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Miscellaneous - 41 BEAR HILL ROAD 4/30/2018 (2)
41 BEAR HILL ROAD 210/064.0-0078-0000.0 Date.......... 11416 of NORT/�,� TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING s`4ACHU , I This certifies that.............. . ..L - .............................................. has permission to perform......x.0 .NN.pj.....................................I................ plumbi gin e bu�inU of......�D Q ?............................................................. at.. ....... G . ........................... North Andover, Mass. Fee.... ......Lic. No. ...1..�J . . ................................................................................. 4 d PLUMBING INSPECTOR Check# 1 Date... ��..:.—'y .............. NOR 7H OF TOWN OF NORTH ANDOVER 1- 9 PERMIT FOR GAS INSTALLATION ` r- ,ssACMUs�t Thiscertifies that ................................................................................................................... has permission for g installation ...,***i9Z tN�,2_@S in the buildings o ............................................ ....................................................... at................�................... c. 'North Andover,Mass. Fee..�..(�. ........ Lic. No. ).�.3....... ..................................................................... GAS INSPECTOR Check +# (lJl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE o f ..LSPERMIT# JOBSITE ADDRESS �'I[ c� �� dl OWNER'S NAMEt So,oY S' POWNER ADDRESS L TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: F] RENOVATION:El REPLACEMENJ;.� PLANS SUBMITTED: YES E9 NO© FIXTURES 7. FLOOR- BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I i --J F-----Jl= CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _� ....___ J ___._J __.___J —j DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM ___( ___._J DEDICATED GRAY WATER SYSTEM t .-. ,C ^� I ' I _,_....__! J DEDICATED WATER RECYCLE SYSTEM i Lai DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN -1= INTERCEPTOR(INTERIOR) ! i _--. E �_3 _-__E KITCHEN SINK LAVATORY _J .____ _.__1 _._—J __.._J __ l ___! ______i .--_...1 .:_.__! _.___1 ( ! -------i ROOF DRAIN ) Si-VWER STALL SERVICE l MOP SINK TOILET URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING OTHER I ! ---._.J INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Y NO Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POL OTHER TYPE OF INDEMNITY Dl 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT 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 in corn' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r �l�---- PLUMBER'S NAME l =LICENSE# SIGNATURE MPOP JP0i CORPORATION F1 PARTNERSHIP Q# LLC COMPANY NAME N(r, w•6h' [ oto, ADDRESS CITY� --(STATE �j ZIP 01-gfy-7 - fI TEL - - -- FAX L € CELL��EMAIL 1�� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL SP CT NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I I i i i i f i - I { { I + The Commonwealth of Massachusetts Department of IndustrialAccidents ;..r.. - 1 Congress Street,Suite 100 M, • • gym . d Boston,MA.02114-2017 s" www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/P lumber S. TO BE BIDED WITH THE PEMTTING AUTHORITY. -.Please Print Legibly A IcantInformationj� r ,� Nc Naine(Business/Organization/Individual): lb°h�\ f lif�hbr� Address: 3s G a�k ! JV-f— A �3 Phone#: -7b1 City/State/Zip: Are you an employer?Check the appropriate box: Type Of project(�ecluired) 1.❑lam.aemployer with employees(fidl andlorpart-time). 7. ❑Ne V construction a sole proprietor or partnership and have no employees Working for me in 8. Remo deliiag t/—anycapacity.[No workers'comp.insurance required.] 9, ]7emoliti.4 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.;$`Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11 a Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.$ 14 Other 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.] out the section below showing their workers' *Arty applicant that checks bbk#i must also fill compensation policy information: i Homeowners who sAb uitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatinghsuch aye $Contractors that cheekthii box must attached'an additional sheet showing the name of the sub-contractors and state whgther or not(hose, employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. . lam an employer that is providingworkers'compensation insurance for'my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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 verlf cation. Tc v hereby ce un er tlz pains andpenalties of perjury that the information provided above is true and,correct. . `�Si ature: Phone#: 01 fr�0 l 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 hfze, 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<trusted 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 6f 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasb 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 certificates)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 confumation o£insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained 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. Anew affidavit must be filled out each year.where a homeowner 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 requited 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 ^g, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IGn�.__ n�ovu- MA DATE v PERMIT# ��zz (� JOBSITE ADDRESS �� q� 111 =OWN ER'SNAME I <<Z r GOWNER ADDRESS L j TEL TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONALRESIDENTAttl' PRINT CLEARLY NEW: RENOVATION:Ej REPLACEMENT:® PLANS SUBMITTED: YES NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER11- BOOSTER -- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - OVEN POOL HEATER - ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I _ UNVENTED ROOM HEATER ( - _ t�. WATER HEATER OTHER I .-- - — - .................. .- T J _ INSURANCE COVERAGE have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YE _1 NO [l I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OFCOVERAGE B CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC;(' OTHER TYPE INDEMNITY D BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Fj 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 in complia a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAMEnaLoc��a�l' LICENSE# S413 ( SIGNATURE MP�MGF[A JP® JGFJ LPGI CORPORATION E14n PARTNERSHIP EN { LLC D4 COMPANY NAME[-( a.c QIKt(,hamc ADDRESS CITY _ STATE�ZIP Q(. ]TEL 7 FAX I ._ CELL 1EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ J f !� �� r FEE: $ PERMIT# / d PLAN REVIEW NOTES S l r :COMMQ�W�qLIFH OF M $SACI=IUSETTS • • • - -• IMM • PLUMBERS: AN0 GASFIT�1 .$ ISSUES THE FOLLOWING LICENSE i L I CENSER AS A. MASTER P.L`UMBER' Con i BR,1AN'J LOCKHART 35 C0L01V 1 IRILI R1,AaING �J t mA 01867 1336 1 81• 8764 ELSEM-1 OP ID:SG CERTIFICATE OF LIABILITY INSURANCE °A10/14/2015TE ' 10/1412015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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 confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Planright Insurance-Salem NAME: Jason M Mlocek 224 Main Street Suite 3C AICNo ,d E ,603-890-6439 ac No;603-890-6521 Salem,NH 03079 A DRE Jason M Mlocek SS:Jason@santoinsurance.com INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Peerless Indemnity Ins Co 18333 INSURED Daniel Elsemiller INSURERB: 64 Old Yankee Road Haverhill, MA 01832 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD y VD POLICY NUMBER MMIDDYEFF IYYYY MMI DmYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE DAMAGE TO RENTED OCCUR BKS56719089 09107/2015 09/07/2016 PREMISES Ea occurrence $ 300,00 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY 1 JEST 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ HENTION OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—]N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: 7 Sutton Place CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Inspectional Services 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Date....3.`�: �......... �L NOR7N °f, •�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;,SSACH This certifies that ........irk! �..... ............ .... .................................. has permission to perform .......... r" T.................................................. wiring in the building of T.........TA.ve 5.................................:........... Y l&&, � at.... /--&....2 North Andover,Mass. ................................... ..... ......................... Fee.�.oo..... Lic.Nd � Y C............. ..... ' + q �. CfAICALINSPECfOR �� Check # ` U 8621 commonwealth of MassachusettsOfficial Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] Qeave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATIO City or Town of: pate: 1 NORTH ANDOVER "v2`D,p To the Inspe to ofjWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Lff Aleve Owner or Tenant 0/)Zf Telephone No. Owner's Address V Is this permit in conjunction with a building permit? Yes PNO ❑ (Check Appropriate Boz) Purpose of Building /�!!/azli G Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No,of Meters New Service Amps / _Volts Overhead ❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: . /Zvli6.��Cir7�ll✓ �fi/�1�` fl✓f,�ir/�ill Corn letion of the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Nu-of i Total ' No.of Luminaire Outlets No.of Hot Tubs Transformers KVA Generators KVA No.of Luminaires Swimming Pool Above 1:1In- ❑ o,o mergency ig ung d• rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners aFT14fa No. of:.ones No.of Switches No.of Gas Burners No of Detecfion and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: —_._.___......_.___..._.._...... _.__._. Detection/Aleriin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security systems:* No.of ater No.of No.of Devices or Equivalent Heaters KW Si s Ballasts . Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal poIicy.) v Work to Stark gh./a I Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE &O- RAGE: 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 Q� BOND ❑ OTHER F-1 (Specify:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: LIC.NO.: Licensee: VZwmrf ��lW�,pi� Signature o (If applicable, nter"exempt"in the license number line.) LIC.NO.: � Address: v Bus.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt.L cl.No..47 F' �n y y, V1y 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 ❑ owner's agent. Owner/Agent Signature Telephone No, PERMIT FEE. $ �.. ,�I. '3��� �� - ®� ��� �� �.--- �. m i !' The Commonwealth of Massachusetts k. ! Department of Industrial Accidents Office of Investigations i 4i 600 Nrashing ton Street ,%':�a Boston, MA 02111 { www.nzass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Pr]!nt Le-i6ty Name(Business/Organization/Individual): 2 Address:_ l✓dll�/�'��lJ � City/,State/Zip:_4l�fxillC]. 097.4 Phone Are you an employer?Cheek.the appropriate box: L❑ I am a employer with 4, TYPe�project(required): ❑ 1 am a general contractor and I mployees(foil an part-time),* have hired the sub-contractors 6 New construction 2. I am a:sole proprietor or partner- Iisted on the attached sheet t 7. ❑ Remodeling ship and have no employees These subcontractors have 8. Q Demolition working for me.in any capacity. workers' comp.insurance. [No workers comp. insurance S. 9. ❑Building addition ' P ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL i I.Q Plumbing repairs or additions myself.[No•workers'comp. Ic. 1.52, §1(4),and we have no insurance required.]t 1-❑Roof repairs �I ] emplaye:es. [No workers' comp. insurancerequired.] 13-El Other I "Any eppiicam that checks bo> #I must also fill out the section beiow showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they ate doing all work and then hire otnside,contractors must submit a new affidavit indicating such. 4c mtractom that check this box mustattached an additional sheer showing,the name of the sub contractors and their worlraR'comp.prlicJ i: nation. ! am an employer that is p>Y►vrding:warkers'compensation insurance f or my.employees, Below is the policy and job site information Insurance Company Name: Policy#or Self-ins.Lie,#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number-and expiration date). Failure to secure coverage as required under 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 instuiance coverage verification. !do hereby c rt'y under the pains and penalties of perjury that the information provided above is true and correct, Si tore: -Date- Phone ate:Phone#: Official ase only. Do not write in this area,to be completed byy city or town official City or Town: Permit/License 4 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 emp)oyers 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 ofthe'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or tntstee 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,oon6iruction 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 empioyer." MGL chapter 152,§25C(6)also states that"every state or docaf 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 evidenr6'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 numbers)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'cornpensation 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,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please cal]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 lnvestigations 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 bum 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: I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-7274900 axt 406 or 1-877-MASSAFE Fax#617-727-7744 Revised 5-26-05 wvvw.mass.gov/dia , Location No. -71 Date "7" TOWN OF NORTH ANDOVER L 9 A�o Certificate of Occupancy $ S1 CM Building/Frame Permit Fee $ G Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # r 1 1 9 31 Building Inspector Of'10FTH .e, p TOWN OF NORTH ANDOVER '•o'�� .._. ,••x APPLICATION FOR PLAN EXAMINATION qt �^+ u ♦'t9 �SSwCHU5E4 Permit NO: Date Received: 3 D Date Issued: ' IMPORTANT: Applicant must complete all items on this page LOCATION ql 6 ear W,-/ KO ay Print PROPERTY OWNER r J1e4,llk,- �Q ' Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ?'One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: C✓Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED J1d1AG dn� Identification Please Type or Print Clearly) , ` Je/1/Ir v n tJ y6 ; OWNER: Name: ��IG � .J� Phone: Address: No ,tidy. ops scrJ2Y �� Rc - a CONTRACTOR Name:-DIUY&OM- t C. Poo 11-d;M-- �? 111f-.- Phone:- Address: ad d0fin - slit lVd?A -VAdOL& kk— 00f Supervisor's Construction License: '/ G Exp. Date:Home Improvement License: l4 `t ro 1 Exp. Date: 7L1,110 S ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERM/T:$10.00 PER$1000.00 OF THE TOTAL EST/MATED COSTqAJED ON$125.00 PER S.F. Total Project Cost I G-tdn).-r° xA00=FEE:S Check No.: n Receipt No.: Page Iof4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable)- - o Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPAR"TM ENT:BPFORMOS Page 4 or4 TYPE OF SEWARGE DISPOSAL Public Sewer Swimming Pools ❑ ❑ Tanning/Massage/Body Art ❑ Well Tobacco Sales ❑ Food Packaging/Sales ❑ ❑ ❑ Permanent Dumpster on Site 11Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fiend Signature of Agent/Own r Signature of n Contractor Plans Submitted ❑ Plans WaivedV ❑ Cert f ed Plot Pfan " ❑ 'Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS • I DATE REJECTED DATE APPROVED CONSERVATION F1 , �] S COMMENTS DATE REJECTED DATE APPROVED HEALTH ' ❑ ❑ COMMENTS Zoning Board of Appeals: Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Coimnents Conservation Decision: Comments Building Setback(ft.) Front Yard Side Yard Rear Yard Required Provided Re wired Provides Required Provided Water &Sewer connection signature&date Temp Dumpster on site yesno Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 DIMENSION Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq.ft.: NOTES and DATA—(For department use) Page3 of4 Doc 1INSPECTIONAL.SERVICES DEPARTMEN ARFORM05 atc,lcd JMC..m�,.,00a d t")RTHTown of dover No. 72oo"— _ dover, Mass. ' • n re Y = LA E ^ 1 COCMICMEWICK ` �IV � ADRATED P`P� 1S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR TRIS CERTIFIES THAT.... .. _] 4 .... 4 J.0 .......................................................... "" " "" "' Foundation ......... ... has permission to erect........................................ buildings on...... .7 40 .... ...I......... .. .............. Rough to be occupied as...............4J ...... 1.d#.•. ....... ...... �. ....a.......................... ................................ Chimney provided that the person accepting th s3ermit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTTiS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO T Rough ............................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall ho BeDoneFIRE DEPARTMENT Until Inspected and Approved byte Building In spector. Burner Street No. SEE REVERSE SIDE Smoke Det. \ Boa (I of Iluildiu"ILculatiuus and Standards HOME IMPROVEMENT CONTRACTOR Registratidn: 104569 Expiration: 7/14/2008 Type. Private Corporation DAVID CAS'rRICONE ROOFING,SIDING& David Castncone t00 SUTTON ST SUITE 226 NORTH,L N6OVER, IVA 01845 Deputy Admiuistralur x The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,M4 02111 s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contractors/Electricians/Plumber3 Applicant Information Please Print Legibly Name (Business/Organization/Individual): DAu(b C}J T ('.0/J� kV0F;A G + S 1'b i(J _rw C Address: zoo S uTrD/11 Srt- SU4r-e (p City/State/zip:l�D /q'1�.D01/��, 1fI�4 b l P, Phone#: 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 employees(full and/or part-time).* have hired the sub-contractors 6, ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information• 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContracton 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: rr ' �_ • Policy#or Self-ins.Lic.#: Y Ip OO 14 i 0O I O1J D T Expiration Date: Job Site Address: '�� &ai-k /1 'eal City/State/Zip: M. idov�•- /V dw Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year:imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: �'/ �j C Date: F/ 3 C Phone#: 7 / U 6 0 � Oficial 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 foi ilheir eni loyees.. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contractof.;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 of 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 Deparnnent 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 can. 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 Town of North Andovero� NORTI► Building Department a° 4 27 Charles Street North Andover,Massachusetts 0184540 .; (978)688-9545 Fax(978) 688-9542 �� CHUS DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit 4 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cI 1, s150a. The debris will be disposed of in/at: Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. DAVID CASTRICONE ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO.ANDOVER MA 01845 7 HILLSIDE ROAD,BOXFORD,MA 01921 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverlttll 978-374-7314 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 specifkatious,terms and conditions,on premises below des riTbed: Owner's Name........ i 1.t r...> 11..�n n t. t r ....>/.n: ..................................Telephone#..... .7 Job Address..... �... a r:... h� ....R ..........................City.. G.... .�a.At rr¢..................State...../ 4, ......... Specifications: ................................... ..'... ............ .........................I................ .....I....... .............................................................................. .......... ..`.... .1. ...e........f.1. .........h'l.at.6iJ'a..C.........��,`A..'kl..�.:�..n......'� ""�'/ .............. 1`d ..........S..l.�l.. ..J.........J.1.J ..¢.S.X ......G ......�.2 O.P.I.5......../ 4y......................... ............. �..lr.........�, e �. 11 . ... ...... .......... nA��..1. .........�7./e ..- ,re... �'.J.a'_rt.�........C� 1.1.��2 IL.... .J(.D.........c.t........5. -�. _f...... ........... . ....kl.e ..:....... �. .. ,j.h€, ...... ...... /..... ..... } /pL.................eft ...... . ........C.o. .. ...T,t.a. � �� "'�.1�•I�L. ,.. ........... ......rt�..1.Q 5........t.II ....,S.L ..4�....1e1�...... �l.rQ=9 1. r.............................. .............................................................:..................................................................................,........,.................................. ...................................................................................................................................................................................................................... One Year Workmanship Warranty(Not Transferable) Manufacturer's Warranty as specified by manufacturer/ Materials and Labor to cost$....., -0................. Payable......3.3.0.0.........on.....� . Payable.............................on......................... VDalance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior ofproperty,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces,water stains when roofing shingles have not had adequate time to cure). Upon completion of above work,all undersigned agree to execute and deliver to contractor,theirjoint note in accordance with his(their)above obligation as requested by 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 the contract and/or any lien in connection herewith. i 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. The undersigned warrant(s)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s). — There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the 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. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration One Ashburton Place Room 1301,Boston,MA 02108 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-related permit or deals with unregistered contractors shall be excluded from access to the Guarantee Fund. Approximate starting date of work..�is i7,c. t,..,..f T ....94.9.4....... Completion date.............................................................. 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. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner has three business days to cancel this contract and incur no penalty. 99 TT IN WITNESS WHEREOF,the parties have hereunto signed their names this......13.1. day of. 20....V 3 Jr......... Accepted: / Signed.......r... ..1�/ Y ................................Owner Signed.........................................................................................Owner Per. oa�...g�... Representative