date theaffidavit. 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 aworkers'
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 i a (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town maybe 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 Cozy onwcalthofM-0ssardhweutts -
Dop-ariment ofIndustdal Accidouts
Office ofWestigaMM
6.00 Wash .gtoa 8-treett
Boston, MA 02111
Tel, # 617-727-4900 Qxt 406 QX- 1-877, TASS.AF`B
Revised 5-26-05 Fay, 0 617-727-7749
wwwaaagovfdia
U Ny::..:..;.:., ,,q 01844
I
Date ... ��Z' ..� ..�'�
.....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that) ':c1'. ..................................
fhas permission to perform......................................COY!..F..c...-....................................
6.^ fi
wiring in the building of. '�' �+?��'.............. C
..`�c...........................................
at' .46-1 .... '..... !.� , ............................. . rth Andover, Mass.
................
I~ee..�.T-) ......... Lic. No. k.71.7 . .....�.b'•......A141CAL
� ELEINSPECTOR
Check #
1313 ')(vrA4, � � rn 312.1 6
Commonwealth of Massachusetts Official Use Only
Permit No. �--
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (1VM, 527 MR 12.00
(PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date:
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) 411) 7 tv o d e9 4392. L^,ve-
Owner or Tenant ,f *- W -e 19 b%j i Z Telephone No.0/?-
Owner's Address G' `/ '%v %t'. °G`t r 12e
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing ServicegO 0 Amps� C/ / Volts Overhead ET" Undgrd ❑ No. of Meters I
New Service Amps
Number of Feeders and Ampacity
Location and Nature of Proposed
K- lN`C
/ Volts Overhead,,[] Undgrd ❑ No. of Meters
ElectricalWork: ���,�i/'k oy*t'� ; )C_te-6
Completion of the following table may be waived by the Inspector of Wires.
No. of Ceil: Susp. (Paddle) Fans No. of Total
Transformers KVA
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires '�
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o mergency Lighting
Batter Units
No. of Receptacle Outlets `7
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burgers
No. of Detection and
InitiatingDevices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
p
Heat Pump
Totals:
Number
.........................................................
Tons
KW
No. of Self-Contained
Detection/AlertingDevices
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. of Water RW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Estimated Value of Electrical Work:
Work to Start:
Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑
I certify, under the pains and enalti pert
FIRM NAME:. 70 M eyr(
Licensee. Thle Wo --s &YA V -
(If applicable, enter " xer t" in the license numberd
Address: i o ve , M -6
OTHER ❑ (Specify:)
that thein ormation on this application is true and complete.
f -e C i C: LIC. NO.: —2 I
_ Signatu LIC. NO.: ? I al "
v� V ot �r Bus. Tel.
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security Work requires Depa ent of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signa4ire bel V, I hereb waive this requirement. I am the (check one), ' owner El owner's agent.
signature
g aturee Telephone N . l PERMIT FEE: $ °-D
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance:with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass EN
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass n
Failed IN
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass n
Failed I
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECT ON:
Pass V
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comm nts:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustriglAceldiints
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www mass gov1dia
Name (Businesslorgal&ation/in(Rviduat): _
Address:
City/State/Zip: Phone A
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. [] New cOnstraction
employees (full and/or part-time).* have Medthe sub -contractors
2. El am a sole proprietor or partner listed on the attached sheet. 7• ❑Remodeling
ship and"have no.employees These sub -contractors have 8. [] Demolition
working forme in any capacity. workers' comp. insurance. 9• [l wilding addition
[No workers' comp. insurance 5. [] We are a corporation and its
recluix�eficers have exercised their 10.❑ Electrical repairs or additions
d.] of
3. ❑ X am a homeowner doing all work right of exemption per MGL 11. E]Plumbing repairs or additions
myself. [coworkers' comp. c. 152, §1(4), and wehave no 12.❑ Roofrepairs
insurancere ed. employees. [No workers'
] � 1311 Other
comp. insurance required.]
?Any applicautthat checks box#1 must also fill outthe section beldw showingtheir workers' compensation policy intormation.
i Homeowners who submit this a f"idavit iadicatingthey 2"re doing allwork and then hire outside contractors must submit a new affidavit indicating such.
tContractors that cheekthis box must attached as 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 ernployees. Burow is the policy imd joh site
information.
Insurance Company
Policy # or Self ins. Lic. #:. Expiration D ate:
Job Site Address: City/State/Zip:
Attach a copy o#the workers' compensatlonpolicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as re,�uiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a
'q�e up to $1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fm
of up to $250.00 a day against the violator. Be, advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA. for insurance coverage verification.
f do hereby cert& under tlie•pains and penalties of perjury that the ir2formation provided above is true and correct.
Signature:
Phone #:
Official use only. Do not write in this area, to be completed by city or tort official.
City or Town: Permit/License #
issuing Authority (circle one):
1. Board of Health 2. Building Department I 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 defted as "...every person tri the service of another under any contract of hire,•
express orimpliod, oral ox written."
An employee is defined as "an individual, partnership, association, corporation or other legal entity, or anyiwo ox more
of the foregoing engaged in a joint enterprise, and including the, legal representatives of a- deceased employer, or the
xedelver or trustee of au individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having notmore than three apartments and who resides therein, or the o ccupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such. Awelling 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 beenpresentedto the contracting authority."
Applicants
Please fill, out the workers' compensaiion affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) andphone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the
members or partners, are notrequired to carry workers' compensation insurance. If au LL C or LLP does have
employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Iudustrial
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 Towns Officials
Please be sure thatthe 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 bo -sure to fill inthe permit/license number which will be used as a reference number, in addition, an applicant
thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Sob Site Address" the applicant should write "all locations in (city or
tow:a). " A' copy of the affidavit that has been officially stamped or marked by the city or town may b e provided to the
applicant as proof that a valid affidavit•is on file for fature 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 orpermit to bum leaves eta.) 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 aiid fax number:
They Cox onwea th of Momacjxvsetts -
Depal ent ofIndusWal Accidonts
Off toe offAvediigauoju
600 Washhai&ji Street
Boston, MA 021 It
TO # 617-22,2-4900 ext 406 ox 1-87`x:11 WAS
VX
Revised 5-26-05 Fax # 617-727-7749
�wt�'.�ass,govfch`a
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Residential Property Record Card
PARCEL 0:2101022.0-0068-0000.0 MAP:022.0 BLOCK:0068 LOT:0000.0 PARCEL ADDRESS:407 WOOD LANE FY:2015
PARCEL INFORMATION
Attic:
�__ 4 �._ +
BsmtArea: 1300
- r - m ea: o"
Fn BsmCArea:
i,:.. a- _ . .
Bsmt Grade: V
Use Code'
�. _._
101�w Sale Pnce 0 Book 00840
.._
Road Type:
-- ---
Inspec [5
—
_01/011200
_
Current Total: 298,500 Bldg: 119,900 Land: 178,600 MktLnd: 178,600
_.
Tax Class.
T Sale Date 12/31/55 m�Page 0110
Rd Condition: P
Meas Date
01/01/200
Owner:
Year Built: 1956
Tot Fln Area 1300 Sal e Type�m'"° CeNDoc"
Traffc M
Entrance:
�X m
PULVERENTI, ANTHONY J
f.... m
- CosfBldg: 119 900
LaArea.
Tot�nd
_ Valid-.
0.41 -Sale V: N
Water.��Collectld:��RRC
Condition:
Att Sir Val1:
C/O SANDRA HARZ INC
Central'AC�N
.�
a Grantor: � �
Sewer:
Inspect Reas:
Address:
.%Good P/F/E/R:--
--
- _ _ _ .�� . -- _. _ _-_
--
_
_ _
64 BLUE RIDGE ROAD
PHOTO
Exempt -B/L%
I Resid-B/L% 100/100 Comm-B/LP/a
Indust -B/L% I
Open Sp -B/L%
/
NORTH ANDOVER MA 01845
9
RESIDENCE INFORMATION
Style: RN Tot Rooms 6 Main Fn Area__ 1300
Y _ _
Story Height 1.00 Bedrooms 3 P.Up Fn Area:
�--1 `-' ry r .'
Roof:``- G Full Baths. 1 Add Fn Area: _
Ext Nall AV Half Baths Unfin Area:
Attic:
�__ 4 �._ +
BsmtArea: 1300
- r - m ea: o"
Fn BsmCArea:
i,:.. a- _ . .
Bsmt Grade: V
LAND INFORMATION
NBHD CODE 5 NBHD CLASS: 5 ZONE: R4
Seg Type Code Meti�iod Sg Ft - Acres Infl6-Y Value Class
1 P.:.: �.
109 S -17979-0.410 �.. :- 178,559 Y
VALUATION INFORMATION
Masonry Tnm
ExtBah Flz _0
TCN
Tot Fin Area ' 4300
_
_
Current Total: 298,500 Bldg: 119,900 Land: 178,600 MktLnd: 178,600
Foundation.
Bathdual T
-"` KItCh QUaI. T'Eif Yr Built: f970
RCNLDu 119945
Mkt Ad/:
Prior Total: 288,200 Bldg: 113,600 Land: 174,600 MktLnd: 174,600
Heat Type:
HW Ext Kitch:
Year Built: 1956
Sound Value:
Fuel'Type:
O" `"
Grade: A
'AM
f.... m
- CosfBldg: 119 900
Fireplace:
1—Bs'mt Gar Cap:
Condition:
Att Sir Val1:
Central'AC�N
Bsmt Gay SF:Pct
Complete:
Att"Sty Val2: "" �
AttGar SF
.%Good P/F/E/R:--
---/100/100/75--""'-"'
SKETCH
PHOTO
ws
9
1360 Sq.Ft
-
39
1
28
s_
308_S%F
22
iz
407 WOOD LANE
Parcel ID: 210/022.0-0068-0000.0 as of 2/24/15 Page 1 of 1
Date ....... ..... 11.114 ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
tkk—'�D
This certifies that ...................................................................................... 11-�2..
............................
has permission for ga installation .... rm� .... vvub��A .01P
in the,, buildings of. vlv-�ere . ...... ...................................................................
at ....... .u-.1 ..... wN.J ... Lt ......... North Andover, Mass.
.......... 0
Fee .W70 .... Lic. No. .....
....................................... ....................
GAS INSPECTOR
Check#
9225
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Beta Lden�""�-' ter142 ofthethatatt°tthand installations p 1 hereby certrfY bin9 WOrk bin9 C50and that all P State Plum TIOMassach NAME CORPO� 1Et 508 832-329
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41 Central St
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MGFr-'I JP® S1 ATE
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COMPANY NAM' EMA JMarino@RHwhlte•c0m
Auburn 508-832 4614
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04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02
ACCiA'1
b® ( /DIog/CERTIFICATE OF LIABILITY INSURANCEP. e 29/2013
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
S
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IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
theterms and conditions of the policy, certain policies may require an endorsement. A statement on this Certifleate does notconferrights to the
certificate holder in lieu of such endorsement(s).
willim of Maseachuaetts, Inc.
C/o 26 cHritury Blvd.
R. 0. Box 305191
NnRhville, TN 37230-5191
R. H. White Construction Company, Inc.
41 CentrAl Street
P. 0. Box 257
Auburn, MA 01501
d L'.%'
o.+n®rw nrrvi%u1NW t.VVtKAGt NAIC B
INSURERA:The Charter Oak fire Ineuran09 Company 25615-001
INSURERS: TraVQ1"8 Property Caevalty COV%any of Am 25674-003
INSURER C:NatiObdl Union Firs) Inauranco Company of 19445-001
INSURER 1); Travelers Indamnity Company 25659-DO1
UYLKAGES CERTIFICATE NUMBER: 20287680
TWIS 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.
I TYPE OF INSURANCE
ADOI
SUBR,
POvuvn LICY NUMBER
GENERAL LIABILITY
EACH OCCURRENCE
VTC2000 977X9948-13
X COMMERCIAL GENERAL LIABILITY
FeTO RENTP,D
PRE I S5 Meoccuronro
_
-
300 _000
CLAIMS -MADE OCCUR
$
101000
PERSONAL&ADV INJURY
GEN'LAGGREGAT@ LIMITAPPLIES PER;
POLICY PRO LOC
GE.NERALAGGREGATE
$
41 000 000
AUTOMOBILE LIABILITY
$
, 000 000
VT,7CAP 977K955A-13
X ANY AUTO
TOMSTEDSINGLFent).LIMIT
$
ALLOWNED SCHEDULED
BODILY INJURY(Per person)
S
AUT08 AUTOS
$
araccltlent
X HIREDAUTOS X NON -OWNED
S
AUTOS
EACHOCCURRENCE
$
S, OOO 000
—Coll Deb
X Co Defl X ando
!__9'000
000
UMBRELLALIAII R OCCUR
XD TH
T&R U
BES766140
X EXCESS LIAR CLAIMS -MADE
E.L.EACHACCIDENT
$
1,000,000
DED I $ IRETENTIONS 10,000
WORKERS COMPENSATION
E,L,DISEASE- POLICY LIMIT
S
VTRXUB 820SA185-13
AND EMPLOYERS' LIABILITY yyy��INNN
ANY PROPRIETDRIPARTNERIEXECUTIVE N
NIA
VTC2KVB B203A71A-13
OFFICER/MEMBER EXCLUDED?
(Mentletialn NN)
B
e9,desErlbOundnr
u�y Kb• I IUN UI.OftRATIONS below
)/1/2013
9/1/2014
(/1/2013 X9/1/2014
/1/2013 19/1/2014
9/1/2013 19/1/2014
9/1/2014
9/1/2013
Ivr,NUaI[Dnpinemarxescneevla,Ifmore GoBed
REVISION NUMBER.
:D NAMED ABOVE FOR THE POLICY PERIOD
OCUMENT WITH RESPECT TO WHICH THIS
> HEREIN IS SUBJECT TO ALL
THE TERMS,
LIMITS
EACH OCCURRENCE
F_
2,000,000
FeTO RENTP,D
PRE I S5 Meoccuronro
_
-
300 _000
MEDEXP(Alryone arson
$
101000
PERSONAL&ADV INJURY
S
2 DOG, 000
GE.NERALAGGREGATE
$
41 000 000
PRODUCTS-COMP/OPAGG
$
, 000 000
TOMSTEDSINGLFent).LIMIT
$
2,000,000
BODILY INJURY(Per person)
S
BODILY [NJ URY(Per accident)
$
araccltlent
$
S
EACHOCCURRENCE
$
S, OOO 000
AGGREGATE
!__9'000
000
S
XD TH
T&R U
E.L.EACHACCIDENT
$
1,000,000
E.L.DI8EA8E-EAEMPI,OYFE S
1,000,000
E,L,DISEASE- POLICY LIMIT
S
1,000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Evidence of InmurBence AUTHORIZED REPRESENTATIVE
0011:4197604 Tp1:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
TOWN OF NORTH ANDOVER
BUILDING DEPAR'TMEN'T
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: �q DATE ISSUED: ! -
SIGNATURE:
Buildin CommisslonerII for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Propertyddr�ess: 1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
�(1�.3' CZoning
Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
ReqWred Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner o cor
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
23 /0 /yct
Licensed Constructi n Supervisor:
/D)jP P License Number
Address 7 l
3 l G�GOf'v
Eviration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (NL 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 ....... 0
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:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed b Permit applicant
° g(IFFIIA
w
USE OIViY ,
'
I. Building
1W
00
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
... or
4 Mechanical HVAC
5 Fire Protection
5 Total 1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION 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
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Prn t Name �./�
1' 1 t— I �R C 1 r) GI-
Si ature of Owner/A ent Date
1@11MM111111111111 IM
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS Isl 2ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
,� ~ `;'c 2lie Commonwealth of %fassachusetts
o
Department of 1ndustrizdAxi4&nts
1 ��
�`• "J1 "��
` ofinvestations
6o0 Washington Street
(Boston, WA 02111
Workers' Compensation Insurance Affidavit
Please PRINT Legibly ;_
0 I am a homeowner performing all work myself.
Telephone M O a � 3 �C -7e
ED I am sole proprietor and have no one working in my capacity
D I am an employer providing workers' compensation,fogmy em;Apyees working on this job
Cbmpany Name: �z ���i �r
Address:
2 4� �(
City: Telephone #:
Insurance Company: it//(�°� Policy#:����%%.%i�!�i��(�����
D I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
workers' compensation policies:
Company Name:
Address:
City: Telephone #:
Insurance Company: Policy #:
Company Name:_
Address:
City:
Insurance Company:
Telephone #:
Policy #:
Attach additional sheet if necessary
Failure to secure coverage as required under Section' 5A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S 100.00 a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herebcerezfy under the pains and penalties of perjury that the information above is true and correct. ,
QrSignature: CJf H' OC >„it Date: 0
Print Name:_ CZk7e Phone # JQ :;,tG/
Official Use ONLY - Do not write in this area
o Building Department
City or Town: Permit/License #: o Licensing Board
o Selectmen's Office
o Health Department
0 Check if immediate response is required o Other
e
�; � ��ze �omvmoizurecz�i � /��,�.caelt
i
BOARS) OF BUILDING REGULATIOAS
.: License: CONSTRUCTION SUPERVISOR
Number:' CS 034049
Birthdate: 12/08/1923
.Expires: 12/08/2001 Tr. no: 10391
Restricted To: 00
i
MARIO T CASTRICONE
31 COURT ST
N ANDOVER, MA 01845 Administrator
I
r
TIM e..ld
NONE IMPROVEMENT CONTRACTOR
Registration:
103317
Expiration: 07/07/2002
N Type: DBA
CASIRICONE ROOFING & SIDIN
qMa io Castricone
°I Court St.
ADMINISTRATOR N Andover NR 41B4S
Castricone Rooring & Siding
e ` y REPAIRS FREE ESTIMATES
f Telephone (978) 682-4266
(� i MARIO CASTRICONE
31 Court Street, North Andover, Mass. 01845
I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on remises below desc ibed:
Owner's Name.. �/ ,��' ......
.. �.... :. .....�..
Job Address.. ........G. i..,.....r' .....................................City. �1:..:4'l��Gt.. f..State�.0 .....................
SPECIFICATIONS
.................................................. ..........
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- M ...........................
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.......... ......
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1.
Materials and labor to cost $ ... ..................................... Payable on .. .
......................and balance in....:.......
monthly installments of $... .......................................each, payable on........................................ day of each and every month thereafter until paid
in full (..............% charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a
completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid
immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in
addition to the amount due and unpaid, that shall be incurred in enforcing the terms.and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates
of the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this
contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed
by all parties.
Cover attic storage cleaning not included.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and
the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in yra . n.
IN WITNESS WHEREOF, the parties have hereunto signed their names this ...... ..... day of.. 1, . .........,
Accepted: �- __._•_
Signed/!1✓?:�..... k_—LIU:' ice.°/ ........
Owners%
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT)
Per...... ���.:: � �.....c2e.;Z.I/
wC.. 'wc.............
Representative
Signed......................................................................................
Owner
Signed......................................................................................
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