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Miscellaneous - 43 CHRISTIAN WAY 4/30/2018 (2)
- - 1 43 CHRISTIAN WAY 210/104.D-0002-0000.0 r North Andover Board of Assessors Public Access r Page 1 of 1 M forth n-dov2r Seard cl Asz.2szars Q -- • Property Record Card Cts Sc---'To Re— Parcel ID :210/104.D-0002-0000.0 FY:2014 Community : North Andover SUL-TCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge ' k Search for Parce?s Search for Saes t Surm-ary Residence Dem Sbuctsre Condo 43 LM CHIS tl MY Co:rt7temal Location: 43 CHRISTIAN WAY Owner Name: PELLEGRINO,DENNIS A NANCY M PELLEGRINO Owner Address: 43 CHRISTIAN WAY City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:7-7 Land Area: 1.30 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3160 sqft ASSIESSM. EN-FS CURRENT YEAR PREVIOUS YEAR Total Value: 594,700 606,200 Building Value: 368,700 368,700 Land Value: 226,000 237,500 Market Land Value: 226,000 Chapter Land Value: LATEST SAFE Sale Price: 579,900 Sale Date: 06/28/2001 Arens Length Sale Code: Y-YES-VALID Grantor: GRAD ROSENBAUM Cert Doc: Book: 06231 Page: 0062 http://csc-ma.us/PROPAPP/display.do?linkld=2439071&town=NandoverPubAcc 5/14/2014 Residential Property Record Card PARCEL ID:210/104.D-0002-0000.0 MAP:104.D BLOCK:0002 LOT:0000.0 PARCEL ADDRESSA3 CHRISTIAN WAY FY:2014 PARCEL INFORMATION Use-Code: 101 Sale Price: 579,900 Book: 06231 Road Type: T Inspect Date: 07/06/2011 Tax Class: T Sale Date: 06/28/01 Page: 0062 Rd Condition: P Meas Date: 07/06/2011 Owner: Tot Fin Area: 3160 Sale Type: P Cert/Doc: Traffic: M Entrance: X PELLEGRINO, DENNIS A Tot Land Area: 1.30 Sale Valid: Y Water: Collect Id: RRC NANCY M PELLEGRINO Grantor: GRAD ROSENBAUM Sewer: Inspect Reas: C Address: 43 CHRISTIAN WAY Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION r. Style: CL Tot Rooms: 10 Main Fn Area: 1584 Attic: N NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1576 Bsmt Area: 1584 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 400 1 P 101 S 43560 1.000 223,713 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.300 2,280 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 3160 VALUATION INFORMATION Foundation: CN Bath Qua]: S RCNLD: 368707 Current Total: 594,700 Bldg: 368,700 Land: 226,000 MktLnd: 226,000 Kitch Qual: S Eff Yr Built: 1992 Mkt Adj: Prior Total: 606,200 Bldg: 368,700 Land: 237,500 MktLnd: 237,500 Heat Type: HW Ext Kitch: Year Built: 1987 Sound Value: Fuel Type: O Grade: G Cost Bldg: 368,700 Fireplace: 2 Bsmt Gar Cap: 2 Condition: G Att Str Val1: Central AC: Y Bsmt Gar SF: Pct Complete: Att Str Val2: Att Gar SF: %Good P/F/E/R: /100/100/90 Porch Type Porch Area Porch Grade Factor S 168 W 168 SKETCH PHOTO �f fi 16 12 168 6q, 12 16059.1l'1 4t97. 14 5614 FU/'FM10 Y r , 1536 Sq,Pk Re ' 19 'L HgeF 43 L-9A CHRI 7 1 IAN WAY Parcel ID:210/104.D-0002-0000.0 as of 5/14/14 Page 1 of 1 AMERICAN CLAIMS SERVICE MULTI-LINE ADJUSTERS BUILDING INSPECTOR/COMMISSIONER, BOARD OF HEALTH AND/OR BOARD OF SELECTMAN Building Inspector Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 INSURED: Pellegrino ADDRESS: 43 Christian Way North Andover POLICY: PHO0100649081 LOSS DATE: 02/18/2015 LOSS TYPE; Ice Dam ACS FILE: 31211 PD Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Craig Gillespie Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 02/20/2015 7 KIMBALL LANE,BUILDING C,LYNNFIELD,MASSACHUSETTS 01940 TELEPHONE (781)245-9516/FAX(781)245-1077 E-MAIL—daims.acs@verizon.net ,,f Date..6.....L. .� ................ Q OF 00pTh,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU5� ��� P r� "�r`J/L This certifies that ...................................................... ;......... has permission to perform ✓� f(,. l r .... ...../) ...! ..........�............. .................................... wiring in the building of..... f'..C./.': c?....^ �................................................................ 7 � ... G.J .�........................ No A dove ,Mass. at , .....;..........�.. . ....� ........� .... Fee!6..............Lic.No. ................... . . ................................... y ELECTRIC INSPECTOR Check# lg d Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 ININK 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) 4/3 C f�,-;6 ,AA) (,!J Q,ta Owner or Tenant Pel,&R s Nc(<<15 f",e Jo Telephone No. Owner's Address r Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building A005, Utility Authorization No. - Existing Service 2c9d 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: I\ Completion of the following table may be waived by the Inspector of Wires. (Z- No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA v No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets 10 No.of Oil Burners FIRE ALARMS No.of Zones A,_ No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons J.K.W No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers ( Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No,of Devices or Equivalent No.of Water KW 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: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1060 (When required by municipal policy.) Work to Start: fo ` Z 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 i the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: /D Licensee: ignature LIC.NO.: _ (If applicable,enter "exempt"in the ' e e number I Bus.Tel.No.- �• Address: Gc fe/ ( /) Alt.Tel.No.: *Per M.G.L c. 147, 57-61,security work requires Depahment 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 signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent �f3 /� 1�� PERMIT FEE. $ Signature Telephone N 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the n Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 1 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 Chanter 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 li11 mited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval "11 in e 11 ffe11 ct or e 11 x 11 i 11 s 11 t 11 e 11 nc11 e"d 11 u 11 ri11 n 11 g the qualifying period beginning on August 15,2008 and extending through August 15,2012. that was 11 ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: ----------------------------------- Trench Ins ection Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: �r Pass Q Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: I20UGH INSPECTI N: Pass Failed IN Inspectors Comments: Re-Inspection Required($.) ❑ Inspectors Signature: ^` Da 'INAL INSPECTION: Pass Q Failed Re-Inspection Required($.) ❑ nspectors Comments: �Gyll 110: i Inspectors Signature: Date: iB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhofd@townofmerrimac.com i The Commonwealth of Massachusetts , - DepaYtment of lndusftigl Accidents Office oflnvestigations 604 Washington Street Boston,MA 02111 www.mass gov1d1a Workers'Compensation bmurance ATUdayff:BuilderrsfContractors/Electric ians/pliiinbers •Applicant bformation Please Print Ledbly Name(Businessiorganizationadividual): ^G Address: C 03 City/State/Zip:/ ,^ y Phone 0: Are you an employer?Check the appropriate box: Type of project(required): 1.[( am a employer with 4. [l I am a general contractor and I 6. ❑New construction f employees(pull and/or pati tinge)* have Hired the sub-contractors 2. I 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 forma in any capacity. workers'comp.insurance, g• []Building addition [No workers' comp.insurance 5. ❑We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised.their 3.[] I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself[N•oworkers'comp. c.152,§1(4),andwehaveno 12.❑Roofxepairs iusurancere ed. employees.[No workers' ] 13.❑Other comp.insurance required.] !Any applicant that checks box#I must also fill out the section below showing their workers'compensaf[onpolicy information. i-Homeowners who submitthis affidavit indicatingthey ore doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an gdditional sheet showing the name of the sub-contractors and their workers'comp.policy information. f am an employer that zs providMg workers'compensation insurance for my employees .Below is the policy and job site information. Insurance Company Name:. Policy##or S elf-ins.Lic.ff: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of fire workers'compensatlon-pollcy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine i?p to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD 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 certify under the pains and penalties of perjury that the in,formation provided above is true and correct. - Signature• Date: - _ - Phone#: Official use onfy. .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 H. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to flus statute,an employee is defined as"...every person in the service of another ruder any contract of hire, express orimplied,oral or written." An employei is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a:deceased employer,or'& receiver or trastee 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 o ccupant 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 shallnot because of such employment be deemed to be an employes." MGL chapter 152,§25C(6)also states that"every state or local lie-ening 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 Please fill out the workers'comp ensailon affidavit completely,by checking the boxes that apply to your situation and,if n6cessaty,supply sub-contractors)name(s),address(es)and phone number(s)along with their certi£icate(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 orLLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for con irmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Oificials Please be sure thatthe affidavit is complete andpxinted 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 thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(i-fnocessary)and under"Job Site Address"the applicant should write"all locations in. .(city or towzi).'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.news affidavit moist 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 IA a dog license orliermit 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: Tho Goxr_>Moil-wealth ofMamar"A "Ats DeTadMout of TndusWal Accidents Offlee offnyestzga-Uous 6bQ Waftglan Sftost . Revised.5-26-05 FRY,0 617-727-7749 Www.MapV1414 roiu. ......---- -- c01 C_ OMMONWEALTH OF MASSACHUSETTS ELECTRICIANS `ISSUES THE FOLLOWING LICENSE ASA : REGISTERED MASTER ELECTRIC•IANti \i a z K€VIN' J LEKARCYK ' y i� 1 CYRILtd-RD 'W ;U DERRYNH 03038-4 45 9�.OR C7/31/ > 42002 Date. ^ ..�.�k i...... o*".�R'T"q� TOWN OF NORTH ANDOVER 0 p PERMIT FOR PLUMBING - 88'�CMUSE _t This certifies that`�1..��.. - .. v2 IL-'-.............................................•< ...?. has permission to perform.. ;.. r. .,� �. Wit. ✓ °,r o ,Q ....... .... ............................................... J plumbing in the buildings of.......P 1�£.._co..t mo.............................................. at............... ... ............................. ...... ....... , North Andover, Mass. Fee 5I, d..."......Lic. No. �L!A,0.... .....`.:'�... ..... ............................................................ PLUMBING INSPECTOR Check. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER MA DATE 6-18-14 PERMIT# JOBSITE ADDRESS 143 CHRISTIAN WAY OWNER'S NAMEJ DENNIS PELLEGRINO POWNER ADDRESS I SAME I TEL �FAX� TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR— BSM 1 1 23 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 7 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 { URINAL WASHING MACHINE CONNECTION ..= WATER HEATER ALL TYPES WATER PIPING THER ICE MAKER LINE 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW nj1 LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY ❑ 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 ❑ AGENT ❑ 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 com lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I JAMES BURKE LICENSE# 10469 SIGNATURE MP JP❑ CORPORATION M#1 2727C PARTNERSHIP❑# LLC❑# COMPANY NAME I BURKE&SONS PLG&HTG INC ADDRESS I PO BOX 102 CITY GROVELAND STATE MA ZIP 101834 777�� TEL 978-374-7837 FAX 978-373-6615 CELL 1 978-360-4453 EMAIL I JIM@BURKEANDSONSPLUMBING.COM C ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No d THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 17 IW FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Deparbu nt of lndustrigl.4celdle is Office Of.Investigations 600 Washington Sheet .Boston,MA 02111 www.mass.gov/dza Workers'Compensation bmurance Affidavit:BuifderslContractol s)Electriplans/Pliiiubero Applicant Information Please Pr` t Lie 'bl ff Name(Business organization/. ,itvldud): c-),, So m Eh 'C C Address: j Z' City/S�afelZip: J I�� Phone#: 0� ��j ✓tel � 7�J 1 Are you an employer?Coed the appropriate box: Type of project(required):BJ 1. 1 am a employer with �/ 4• F1 Z am a general contractor and 1 6. EJ New construction employees(full and/or pax(-time).* have liiredthe sub-contractors 2111 am a sale proprietor orpartnex- listed on the attached sheet. 7• ❑Remodeling ship and'haveno.employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp,insurance. g• E]Building addition [No workers'comp.insurance S. ❑We are a corporagon and its 10.[(Electrical repairs or additions required.] officers have exercised.their 3.[I I am a homeowner ttoing all work right of exemption per MGL 11.[1 Plumbing repairs or additions myself.[No workers'bomp. c.152,§1(4),andwehaveno 12,0 poofrepairs ed. employees.[No workexs' insurancere a 13.❑Other comp.insurance required.] xAny applicantthat checks box#1 must also fill out the section beldw showingtheir workers'compensagoapoEcy information. f-Homeowners who submit ibis affidavit indicatingilrey ke doing allworK and then hire outside contractors must submit anew affidavit indicating such. TContractors that cheekthis box must attached as additional sheet showing the name ofthe sub-contractors andtheir workers'comp.policy information. I aln are employeN that is providing workers'compensation insurance formy employees, Below as the policy an4joh site information. Insurance CompanyN'ame:_ ✓Z-C I .. Policy#or Self ins.Lic.#: 31qb) Expiration Datye�:/ lob Site Address: ���� '1 � City/State/Zip: Attach a copy of tete workers'compensdeclaration page showing the policy number and expiration date). Failure to secure coverage.as requ' dunder Section 25A ofMGL o.152 can lead to the imposition,of criminal penalties of a fine up to$1,50 0.00 and/or one-year imprisonment,as well as civil.penalties in the form da STOP WORD ORDER.and a fins ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office-of- Investigations fInvestigations of the DIA.for insurance coverage verification. f do liereby cert f under' ae pains and penalties o?f ' ry dial the information provided alcove is true and correct. Signature: Date: Oficial use oply. .Do not write in dais 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 3.City/Town Clerk 4.Electrical Inspector 5.PluzubingInspector 6.Other Contact Person:. Phone#: v • 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 tri the service of another under any contract of hire, express orimplied,oral orwritten2' An employes is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore of the foregoing engaged in a j oint enterprise,and including the legal representatives of a•deceased employer,or the xeceiver ox trustee of an individual,partnership,association or other legal entity,employing employees. ;Sowaver the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant of the dwolling 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 deemedto bean 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 beenpresentedto the contracting authority." Applicants Please:flu u out the workers'compensation affidavit completely,by checking the boxes that apply to your situation.and,if necessary,supply sub-contractors)nam.e(s),addresses)andphonenumber(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than,the members or partuers,are notrequired to cant'workers'compensation insurance. If an LLC or LLP does have employees,apollcyisrequired. Be advised that this affidavit may be submitted to the Department of Industrial Accidents fox 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.polky,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 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 be-sure to fill in the pennit/Rcense number which will.be used as a reference number. In addition,an applicant thatinust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating cutrent policy information(if necessary)and under"rob 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 pr' ofthat a valid affidavit"is on file for Mune p ennits or licenses. Anew 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 burn leaves eto.)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: TheC.`Q 911wean ofM-amac vuetf q Depubelal 4fJhdwWal Accideats ():floe QTnedZaon 6b Wa8bfi%ton xe� Boston, ,02111 Revised 5-26-05 Fax 617-727-7749 t I C0 COMMONWEALTH OF MASSACtilisETTs PLUMBER>P 5SF ITTERS ` 1 ISSUES TH'F FOLLOW N:G LICEIJ'SE I I ..L IC.E . .N.SED ASA MASTER PLUMBERW. h JAMES;: A BURKE t W t 73 WILL(fT \tib ,y _ ]�t'z I i HAUERHILLMA 01 83230Y 1o46g 05/01/16 f : 223330 j Location L No. Date „T ,AORTA, TOWN OF NORTH ANDOVER F n Certificate of Occupancy $ Building/Frame Permit Fee $ 14Ustt�' Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ *� Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works 311T NO. APPLICATION FOR PERMIT TO BUILD- NORTH ANDOVER, MASS. PAGE MAP+4 0. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE ZONE I SUB DIV. LOT NO. ` 1 1 LOCATION !Zlj PURPOSE OF BUILDING �06 OWNER'S NAME l� n�l/L' Ll NO. 0/ STORIES L Z�512E ,C OWNER'S ADDRESS r BASEMENT OR SLAB �^��� ARCHITECT'* NAME tJ 812E OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME , / it �Aj� SPAN DISTANCE TO NEAREST BUILDING (J,i DIMENSIONS OF SILLS DISTANCE FROM STREET - pOST6 — •a DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS 18 BUILDING NEW _ SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY -ss IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY If BUILDING CONNECTED TO TOWN SEWER If BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS a PROPERTY INFORMATION LAND COST SEE BOTH SIDES EBT. BLDG. COST PAGE I FILL OUT SECVIONi I - ] EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - t2 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPf MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY .► ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATION• PLANS MUST BE FILED AND APPRO ED BY BUILDING INSPECTOR DATE FILED : BUILDING INSPECTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE 6 (6 OWNER TEL# PERMIT GRANTED CONTR.TEL I O ,S9 __� L� CONTR.LIC./ 3 F T10RT/y Town of over No. m • � °o- ^ � �..E . � over, Mass., /yl y o`�fl 19 97 A 9A cocH�cNcwic� '��• '9 �' 'A E o pP`y •(� is E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �j-�Q, .........Rd..$R.!2..4a.(4W- .................... ......... .. ..................................................... v oun tion has permission to erect......#4 f./fid ..r buildings 1 .. . ..... buildin s on........ .. ......C. �lcS . .:t�.....1.�/ �y/.................... Rough to be occupied as �+ �. /f.. '+Q.�r�" .........,.?.. ... ... .. .......................... ....�LA 4.4F....0. A!�.....�...�y��..... . Chimney provided that the person accepeiing this permit all 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 Final IT PERMEXPIRES IN 6 MONTHS - ELECTRICAL INSPECTOR UNLESS CONSTRUCT, STARTS Rough J .............. .. .. ...... ......... "' e. Service BUILDING INS ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove F ugh No Lathing or Dry Wall To Be Done FIRE Until Inspected and Approved by the Building Inspector. DEPARTMENT > Burner Street No. Smoke Det. 1 Date....Q.... .1.....��...�.. f NORTH, 3�;.<;�``°.;•�."�o� TOWN OF NORTH ANDOVER 0 -Ewa PERMIT FOR WIRING ACMUSE� ^ This certifies that / /r1. has permission to perform ..................`............................................................ wiring in the building of �'' f 1 G � t .�.f....J G! ............. .North Andover,Mass. Fee... Lic.No. t ELECTRICALINSPECTOR .a Check # r The Commonwealth of Massachuset s Department o/ Public Safety > occuprncr BOARD OF FIRE PREVENTION REGULATIONS 527 CM 12:00 (3/90 twr. w.,rr ! APPLICATIAON FOR PERMIll work to be performed in nT Tce OP RFnORtM ELErical Code, CTRICAL WORK (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date To the Inspector of Wires: The undersigned applies for a permit to perform the electrical Wo k described below. Location (Street & Number) �5� �✓ /�fiq c Owner or Tenant Qp Owner's Address Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters NurnDer of Feeders and Ampacity Location and Nature of Proposed Electrical Work No of L gh!,ng Outlets No.of Hol Tubs Awe In- No.of Transfprmers Total KVA No of L gnl ng Fixtures Swimming Pool grind. ❑ rind, ❑ Generators KVA No of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Ba"ery Units No of Swncn Outlets No.of Gas burners FIRE ALARMS No.of Zones Nc of Ranges No of Au Cond. Total No.of Defection and Ions Initialing Devices Nc of D,sposaisHeal Total Total No of Pumps Tons KW No.of Sounding Devices NC of D,snwasners Space/Area Heating KW No.of Sell Contained Detection/Sounding Devices No of Dryers Healing Devices KWLocal❑ Municipal Connection❑Other 'vc of water HeatersKyy No.of No,of Low Voltage Signs Ballasts Wirin Nc ra c Massage Tubs No.of Motors Total HP �'HeR a NSL,RANCE COVERAGE Pursuant to the requirements of Massachusetts General Laws ^a.e a c,rrent _ao f,ry insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ -a,e s�ommee ,ahs proof of same to this office. YES ❑ NO ❑. ra_ nate cneeCKeeo YES. please indicate the type of coverage by checking the appropriate box. ;R 'rS_ ANCE f BOND ❑ OTHER ❑ (Please Specify) Es::ma,ec vawe of Electrical worts S I-yo (Expiration Dale) evon C Star 7- /y CIf 5,9nF`' ler "e penan es of perjury arr .AmE LIC.NO. _ Signature ` LIC. NO _o ass / /'2q�:J S' —� us.Tel.No. ^ ' �� All.Tel.No. c ;NSURANCE WAIVER I am aware that the licensee does not have the Insurance coverage or its substantial ec c, Massac%sens General Laws.and that my signature on this equivalent as ,-� perms application waives this requirement. er _ en!A 9 (Please check one) Telephone No. PERMIT FEE $ S-gna!„re of Owner or Agent) TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �'A�� �y Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION �!-4R�S'r1A� WAS r�Print PROPERTY OWNER / c Print 100 Year Old Structure yes no o MAP NO: I tb PARCEL: 0 -4 ZONING DISTRICT: Historic District yos no Machine Shop Village ye8 no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other V'Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: C>E,&rA%s '�®.�,�����ao Phone: °t'1 ga X088 633 Address: 43 CN Rye,-c % kN W.!� CONTRACTOR Name: f4/ 14,&(16Uwi Phone: -12Eo Address: Ad SOX Supervisor's Construction License: CS "Uf`f.� Exp. Date: q16VW. Home Improvement License: 130g76 Exp. Date: 7 ARCHITECT/ENGINEER let Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3 S 3 FEE: $ Check No.: /09 Receipt No.: _ NOTE: Persons contracting with unregistered contractors do not have access t i uaranty fund \k �ignature of Agent/Owner� mature of contractor Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans -: Plans Subm itted: -.Plans Waived ❑ ... _Certified Plot Plan ❑ Stamped Plans ❑ - TWE DF:SEWERAGE"DISPOSAL" Public Sewer ❑ Tanning/Massage/BodyArt ❑. . .Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private,(septic tank,etc._ ❑- _: Permanent Dunpster on Site ❑ =THE-FOLLOWING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE.REJECTED: . DATE:APPR-OVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH ' ' Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes_ no Located'at 124 Mair, Street - -Fire Departme►it signatur_eldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. _Total land-area; sq. ft.: ELECTRICAL: -Mo-vement of Meter location; mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: . Yes No MGL-Chapter 166.Section.21A-F and G min.$10041000.fine NOTES and DATA— (For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The following is'a list of he required.forms to be filled out-for the appropriatepermit to.be obtained. Roofh-- g, Siding, Interior Rehabilitation Permits Building Permit Application -,A, Workers Comp Affidavit Photo Copy Of H.I.C. And/GrC.S.L Licenses Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster_permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified 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) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses n Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 apt)•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subWted with the building application Doc: Doc.Building permit Revised 2012 Location X(A/No. O 7 Date - K . - TOWN OF NORTH ANDOVEK Certificate of Occupancy $ � Building/Frame Permit Fee $ 1;;- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# /0 / �r Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost 3�-5;,111131,0;0) $ - $ 421.36 Plumbing Fee $ 52.67 Gas Fee 100 comm. $3 1:u0?0:o) Electrical Fee $ 52.67 Total fees collected $ 626.70 43 Christian Way 828-14 on 5/14/14 Remodel Bath and Kitchen I i NORTH own of 2 tAndover - 10 No. Iq C,, h ver, Mass, COC HIC"tWItn S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System r BUILDING INSPECTOR THIS CERTIFIES THAT ........�l-�v'r�l.t..�".......�...ls:.fr.:�.::►.a....................................................................... has permission to erect .......................... ...................... ....-:�C�..... � ...�rt/. ........................... Foundation p buildings on �.cj / Rough to be occupied as ,L � p ............... ../..�j..... ....!..1:. C�l:,t. :nt:... . . .. '7.�� ss. ................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relatingto the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR _.. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough -w Service ................................"'..:.(...........a.. ...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of.Massachuseds • - Depaphnent oflndustriglAceid&ts Offace offnvestigations 600 Washington.Street Boston,.MA 02111 www.mass gov1d1a Workers'Compensation Insurance Affidavit:Buifders/Cont°actors/Electr icians/Plumhexs AppReant Information Please Print Le�.ibk Name(Businesdorgani-zationftdividual): t`� '�'v'� �� /,�j�'/��� `I V t Address: City/Stafe(Mip: ���°�C/ lf� l /� � Phone Are you an employer?Check the appropriate box: Type of project(required): 1.[l I am.a employer with 4. [l I am a general contractor and I 6. []New construction _,employees(full and/or part-time).* have hiredthe sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and•have no.employees These sub-contractors have 8. []Demolition worldng forme in.any capacity. workers'comp.insurance. 9• E]Building addition [No workers' comp.insurance 5. ❑We are a corporation and its ME]Electrical repairs or additions required.] officers have exercised.their 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),andwehaveno 12.[]Roofrepairs insurancere edemployees.[No workers' required.] 13.❑Other comp.insurance required.] !Any applicant that checks box#1 must also MI out the section below showing their workers'compensationpolicy information. i momeowners who submit this affidavit indicating they Aia doing allwork and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self inns.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 requiredunder Section 25A ofMGL o. 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 ofup to$250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA or insurance coverage verification. I do hereby cert rid iepains dpenaid s ofperfury that Me information,provided abo 'sjtrue and correct. - Si afire• Date: i7� f Phone#• Official use only. Do not write in Mis 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.Clty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ContactPerson: 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 anY other under an 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 trdsfee ofan individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house havingnotmore than three apartments and who resides therein,or the occupant ofthe 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 lie-ening 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),address(es)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'compensation insurance. If an LLC or LLP does have employees,apolicy is required. Be advised that this 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 thepermit 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 andpriated 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 Ellin the 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(ifnecessary)and under"Job Site Address"the applicant shouldwrite"all locations in (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-ii on file for future permits or licenses. Anew affidavit must b e filled out each year.Where a home owner or citizen is obtaining a license ox 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 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 Ca onweafttLof�tas�ao??usPtts - Depax(Meut ofzudusWa, A cc%de t • Qf�ce Q£Tu�'e�ti�a-�on.�• ' 6,00 Waft&n ft-t Boston,NA 0.2111 . 8 Revised 5-26-05 Fax 0 617"727'77¢9 wWw.Ma.agQv1d3a Advanced Custom Cabin( � ADVANCED CUSTOM CABINETS13 Prescott Road Brentwood,NH 03833 _"A F i n P C: a b i n e t r ; i n c e i R '7 2 (603)772-6211P (603)778-7604 F Dennis and Nancy Pellegrino 43 Christian Way N.Andover, MA 01845 GENERAL CONTRACTOR SERVICE ESTIMATE as of The following is the cost estimate for the elements described below. 05/07/14 KITCHEN AND BATH(REMODEL) KITCHEN AND BATHROOM CABINETS $ 22,938.00 REMOVE AND REPLACE KITCHEN AND 1ST FLOOR BATHROOM CABINETS SAME LOCATIONS FOR ALL CABINETS,SINKS,APPLIANCES ADDING A NEW OVEN IN NEW CABINET INCLUDING NEW COUNTER TOPS REPLACE KITCHEN WINDOW OVER SINK WITH SAME SIZE AND TYPE $ 975.00 ELECTRICIAN TO DISCONNECT AND RE-CONNECT NEW APPLIANCES $ 3,200.00 COOK TOP SAME LOCATION MICROWAVE DRAWER IN ISLAND(NEW FEED REQUIRED) REFRIGERATOR(SAME LOCATION) OVEN(NEW FEED LINE REQUIRED) UNDER CABINET LIGHTING(TO BE ADDED LOW VOLTAGE 12V) PLUMBING TO INSTALL NEW SINKS IN SAME LOCATION $ 1,500.00 REPLACE TOILET WITH NEW(SAME LOCATION) NEW APPLIANCES(ALL ESTIMATED BY CLIENT)(NOT ORDERED YET) $ 6,500.00 TOTAL $ 35,113.00 5/10/2014 Q:\General Contractor Work Estimates\2014 GC\GC work PELLEGRINO REMODEL FINAL REV 5 DTD 5.7.14 'Aj Advanced Custom Cabinets 13 Prescott Road ADVANCED CUSTOM CABINETS Brentwood,NH 03833 € [ ine Cahiraetr} Sinee 1 972 (603)772-6211 P (603)778-7604 F CONTRACTOR NAME: 0 CUST.NAME: Dennis and Nancy Pellegrino ADDRESS: 0 ADDRESS: 43 Christian Way 0 North Andover, MA 01845 TBD PHONE: 0 PHONE: 978-688-6338 CELL: 0 CELL: 0 FAX: 0 FAX: 0 Email: nancype11222@verizon.net INITIAL DATE OF 1ST QUOTE: 2-Apr-14 DATE OF CURRENT QUOTE: 2-Apr-14 Terms and Conditions NOTES: 1 The pricing quoted above is subject to change(up or down)during the design process. In all cases,the customer will approve and sign off on the the final pricing before work can begin. 2 Quotation is valid for 30 days. If a deposit is not received within 30 days,pricing must be reviewed. 3 Jobs will not be considered as scheduled until a deposit is received. 4 ACC does not specify or install appliances.ACC installs appliance door panels ONLY after appliance installation by others. All appliance specs must be provided and clearly identified for style and model no. for ACC designers to accurately integrate into the cabinet designs. 5 Jobs not completed within 6 months after sign up are subject to material/labor increases to be applied at final repricing phase prior to cabinet final construction. PRICING SUMMARY: Total Kitchen Quote $ 18,956 Total Vanity Quote vanity and full ht cab $ 2,016 Total Counter Quote kitchen prelim est eng stone/wood top $ 1,966 $ 22,938 TERMS:(ACC installs) 33%of total is due to sign up a job and get into the schedule. Cabinetry/wood tops by ACC 33%due with design completion/production start up Balance for cabinetry is due, less installation cost, prior to delivery Completed balance is due the last day of our installation. TERMS: Installation by Others OR balance due upon delivery or pick up of cabinetry. TERMS:Counter tops Counter tops added to scope of work during the project require 50%deposit with order and balance due day of counter top installation. SIGNUP/DEPOSIT: To signup and have this job scheduled,a deposit of $ 7,646 is required. Any changes,either up or down,will be made to the remaining balance and statements. Schedule Delays Custom cabinetry schedules are contingent upon job site readiness. If the production schedule is agreed upon by all parties and cabinetry is fabricated but can not be delivered due to job site delays that occur after fabrication has started,the following will be required: a. Payment in full less installation labor to be provided first day of storage b. Storage arrangements by customer or agreement with ACC WARRANTY: ACC provides a limited lifetime warranty. Details provided at www.advancedcustomcabinets.com Limited Lifetime warranty The period starts the day after we complete our installation. Call backs for any reason that are covered under the warranty will be addressed in an expedious manner. No warranty work can be scheduled until we have complete payment. APPLIANCE PANEL HARDWARE: Custom Appliance panel hardware is not included in the estimate until chosen NATURAL MATERIALS: Working with natural materials i.e woods and granites provide for many variables (wood,paint,&natural finish) that affect the color,texture and look of these materials. We hand select the best available sections of the materials for each application but can not guarantee against these variations. All wood changes color with age and exposure to ultravilot rays. Installation by Others: When customer chooses to have installation done by others, an ACC installation waiver must be signed ACC does not accept responsibility for improper installation techniques by others. REFUND: In the event a deposit is returned or job cancelled by customer,Advanced Custom Cabinets will refund the deposit amount less 20%plus any costs of labor, materials or expenses incurred to date ACC does not issue refunds for unused custom ordered materials or components. CASH DISCOUNT included: Quoted amounts assume payment via cash or check. All Master Card,Visa or Discover payments require an additional 3%for each transaction processed. ( I/We)have read, understand and accept the quotation. Page#1 Terms Conditions Pellegrino Dennis 4-2-14 G" �y pc�dc�aa6/c14e16- C�fe Iorn�vaaaizauca Cf I Office of Consumer Affairs&Business egulation SOME IMPROVEMENT CONTRA&gR Type. egistration: ,138470 Private Corporatic xpiration: 417/2015 'Private CONSTRUCTION INC, RAYMOND.DANDURANT g� 4 COLONAIL DRIVE MERRIMAC,MA 01860 Unb'ersecretary Massachusetts-Department of Public Safety i Board of Building Regulations and Standards Construction Supervisor License: CS-083143 RAYMOND S DANSUR 6F ernwood Avenue _ Haverhill MA 01$35 ' Al Expiration v-' 04/14/2016 Commissioner Issue Date:Jan 1Q 2014 LI S I G This certificate is issued as a matter of informa on only and confers no rights upon the certificat holder. LomLer Industries Self Insured Group 11vst 110 13ox 3773 This certificate does not amend,exten or alter Concord.NH 0.3302-3773 the coverage afforded by the polici below. Certificate Holder Certificate of Insurance Wayne Donohue Companies Affording Coverage Wayne Mfg.d/b/a Advanced Custom Cabin Company Lumber Industries Self-Insure Grou 13 Prescott Road Letter A Brentwood,NH 03833 Company Safety National Letter B This policy is effective at 12:00 am on 1/1/2014 ,and will expire at 11:59 pm on 1/1/2015 This policy willtautomatically:be.renewed unless notified by either party by October 1st of any fund year. Coverages This is to certify that the Workers' Compensation and Employer's Liability Insurance has been issued to the insured named above for the policy period indicated,not withstanding any requirement,term or condition of any contr ct or other document with respect to which this certificate may be issued or may pertain,the insurance afforded the policies described herein is subject to all the terms,exclusions and conditions of such policies.. Type of Insurance/Carrier Policy Number Effective Date Expiration Date LIMITS A:Workers'Compensation &Employer's Liability E.L.Each Accident $1, 00,000 Lumber Industries Self-Insured Group LT0120140000412 1/1/2014 1/1/2015 E.L.Disease-Pol Limit $1, 00,000 E.L.Disease-Each Emp $1, 00,000 B:Excess Insurance Workers'Compensation sta tory Employer's Liability $1, 100,000 Safety National SP4049863 1/1/2014 1/1/2015 Description of Operations officers Excluded Member Cancellation Wayne Donohue Should any of the above described policies e Wayne Mfg:d/b/a Advanced Custom Cabin cancelled before the expiration date there 'the 13 Prescott Road issuing company will endeavor to mail 30 ays Brentwood,NH 03833 written notice to the certificate holder na d to the left,but failure to mail such notice st all impose no obligation or liability of any kin upon the company,its agents or representatives. Administered by: Comp-SIGMA Ltd. swat Ian 10 2014 \�%orken'i:mm�rnsnti+,n A,lrcrn:ui,ras Authorized Representative Date { CERTIFICATE OF LIABILITY INSURANCE 5 '1 0 "' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY HE 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(les) must be endorsed. If SUBROGATION IS WAN D,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not coril ir rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NA M Lumber Eastern Insurance Group LLC PHONE (508)651-7700 FAX 233 West Central Street .MAIL ESSO INSURERS AFFORDING COVERAGE NAIC N Natick MA 01760 INSURER A:Penns lvania Lumbermen INSURED INSURER B Wayne Manufacturing Industries LLC, DBA: INSURERC: Advanced Custom Cabinets & Advanced Flooring INSURER D: 13 Prescott Road INSURER E: Brentwood NH 03833 INSURER F: COVERAGES CERTIFICATE NUMBER:13/15 master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE OLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 0 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. INSR TYPE OF INSURANCEADDLISUBRI POLICY EFF POLICY EXP L POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ED E 100,000 A CLAIMS MADE a OCCUR 8W0080114 /26/2013 /26/2015 MED EXP(Any one person E 5,000 PERSONAL 8 ADV INJURY E 1,000,000 GENERAL AGGREGATE E 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2'000,000 000,000 X POLICY PRO- LOC E AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT aaccid n 1 000 000 A X ANY AUTO BODILY INJURY(Per person) E ALL OWNED SCHEDULED BA28WO080214 /26/2013 /26/2015 BODILY INJURY(per accident) E AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE E AUTOS Per accident Medical payments E 1,000 X UMBRELLA LU16 X 2,000,000 OCCUR EACH OCCURRENCE E A EXCESS UAB CLAIMS-MADE AGGREGATE E 2,000,000 DED I X I RETENTION$ 10,00C CEL28w0080313 /26/2013 /26/2014 E WORKERS COMPENSATION I WC STATU- '-70TH- AND EMPLOYERS'LIABILITY LIMITS I I FR ANY PROPRIETOR/PARTNER/EXECUTIVE aN[::] NIA E.L.EACH ACCIDENT E OFFICER/MEMBER EXCLUDED9 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE E If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Job: Linda Linderman, 4 Cedar Road, Andover, MA 01810 Ford Properties is named as additional insured with respects to general liability coverage. CERTIFICATE HOLDER CANCELLATION (� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANC ELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Rosemary Fulham/MGl "'""a'�~ ' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All ilghts reserved. INS025onmmmnt Tho arr1Rn namo anrt Inn^aro ronictorarl mnr,rc^f ar npil 101/4 —37314— 21 10 3/4 21 158 69 8 3/4 159 1/4 1631/4 712 7512 18 481/4 203/4 21 6512 7512 18 • T:- # 5 C xmc urz........ #7 8 #-26 .'r #6#6 3 44516 4 S a X. #22 #21 j . ..... #20 #1'9 17 i, #25 i #24 #23 a a :•:;•::•::•::•:•:•:•::•:•:•:•::•:•.•::::•:::•:•:•:•::•:•::•:•:•:•:•:•:t:.....•:•:•:•::•:•:•::•:•::•:•:t•:•:•:•:•:•:•:•:•:•::;•: e 67 2z 3s 12 a 41 12 11s 12 log �. as 12 �-i 41 �- 115 87 220 307 //1� Dennis and Nancy Pellegrino Title: Default //.�� �� ADVANCED CUSTOM CABINETS Approved 43 Christian Wa L� L.I F i n C a,,„o t r 7 S I n a o 1 9 7 2 y 5cale:1/4"=1' Date: 05/09/1 13 Prescott Road Brentwood NH 03833 North Andover State:MA MG.By' Sheet# Phone:603.772-6211 Fax:603-778.7604 Elejected(As Noted) Pellegrino WAYNE Sheet 25