HomeMy WebLinkAboutMiscellaneous - 46 SUTTON PLACE 4/30/2018 46 SUTTON PLACE
210/060.0-0112-0000.0
a Date... ... .1 :.. .` ,,
f NOR1M
3:;•';�``°;°�"�O� TOWN OF NORTH ANDOVER
` p PERMIT FOR WIRING
SACHUS�
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This certifies that ......... ...................... �. . .............
has permission to perform ............................ ....`.................
wiring in the building of A-11 f a 4 .... ..-':..,
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dovev; asks.
........ Lic.N6: D.. �,/. ..........f...`... ra,......................
f_ 1 ELEcmi&C �rNSPECTOR
Check #
` 0576
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in 1v aL.c.F43,§3L.
Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed.by the.Inspector-of_Wires abandoned.and-invalidif he—. --
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entitystated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
Rule 8—Permit/Date Closed:,/—/ Note:Reapply for new per
❑Permit Extension Act—PermitMate Closed:
4
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4 _. _ ( omnwnwealth o` aaeace ---- Official Use Only
_eLJepa�tmento�..tire_�ervieee_ � -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 accordance with the Massachusetts Electrical Code(ME ),527 C 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: J / 7 /
City or Town of: 0Or-f-� Qne- L/- ./Z To the Inspector ofWires:
By this application the undersigned gives notice of his or her i tention to perform the electrical work described below.
Location(Street&Number) L16 &J-110h S.
Owner or Tenant / ; // Cot)-] PQ,S' h o r4— Telephone No.
Owner's Address 'SG ry\jp—_
Is this permit in conjunction with a building permit? Yes ❑X No ❑ (Check Appropriate Box)
Purpose of Building SXY,. M -/ 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:! Rc) t l, 4�OUr-A
Completion ofthe,following table may be waived by the Inspector of Wires.
d No.of Recessed Luminaires Z No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators K-VA
,. No.of Luminaires Swimming Pool Above ❑ In- 11o.o mergency ig ing
rnd. rnd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
of Detection and
No.of Switches �� No.of Gas Burners No. Initiating Devices
No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices
No.of Waste Disposers Heat Pump 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 E uivalent
No.of WaterNo.KW No.of No.of Data Wiring:
Signs Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
j OTHER:
i dAttach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: k !50010— (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
p ! 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: Q�CCC'C' `QCtS.L LIC.NO.: zosd,o
Licensee: R"C,t.C_ i��,C C ru Signature LIC.NO.• 390)--�.
(If applicable,e�{te xempt"i the license a ber line.) Bus.Tel.No. a3 1377
Address: _I 1 ( S SCV�l�S Q[�Cxo Alt.Tel.No.: 1.14- 7G0)
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required b law.
q y By my signature below,I hereby waive this
requirement. I am the(checkone
F1 owner ❑owner's agent.Owner/Agent
Signature
Telephone No. PERMIT FEE. $ f
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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): �`1 LC (TJA E: C'�J
Address:
City/State/Zip: ScosuC, fr\o- 0 Phone
Ar ou an employer?Check the appropriate box: Type of project(required):
1.QIam,a employer with - 4. ❑ I am a'general contractor and I 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.# 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. worker's' 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.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,'§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' . . 13.❑Other
comp: insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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: CQ M (C-e— V VAS
Policy#or Self-ins.Life,#: Expiration Date:
Job Site Address: �U�l�CJ� + C(�O City/State/Zip:c� •�J`CJ l�
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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c n and penalties of perjury that the information provided above is true and correct.
Si nature: Date: 1
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CONTROL# H 0 2 6 8 5 3
IMPORTANT
`DOINMONYVEALTH 0 MASSAGFiIi l$
If this license is lost or destroyed, notify your Board at the: _ �>
Division of Professional.Licensure, 1000 Washington St., • • • ••. • --
Suite 710,Boston,MA 02118-6100. " ' •
If our name or address shown is changed, notify your board i4S A REG JOURNEYMAN ELECTRICIAN•
Y ISSUESZHE ABOVE L�CENSE TO
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number. s '� ,
This license is subject to the provisions of the General Laws RICHARDfC pICARDI JR
as amended.It is a personal privilege,and must not be loaned f5 .
or assigned to any other person. Keep this license on your 14 GREYSTONE
person or posted as required by law. }v.
WARNING THIS DOCUMENT HAS
FNHAN a RnFF-A—rRr Pfi 'SAiJGUS '' 'MA 'r01906 .211"6
X39029 E
07/31/13 832195E "
C®IIMO1.
N1VEALTH OF IUI�gSSACFTUSETI°S w",a
• '•
REGISTERED MASTER ELECTRICIAN fl
ISSUES THE ABOVE LICENSE TO
RICHARD PICARDI JR
14 GREYSTONE .RD.
CLt
t SAUGUS �.��
-. '— 'NA 0.1906"21:.-1,6.
CONTROL# H026854 I 2os2o A
07/31/13 832 `
IMPORTANT I �19,6If this license is lost or destroyed,noti ___j Division of Professional Licensure, 1000y WaBh ngtoat n the _ J
Suite 710,Boston,MA 02118-6100. St'
If your name or address shown is changed, notify your board.
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
as amended. It is a personal privilege,and must not be loaned
or assigned to any other person. Keep this license on your
person or posted as required by law.
WARNING T)JIS DOCUMENT HAS
- —_. INFiA�ClrD SEGUFiITX�EAT(�BES__---- . i
,'i LI
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured: William & Gail Compagnone
Property Address: 46 Sutton Place
Policy Number: HP1828248
Date/Cause of Loss: 6/6/2014, Sewerage Back-Up
File or Claim Number: 29734-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
Signat r and Date /I
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
9275 Date. ..
NORTH
°;<. •o TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
'SSACMUSf`
This certifies that ���!?!'. . .4u/1�*e/^. . . . . . . . . . . .
has permission to perform . . � �. , 014 0l��. . . . . . . . . . . . . . . .
plumbing in the buildings of . . . hang.. . . . . . . . . . . . . . .
at. p1s4e . . . . . . . / . . NNort Andover, Mass.
Eee.7. Lic. No..4?03.5!I`' . . . . . . . .
1" PLUMBING INSPECTOR
Check # Z�
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY <_ �����. MA DATE �4-*' PERMITIt
JOBSITE ADDRESS 4 6. $ I OWNER'S NAME1/3, ( f6f 9 e
OWNER ADDRESS TEL�7*.*,6X/fjj'?jFAX I
TYPE OR OCCUPANCY TYPE COMMER IAL EDUCATIONAL .. RESIDENTIAL
PRINT
CLEARLY NEW:(..� RENOVATION:I REPLACEMENT:I r� PLANS SUBMITTED: YES[j NO]-]
FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 ti 9 10 1 11 12 13 1 14
BATHTUB -
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM a i . ._.__
DEDICATED GAS/OIL/SAND .
SAND SYSTEM .- I i ' 19 } __ ,.i p I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
! l
DEDICATED WATER RECYCLE SYSTEM I f .. ;i } I'
DISHWASHER I I
DRINKING FOUNTAIN ! ! };._. i . ._i !
FOOD DISPOSER I'_ f. 1
FLOOR/AREADRAIN } I 1
INTERCEPTORINTERIOR 1 V 1 i I
KITCHEN SINK I
LAVATORY ] I f # } € i #
ROOF DRAIN
SHOWER STALL i —f , '✓'
SERVICE/MOP SINK
TOILET
URINAL I 1 _ ! 1 l P # E
WASHING MACHINE CONNECTION _ l
WATER HEATER ALL TYPES,
WATER PIPING
OTH
Ir
_.
I
INSURANCE COVERAGE:
I have a current l abilit insurance policy or its substantial equivalent which sleets the requirements of MGL Ch.142. YES[L,�,/NO [ ¢
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IV OTHER TYPE OF INDEMNITY BOND LI
OWNER'S INSURANCE:WAIVER:1 6
ant aware that the licensee.does not have the'insurance coverage required by Chapter'142 of the
Massachusetts General Laws,and that 1ny signature on this permit application waives this requirement:
_ CHECKI}NEONLY: OWNER .I AGENT [ .�
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have subimilled 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 c Itarfce vaul all P in ro 'ston of the '
Massachusetts State Plumbing Code and Chapter 142 of Hie General Laws.
PLUMBER'S NAME jr(o j1�rd 1 l/ I LICENSE It 10763 U Yi SIGNATURE
MPU JPIvr CORPORATION1 j#lj ;PARTNERSHIPI !01' �LLC J I11�
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COMPANY NAMEI ADDRESS " y(a ��G� i
m1c�1 X51 14 1`� A � P
CITY 'LC(�$ (oW f STATEIN ff ZIP a DP TEL
FAX - _ CELLIG613 N 13 All
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ROUGH PLYING INSPECTION NOTES BELOW FOR 0M- CE USE,ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICAMOW SMVES AS THE PERMIT Q. 7
FEE: $ PERMIT 9
PLAN grg4VEEW NOTES
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)Policy Information(ifnecessaty)and tuidef"Job SireLAddress"the applicant'shouldwrim"all locaiionsIn . . (ciwor 1
(bairn)-"'A Cgpy afthe O ffidatitthathas been officially stamped or marked tip the city or toitn may be-provided to[lie '
aliplicant asproof fhafa ttat'td lfttdavitis oti fi[e forfit[ureperutits or Licenses. 4•tiew.6f idavit mustbe filled ottt each
year.tl'hema hone as mer or citizen is dbtaining.a license oiperniit not related to anybusiucss orcomniercial ti'entute F
e.a dog license ortieem k to burn leaves etc.)said person is NOT rqukcd to cohtplete this nffdmit_
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Ttte I)eparfEuttt'sa(ldr�ss,telephoneand fax ntEntTiet:
The 0.onitrttz 1-t ' ltl>q l Pts r£}tf�setts -
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-=
01 4e CE Permit No.
i3epartment of Public i*afetq Occupancy& Fee Checked
3/90 (leave blank)
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BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 C
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 2- 2-1 -' /
(M* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a�permit to perform the electrical work described below.
Location (Street & Number) i `SVrL all
�' l a C
Owner or Tenant (sir 11 !G .(44 C W f ll6,-4 1 -7
Owner's Address _sa 610
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building ,l� C) Cf i 77C� b1 Utility Authorization No.
Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity /
Location and Nature of Proposed Electrical Work (.c> (r!2
No. of Transformers Total
No. of Lighting Outlets � N . of Hot Tubs KVA
No. of Lighting Fixtures 3 I Swimming Pool Above In
g grnd. ❑ grnd. ❑ I Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets I No. of Oil Burners ( Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
No. of Air Cond. Total No. of Detection and
No. of Ranges I tons Initiating Devices
No. of Disposals Dis No.of Heat Total Total
p Pumps Tons KW No. of Sounding Devices
No. of Self Contained
No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices
Municipal
No. of Dryers Heating Devices KW Local ❑Other
❑ Connection
No. of No. of Low Voltage
No. of Water Heaters KW I Signs Ballasts Wiring
No. Hydro Massage Tubs I No. of Motors Total HP
1 OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES NO _ 1
have submitted valid proof of same to the Office. YES = NO —_ If you have checked YES. please indicate the type of coverage by
checking the a p priate box.
INSURANCE BOND OTHER — (Please Specify)
//'' (Expiration Date)
Estimated Value of Electrical Work
�S wOD
Work to Start 2-1'� ✓ Inspection Date Requested: Rough Final
Signed under the P altiestot perj ry:
FIRM NAM Vv LIC. NO.
Licensee Signature LIC. NO.
'_2 S49Bus. Tel. No.
Address Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Age t
(Please check one)
Telephone No. PERMIT FEE 5 C/
(Signature of Owner or Agent) x•5565
�..."�i,..,.�,,• •`r�S:,J-�'.�..,;y,-�- '•'�.�.,.;.,,p1.,++ Ya .. ,k.+..o�. -�r ..-a it � �'T r' a"ivd...y �
Date.
4 3 G ............................. W
920
�c
HORT1,
TOWN OF NORTH ANDOVER {
p PERMIT FOR WIRING
SAc MUSft
This certifies that .......r:.... f...... ..:...�� `...�...:.........�...�.. .
............
,t :n
has permission to perform ........ .'..G....t ...... r.e!s'...:.?'%.✓..1 t.................
L
wiring in the building of...... .r!.r>.`.A':.'..f�K�.E: .!........................................ c.
r
at............ ........ !. 1'R' ''!........ ..... ,North Andover,Mass.
.. ..... Lic.No/=/-`.' 1 :............................................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File
BUILDING-PERMIT F NORry
f TOWN OF NORTH ANDOVER O "LED
.r h6
APPLICATION FOR PLAN EXAMINATION �-
Permit NO: D
ate Received q��-'•-•-•.
Arm
Date Issued: SSgC US
F� y,f IMPORTANT:Applicant must complete items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building. One family
Addition Two or more family Industrial
terati No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF�ORK TO BE PREFORMED: �,,d,u _�cJ-`���'��'•f!��{�r; �'
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OWNER: Name:_ ��t [,, �� �, Phone
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ARCHITECT/ENG INEER
_ f��� Phone:
Address:
Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PFR S.F.
Total.Project Cost: $
/06 ( � f
Check No.: Receipt No.: p�
NOTE: Felsons contracting with unregistered contractors do not have access to the guaranfund
fix ...-•,-�.s.�r.,.�.,
S�rr»fure� fF �ntYO�aruner � `'4TT..d rv�. _
4
Plans Submitted Plans Waived Certified Plot Plan- Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools '�_,• ��
, A
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 APPROVED. `
PLANNING & DEVELOPMENT
COMMENTS
• I
CONSERVATION Reviewed on Signature
Gi lMENTS
HEALTH Reviewed on Signature
COMMENTS
,
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 aqaodgtreet
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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 2010
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 N.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
o 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
❑ 'Ce "r:e -ropos
d Plct Plan.
!l . P
[3
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 a
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:Building Permit Revised 2008
Location 5,
No. Date
l
NORTry TOWN OF NORTH ANDOVER
3? _ 0 7
Certificate of Occupancy $
JACMUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
bd
TOTAL $
Check #
24Q a
958 Building Inspector
NORTH
0 0Andover .,
�
0 . ,
d
� � 111 1'L
, ower,
o Mass.,
2COCKICKEWICK
RATED
7 U BOARD OF HEALTH
PER .M IT T D
Food/Kitchen
Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.......... ..........C ....................... ............................................... Foundation
V
has permission to erect..............4*�,**.............. buildings on ................ ......SM.. . . No...........fla."W.... Rough
Chimney
to be occupied as iN..�.........� R.� y
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 INSPECTOR
• . UNLESS CONSTRUCTXTIqPSTS Rough
Nk
................................................................................................... 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.
NORTH
T011 of
:;.: t
SVY -.77
a , dover, Mass.,LAKE
COCHICHE WICK
DPEAORATER* MIT T O pP�,c�CS
S U BOARD OF HEALTH
Food/Kitchen
Septic System
11
BUILDING INSPECTOR
THIS CERTIFIES THAT.......... ..1..1�.'.........��` .w!.. . ........ . .!1� .............. ............................................... Foundation
j
has permission to erect................. .. .................. buildings on................ ......IS.V... . -ft.......�.1.�. .... Rough
Chimney
to be occu red as . . ��......... . ........R.� ...............:......................... y
. .. . . ........................................
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 INSPECTOR
• . UNLESS CONSTRUC TS 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 BeDone FIREE_DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner,
Street No.
SEE REVERSE SIDE Smoke Det.
169 Boxford Street
North Andover,MA 01845
PH:978-688-5335
Building Contractor FAX:978-688-XX)O(
Proposal
Ta Bill Compagnone
46 Sutton Place All Havre improvement Contractors and Subcontractors
ergaged in home improvornent contracting,unless
North Andover, Ma. 01845 sPeaficatly exe npt from registration by Provisions of Chapter
14M of the general laws,nxrst be registered with the
Commonwealth of Massachusetts.Inquiries about
registration and Status should be made to the Director,Home
Impravernent Contrat Registration,one Ashburton Place,
From: Kevin Murphy Room 1301,Boston,MA 02108.(617)-727 8598
CC:
Date: 11/5/2011
Job: Bath remodel
Date of plans: None
Architect: None
Location: Same
I
Section 1-Work Schedule
— Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in
writing contractor will begin work on or about 12/1/11.
Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 1/15/12.The owner hereby acknowledges
and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as
violations of this agreement. r
Section 11-Warranty
The Contractor warrants that the work famished hereunder shall be free from defects in materials and workmanship for a period of 1 year
following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or
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 expense,forthwith remedy,repair correct,replace,or cause to be remedied,repaired,or
replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in
connection with the agreed-upon work.
Section III-Scope of Work
Page 1 of 4
ReVEMMM
UP y Page 2 of 4
Building Contractor
169 Boxford street
North Aridover,MA 01845
PH:978-688b335
FAX:978.6WXXXX
General
Proposal is to renovate existing three quarter bathroom. Building permit will be provided by contractor. Plumbing
fixtures/footprint of bathroom to remain the same.
Demolition
Existing bathroom will be completely gutted.
Building
Any framing materials required will be supplied. Ceiiing above shower will be raised. Existing window and
interior door to remain.
Plumbing
Plumbing work required to renovate bathroom will be provided. New copper pan for the shower will be provided.
Plumbing fixtures to be supplied by owner. Other miscellaneous plumbing materials will be supplied by
contractor ( new shut offs etc.) . Shower head and hose in second existing bath, will be replaced. fixture
supplied by owner.
Electrical
Electrical work required to renovate bathroom to meet code will be provided. Bath cuircuts will be gfi protected.
New Panasonic bath fan/light unit will be supplied and installed. Surface mounted fixtures (vanity lights)to be
supplied by owner, installed by contractor. New bathroom fan,and existing bathroom fan(in second bathroom)
will be vented outside through soffit.
Heating/Air Conditioning
New baseboard heat cover will be supplied/installed.
No allowance has been made for any air conditioning .
Insulation
Bathroom will have all new fiberglass insulation installed. R-13 in exterior wall, R-30 in ceiling
Plaster
Bathroom will have new smooth plaster ceiling . Walls in shower will have durarock installed . Walls in entire
bathroom will be tied.
Interior Trim/Doors
New interior window and door trim will be supplied and installed to match existing. Vanity , countertop , and
medicine cabinet to be suppllied by owner, installed by contracor.
Painting
Any interior painting will be provided.
Revfim Mmmphy Page 3 of 4
Building Contractor
169 Boxford Street
North Andover,MA 01845
PH:978ZBB,5335
FAX:978-88-X)=
Flooring
i
Floor, shower,and bathroom walls will be tiled.Owner to supply the materials.
Waste Removal
All demolition/construction debris will be disposed of by contractor.
ReVEM MWEV ty Page 4 of 4
Standing Contractor
169 Boxford street
North Andover,MA 01845
PH:978-6665335
FAX:978.6W)CM
Section IV-Price Schedule
We hereby propose to furnish material and labor=complete
in Accordance with above specifications for the sum of... ... ... ...... ...... ... ... ... ... ....$ 12,000
Payment to be made as follows:
Percentage/item Description Amount
1 Demolition complete $2000
2 Plastering complete $5000
3 Tile complete $3000
4 Job 100% complete $2000
Total 4 $12,000.00
'"Notice:No agreement for Home improvement contradmg work shall regrme a down payrnent(advance deposit)of mom that one hied of the total contract price of the total amount of all deposits or
payments which the contractor must make,in advance,to order andlor otherwise obtain delivery of special ode materials and egrripmerrt,whichever is greater
Contractor: Kevin Murphy
169 Boxford Street
No.Andover, MA 01845
Registration No: 101874
Section V—Acceptance
Acceptance of Proposal—I have read 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 will be made as outlined above.
You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this
transaction cancellation must be done in writing
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ............. ...............
....... . . . . .
has permission to perform .....A41.*I�*,v.................... .............
wiring in the building of.......VKRA.!.../..... .................................
at... 5 c4 1cm
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..". ................ ....I........................................... ,North Andover,Mass.
Fee...��Oq. Lic.No...E:�O-f.........................................................
ELECTRICAL INSPECTORC, M�/owqa o9a, 25.oo PAID
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
THE09M10NWE4LTH0FIK4MCHVSEM Office Use only
DEPARTAMWOFPUBLICS4FE1'Y Permit No. Q k
BOARD OFFIREPRBEWONRWUL4TIOAN 527CMR 12:110 —r�
' Occupancy&Fees Checked
APPUCATION FOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date l
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number) C s 0V� e
Owner or Tenant fnaVI
V1 C4 e-in
Owner's Address
Is this permit in conjunction with a building permit: Yes�No (Check Appropriate Box)
Purpose of Building - ee-5, L,, Utility Authorization No.
Existing Service d00 Amps�OVolts Overhead nderground M No.of Meters
New Service Amps Volts Overhead M Underground No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work 7i4 M 0L/,--
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of Lighting Fixtures Swimming Pool Above ground' Below 171 Generators KVA
.w ground
No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units
No.of Swi0j0utlets
' No.of Gas Burners
No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tons
No.of Disposals No.of Heat Total Total No.of Detection and
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No.of Dishwashers Space Area Heating KW No.of Sounding Devices
No.of Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal a Other
Connections
No.of Wu er Heaters KW No.of No.of
Signs Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
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TOWN OF NORTH ANDOVER 32 611!C ;6s94 o
APPLICATION FOR PLAN EXAMINATION
Permit NO:-3
Date Received
Date Issued:
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
IS
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DESCRIPTION OF WORK TO BE PREFORMED: r 'k
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OWNER: Name:'A' Phone:
Address:
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ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED_ON$123.00 PER S.F.
Total Project Cost: $ ' - q-30" 00 FEE: $ /50
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund
S�� natures�f`A ent/O rJu�er � n .
gr at.oFMnsraet�r�x
r
- f i
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
Private(septic tank,etc. Permanent Dumpster on Site
' 1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING &.DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMEivTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water $ Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
r:. .
Located Osgood reet
:: �Y�2 EjP ►SRT 1f1EjN ' eer Dur pster�:P!S.!
Loca#edt �llllain K a
�r ,eaparrnen
73COMMNJ S h
-f
( 4 S
L
Q a
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)
1
i
1
❑ Notified for pickup - Date
'i
Doc.Building Permit Revised 2010
I
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
❑ 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
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract K
❑ 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)
q
❑ Building Permit Application
...c•t• r1
❑ Cletiiied 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 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:Building Permit Revised 2008
Locations
No. 3-17— xo Date
NORTH TOWN OF NORTH ANDOVER
0
F R
9
} ° Certificate of Occupancy $
s Musa 9 Buildin /Frame Permit Fee $
Foundation Permit Fee $
Permit Fee $ (,fiP40F)
/50-vv
TOTAL $
Check #
23646 Buildinli+ gspector
NORT►y
Tovm of Andover .
p ,' ' 1" V0
No.7
=N dover, Mass., opo
GOC MICM_WICK �1k
AORATED PPat�y
S U ` BOARD OF HEALTH
P �ERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT................. ..... . .. . . /�'
. .... (/ ............................................................................/.......... Foundation
has permission to erect......6-7: F....... buildings on ...... � TPN............. ........... / Rough�4E
tobe occupied as................. .:J....... ...... .....................................................................::.-...........................:.......:-...............: - 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 INSPECTOR
UNLESS CONSTRUCTIONT;.,
Rough
......... Service
UIL ING 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.
6 Wo
ui e ula(n
s
g g anftan�dars
One Ashburton Place - Room 1301
°a Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 117870
- Type: Private Corporation
p y Expiration: 12/12/2010 Tr# 278798
GEORGOULIS CONSTRUCTION;;INC='
SCOTT GEORGOULIS _' b
96 ARLINGTON AVE _
r t ,
DRACUT, MA 01826
-�- p-
Update Address and return card.Mark reason for change.
_- ❑ Address Ej Renewal Q Employment F-1 Lost Card
DPS-CA1 w 50M-07/07-PC8990
i
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction.supervisor License
License: CS 58498
Restricted.to: 00
SCOTT C GEORGOULIS
96 ARLINGTON AVE
DRACUT, MA 01826
Expiration: 10/21/2011
Cmuni Nioncr' Tr#: 5031
GEORGOULIS ROOFING & CONSTRUCTION, INC.
96 Arlington Ave.
Dracut,MA 01826
Al Greene-Estimator
1-978-453-4242 Office
1-978-888-1700 Cell
georgoulis l 4@aol.com
PROPOSAL
Bill Compagnone
46 Sutton Pl. 10/20/10
N.Andover,MA r" t
1-978-886-1955 4.
rover9na aol com
Job Location:46 Sutton Pl.N.Andover,MA
Scope of Work: ;.
Remove all layers of woofing down to wood deck on entire house roofs. Shed r t*. a,%% , j,clujej.
i Install 6'of GAF Weatherwatch Ice/Water Shield underlayment on all roof eaves,around skylights,
i around stack pipes,up racks at all roof to wall locations,and in all valleys.
`
Install 15#felt paper over remaining exposed roof deck. t.
Install 8"-025 gauge heavy duty white aluminum drip edgeon entire roof perimeters.
Install GAF Timberline Prestique high definition 30 yr..Architeciurai shingles with 3-Tab caps on roof.
Install new stack pipe boots on plumbing pipes:. ,
Install new Coravem V-400 ridgevent on main house ridges. r r
Remove all job related debris fromro
P periy on a daily basis and at jobs completion.
$55.00 Per Sheet Extra Cost to replace any damaged plywood(if needed).
$2.50 Per Lineal Foot Extra Cost to replace an dam
agedEntire job includes GAF Smart Choice Warranty, First20 Y�is non-prorated,� n fu
ll material coverage from GAF. labor and
WE PROPOSE hereby to furnish material and labor complete in accordance with above specifications,
for the sum of. r
paP.Pa;d S'13000 tc�a�lie
Twelve Thousand Four Hundred Thirty Dollars �K tS`ia
$12,430.00
PAYMENT TO BE MADE AS FOLLOWS:
$5 430.00 PAID IN ADVAN E FOR MATERIAL COST.$7,000-00 PAID IN FULL WIIEN JOB IS
COMPLETELY SRFD ACCORDING TO THE ABOVE LISTED PROPOSAL. °
cad°�
All material is guaranteed to be ass
pacified All work to be completed in a substantial workman like manner according
to specifications submitted per standard practices.Any alteration or deviation from above specifications involving
extra costs will be executed only upcm written orders,and will become an extraa over and above theestimate.
All agreements,contingent upon strikes,accidents or delays beyond our control. m (tet
necessary insurance.Our workers are fully covered by workers compensation and oma G1
pensationins
Authorized$ignature
This proposal may bewithdrawn by us if not accepted within 30 days.
Acceptance of Proposal-The above prices,specifications are satisfactory and are hereby accepted. You are authorized to do the work as specified.
Payment will be made as outlined above.
Signature_��
-- Date of acceptance 10 t22 1116 4 t�
From: 10/27/2010 09:36 #721 P.002/002
'4 EP* CERTIFICATE OF LIABILITY INSURANCE °10/27/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
i IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. it SUBROGATION 18 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endoreement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER (978)459-2101 coNracT
Albert A. Daigle Iris Agency, Inc PHONE FM
313 Willard Street AD—DRFSS_ _
Dracut, NA 01826-5099 PRODUCER
INSURERS)AFFORDING COVERAGE NAIC 11
INSURED INSURER A:American Nome Assurance
6eorgoulis Construction Inc. INSURER B:
96 Arlington Ave. INSURER C:
Dracut, MA 01826 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POUCY EFF POLICY EXP
LTR TYPE OF INSURANCE MR wvo POLICY NUMBER DDIYYVY DIYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES fEa omulrence $
CLAMS-MADE D OCCUR MED EXP(Ary one person) $
t
PERSONAL&ADV INJURY $
s GENERAL AGGREGATE $
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/UP AGG S
POLICY PRO-JFCT LAC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea acadam)
ANY AUTO BODILY INJURY(Per percon) $
ALL OWNED AUTOS
j BODILY INJURY(Per eooldenl) $
SCHEDULED AUTOS
PROPERTY DAMAGE $
HIRED AUTOS (Per accident)
NON-OWNED AUTOS S
$
UMBRELLA LIAOOCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
DEDUCTIBLE 8
RETENTION $ $
I WORKERS COMPENSATION WC STATU- DTH•
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETORIPARTN£R/EXECUTIVE E.L EACH ACCIDENT $ 10O 000.00
A OFFICERIMEMBEREXCLUDE Dt NIA IYCOO9-75-2868 09!26/10 09!25!11
(Mandatory in NN) EL.DISEASE-EA EMPLOYEd S 100 000.00
Ii yea describe under
DESCRIPTION OF OPERATIONS be)ow EX.DISEASE-POLICY LIMIT I$ 500 000.00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atlaoh ACORD 101,AddidoaN Remarks Sdiedulo,h moro opine Is squired)
CERTIFICATE HOLDER CANCELLATION
Bill 1 ton I'l ne
4SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
46 Sutton I THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover NA 01845
AUTHORIZED R6DRtFTAT
I
®1986-2 CORD RATION. All rights reserved.
910
ACORD 25(2009) The ACORD name and logo are registered marks of ACOR
10/25/2010 1:21 PM FROM: Gallant Ins Agcy Gallant Ins Agcy TO: 919789589997 PAGE: 002 OF 002
ACOROa CERTIFICATE OF LIABILITY INSURANCE DATE (MMND YYYY(
11111 10!25!2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed.If SUBROGATION 13 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsemerd(s).
PRODUCER Phone: (978)2633500 Fac (978)263-1438 CONTACT Kathryn Bergqdst
NAME.
GALLANT INSURANCE AGENCY,INC. PHONE Ax
199 GREAT ROAD/P 0 BOX 975 MAia Ea: Ac No
ACTON MA 01720 SORES Kate�gallarttlns Com
PRODUCER, 36702
CUSTOMER IU
! INSURER(S)AFFORDING COVERAGE NAIC i
INSURED 'INSURER A : Seneca.Specialty Ins Co
GEORGOULIS CONSTRUCTION INC.
C/O SCOTT GEORGOULIS INSURER e
96 ARLINGTON AVENUE INSURER C
DRACUT MA 01826 INSURERD
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: 21953 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
INSR TYPE OF INSURANCE AOD'L SUER POUCY NUMBER POLICY EFF POLICY EXP LIMITS
TR INSR VIVO MMJDDJYYYY MM.UD/YYYY
A GENERAL LIABILITY BAG4001034 03/05/10 03/05/11 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY P='T0 RENTED $ 100,000
CLAIMS-MADE IX OCCUR MED.EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN1 AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY1:1 JFCT PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea acciderd)
ANY AUTO
BODILY INJURY(Per person) $
ALL OWNED AUTOS
BODILY INJURY(Per accident) $
SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Per accident) $
NON-OWNED AUTOS $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB HCLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ 1 $
WORKERS COMPENSATION WC STATII 111H $
AND EMPLOYERS' LIABILITY YIN TO",
I.
T
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFtCER/MEMBER EXCLUDED? NJA
(Mandatory in NN) E.L.DISEASE-FA EMPLOYEE $
It yes.d8sorlbe Urwer
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS 1 LOCATIONS i VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
BIII Compagnone THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
46 Sutton Place
North Andover,MA AUTHORIZED REPRESENTATIVE
Attention: Nicole#978458-9997
Ray Gallant
ACORD 25(2009/09) B 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
I Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #: /- q - z1r3- ld
Are you an employer?Check the appropriate box: Type of project(required):
1.R5 I am a employer with 4. ❑ I am a general contractor and I 6. ❑Newconstruction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ 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 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
*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: /y W,30Z 1 Ju,��e_t
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: ��/ >� ��, City/State/Zip: d
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 u der the pains and penalties o perjury that the information providedAZ/above is true and correct.
Si nature: Date: / b
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cavy 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 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 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 infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia