HomeMy WebLinkAboutMiscellaneous - 457 BEAR HILL ROAD 4/30/2018 (2) / x:457 SEAR HILL ROAD
J 2101064.0-0111.0000.0
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AdIdress� �`�7 '� � , �Iri,� k2QTitle of File Page 9 of
Date f=ile Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action De artment
Board of Appeals - Board of Health - Planaiing Board - Conservation Commission - Building Department
North AndoverBoar&of Assessors Public Access Page 1 of 1
NORT#t North Andover Board of Assessors
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9SS"CHU roperty Record Card
Click Seal To Return Parcel ID :210/064.0-0111-0000.0 FY:201.3 Community:North Andover
SKETCH PHOTO
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Summary `
Residence
Detached Structure
Condo
457 BEAR HILL ROAD
Commercial
Location: 457 BEAR HILL ROAD
Owner Name: ELIZABETH H.DAIGLE 2004 TRUST
DAIGLE,ANTHONY&ELIZABETH TRUS
Owner Address: 457 BEAR HILL ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood:8-8 Land Area: 1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 3284 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 693,900 641,1.00
Building Value: 454,200 411,100
Land Value: 239,700 230,000
Market Land Value: 239,700
Chapter Land Value:
LATEST SALE
Sale Price: 100 Sale Date: 09/23/2009
Arms Length Sale A-NO-FAMILY Grantor: DAIGLE,ANTHONY
Code: &ELI
Cert Doc: Book: 11775 Page: 3
http://csc-ma.us/PROPAPP/display.do?linkld=2254488&town=NandoverPubAcc 10/22/2013
Residential Property Record Card
PARCEL ID:210/064.0-0111-0000.0 MAP:064.0 BLOCK:0111 LOT:0000.0 PARCEL ADDRESSA57 BEAR HILL ROAD FY:2013
PARCEL INFORMATION Use-Code: 101 Sale Price: 100 Book: 11775 Road Type: T Inspect Date: 05/13/2008
Tax Class: T Sale Date: 09/23/09 Page: 3 Rd Condition: P Meas Date: 02/06/2006
Owner: Tot Fin Area: 3284 Sale Type: P Cert/Doc: Traffic: M Entrance: X
DAIGLE,ANTHONY&ELIZABETH TRUS .
ELIZABETH H. DAIGLE TRUST Tot Land Area: 1.00 Sale Valid: A Water: Collect Id: SGC
ELIZABETH --
Address: Grantor: DAIGLE,ANTHONY&ELI Sewer: Inspect Reas: M
BEAR HILL ROAD
NORTH ANDOVER MA 01845 Exempt-B/L-/. / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
NO
RESIDENCE INFORMATION LAND INFORMATION
Style: CL Tot Rooms: 10 Main Fn Area: 2028 Attic: NBHD CODE: 8 NBHD CLASS: 8 ZONE: R1
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1256 Bsmt Area: 1832 Seg Type Code MetI od'_Sq-Ft' -Acres Influ-Y/N' Value Class
Roof: H Full Baths: 3 Add Fn Area: Fn Bsmt Area: 400 j 1 P 101 S 43560 1.000 ®' 239,693
Ext Wall: BV Half Baths: Unfin Area: Bsmt Grade: FA' VALUATION INFORMATION
_ --
Masonry Trim: Ext Bath Fix: 0 Tot Fin Area _.._: 3284 _ Current Total: 693,900 Bldg: 454,200 Land: 239,700 MktLnd: 239,700
Foundation: CN Bath Qual: T RCNLD: 454163
Kitch Qual: T Eff Yr Built:' 1992 Mkf Adj: Prior Total: 641,100 Bldg: 411,100 Land: 230,000 MktLnd: 230,000
Heat Type: HW Ext Kitchi: Year Built: 1985 Sound Value:
Fuel Type:` O Grade GV _ 'Cost Bldg:.-.. 4-54',26-0-
Fireplace'
54,200Fireplace1 Bsmt Gar Cap: Condition: IT G Att Str Val 1:
Central AC: Y Bsmt'Gar SF: Pct Complete: Att Str Val2:
Att Gar SF: 576%Good P/F/E/R: /100/100/91
Porch Tyne Porch Area Porch Grade Factor
W 630
SKETCH PHOTO
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18 630 Sq.R]I-fFJM
96 S �
576 Sq.R FUIFMIB 576 Sq.
24 1256 Sq.Ft �q 24 �II41�}I 7 a
24 24
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457 BEAR HILL ROAD
Parcel ID:210/064.0-0111-0000.0 as of 10/22/13 Page 1 of 1
? Date.. �....�...... . ..
NORTH
°!t�`` °•'"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
wr
SSACMUSE�
This certifies that . y �LCr!
........ ................................................. ...............................
r
has permission to perform .........PA./...���.f... .................
wiring in the building of........ ................... ...7''
at..............�.............. ....................., ................. ,North Andover,Mass.
/� Z.o.SZa
Fee..../. Lic.No.............. ...... ........... !
d ELECTRICAL INSPECTOR
Check # -6- 7406 '
7380
Commonwealth of Massachusetts
��a�fl=ficial U�sepOnl
Permit No. � a
Department of Fire Services
s1 Occupancy and Fee Checked
? ' BOARD OF FIRE PREVENTION REGULATIONS . Rev. 1/07
ri. (leave 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
(PLEA SE PRINT IN INK OR TYPE ALL INFORMATION) Date:_ /S-/ C)7
City or Town of: NORTH ANDOVER To the Inspector o Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) VS-7 Sear A,-// R D
Owner or Tenant "JR0 '� f- ( h Qui�4 irp Telephone No.
Owner's Address Saw-
Is
awee_Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building 5 i rl 1p �-��� ` `� 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: pock �� Cj V-\.
Completion of the following table may be waived by the Inspector of'Wires.
No.of Recessed Luminaires J(� No.of Ceil.-Susp.(Paddle)Fans No.o Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- F] o. o Emergency Lighting
rnd. rnd. Batter Units
No.of Receptacle Outlets 3® No.of Oil Burners FIRE ALARMS No.of Zones
No.of SwitchesNo.of Gas Burners No.of Detection and
1 S Initiating Devices
No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices
No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained
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: C Z �&1 Gitz
Attach additional detail if desired, or as required by the Inspector of Wires.
y Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: i rc.X-6, LIC. NO.: A-901S cZo
Licensee: q�L V- P C- Signature .L LIC. NO.: 3Sp� 5 C
(If applicable, enter "exent t"in the license number line.) Bus.Tel No.: 2 /-i-3�7
Address: I�A�`Q_.y s'nc� S� Alt.Tel. No.: (- y^7GQ%
*Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety "S" License: Lic.No.
OWNER'S INSURANCE WAIVER: 1 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 PERMIT FEE. $
Signature Telephone No.
t+w
The Commonwealth of Massachusetts
Department of Industrial Accidents
�+ Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: 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 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. + E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LF Plumbing repairs or additions
myself. [No workers' comp. c. 152, §l(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
l3.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and,job site
information.
Insurance Company Name:
Policy #or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sip-nature: Date:
Phone#:
Of use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �/ Date Received
Date Issued: to .
IMPORTANT: Applicant must complete all items on this-page
LOCATION
�._ _ - Print
PROPERTY. OWNER �` Z� �'�
Print 100IYear o,( Structure yes no,
MAP NO: �_�? ,PARCEL: 11-- . ZONING�DISTRICT �Histonc'Dlstnct yes.
Machi, NR Village" yes 'do-
TYPE
. -
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ?15ne family
El Addition 11 Two or more family 11 Industrial
e-Ateration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septe D Well Floodplain 01Netlands ❑ Watershed pistrict
_o Water/$,ewer _z_
DESCRIPTION OF WORK TO BE PERFORMED:
�Jv1a 4 O x s c��-� /-C,�
Identification Please Type or Print Clearly)
OWNER: Name: ''��� vv` ,C- Phone: 7K
Address:
r -
CONTRACTOR `Name: i^� e.S_ LL.
P>pt--vw
Address: S, -- ,._
Supervisor's Construction License C,-_ � ' 0_- Exp Date:
T T_
Home Improvement.License: . - a' �!-- - Exp. Date: _ - -
ARCHITECT/ENGINEER 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: $ � ® FEE: $
Check No.: �G/ �� Receipt No.: 7 O��—.
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature,of contract
o[„-- Co k. ;++oA F-11 Plnnc WnivAri FI ( Prtifipd Plot Plan ❑ Stamped Plans ❑
Building Department
The fol;owing is--a-fist of the required-forms to belilled out for the appropriate.permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o.. 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
❑ 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
❑ 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 cans.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
i
3
LocationG'/�.
No. — Date
• - TOWN OF NORTH ANDOVER
.} y Certificate of Occupancy $�
Building/Frame Permit Fee
Foundation Permit Fee $
M,
Other Permit Fee $
TOTAL $
A
Check
/ 019 Building Inspector
J
i
Plans Submitted'❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ {
.-TYPE_OF-SEWPRAGEDISPOSAL
Public Sewer ❑
Tanning/Massage/Body- Swimming Art ❑. . .. g Pools ❑
Well ❑ Tobacco.Sales
Food Packaging/Sales ❑
Private(septic tank, etc.. - Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED: DATE.APPR.OVED
PLANNING & DEVELOPMENT ❑ JDA
COMMENTS
CONSERVATION Reviewed on 3 Si nature
COMMENTS
i
HEALTH Reviewed on Signature
COMMENTS
i
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation C" s.:rvation Decision: Comments
Water& Sewer Connection/signature & Date
Driveway Permit �
DPW TOW;2 Engineer: Signature:
FIRE OE0_ARTM�=NT Temp Dumpster on site yes Located 3noOsgood Street
Located-at 124 Mair,Street -
Fire Departmerit signature/date
COMMENTS
i I
.. I
- I
i
-Dim-ension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.__
.Total land area; sq, ft.:
ELECTRICAL: Movement of Meter location, mast or service droprequires
Electrical Inspector yes No approval of
DANGER ZONE LITERATURE: Yes No
MGL Chapter-166.Section 21A=F and G min.$100-$1000.fine
NOTES and DATA— (For department use
40 ,
I,
lJ Notified for pickup - Date
M
Doc.Building Permit Revised 2010
r
Enter construction cost for fee cal - North Andover Fee Cakulatlon
Construction Cost
$ 27,05'58.00 m
$ - $ 324.70
Plumbing Fee $ 40.59
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 40.59
Total fees collected $ 505.87
457 Bear Hill Road
371-14 on 10/21/13
20x14 Screen Porch
NORTH
own of 1, Andover
0
No. 31 _ 14
: -
�! Za Q
O IANf h , ver, Mass, � z
COCHICNf WICK
A°RATEo ►f�',�.c5
s �
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .........��2..rY. ..... . ..s. ?`.................... .................... ...... ....................... BUILDING INSPECTOR
.�./� ^,.. .�� Foundation
has permission to erect .......................... buildings on . f/",7 ( ........................
� - Rough
tobe occupied as .......................I..�......T ...............................,........................................................... 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 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
.......Ic
.... ..-................................... 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.
SEE REVERSE SIDE
_7
✓le .�om>rino�.urea�i o�./�.aaoac�u�aer��•r
Office of Consumer Affairs&Business'Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:,-4120296 Type:
Expiration: 1 )42013 YP
_ , DBA
TESTA'BUILDING&REMOUELINO'{
JAMES TESTA
5 APPLETON STREET : _ I
N.ANDOVER, MA 01845
Undersecretary
Massachusetts -Department of Public Safety
o `
, `•� Board
I f Building Regulations and Standards
Construction Supen isor
License: CS-054718
JAMES M TESTA
5 APPLETON ST.:
N ANDOVER MA- 01845 �
r
k
Expiration
Commissioner 06/08/2014
r
39.4'
175
,
EXISTING
DWELLING
40.0'
N
85.4'
PROPOSED
24' X 24'
0 102.3' ADDITION
LOT 48A
t_ 239' \®+
PROPOSED ADDITION
CLIENT: ANTHONY &
ELIZABETH DANGLE
13� ;; PSP::�>•i;'�.:y �� �
LOCATION: 457 BEAR HILL ROAD \
DATE: 10/2/06 SCALE:1 0=50'
CHRISTIANSEN &SERG1PROFESSOM �'E
160 SUMMER Sr HAVERNILL,MA. 01830 IM 978-373-0310
02006 BY CNRf UMSEN & SEW INC.
DWG.N0.:06019004
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The Commonwealth of Massachusetts -
Department o,f Industrial Accidents
Office o fInvestigations
600 Washington Street
Boston,MA.02111
qu www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizationlfndividual): '7C.,s•,'
Ad&ess:_ A (JN lelitJ
ai gy s �7S —G�� — Zia 3
City/State/Zip: 1J. A44--e- /�►0 Phone#:
Are you an employer?Check the appropriate bog: Typo of project(required):
1.❑ I am a employer with 4. ❑ 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.+ �• E]Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g, Building addition
We are a corporation and its
workers'comp.insurance $• 0 W �
eq work p ul 10.]Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner.doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance .re uiredemployees.[No workers'
required.)� 1311 Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees Below is the,policy and job site
information.
Insurance Company Name:.
Policy#or Self-ins.Lic.M ExpirationDate:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL 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 cerfi under the pains andpenalties of perjury that the information provided above is true and correct.
Si afore: Date:
Phone#• "7 g— G1 ia'1
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/lAcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
•-• , •-• _ Phnna�f•
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 ofhire,
express or implied,oral or.written."
An employeY is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits 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'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)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 LL C or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permithicense 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 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 acid fax number:
The CoWmojawaafth ofM,9ssac??v:setts
Dapafteat offadusWal Accidents
Wee offavostigatims.
604 WasWugtoll Streit
Boston}MA 02111
TQL#617-727-4900 at 406 qx 1-877MASSA F,
Revised 5-26-05 Fay d 617-727-7749
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Building and Remodeling Start date
5 APPLETON STREET Finish date
NORTH ANDOVER , MA 01845 HIC Lic. 120296 Expires 11/19/13
(978) 682 2023 CSL Lic. CS 54718 Expires 6/8/14
Proposal
October 15 2013
Proposal
Proposal Submitted To:
Tony Daigle
457 Bear Hill Rd
North Andover,MA 01845
Job: Screen Porch H Rebuild portico
Obtain building permit
Complete removal of all demolition and construction materials
generated by Testa Building and Remodeling and its subcontractors.
PORTICO
Rebuild portico same size all PVC trim and posts all maintenance free. New columns
And new rubber roof. No railing on top portico to be 12 x 7 Square instead of rounded.
Price: $ 5,400
SCREEN PORCH
Frame a new pressure treated deck 20 x 14. Dig and pour new footing using big foot columns .
All new timber tech PVC decking . Tie the new roof into existing sun room roof matching all fascias
and soffits. 4 x 4 posts every 36 "to create a space for removable screen panels. Wire railing system
Installed where railings are need.. 4 x 14 deck that will tie the screen porch to the patio/driveway.
Roofing materials to match existing as close as possible. All exterior trim will be PVC .
Price $ 21,658
i
A finance charge of 11/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the
customer shall be responsible for all costs associated with collection,including reasonable attorney's fees.
I propose hereby to furnish material and labor complete in accordance with above specifications,
for the sum of:
$ $27,058 Twenty Seven Thousand Fifty Eight Dollars
One-third to start,one-third after rough inspection ,one-third upon completion.
Authorized signature c,-
I reserve the right to cancel this contract if not accepted in_30_days
Signature
Signature
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement.However,
homeowners may be excluded from certain rights if the contractor they choose is not properly registered as
prescribed by law.Homeowners who secure their own building permits are automatically excluded from all
Guaranty Fund provisions of the Home Improvement Contractor Law.The contractor is responsible for
completing the work as described,in a timely and workmanlike manner.Homeowners may be entitled to other
specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials.
In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an
implied warranty of merchantability and fitness for a particular purpose.An enumeration of other matters on
which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do
not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,
contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have
been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with
attachments is to be given to the owner and the other kept by the contractor.Any modification to the original
contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties
have received a fully executed copy of the contract,and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases
where the homeowner deems him/herself to be financially insecure.However,in instances where a contractor
deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be
placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from
said account would require the signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or
other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home
Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston, MA 02116
617-973-8787, 888-283-3757 or visit the OCABR website at httD://www.mass.gov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information
specifically about the contractor registration component of the Home Improvement Contractor Law,contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
http://db.state.ma.us/homeimprovement/licenseelist.as
This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include
standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should fust
obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may
obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787
or 1-888-283-3757 or on our website.
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.
MGL chapter 142A.)
Express Warranty-Is an express warranty being provided by the contractor?
B
No
11 1
Yes(all terms of the warranty must be attached to the contract)
Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any
third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all
subcontractors for materials and labor under this agreement.
Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this
document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following
cautions and notices carefully before signing this contract.
•Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear.
•Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home improvement contractors
and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor
registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757.
•Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask
to see a copy of a"proof of insurance'document.
•Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify
the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than
midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation
of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies of the contract must be completed and signed.One copy should go to homeowner.The other copy should be kept by the contractor.
IO I5 . (3 CM..10 /�
Homeowner' ! tune Contractor's Signature
Date Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as
an alternative to court action)if they have a dispute with a contractor.The same right is not automatically
afforded to a contractor,however.The contractor would have to resolve anydis dispute he/she
has with a
homeowner in court unless both parties agree to the optional clause provided below.This clause would give the
contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor
Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a
dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has
been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the
consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter
142A.
Homeowne gnature Contractor's Signature
I
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1-11/22/201
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR
OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE
BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE
INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN
BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU
CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF
THE TRANSACTION WILL BE CANCELED.
IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT
YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN
RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR
SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF
THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE
SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE
SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF
CANCELLATION,YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT
ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE
TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER
AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL
OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND
DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN
NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place
of Business] NOT LATER THAN MIDNIGHT OF to o (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: (6 ' 5'' 1 Buyer's Signature:
Date. f .
$ 9 �� a !
~O�T'',ti0 TOWN OF NORTH ANDOVER
OL
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PERMIT FOR PLUMBING
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SA US
This certifies thatvr�i
has permission to perform IL�e/�?�.�/r . . . . . . . . . . . . . .
plumbing in the buildings of . . . . . . . . . . . .
at. , . , Nort A dover, Mass.
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Fee. 0 Lic. No.. . ./014, . . . .
PLUMBING INSP OR
Check # 0 'h
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: 6 - 2 - 11 Permit#
Building Location: ys vb e Owners Name: Tb (n Y S % S /e
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:❑ Renovation:0 Replacement: ❑ Plans Submitted: Yes❑ No
FIXTURES
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Installing Company Name: {0/v r, IBCheck One Only Certificate#
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Address: • S '0 State:
❑Partnership
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Name of Licensed Plumber: / j 9 v )9v JS
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 have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Signature of Owner or Owner's Agent Owner El Agent E]
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 compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Title ®..Plumber Signature of Licensed Plumber
Citylfown E"Master
APPROVED OFFICE USE ONLY []Journeyman License Number:
Date.
I�
HOR1M
Of ..ao ,4'°
o? °` TOWN OF NORTH ANDOVER
-PERMIT FOR GAS INSTALLATION
i�,s3^CMUSE1SyR
This certifies that
has permission for gas installation
in the buildings of . ..f? .�p(-. !... . . . . . . . . . . . . . . . . .
at . .7. 7. L?stf L. . . . . . . . ., North ndover, Mass.
PFee.,, .: Lic. Nolr�ldZ? .G , . . . . . .
GAS INSPECTOR
Check#
7969
AA%ACMSE1'1 S LIN
7FMNI APPLICATON FOR PERt�'IlT TO DO GAS F1'I'TING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations �. 7 RP�� /Y J 1 1?D Permit#
i7 Amount$
Owner's Name
New Renovation ❑ Replacement Plans Submitted
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B A S E M ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4T I3 . FLOOR
5TH . FLOOR
6TH . FLOOR L"
7TH . FLOOR
8TH . FLOOR
a
(Print or typ ) n� - Chec ne: Certificate Installing Company
Name JJ-�� 10 4frs A e (S
Corp.
Address rl �itl�
O e/ Partner.
Business le ephone C) 7 —(0 77 Firm/Co.
Name of Licensed Plumber or Gas Fitter
[INSURANCE COVERAGE Check o
have a current liability Insurance p 'cy or it's substantial equivalent. Yes No you have checked�, please ' icate the type;coverage by checking the appropriate box.
ability insurance policyin 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
Mass. General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agentrl
i hereby certify that all of the details and information I have Submitted('or entered)in above application are true and accurate to the,
hest of m� knowledge and that all plumbinv work and installations performc;d[Index Permit Issued for this application will be in
compliance with all pertinent provisions of the)vlassachusctts, tayc Gas Code ane Chapter 14.2 of the General Laws.
By: L Signature of Licensed Plumber Or Gas Fittcr
Titl l� / Plumber
City/Town 0 Gas Fitter tcense i um er
tblaster
APPROVED('OFFICE USE ONLY) JOtlrneYman
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /f t Please Print Le ibl
Name (Business/Organization/Individual):/ T'►I7^P� �S
Address: 41w-rf //Wl
City/State/Zip: &liernn (,P--7_ 001 Phone #:
Areyi an employer? Check the appropriate box: Type of project(required):
1.LTJ/ l am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-ttme).* have hued 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 for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
-[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 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'
comp. insurance required.] 13.[:] Other S r 1
Any applicantthat checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must%submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce nder the pains penalties of perjury that the information provided above is true and correct.
Si nature: �/'✓� � Date: z'�/
Phone#: �f - 3(,06- k17
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Date.. �� Z- . ......
HORTIy
Of ,h
p TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
�,SSAC HUSESSh
C- �/ /
This certifies that . ././g/ne/:74. ./4;ee./,S. . . . . . . . . . . . . .
has permission for gas installatioU !�.�sri.f.Tr . . . . . . .
in the buildings of . . . ` ? Q. . . . . . . . . . . . . . . . . . . . . . . . . . `
at . . . . . . . . .. North Andover Mass.
Fee.a�,f..a!. Lic. No.�����. . . ��`'`i . .
GAS INSPECTOR
Check# �,$�L
8071
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:_}, AY) C} P )^ MA. Date: 7_ Permit#
Building Locati :_4, 1 2fy+h11' Ll Owners Name: �.
Type of O cupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
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SUB BSMT.
BASEMENT
151 FLOOR
-2w-FLOOR
3 FLOOR
4 FLOOR
5 FLOOR `
6TH FLOOR '
7 FLOOR
8 FLOOR
;hk O my Certificate#
Installing Company Name:
1 rporation
Address z6IL -6-1 I6�(1��l� ity/Town:tawelyx State: `—
❑Partnership
Business3 -7
Tel:��ya --0�7 -3 Fax:
-j ❑Firm/Company
Name of Licensed Plumber/Gas Fitter: n vl
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesNo❑
If you have checked Yes,please indica a type of coverage by checking the appropriate box below.
A liability insurance policy 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
Signature of Owner or Owner's Agent Owner ❑ Agent El
By checking this box❑;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 Knowle ge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent pr si of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By
❑ Plumber
Title Z Z9 /Z El Gas Fitter Sig atu of Lic nsed Plumber/Gas Fitter
El Master /'�
City/Town [:]journeymanLivens Number: �/
APPROVED OFFICE USE ONLY El LP Installer
I
54
The Commonwealth of Massachusetts
Department of industrial Accidents
Office ofInvestigation
600 Washington Street
Boston, MA 02III
www massgov/dia
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name(Business/Organization/Individual):
- Address: - - –– —
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1•❑ I am a employer with 4. ❑ I am a general contractor and Ir7. []
f project(required):
employees(full and/or-part-time).*' have hired the sub-contractors New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ Remodeling
ship and have no employees These sub-:Contractors have
working for me in any capacity. workers' comp,insurance. g' ❑Demolition
[No workers'comp.insurance 5. ❑ We are a corporation and its 9- ❑Building addition
3.❑ required.] officers have exercised their 10.El Electrical repairs or additions
I am a homeowner doing all work
right of exemption per M
myself [No workers P comp, c. 152,§I(4),and we have ne no .11.❑Plumbing repairs or additions.
insurance required.] t employees. [No workers' 12'❑Roof repairs
comp.insurance required.] 13.❑Other
A-ny aPPscant that checks box 41 roust also El out the section belor., . : e
T Homeowners who submit this affidavit indicating they are doing all work and then hit outside contractors must submit new affidavit indicatin such.
comp.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' olic g
P y information.
I aman employer that is providing workers'
information. compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers'compensation policy declaration page(showing
Fa' . . p g ( mg the policy number and expiration
Failure to secure coverage as re xp t<on date).
g required under Section 25A o
fine u to 1 50 of c. 152 can lead to the im osition o
P $ 0.00 and/or one-year im risonme P f criminal penalties of a
Y p nt as well
of u to$250 as civil penalties in the form of a ST
P .00 a da a ainst the violator. Be advised that a co OP WORK ORDER and a fine
Y g 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 andpenalties o e ' ,
P fP rjur� that the informationrovided above ove is tr
ue and correct:
Sienature-
Data:
Phone#:
[6.
cial use only. Do not write in this area, to be completed by city or town officid
or Town. Permit/License#
ng Authority(circle one):
ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
heract Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or-repair work on such dwelling house - —- —or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,'§25C(6)also states that"every state or local licensing*agency shall withhold the issuance or
renewal of a license orermit too operate a business or to construct buildings in the commonwealth for any
P P g
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 perimtt or hcensY is being requested,not thr Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a homeowner or citizen is obtaining a license or permit not related to any business.or commercialventure
(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 than you in advance for your cooperation and should you have any questions,
please do not-hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesfibations
600 Washington Street
Boston,IMA.02111
Tel. #617-72.7-4900 ext 406 or 1-8.77 MASSAFE
Fax#6.17-727-7749
Revised 5-26-05
viw.rnass._govfdia
Date.......�.'..�..�..'....�2-
NORT"
0� TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
VSs^CHU
This certifies that ..........t .r�.........JZ. . .....
has permission to perform ......... � ...kl. ... t? .................
wiring in the building of ........o
at... .......................... .North Andover Mass.
2-34777.
a OiL 4RICAL INSPEC OR
7**"*"*
t
Check
`t 0586
I
l ommoncuealth o� aa�achu�¢[ Official Use Only
c� Permit No. � -
-
Occupancy and Fee Checked
y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave 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 IN INK OR TYPE AWLNbRMATION Date: `/D — 1.2—
City or Town of: �� b U To the Inspector of Wires:
By this application the undersigned gives notifcd of his or her inten ion to performthe electrical work described below.
Location(Street&Number) 6'9
Owner or Tenant 0►/'//? D /f /7�fC�Lf� Telephone No.
Owner's Address StS1 m
Is this permit in conjunction with a building permit? Yes ❑ No [� (Check Appropriate Box)
Purpose of Building L)w 1=Z-L? "'? ('j— 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: t f jX I h 6— ' a Ap,)
Completion o the following table mav be waived by the Inspector of Wires.
k No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
rnd. rid. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.iTf
Initiating Devices
No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices
No.of Waste DisposersHeat Pump Number.. Tons KW...... No.of Self-Contained
Totals: Detection/Alertine Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water
No.of Devices or E uivalent
Heaters KW No.of No.of Data Wiring:
signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
I
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains an penalties of perjury,that the information on this application is true and complete..
FIRM NAME: ,4 LIC.NO.:
Licensee: /yjLr Signature LIC.NO.:
(Ifapplicable,enter "exempt"i the license n ber line.) Bus.Tel.No.•.5 dc�'— .t/ yg7J
Address: �: B N /✓UQ N �' v� d Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Deparfirient 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 ve this requirement.ent. I am the(check one ❑owner
❑owner s agent.
t.Owner/Agent
Signature
Telephone No. PERMIT FEE: $
P
s
� 27 � � ��
The Commonwealth of Massachusetts
Department of Industrial Accidents ----
- -- - --- - - - -- Office of Investigations -
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): ��
Address:
City/State/Zip: (/J- Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.� ployees(ftill
I a employer with 4. El am a general contractor and I 6. ❑New construction
and/or part-time).* 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. EJ Demolition
working for me in any capacity. workers' comp.insurance.
9. ❑ g Buildin addition
[No workers' comp.insurance 5. ElWe are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 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#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under 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.
Ido hereby certifyunder the pains and enalties of,eryury that the information provided above is true and correct.
Sign �w l
/� Date:
Phone#: D Y-- l 1V 7d D
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#:
"10-, 30 Date.... ..�..7. ....
� pOFT1�
"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
SSACMUS�
This certifies that ' f�
has permission to perform
wiring in the building of.... `
at. .7s ........ f ....... l ...�,North Andover,Maw..
,gyp
Fee..d..>............ Lic.No.1 X�: G
CTRICAL I SPECTOR
S 2
Check #3
l.onunonwra[pr ofcca�ael Official Use Only
S pa
.l. 1 41tment.o�.}trr lcea Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
ev. 1/07] leave 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
(PLEA SE PRINT IN INK ORTYPEALLINFORMATION) Date:
City or Town of: A,&, 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)
Owner'orTenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes 91 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
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the ollowIn table may be waived by the Ins ector of Wires.
No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans °•° Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimmin pool Above - o.o Emergency Lighting
g rnd. d. Battery Units
No.of Receptacle Outlets fo No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches ] No.of Cas Burners o.o Detection an
initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers eat Pump um er ons e.o elf ontained
Totals: I Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Secii0ty Systems:
x
o.o Water o.o o,o No.of Devices or Equivalent
Heaters KW Signs Ballasts No.
No.of or E 5uivalent
No. Hydromassage Bathtubs No.of Motors Total HP eleeommunications ti inn&:
No,of Devices or Equivalent
OTHER:
Attach additional detail ifdesired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be-requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Eb BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the Information on d' ppii ti is true and complete,
FIRM NAME: Dhv i D 1:L c C Tiei CAL Co"-rV*c fj L44. LIC.NO.:
Licensee: (7A V j t7 1$A(,6,n} Signature LIC.NO.: j {1 L,3
(If applicable,enter"exempt"in the license number line.) /)1 Bus.Tel.No.• `17 F -";F;)
Address: R7 i3c-LAVA't' Sr TiDRTI� ATivnvt=i2 11>+rt . Alt.Tel.No.:17Jh" 3'7 -5'737'
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic,No,
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does'rot 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 �i/ _
Signature Telephone No. PERMIT FEE: $ X�
�.' `-`L
a� 1 G�
.L
The Commonwealth of Massachuyetts
Deparbnent of Indus&W Accidents
Of,rice of Investigations
600 Washington Street
Boston,MA 02111.
www mass.gov/dia
WorkersCompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorAndividual):__DA*4 (D ELr CT IZ i C AL- Co N r R A c T I N G L t-C-
Address: 9-7 8E1-1q101QT- ST"
City/State/Zip: NORM AW v,Q ►4, OHS' Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.E� I am a employer with g 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. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity, employees and have workers'
9. F] Building addition
[No workers'comp.insurance comp.inst ranee.
Ceguired,] 5. ❑ We are a corporation and its MdAUectrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required]t c. 152,§1(4),and we have no 13.[] Other
employees.[No workers'
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ti mew affidavit indicating such.
{Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 4AN 0V1(Z ln
�mm cAH
Policy#or Self-ins.Lic.#: w 21J 5-0 9 O 1 -1 2 Expiration Date: 3
Job Site Address: ZJ1--7 Z� e / City/State/Zip: %Aeplll�- �
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 coverapte verification.
!do hereby certify un th airs dWallies ofper}ury that the information provided above is a and correct
Signa Date:
afore: �i /
_
Phone#: 7 g L262
Official use only. Do not write in this area,to be con;pkied 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#:
i
i
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: VolDate Received
Date Issued: "('t(
IMPORTANT:Applicant must complete all items on this page
LOCATION -7 'N34P . `o�, J
Print
PROPERTY OWNER e+ )Ct
Print �,
MAP NO: (o�( PARCEL: �) ZONING DISTRICT: Historic District yes /no
Machine Shop Village yes �nq
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 9-0-he family
❑Addition ❑Two or more family ❑ Industrial
PolIteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
�rSepfic q`Well, (]Floodplain ❑IWetl'andst . ` Df Water-s District,.
ON
ater/Sewer?
DESCRIPTION OF WORK TO BE PERFORMED:
Tzcv—,o RL
L,/A i t
C^ -ca S
(Identification Please'Type or Print Clearly)
OWNER: Naive: OA rc, I.e
Phone: ? (.S n
Address- (45-77 A .�
CONTRACTOR Name: S*',-A Phone:
Address: S P p e 7-C i o, S
Supervisor's Construction License: 5-L17/ $ Exp. Date: C, f
Home Improvement License: 10�®t �' Exp. Date:
ARCHITECT/ENGINEER 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.
I
Total Project Cost: $ 5'0( � ° FEE: $ �O
Check No.: 592 ' Receipt No.: a')(01 O�&
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature)of,�Agent/,Owner; _ Signaturetof,contractor
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed.Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan.Of Proposed Work
p With Sprinkler Plan And
Hydraulic Calculations (If Applicable
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New ConstructionSin le and Two F
( g amity)
Li Building Permit Application
Li Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
o 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 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: Doc.Building Permit Revised 2008mi
Location
No. Date
TOWN OF NORTH ANDOVER
10
9
}�e ; 1 Certificate of Occupancy $
CNus.� Building/Frame Permit Fee $ v
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
v
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools
Well ❑ Tobacco Sales ❑ Food Packaging/Sales D
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
f
DATE REJECTED DATE APPROVED
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
E
Conservation Decision: Comments
Water& Sewer C®ttl'6ect9®r6/Sis9nattcre& ®ate Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT --Temp Dumpster on site yes no
Located at 124 Main Street',
Fire Department signature/date
COMMENTS
I
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement 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.$100-$1000 fine
NOTES and DATA— For department use
Notified for pickup - Date -
Doc:.Building Permit Revised 2008mi
Date......... ............... ....
' NORTq
°!t"`°;•1"° TOWN OF NORTH ANDOVER
3? •`,� OL
p PERMIT FOR WIRING
�,SSACHUS�
A3This certifies that .....................�..3! ..../................... ................................
has permission to perform ......��EGG/? ii �1...... Cid/ .........
wiringin the building of......... ............... L.. ............................................
�i!S f- ///�G /�/ .............lr�orth Andover,Mass.
Fee.... ic.No..Y C.. ....................... f,........
......:......:.......
C; ELECTRICAL INSPECTOR
Check # 3�!_7ZZ 7
9190
' !umrnoniveak .1 X1ssacL"tb Official Use Only
_ dlJeParEmen�o��ire �ervicee Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS (Rev. 1/07) (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in acGo,dance with the Massachusetts Electrical Code(MEC);527MR 12.00
(PLEASE PRINT IN INK OR TYPE ALL 11INFORMATION) Date:— f Q/,50/6 9
City or Town of: d)oNI %J�/t✓ 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�;71, j tgP—
Owner or Tenant „ t ,e Telephone No.
Owner's Address
Is this permit in conjunction with a building permit': Yes ❑ No LAJ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service r.mps `�^!ts C:verhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
y 1 Location and Nature of Proposed Electrical Work:
Completion of illefollowing table may be tivaived by the/ns ector Of lVires.
x No. of Total
No. of Recessed Luminaires No. of Ceil.-Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No. of Hot Tubs Generators KVA
Above In- o. o merpency Lighting
No.of Luminaires Swimming Pool rnd. grnd. Battery Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
of
No. of Switches No. of Gas Burners No. In Detection and
InDetection
Devices
No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices
Heat Pum Number Tons K\V No. of Self-Contained
Disposers,No. of Waste P .... .
Totals: I Detect ion/Atert.tng Devices
No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No. of Dryers Heating Appliances KW Security Systems:*
Y No. of Devices or Equivalent
No. of Water No. of No. of Data Wiring:
Heaters KWSi ns Ballasts No. of Devices or Equivalent
Telecommunications Wirino•
No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent
OTHER: ���� ��Q 3�—
�Y(7 Allach od:i1ionn1 detail if desired, or as required bt•the Inspector of Hires.
Estimated Value of Electrical Work: � ' (When required by municipal policy.)
Work to Start:hsq P Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:)
/certify, under the pails and penalties of perjurr, that the informalion on this appliculion is trite mid complete.
FIRM NAME: /-,DT �50-ial' l _ L!C. NO.:
Licensee: ^n u )!� Signature �"'�""� <•1.�� I,IC. NO.: r2�
(If npplicnble, enter "exen p�the lid n ,t ��b ne. r J�� I 1 q Bua.Te:. No.:—
Address: // (� "" II ts, N GS/ AII. Tel. No.:
*Per M.G.L. c. 147, s. 57-61,securi,y work requires Department of Public Safety"S" License: L!c. No.SSC.0 6o/
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) El o\ ner ❑owner's -Lent.
Owner/Agent — — 1'L'2�11%'FEr: S -s'�
Sibnature Telephone No. _
i
z
Department of Public Safety
sOne Ashburton Place, Rm 1301
Boston, Ma 02108-1618
License: Certificate of Clearance
Number: SS CC 001975 Expires: 10/09/2011 Restricted To: 00 .
KENNY WONG
18 CLINTON DR
HOLLIS, NH 03049
Tr. no: 558.0
Keep,top for receipt and change of address notification.
'S-CA1 C, 40M-08/08-OBSLIFORMCA106212008
�u �omvnxon+uecr� o�,/ffaasa�auaetle---._.
_ DEPARTMENT OF URL!C SAFETY
Certificate of Clearance
ly
Number: SS CC 001975
Expires: 10/09/2011 Tr. no: 558.0
S-License: ADT SECURITY (o G Q
KENNY WONG
18 CLINTON DR
HOLLIS, NH 03049 DIG SAFE CALL CENTER: (888)344-7233 fi
C0l4WIcva-;:A LTH O (k'hSkC!IUS;7 I I = a
LECIANb
REGISTERED SYSTEM TECHNICIAN
15-lu_S 11115
KENNY Q 4dONG
22 FIELDSTONE DRIVE
BURLINGTON MA 01803-42-13 a
Ar
ORTH
ToVM of Andover
No. Y)o q '°
=:. -o dover, 1VMass.,
�
0�k COCHICMEWICK
ADRATED p`P�t-`y
BOARD OF HEALTH
Food/Kitchen
Septic System
.PERMIT T D
/- BUILDING INSPECTOR
THIS CERTIFIES THAT 4?..... ......................
........... .....��...... . .......................................................... Foundation
has permission to erect........................................ buildings on.... .........:................... Rough
to be occupied as....... .... .... ...... .o..d�� Chimney
.... ............................................................................. ..........
provided that the person accepting this permit 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
Final
�OD — PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTI STARTS ELECTRICAL INSPECTOR
Rough
...... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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 they Building Inspector. Burner
Street No.
SEE REVERSE SURE J1 Smoke Det.
i
The Commonwealth of Massachusetts
_ Department oflndustrialAccidents
Office of Investigations
600 Washington Street
ti Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information . Please P1rinf Legibly
Name(Business/Organization/Individual): "n. -e� d.e
Address:_ A P 1 �-04v 5 �'
City/State/Zip: ;U, A^-k--30,J4-r' MA
Phone#: q $— 6 a a o 3
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
ep
ployees(full and/or part-time).* have hired the sub-contractors
2, ain,a sole proprietor or partner- listed on the attached sheet. t 7• modeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL _ 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] employees.[No workers'
ME]Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating the are doin all work and then hire outside contractors u t ubmit e affidavit indicating such.
• g y gmss anw ffi avFtF g
# >
must attached a additional e
Contractors that check this box n ion 1 she t showing the name of the sub-contractors and their workers comp.policy information.
lam an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.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 maybe forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
I do hereby certify under the pains and penalt' afpeijury that the informationprovided above is true and correct.'
Si ature: G'"'v Date: 611111
Phone#: �7 -7 S
Official use only. Do not write in.this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or-on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation'affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)naine(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 cavy workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confinnation 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 ifyou 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 pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwalth of Massachusetts
Mparfeut 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
!;r
Office of ConsumerAffa�B 10/i�naaac�aauQe/�`
HOME IMPROVEMENT CONTRACTOReis g 0°
Registtationc^I,
Exp ration 120296
ZE
1 U19l2011
T �` Tr# 290924
YPe �; Ind� dual ->,
TESTA BUILDING8 �
JAMES TESTA
REMODELI ,G
_
5APPLETON STR
EiC�� f
ET `_
N.ANDOVE R'''` '
MA 01845
Undersecretary +
�i t�sucltu�ctts D pui tntcttt.o#'Public Saf'eti
Bo t�d of Bui,tie�3 R;uIati0iis`atid
Construction SuperVisor <Lic'ense
License: 'CS 54718
JAMES M TESTA
5 APPLETON ST
N ANDOVER., MA 01845
Expiration: 6/8/2012
('ununisviuncr Tr#.: 29825
TESTA
Building and Remodeling
5 APPLETON STREET
NORTH ANDOVER , MA 01845 HIC Lie. 120296 Expires 11/19/11
(978) 682 2023 CSL Lie. CS 54718 Expires 6/8112
Proposal
June 1, 2011
Proposal Submitted To:
Beth and Tony Daigle Home Phone: (978)258-7650
457 Bearhill Road
North Andover, MA 01845
Job: Remodel kitchen
Obtain building permit
Obtain structual plans
Complete removal of all demolition and construction materials
generated by Testa Building and Remodeling and its subcontractors.
DEMOLITION :
Remove all cabinets and counter tops. Total gut all the walls and the ceiling in the kitchen.
Remove the existing flooring down to the sub floor.
CONSTRUCTION:
Remove wall between kitchen and Dinning room and install beam between kitchen and sun
room. Remove window in kitchen and block up.
PLUMBING :
Remove a strip of heat in the kitchen and add a kick space heater.
Note : There is no allowances for plumbing fixtures for the kitchen.
A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity
is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees.
I propose hereby to furnish material and labor complete in accordance with above
specifications,for the sum of:
$32,329.00 Thirty Two Thousand Three Hundred and Twenty Nine Dollars
One-third to start, one-third after insulated , one-third upon completion.
Authorized signature— L
I reserve the right to cancel this contract not accepted in_30_days
Signatur -
Signature
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
ELECTRICAL :
Remove all old wiring in the kitchen area . Rewire kitchen to code. Supply and install
recessed lights. Supply and install under cabinet lights.
Note : There is no allowances for light fixture other than the one specified .
INSULATION :
Install R 19 insulation with a vapor barrier on all the exterior walls. Insulate the walls in the
bathroom for sound.
PLASTER :
Hang %" blue board on the ceilings and the walls. Skim coat plaster will be applied to all the
walls and ceiling in the kitchen .
CARPENTRY :
Install all the kitchen cabinets and molding as per the designers drawings. Install new trim in
the kitchen around the windows and doors to match the existing trim in the house. Installation of all
kitchen appliances.
TILE :
Install and grout tile for kitchen back splash .
Note : No allowance for tile and grout. Labor and adhesive only.
VENTING :
Pipe the exhaust blower for the stove. Will provide all duct work needed.
A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity
is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees.
I propose hereby to furnish material and labor complete in accordance with above
specifications,for the sum of:
$32,329.00 Thirty Two Thousand Three Hundred and Twenty Nine Dollars
One-third to start, one-third after insulated , one-third upon completion.
Authorized signature
I reserve the right to cancel this contract if not accepted in-30_days
Signature
Signature
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
CEC
COLLOPY ENGINEERING CONSULTANTS
FRANCIS H. COLLOPY
REG.PROFFESIONAL P.O.Box 1684
ENGINEER Seabrook,NH 03874
Tel:603 760-2273
Structural Engineering Services
May 9,2011
Mr James Testa
Contractor
5 Appleton St
North Andover,MA 01845
Dear Mr Testa:
I am writing in regards to the proposed renovation that you are planning for the Daigle residence at 457
Bear Hill Road in North Andover,MA. The enclosed beam designs shown on the attached Sheets D1 to
D3,are based on my recent site visit,and the span measurements that I made at the site.At the time of my
site visit,we discussed the desire of the Owners to enlarge an existing opening to the enclosed rear porch
by adding a new header beam over a 10 foot opening in the kitchen area. The enclosed design sheets
show options for the beam,both in steel,and in the use of engineered wood comprised of multiple lvls.
The beam is designed to properly support appropriate roof loads,the bedroom floor and attic loads above,
including a bearing wall between the second floor and the attic framing.
If you have any questions in this regard,please do not hesitate to call this Office,and we can discuss it
further.
Sincerely,
COLLOPY ENGINEERING
4?
FRANCIS H
X COLLOP
u 2017
Francis H.Collopy,P.E.
ONA%. Structural Engineer
Enclosure; Sheets D1-D3
cc:North Andover Building Inspector
JOB t--171&f 2�S 1AE!16 E
FRANCIS H. COLLOPY PE
Structural Engineer SHEET NO. D of 3
P.O. Box 1684 CALCULATED BY d4W:7 DATE
Seabrook, NH 03874
TEL: 603 760-2273 CHECKED BY DATE
SCALE ,J /-0"
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COLLOPY ENGINEERING, Design by Francis H.Collopy, P.E.
P.O. Box 1684, Seabrook NH Tel:603 760-2273
BeamChek v20081icensed to:Francis Collopy Reg#7121-1001
DAIGLE RESIDENCE Header Beam
B1 Prepared by:FHC Date:5/10/11
Selection W 8x 15 50 ksi Wide Flange Steel Lateral Support: Lu
Conditions Actual Size is 4 x 8-1/8 in.
Min Bearing Length R1=0.8 in. R2=0.8 in. (1.0)DL Defl= 0.06 in Recom Camber=0.09 in
Data Beam Span 10.0 ft Reaction 1 LL 4460# Reaction 2 LL 4460#
Beam Wt per ft 15.0# Reaction 1 TL 6370# Reaction 2 TL 6370#
Bm Wt Included 150# Maximum V 6370#
Max Moment 15925 # Max V(Reduced) N/A
TL Max Defl L/240 TL Actual Defl L/584
LL Max Defl L/360 LL Actual Defl L/834
Attributes Section(in 3) Shear(int) TL Defl(in) LL Defl
Actual 11.80 1.99 0.21 0.14
Critical 6.37 0.32 0.50 0.33
Status OK OK OK OK
Ratio 54% 16% 41% 43%
Fb(psi) Fv(psi) E(psi x mil)
Values Ref.Value Fy 50000 50000 29.0
Adjusted Values 30000 20000 29.0
Adiustments YP Factor, Lu 0.60 0.40
Loads Uniform LL:892 Uniform TL: 1259 =A
FRANCIS H.
(�• COLLOPY
2 172
4�
S�pNA1.E�
Uniform Load A
0
R1 =6370 R2=6370
SPAN=10 FT
Uniform and partial uniform loads are lbs per lineal ft.
a n1
IT : W 8 x r g441� 5a ��eP rA.&O
Bose Cascade Triple 1-3/4" x 9-1/2" VERSA-LAM® 2.0 3100 SP Floor Beam%F1303
BC CALC®3.0 Design Report-US 1 span No cantilevers 10112 slope Tuesday, May 10, 2011
Build 517
File Name: Daigle Residence
Job Name: Daigle Residence Description: FB03
Address: 457 Bear Hill Road Specifier:
City, State,Zip: North Andover, MA 01845 Designer: Francis Collopy, PE
Customer: Jim Testa builders Company: Collopy Engineering
Code reports: ESR-1040 Misc: For Jim Testa
3IT
f
10-00-00
B0,3-1/2" B1,3-1/2"
LL 1,360 lbs LL 1,360 lbs
DL 1,905 lbs DL 1.905 lbs
RLL 3,100 lbs RLL 3,100 lbs
Total Horizontal Product Length=10-00-00
Live Dead Snow Wind Roof Live Trib.
Load Summary
Tag Description Load Type Ref. Start End 100% 90% 1150/6 133% 125%
1 Header Beam over 10 foot o... Unf. Lin. (plf) L 00-00-00 10-00-00 155 620 n/a
2 Unf. Lin. (plf) L 00-00-00 10-00-00 272 132 n/a
3 Unf. Lin. (plf) L 00-00-00 10-00-00 0 80 n/a
Controls Summary Value %Allowable Duration Case Span Disclosure
Pos. Moment 14,488 ft-lbs 55.4% 125% 4 1 -Internal Completeness and accuracy of input must
End Shear 4,986 lbs 42.1% 125% 4 1 -Left be verified by anyone who would rely on
Total Load Defl. U362(0.316") 66.3% 55 1 output as evidence of suitability for
0.222" 69.7% 55 1 particular application.Output here based
Live Load Defl. U516
(0.222") on building code-accepted design
Max Defl. 0.316" 31.6% 55 1 properties and analysis methods.
Span/Depth 12.1 n/a 1 Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
%Allow %Allow building codes.To obtain Installation Guide
Bearing Supports Dim.(L x W) Value Support Member Material or ask questions,please call
BO Post 3-1/2"x 5-1/4" 6,365 lbs 11.5% 46.2% Versa-Lam 1.9 (800)232-0788 before installation.
B1 Post 3-1/2"x 5-1/4" 6,365 lbs 11.5% 46.2% Versa-Lam 1.9 BC CALC®,BC FRAMER®,AJSTOA,
ALLJOISTO,BC RIM BOARD-,BCI®,
Notes BOISE GLULAM-,SIMPLE FRAMING
Design meets Code minimum(U240)Total load deflection criteria. SYSTEM®,VERSA-LAM®,VERSA-RIM
Design meets Code minimum U360 Live load deflection criteria. PLUS®,VERSA-RIM®,
g ( ) VERSA-STRAND®,VERSA-STUD®are
Design meets arbitrary(1")Maximum load deflection criteria. trademarks of Boise Cascade Wood
Products L.L.C.
Connection Diagram
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M.
FRANCIS H.
• • /� �"G COLLOPY
> �y 2017
a minimum=2" c=5-1/2" I q
b minimum=2-1/2"d=24"
s:c ESV
Bolts are assumed to be Grade A307 or Grade 2 or higher. `10NA�
Member has no side loads.
Connectors are: 1/2 in. Staggered Through Bolt
Page 1 of 1
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/Datfi"oRT". TOWN OF NOROVER
PERMIT FOR PLUMBING
40
"K ,SSACMUS c� 1
This certifies that . . . . .G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform ... -f... . . .° . . . . . . . . . . . . . . .
plumbing in the buildings of . . — . . . . . . . . . . .
.at .`/� .�. . . .�.l� , North Andover, Mass.
Fee--3?? . . . . .Lic. No.- �! . . . . , e. . . . . . . . . . . . .
/ PLUM81t4INSPECTOR
Check #' `l C vv
7324
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) t I
NORTH ANDOVER,MASSACHUSETTS J 2_ 2
�// � � Date
Building Location �z��Y 6!n `I ( Owners Name Permit# 33
Amount
Type of Occupancy
New O/� Renovation Replacement 1:1 Plans Submitted Yes El No
FIXTURES
Ln x
W F H
F
a p
a
x w
a a
a E' d w
S[$BgVIC
in FIDHT
M FIO(R
�FIOQt
4M FIOCR
5IH FUM f
6TH FUM
7M FUM
SIH ROM
(Print or type) Check one: Certificate
Installing Company Name U - Corp.
Address ❑ Partner.'
r
Business Telephone []--Firm/Co.
Name of Licensed Plumber.
Insurance Coverage: Indicate the tyvit of insurance coverage by checking the appropriate box
Liability insurance policy Other type of indemnity El Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three ins 0
Signature Owner Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massac a Plu C d apter 142 of the General Laws.
Y
BY:
Signaumv o tcens um er
T�e of Plumbing License
Title 5� -? 4"--/City/Town tcense Numoer Master Journeyman
APPROVED(OFFICE USE ONLY L_J
I
Date. .--3:.�?'�'. ... .!....
HORTM
2 py. .a o 1.1'40 .1-11.1-110
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSIALLATION
y
S^C.HUSEtt
This certifies that . . . . Q!. . .. . .. . . .��.
has permission for gas installation -x?- -�-►� �.�. -ri . . . . .
` in the buildings of . . . � .- !. . . . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . .'.__,. . . . . . . . . ., North Andover, Mass.
Fee:-�;.-�. . Lic. No;T°��,9. . .� . . . . . . . . . . . .
(f GAS ISPECTOR
Check#
5936
MASSACHUSETTS UNIFORM APPUCATON FOR PERN Irf TO DO GAS FITTING
(Type or print) Date 3 ��
NORTH ANDOVER,MASSACHUSETTS
Building Locations L d S 7 /l< ( �-�'
Permit#
Amount$
Owner's Name
New Renovation Replacement Plans Submitted
a
w
z w a F o x
a F w a p o z p z
a zw x �, i a c
G zz a > w
cw7 H F Z x W
z y w C7 0 > w U y
w > w °� z a Q o 0 W a o x
u a >
SUB-BASEM ENT
BASEM ENT
1ST. FLOOR
2N D . FLOG R
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type Che k one: Certificate Installing Company
Name �G :`L f�
/�� � Corp.
e Address �/ G
Partner.
i
Business Teleptione D Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO
If you have checked ves,please i cate the type coverage by checking theappropriate box. D
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required ed b Chapter 142
of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent
I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perfor under ermit Issued for this application will be in
compliance with all pertinent provisions of the Massachy St e Gadpq an a r 142 of the General Laws.
By: Signature of Licensed Pluinber Or Gas Fitter
Title Plumber
City/Town Gas Fitter License Number
Master
APPROVED(OFFICE USE ONLY) Journeyman
TOWN OF NORTH ANDOVER NORTH
APPLICATION FOR PLAN EXAMINATION o`tt�Eo gtio
Permit NO: Date Received
� oqq
�9SSAC HUS��A�
Date Issued:
IMPORTANT: Applicant m complete all items on this page
U
LOCATION 45 -1
_ Print
PROPERTY OWNER 1 ).- t -
'
MAP NO.: (0`i PARCEL: PrintZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
,
❑New Building ❑One family
-15%Addition ❑Two or more family El Industrial
"OaAlteration No. of units:
❑ Repair, replacement , ElAssessory Bldg [I Commercial
❑ Demolition ,
LlMoving(relocation) ❑Other thers:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
I y -
Identification Please Type or Print Cleary �
` Phone- ZSR -en L e--r)
M
OWNER: Name:
Address: k� �,� `�.�1L- �"�'•� �"�-'
CONTRACTOR Name: `��...�� �^-�.Y`�- Phone: �3
Address: ky�
-
Supervisor's Construction License:
f?S 13 CA O� Exp. Date: J0 Il L`� , U
Home Improvement License: �� Exp. Date:_ 1
ARCHITECTHj)+61NffR S -w� SLS Name: Phone:—
Address: %A,Y2 kk, L,—J --.Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATE p COST BASED ON$125.00 PER S.F.
Total Project Cost :$ '���t�� FEE:$ [ ��
n���
Receipt No.:
Check No.:
Page W4
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)
1 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)
❑ 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 DEPARTMENT:BPFORM05
I
Page 4 of 4
Location -7-
No.
7-No. `r -4--06 Date -dam
N%90 TOWN OF NORTH ANDOVER
F p
i i #
Certificate of Occupancy $
#�'1s'••° ''<�'#
Building/Frame/Frame Permit Fee $
s�CHust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ f
Check #
19855
�builcifng Inspector
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools El
Well
❑ Tobacco Sales ❑ Food Packaging/Sales ❑
❑ Permanent Dumpster on Site ❑
Private(septic tank,etc. Electric Meter location to
project
NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund
Signature of Agerit/Owner Signature of contractor
Plans Submitted lans W�dved ❑ Certified Plot Plan
Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM {
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPME T
COMMENTS e�( �L�r jz�. r`A • c cn�/��e./ �pf /
a
e Z'4 D TE REJECTEDDATE APPROVE
CONSERVATION
COMMENTS i OO
DATE REJECTED DATE APPROVED
HEALTH F1F1
r
COMMENTS i
FIRE DEPARTMENT - Temp Dumpster on site yes ► •. t no
Fire Department signature/date
1 COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer connection/Si nature& Date
Drive wa Permit
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
`'
'r Dimension
Number of Stories:_Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.: p 0
NOTES and DATA—(For department use
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC.Jan.2006
Town o Andover
0 �.7..
No. p ;=,�..
C% AKE I dover, Mass., 2 ''S� 6
0 L
COCHICHEWICK
ORATEDPPS` 0)
BOARD OF HEALTH
Food/Kitchen
. PERMIT T D Septic System
•
BUILDING INSPECTOR
THISCERTIFIES THAT............ ................. ................................... ................................. Foundation
%wp 4 - 0 1
..................................... bu ngs on A ;&
...... Rough
has permission to erect... ... /0;�L
to beoccupled as. ...........a mod Chimney
......................................................................................................
provided that the person accepting this permit 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPEC'TOR .
UNLESS CONSTRU SRough
................................................................... Service
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET-HAVERHILL,MASSACHUSETTS 01830-6318 (978)373-0310 FAX:(978)372-3960
December 1, 2006
Mr.Lincoln Daley
North Andover Town Planner
1600 Osgood Street
North Andover, Ma.
Re: 457 Bear Hill Rd.
Dear Mr. Daley,
In respect to the above referenced property my firm has prepared a plan dated 10/2/06.
Please refer to said plan.
Portions of the lot as well as a portion of the existing dwelling lie within 400' of an
isolated wetland. Additionally,portions of the lot,portions of the existing dwelling and
the entire propped addition lie within the non-discharge area.No part of the locus lies
within the non-disturbance area.
Based on the MassGIS the isolated area does have a hydrologic connection to Lake
Cochichewick.
I hope that this is sufficient for the project to proceed. I can be reached at anytime if
additional information is required.
Re ards,
Christiansen ergi Inc.
Michael J. S gi PLS
RECEIVED
DEC 1 ,. 2006
NORTH ANDOVER
PLANNING DEPARTMENT
39.4'
1'5' �.
EXISTING
DWELLING
40.0'
85.4'
=. 1 / 1
PROPOSED
r` 24' X 24'
0 102.3' ADDITION
LOT .48A
t_ 239'
PROPOSED ADDITION
CUENT: ANTHONY &
ELIZABETH DAIGLE
LOCATION: 457 BEAR HILL ROAD qqF:" ,
,cam
a
DATE: 10/2/06 SCALE:1"=50' r
CHRISTIANSEN &SERGI `R
VEYONS
160 SUMMER ST. NAMML4MA. 01830 Th- 978-373-0310
2006 BY MRlST ANSEN & SERC! 1Nr-
DWG.N0.:06019004
i
tAORTH q
ti
,1<4ED /b
X 0. _ �° O
O L
C OCMIL WKM
�9SSAC HUsti���
PLANNING DEPARTMENT
Community Development Division
Tony Daigle
457 Bear Hill Road
North Andover, MA 01845
Date: November 6, 2006
Dear Mr. Daigle:
I am in receipt of your application for a building permit submitted to the building department to
construct a 24 x 24 addition. Due to the fact thatro
our to
y property rty is Gated within the North
Andover Watershed Protection District, I will need the following information from you to
determine whether or not your proposal will require a Watershed Special Permit from the
Planning Board prior to receipt of a building permit:
1. Q' Proof that your lot was created before or after 1994 (i.e. deed, recorded plan, etc.)
2. A Plot Plan depicting the following:
G� General Zone of the Watershed District;
C� Non-Discharge Zone of the Watershed District
C� Non-Disturbance Zone of the Watershed District;
@� Conservation Zone of the Watershed DistrictC;F urpf;.4.44
C►7-"*' The edge of all wetland resource areas, as confirmed by the Conservation
Commission through a Request for Determination.
3. If project is within the Non-Disturbance Buffer Zone, calculation of total gross
floor area or addition and existing dwelling/structure.
I have attached the applicable section(s) of the zoning by-law for your reference. For your
information I have included a sample plan, from another property, that includes all of the above
information. As soon as I have received this information, I will review your application as
quickly as possible and will contact you regarding whether or not you need to apply for a
watershed special permit.
Sincer ly,
Linco n Dale
Town Planner
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9535 Fax 918.688.9542 Web www.townofnorthandover.com
Kevin Mu hr • 169Boxford Sh"
And
• North Andover,MA 01846
• PH:9784=4336
Building Contractor • FAX.978-SW A7
!"Mal
Ta Tony 8,Beth Daigle
457 Bearhiil Road All HmV ilnpMw rnw t Conftac rs and Subou,liaclixs
North Andover, Ma. 01845 APXnC*—MPtftMMqWH1-byPMW2bWOfaWW
142A of the Proal yrs,must be MisbW tl wMr the
Camrrum OM of Mle=sd s.Inquirla abaft
and SWo Ruud be made to the Directs,Hwa
From Kevin Mu l�Cwh d Re®�m,Ore w Plow,
►y Rom Ro1301,Boston,MA 02108.(617-)-M
Date: 1Q1282Q0fi
.rola Addition/Donner/Bath renovation/Entry renovation
Dahl of plans: 10106
Arclidtank Steve Foster
LAKM M Same
Section 1-Work Schedule
Contractor will begirt the wo(k-N otdet ttae msta'suis heftm ft Usd day 4otiowV tttie sigmng d VM apee nu t,usim spedw here in
writing contractorwill begin work on or about 11115!06.
Barring Delay caused by circumstances beyond Cordectors control,the work will be completed by 5130/07.The owner hereby acknowledges
and agrees that the scheduling dates are approximate and that such delays that are riot avoidable by die Contractor shall no be considered as
violations of this agreenent.
Section 11-Warranty
The Contractor warrants that the work furnished hereunder shall be tee from defects m materials and worlmunship for a period of 1 year
following completion and shag CO!"with the requirements of this Ag whet-to"evet t etky deft�it an vaftlans*as watmks,W
damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job,
including cleanup,the Contractor shall,at his own e)pense,forthwith remedy,repair correct,replace,or cause to be remedied,repaired,or
replaced, such damage or such defect in materials or workmanship. The fbmgoing wsrrandes shall survive any inspection performed in
connection with the agreed-upon wok.
Section 111-Scope of Work
A. Kevin�ea_m� y Page z 01 o
a�ron�d�setg erase:�.�z
169 80AVd street
Wm Aroover,MA 01 W
PH:97868&5335
FAX 978688,V=
General
Building permit will be provided by contractor. No allowances have been made to obtain a variance,
conservation, of board d beab approvat W required by town. Plans to be provided by owner.
Demolition
Trees will be removed from side yard to provide space for addition.
Excavating
Excavation required to install full foundation for addition will be provided. Any additonai fill will be graded out
around etas and rear of addition.BadAiMft and rotl9hgradft
atilt be provided.No allowances have been made
for any landscaping,sprinkler repairs, or lawn repair/installation.
Foundation
Poured concrete foundation will be provided as shown on pians. Concrete cutltrng
will be psdom'ed to gain
access to new full basement area. Four inch thick poured concrete floor will be provided over crushed stone
base.
Building
All frame, roof,and siding materials will be provided as shown on plans/to match existing/to meet code. Floor
joists and roof rafters will be 2x10,walls will be 2x4.All sheathing will be fir plywood(3/4 on floors, 112 on walls,
5f8 on roofs} . Froa�t arxi side viall of addition will be brick. Existing brick to be matched as close as possible.
Some variation may occur due to age and availability. Roof shingles wwilll be provided to match existing. los&
water sheild will be installed at all roof edges. Rear wall of addtion will be sided with cedar clapboards, ( to
match existing)over Tyvek or equivalent Fifteen Anderson doublehung windows Wit be provided in addition as
shown on plans(twelve in great room, three in basement area) .Two Anderson doublehung windows, and one
awning window,will be provided in renovated second floor bath and new closet area.
Plumbing
Plumbing required to install new pefttal sunk in fust floor bath, taundry connections on second floor, and new
shower unit, and jacuzzi type tub on second floor will be provided, Owner to provide plumbing fixtures. Gas
piping required for zero clearance fireplace in addition will be provided.
Elscbicat
Electrical work required to wire addition , master closet , bath , and entry area to meet code will be provided.
Eight recessed lights have been included. Additional recessed lights can be added at a cost of$75 per light.
Bath fan light units will be provided. Phone, cable, and computer lines will be roughed in by electrician, to be
connected by their service provider at owners expense. Surface mounted ftxUms to be provided by owner
vanity lights, ceiling fans etc. ) .
Heating/Air Conditioning
A separate zone of forced hot water heating will be provided in addlon, of off existing boiler. Baseboard Will be
relocated as required in entry and bath areas. New master closet will have heating provided off of existing
second floor zone. No allowance has been made to replace/upgrade existing toiler.
Page 3 of 5
auasuldg :sctrac:aur
169 BoQord Sbea1
NcrM Andover MA 01845
PFI:9786885335
FAX 97&6&Wo=
Insulation
All added / renovated areas will be insulated to meet code. { R-13 in exterior walls, R-30 in c0ings, R-19 in
cellar ceiling). E
Plaster
All added/renovated areas will be blueboarded and skimcoat plastered.Walls will be smooth, ceilings to match
existing, closets will be textured.
interior TdratDoom
Pre-primed interior trim and doors will be supplied and installed to match existing. Doors / columns to be
provided as shown on plans.
Painting
All interior and exterior painting wifl be provided. One coat of primer, and two coats of finish will be provided .
Exterior to match existing, interior colors to be determined. No allowance has been made for any wallpapering.
Flooring
Carpets will be provided in new great room and closet areas . An allowance of$2600 has been included {
approximately$30 per yard installed) .
Tile floors will be provided in existing entry / first floor bath area, and second floor bath / laundry area. An
allowance of$1200 has been included for file materials(approximately$5 per square foot).
Waste Removal
All demolition/construction debris will be disposed of by contractor.
Items Not Included
There have been no allowances made for plumbing fixtures, vanities I countertops, closet organizers/shelving,
landscaping/lawn installation.
Mer Allowances
An allowance of$35oo has been included to supply and instaff gas fireplace, mantle, and surround.
i
buudm w t antwactar Page 5 of 5
169 8adad Sheet
NOM A„dwer,MA oleo
PH:978668{335
FAX'978£88-)000(
N--Price
—.. . ... ........
Section ScheClu�e .
We hereby propose to furnish material and labor—complete
in Accordance with above specifications for the sum of... ... ... ... ... ... ...................$ 153,000
Payment to be made as follows:
Percents eAtem Description Amount
1 Permit obtained $3000
2 Foundation complete $25,000
3 Roofing complete $35,000
4 Siding on dormer/ rear of addition /windows $25,0005 Brick installed $15,000
6 Rough plumbing /electric com lete $121000
7 Plastering-complete $12,000
8 Interior trim /paint complete
$10,000
9 Flooring installed $8000
10 Job 100% complete $8,000.00
Total 110 $153,000.00
"Noke Wapwrxftft"meVtp,wHnenta0ntraq gwt7lcsF�@feqaBadoNJ,pe N(9dNlnoedBpOek>ofmOf9fa[arleM�rd«tfatatalaor t
Pa t r eri>e wpotechar nr da� ,morder enter a1leix9se oWain deJnrtxy of speoN ordlgr rrHBefie16 and eQuipment,*Whiter 0 gem Ihetoml artquetM edl a
Contractor: Kevin Murphy
169 Boxford Street
W.AndonreR',MA 41845
Registration No: 101874
Section V-Acceptance
Acceptance of Proposai--i have head this document and accept the prices,specifications,and conditions stated. I
understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.
Payment wiR be made as dined above.
You the buyer may canei this transaction at any time prior to midnight on the third business day atter-the date of this
mmsacbm cancellation must be done in writing
DO OT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Signature Dade t U\ 3 t t g b
Signature Data
C BOARD OF.BUILDIN" REGULATIONS 1°
" License: CONSTRUCTION SUPERVISOR
f , Numbers C5 053099
y .Egtres '6E72- 20 Tr.no: 12810 t
.._ �'Res ri�
;KEVIN W MURPt�
r ' :169 BOXFORD`ST'',z
N
N ANDOVER; MA
Commissioner '
�i
_ r
✓lie Uornmoruu o�✓ Qatfu6rG
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR'
Registration:• 101874 .
Expiration: 6j29/2008
6170e: Individual
KEVIN MURPHY
Kevin Murphy
169 Boxford St
N:Andover,MA 01845
Deputy Administrator
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
las' i 600 Washington Street
Et Boston, MA 02111
www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant information Please Print Legibly
Name tttusin�hsJt)muniratlittttllndividu:tl):_���b,,,� �ti�.,t, }Lt y R u !�___
Address:_ l�� v S � �
City/State/Zip: �,I, � ) Phone #: °Z'�� � 5-3 �
Are you an employer?Check the appropriate box: Type of project(requires!):
1.❑ 1 am a employer with 4. El ata a general contractor and
* have hired the sub-contractors 6. ❑ New construction
employees(full and/or part-time).
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. . ?• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y � tY� 9.-Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10-❑ Electrical repairs or additions
3.❑ t am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
thyself.[No workers' comp. c. 152,§1(4),and we have no 12.[] Roof repairs
insurance required.] employees. [No workers'
13.C] Other________,
comp.insurance required.] -----
*Any:applicant that checks box 01 must also tilt out the section below showing their workers'compensation policy infortraation.
'Flomeowaters who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new atiidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,lint icy information.
I am apt employer that is pros4ding workers'compensadon insurance for my eniployees. Below is the policy and job site
fttfot'Mlltlit'11t. /� I
y �,_ S �-v.�_
insurance Company Name:-L
Policy#or Self-ins. Lic. #:� w� .__�� Expiration Date:__.J .�_ I
Job Site Address: �"-a L`-��` City/State/Zip:_'V�- h ...,_ r , Q
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 NIGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to S 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do here ce ' u e 'ns amyl enact' per}my that the information provided above is true and c•orrecl.
Sjnah�e'
i
Phone It �?✓ —_... _ __ T—_— __
0J]ICial use only. Do not write in this area,to be comipleted by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health t. Building Department 3.City/Town Clerk -f. Electrical Inspector 5. Plumbing inspector
b.Other
Contact Person: Phone#:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGI, c 40 S 54, a condition of Building Permit
at: athat the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by NIGL
. 11, S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
(.Location ol Facility)
Signat e o e it Applicant
Fire Department Sign off:
Dumpster Permit
Date
FROM :M.P. Roberts Insurance FkX N0. :19786833147 Jul. 16 2006 11:10W P1
CERTIFICATE OF LIABILITY INSURANCE
PkO0u0eR 07/1912006
THIS CERTIFICATE is 1SSM 0.6 A MVAt1gN tYf NifOATM?IflN
Ili.8.ROURTS INSUPANCE AWNCT INC. oNLr OM CONFERS MO aaawrrs WON THIS ceaTFTCATE
1060 08gOOD STAg$T HOLDW THIS C�rWICA" OOT NOIr AIM, "TeND OR
ALTER THE CCWRAOE AFfORDED BY Til! AOLlCli4 YELOlt
NORTH ANDOM MA 01845
7 — 7 M SUMRS AfMORO Ml;COVMRAM NAILS
"` ° ItE1121� Mp'RP'!i'Y BUILDING & RSMODBLING 71"A
pepll naA _PROMEN
11.
169 BOXFORD STRa6T
NORTH ANDOV$R, NA 01845 by
- —
NC
—�COVERAAES
rHE POLMS OF WSMAMCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED MANED ABOVE POR THE POL1cY Peptw AVrATeQ NVO?wrwTAkaNa +
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MAY PBATAIN.THE 018~E AFFORDED BY THE POLICIES DEdORION HEREIN 16 BUBJECT TO ALL THE TEAMS.EXCLUB"S M7o4OH mews or sucH
POLICIES.AGG*EGATE LIMIT!SHOWN MAY HAVE BelN REDUCEDBY PND UAWt
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Town of North Andover t NORTH -1OFFICE OF 3?0,,"•°
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street ' `
North Andover,Massachusetts 01845 9SSACHuS��
(508) 688-9533
May 31, 1996
John A. Gallo
9 Harwood Street
Beverly, MA 01915
Re: Electrical Permit Application- 457 Bear Hill Road
Dear Mr. Gallo:
We are returning herewith your Application form and check#0711 for electrical
work to be performed at 457 Bear Hill Road. Kindly fill out all of the pertinent
information including your Electrical contractor's License number and resubmit to this
office.
Upon receipt of this information, we will then be able to process your application.
Thank you for your immediate attention to this matter.
Very truly yours,
Yom- 9446t.-
James
DeCola,
Electrical Inspector
JD:gb
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
D.Robert Nicetta Michael Howard Sandra Stern Kathleen Bradley Colwell
D0Al10 0!' !'tl'lC *RM/L'N1lUN RSLGULRTIONS bZ7 CMR 12.00 1/90 ll..w bl...t)
Ap.p icAnoN FOR PERMIT TO PERFORM ELEGMICAL WORK
:!
All..-.tea...S.. ,..rt.. J 1, --d-44>H.h tl., M•..,w�A waraa lila s.rls al G:n1v. at? GMn 72.00
(10LEA-LSE PRIN7r IH TNK 012 %IPE ATT. TNMAnWA1'TAW) T1wra J,
City or Torn of Q� (2A To the Znsptetor of Wirest
The undcrsirned applies for ai
LoC1LiOn (9erra•r. /� ?hml,wr) permit to perform the eleatrie.rl work dnscci�od �nlov.
_!
�? l- 1 /CCy.4
0%:ncr or. Tenant F' / Le --.L�►=F'
Owner's'1,ddrass
IS this parnie in conjunction with a building patcmit. Yc.a ❑" ?lo (Cts&ck /+pproyrtrcr 3�)
Arrpoae "of Building Utility Authorization N0.
ExkAptng Service Acp,s / 1_4—volts Overhead ❑ Undgrd❑ No. of Haters
Nev Service Abps�f 7 volts Overhead ❑ Undgrd❑ No. of Heters^
Number of recdcrs and Anpacity,
-Location and Nature of Proposed Elescrical Wolk ScJ S ems. c� 0, Cti
No. of Lighting Outlets No. of Hot Tubs No. of Teansformers ota
KVA
No. of Lighting Fixtures uitrroif►g Pool Above 16rrr--11
Srnd. grno-. Mnarators KVA
No. of Receptacle Outlets No. o Oil BurrAW No. of Emergency Lighting
Battery Unita "
No. of Switch Outlets. No. of Cas Burners FIRE ALARMS No. of Zones
No. of Ranges Total 'No. of Detection and —
No. of AZy�on¢. tons Initiating Devices
No. of Disposals No. of y}��at Total Total
APum s Tons )cq No. of Sounding Devices
No. of Dish%ashersSpaecl�rea,Keating KW No. of Sel Contained
Detection Sounding Devices
No. of Dryers Beating Devices KW Local[DMunicipalNo , Ocher
Connection❑
No. of dater Heatkrs KW Si�nof E o. o is Nirinolta&*
No. Hydro Massage Tuts No. of Motors Total HP
OTHER:
MAY 3 0 -
INSURANCE COVERAGE1 Pursuant to the requirements of Massachusetts Central Laws
I have a current LiabiljC Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES❑ NO [] I have submitted valid proof of same to this office. YES❑ NO []
-If you have Che ed YES, please .indicate the type of coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify) —C
C
Estiaulted Value of Electrical Work S , G r xpirat on ace
Work to Start^ 5� — — Inspection Data Requested: RoughFinA 4�2? l
- . :Signed under the penalties of perjury:
LIC, NO.
-Licensee
Signature LIC. NO.�_
Address LIIC)C� ,v �c Bus. Tcl. No.
l Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I
am aware that the Licensco docs not have the insurance nee covers c or es u
1 equivalent as required by Massachusetts G g s
application Waives thio u requirement. General
Laws and that my signature on this permit
req i Owner Agent Plcasc check S � e one)
Stv.nature of Owrlr.r or ARenc Telephone No. PERMIT FEE S
-------_---------.....
JOHN A. OR MARY E. GALLO Nature,
9 HARWOOD ST. to be commanded,must be obeyed.
BEVERLY, MA 01915
"9 C 53a21412113�
Pay to the
Order of Oc ✓ Q/�
BEVERLY"CO-OPERATIVE.BANK.
;'BEVERLY,.wssACHUSETTS 01915•
Olin
y 11-137"2145 : ± 0530098S.6�i� '
• i
• _ I
I
:
i
Address , tF7� .1�� fJ�� G. �cD Title of File Page of
Date File Open: Date File closed:T
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and noGtes —
action Document/ document/
Num. Action Department
l
I
,
Board of Appeals - Board of Health - Pla'n ng Board - Conservatilon Commission - Building Department
FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: _);;n ; al and L nri Mc-,C onaahv Phone508 -975-7224
t•1
LOCATION: Assessor's Map Number 64 Parcel 81
Subdivision Bear Hill Lot(s) #77
Street /gear. Hil& Road
St. Number 4-7 Z
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved 9a
Conservation Administrator Date Rejected
Comments �hB•5�,cm � j� Jj�. j(O
I
Date Approved
ZTnLP lannerE Date Rejected
Comments
Date Approved
Health Agent Date Rejected
Comments
Public Works - sewer/water connections- � -7/7/C �N-
.►�;Q 7 '1 qL•
- driveway permit
.�d .
Fire Department
Received by Building Inspector Date