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Miscellaneous - 5 BELMONT STREET 4/30/2018
5 BELMONT STREET I -- - - - - - - -- ---- - --- - - - 210/018.0-0016-0000.0 Date.. °�. �`�' i ! 14ORTM 1 L 3:;.,�`'°.;•.�."oo� N OF NORTH ANDOVER F 9 PERMIT FOR WIRING 4CMu This certifies that ... of�.....G..Q � ...... ..... has pernussion to perform . wiring in the buil g of..... ....... '(Z:.,..::J................................................ t-Si { at....... ° . .. ..................... Andover,M Fee.-/ .... Lic.No............ ..HD..... :.......� ..... ELEmicAL INspwmR Check # �Z� JAY `10900 1 1 4�7-2 lj t rel ,h12,4,-2 ld ,fit ti I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. L96�V L Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Jt1A)P 1% 1 Z City or Town of. NORTH ANDOVER To the Inspector oft ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) S 8 EL401v r Owner or Tenant 1 HyQLold Telephone No.279 39Yn021D& Owner's Address Y414 ti Is this permit in conjunctionwitha building permit? YewNo ❑ (Check Appropriate Box) Purpose of Building RPSlXOAIC,"c— 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: /,)/R-& ill FG' 5'�t M IA16 P60� RPyr �n QQA)d19Aj,# rd Q �?rAlQ M - Completion o the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above I ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained .. . ...................................................... Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other p g 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: ®J Attach additional detail if desired, or as required by the Inspector of Wfres. Estimated Value of Electrical Work: /0100 (When required by municipal policy.) Work to Start: Jd lV`L i `1 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: . MCWFAJAl l e— LIC.NO.: Licensee: .J4011aJ F�-I cjk?"✓x/Af Signature LIC.- inihe NO.: 2 Z6 (If applicable,enter "exempt" license number li Bus. No.: 722 0 Address: E Alt.Tel.No.: !FZA -5Z3 *Per M.G.L c. 147,s.'57-6 1,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) owner ❑ owner's agent. Owner/Agent PERIIiIT FEE. $ Signature Telephone No. M C�oxa.ts:ecfoxsyszguatuxe-310 Riifials) _ Slate �'asse��--[ ) •�'aiTe�.--r � � �e 3�us�ectiottxe[�uixec�($ 0.00)-•[ � nspectoxs'co7nmeuts: (.Ctis&etors'ftnature-..o fnitials) Slate Fassell•—f I IazTO--I ?fie us ectio�aequzrec�($50.00) [ Ins.pectoxs'comments: , (lnspeotoxs', ignatuxe��o?nitfaTs) gate ' c asset--[ � �+`a'rle�l--j ) ►�e-�nspectionxequizec�(�50.OD)�[ � ' Ispectors'coammepfs: (Inspectors,olgnature-io W-Rals) Data Q�7�'ECrTTO�'-•0��:' ss ecl�-[ � �'ailec'!�[ ]- '�e�nsp ectioxt xe�uix'etl 050.0 Q)-•[ � - �ectoxs'couim.ents: • 5 Cusp edors'Minatuxe-)ao fiffials) Pate ^bn*P IPA P js h'PV..T" dli7T A"T.W.-RIF nTV.qT'T'TiiW TRF ARM TO BF TA NOT N The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): , PKC AJAIA EL t(, TR- Address: R/ Address: ,3 7 MERRIffACK ST City/State/Zip: ME1_ dFAJ Mh OIJ911f Phone#: 27A -b837 61 6 3Y Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 m a sole proprietor or partner- listed on the attached sheet.$ 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. lectrical 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.] 1313 Other *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: Y 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. f do hereby c rt ffy under t ains and penalties ofperjury that the information provided above is true and correct. 3i nature: F- Date: Phone# a6 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 carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the 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 i of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. i Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a 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 Fax# 617-727-7749 Revised 5-26-05 www,mass.gov/dia J ' i Piref t---AJL- 6QLIA-A— -s 1Al ' Jo 14N WEAW P- &,-) �v /n1Fo#C1"t 6l) � 7— llj Tiq 0 t SCuSS�oNS lv<v4 Nvo� V�cD TPA AM PLAYVS Fo 9 11) Location G No. �5 v Date 0 TOWN OF NORTH ANDOVER o � Certificate of Occupancy $ 01 0 Building/Frame Permit Fee $ oa a Q Foundation Permit Fee $ $, Other Permit Fee $ ` •a xi, TOTAL $ I C j Check# i 26514 Building Inspector I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 3 IM ORTANT: Applicant must complete all items on this page t 'L®CATIONI } PR®PER&VQWN,ER, Pant; 1q-0rYear,Old�Structure� MAPN® �C� __ PARCELl __ONING�DISTRICT °H istoncDistnct� _. .-. Machin"eaShop Village! y_es o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑Addition ❑Two or more family 11 Industrial El Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other77 --- r- .- f ❑Septics .❑1Nell't ' p lFlood-_I n) ❑V1letlarids. ❑ WatershedlDistrict ` 0Water/80wera. DESCRIPTION OF WORK TO BE PERFORMED: I / e1/7 aC✓ G°r / GAJ dYlG�i�/1 Identification Please Type or Print Clearly) 11 OWNER: Name: -/k// Phone: �/rl/ /ldli vee-, Address: J ,g��/�Zc/7`� ��/�t'f" /rC � Phone f CONTRQR Name (? _ ANG = (Address 3 rV MV Superyf%),Q is 'n$trucfiorn License; Y Exp i Homelm rovementLleense -S6y _ tr � f p # _ 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. c i Total Project Cost: $ L' © do FEE: Check No.: a 6, Receipt No.: -12 G rill do not have access to the uaran fund TE: Persons contracting with unregistered contractors h' NO g g ,. r w Signature ofsyAgent/Owner, «. ` : .: . ` _ k S gnature�of,�contractor5 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, mast or service drop requires approval of Electrical Inspector Yes No i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use I I i i I ® Notified for pickup - Date t C Doc.Building Permit Revised 2010 r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming 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 APPROVED PLANNING & DEVELOPMENT ❑ ❑ r I COMMENTS CONSERVATION Reviewed on Signature I COMMENTS HEALTH Reviewed on Signature COMMENTS r z Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;a ]Engineer: Signature: Located 384 Osgood Street FIRE ®EPARTM NT - Temp Dumpster on site yes no Located at 124.MaKStreet. Fire Departine� #signature/date COMMENTS 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 L, 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 Li Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work 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 Construction (Single and Two Family) r o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit La Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 submAted with the building application 1 Doc: Doc.Bui!ding Permit Revised 2012 r 1 t10RT1j - _ : :. .c . : ver 0e h ,� ver, Mass, Q COC Ml WICK NIC �• �p �•9 °a^reo �P���S S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT �' y'� ' BUILDING INSPECTOR ............................................................................................................................ .. Foundation has permission to erect.......................... buildings on � a .. ...................................... Rough to be occuie � p� ................................................ ....:.............:............................................................... 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 5TARTS Rough fr Service ................... . r +b!......;--�............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 a, DAVID CASTRICONE 6 `� C:ASTRICONE ROOFING& SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 -,43 19 JW SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 In North Andover 978-683-3420 In BoxI ord 978-887-6147 Jn HoverhIU 978-374-7314 Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: i Owner's Name......... 1...(It l.,i. 'YJ......... ............................................Tele one#....... ..... y ll/ ........... ... ......... Job Address..... �i�. '.y.7,.a?.bn J....S ...,...............City.... !tt.... .lel Cr.p. .k�'..........state...l Specifications: ...................................................................................................................................................................................................................... •Strip existing shingles.(/} ..Apply new drip edge to all edges. /}r Lc1�. .... ................................................... . ............ ................... ..g.. ....................f.. .................. .............. ................................ pp y (� feet ice and water shieI'd": .. memb.ra..ne.to. botto.m e..d es..of hous.e. 3 eet...ice a.nd wa.t.er.. shie.ld. memb.. ra. ne in valleys and bottom edges of any anheated areas of house. _ ........ ..........r .... ................... ...*..... ........................................................................ . .............. ✓A 1 felt 8 er underla ment. :Install ridge ve o � -+ � s-Reroof using a r. 0-1- .ate shingles with a tZ year warranty. ................................................................................................................................................................................................................. Counterflash chimney. dAtew vc•et pipe flashing. -Enal disposal of all debris. —. ...................................................c?,:.j.. ..... ............. .... .. ^....................... ....................................... Area(s)to be worked on: ..... r .... . . .: ...... ............r... r....... . . of ...1':O- ..0.............................. 1, _. 4.V:...:... �.....J C : ........................................................................................................................................ ........ ......�....S... r .........................................................:. .�..� ........................................................... { ... Roof board replacement if necessary � /sheet lir /4c O✓e,,,- ........................................................ ......................................... /'.........................................................:.......................................... -- Two Year Workmanship Warranty(Not Transferable) Manufacturer's Warranty as sp�' red by manufacturer The contractor agrees to perform the work and furnish the materials specified above for the SX1M of$...�Z.r ........ ........ Payable.............................on................................. Payable.............................c:r.................................. Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of matciWs specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces).items in attic may need to be covered 3y homeowner.All materials are property of contractor. Any dumpster placed by contractor is for his use only.Upon completion of above work,all undersigned ag.ce to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by contractor. Upon refusal to do so,contractor r.iay at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is agreed that,if perrnined by law,contractor sh.JI be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and;:•aditions of the contract and/or any lien in connection herewith.It is further agreed that this contract may be assigned by contractor,and also that the obligations hem,:shall bind and apply to their heirs,successors or estates of the parties.The undersigned warrant(s)that he is(they are) the owners(s)of me above mentioned premisc>and that legal title thereto stands of record in his(their)namcs(s).There are no representations,guaranties or warranties,except such as may be herein mc,..porated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in--14ence hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors tall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:Director,Horr<improvement Contractor Registration, One Ashburton Place, Room 1301,Boston,MA 02108 ' 4 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction- related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A. I Approximate starting date of work... ............................................ Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to caki;el this contract and incur no penalty (see notice-of cancellation).` p IN WITNESS WHEREOF,the parties have hereunto signed their names this...�0..J� day of...... y/!!4 '.,20.13.... Accepted: 7u IIS :. �� � l/ Signed........:. .. .............. Owner � r i Signed............................................................................. Owner David Castricone,President ;` j, \ The Commonwealth of Massachusetts Department of Industrial Accidents V1'<'t ~Aj, ' ' Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CA5?R!L o tl ny�(NCr SfI v I N V N�' Address: a�3 i R gy0 t!1 S�ttGk 3 Ci /State/Zi Q o vel M A D 1145 Phone #: 9? (o%3 3 yd b City/State/Zip:p Nb. '(� Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 8 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 7. Remodeling 2.❑ I atm a sole proprietor or partner- listed on the attached sheet. I ❑ 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 10.❑ Electrical repairs or additions required.] officers have exercised their 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.r�]r Roof repairs insurance required.]t employees. [No workers' 13.0 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 acid their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name:_ Policy#or Self-ins. Lic.#: VV 0-0039 99 U3 Expiration Date: q•A3 •0161.3 Job Site Address: J w City/State/Zip: A AmId io A0(4,0— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: z:1L �J- Date: Phone#: vl re 13 3 q �-O 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#: Town of North Andover 14ORTH Q X o 6 Building Department o ` 27 Charles Street 13 Noah Andover, Massachusetts 01845 f (978) 688-9545 Fax (978) 688-9542 �.9 S < Sq USE CN I DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Buildingpermit # P the debris resultingfrom the work ! scall be disposed p sed of in a properly licensed solid waste disposal facility as defined by MGL c.l 1, s150a.. The debris//will be disposed of in/at: G-� Facility location Signature of Applicant — 6 J-3 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector, I i AC"Rt7 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DOtYYYY) 9/24/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). ONTACT PRODUCER NAME: Select Dept,ext 66807 Eastern Insurance Group LLC - Main PHONE FAX AIC No Ex :508-651-7700 A/O No):508-653 8089___, 233'Aest Central Street E-MAIL Natick MA 01760 ADD R..ss:s -w k terninSanc orn INSURER(S)AFFORDING COVERAGE NAIC d INSURER A:CoLnMerCe & Industry 19410 INSURED 31969 INSURER B: David,Castricone Roofing &Siding Inc INSURER C: 231 Rear Sutton Street, Unit 3A INSURER D: Nort Andover MA 01845 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1 538501247 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 SY 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 I TYPE OF INSURANCE AD B POLICY EFF POLICY EXP LTR IN R.WVD. POLICY NUMBER 'MM,�DD'YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE _ j C:IJh.1haERCIAL GEI'IER,L LIABILITY DAMAGE TOPREMISES A RENTED occunonce !5 C:LAIMS�MIDE I OCCUR l �J MED EXP(Air)'one person) IT$ PERSONAL R ADV INJURY j$ GENERAL AGGREGATE IS uEN'L AGGREGATE UNIT APPLIES PER. I � PRODUCTS�COMP.!OP AGG �S FX.FJ::Y I I IFCT LOC I I 1 �_ AUTOMOBILE LIABILITY 3INED SlIVULt Lam, Ea aCC,111i ANYAUTO I BODILY INJURY(Per person) $ ALL O'Y NED I SCHEDULED -- __ AUTOS t.AUTOS I BODILY WJURY(Per acr deal) $ 14 ON OWNED I PRC)PERTY DAMAGE HIRED AUTOS ,AUTOS' I I(Pei aa:kJenq $ i i I I I I$ UMBRELLA LIAR !_I OCCUR EACH OCCURRENCE S EXCESS LIAR I CLAINIS-MADEI I AGGREGATE $ I DED I i RETENTIONS $ A WORKE RS COMPENSATION 14'C003989723 3/23/2012 0/23/2013 IX SIC STATU- OCH AND EMPLOYERS'LIABILITY Y.N c� IT AIJY PROP R I ETORIFA:7THEWEXECUTIVE I rE.L.EACH ACCIDENT OFF I CERiAdEMBER EXCLUDED? ❑I N;4 $100,000 i(Mandatory In NH) 1 E.L.DISEASE EA EMPLOYEEI$100,000 I It 1'6 S.deSCl Ibe Und61 DESCRIPTION OF OPERATONS bebw E.L.DISEASE POLICYLMIT j$500,000 I I i I DESCRIPTION OF OPERATIONS;LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 231 Rear Sutton Street,Unit 3A North Andover MA 01845 AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010;05) The ACORD name and logo are registered marks of ACORD EASTERPl INSURAMCE _. DATE(MMroD1YYYY) A0 0 CERTIFICATE OF LIABILITY INSURANCE 9�11�2012 PRODUCER 978 273 6368 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willows Insurance Agcy HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 51 Cochichowiok Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I North Andover MA 01845 INSURERS AFFORDING COVERAGE _ _ NAIL;# INSURED INSURERA;WESTERN WORLD INSURANCE CO DAVID CASTRICONE ROOFING 6 SIDING INC b l INsuaEa6; __ .....:. CASTRICONE ROOFING & SIDING INC : INSURER C; 231 Sutton St #3A INSURER D', NORTH ANDOVER MA O1 B45 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIRE-MENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IH9R AD D'u POLICY EFFECTIVE POLICY EXPIRATION LIMITS POUCYNUMBER T DATE GENERAL LIABILITY EACH OCCURRENCE_ 5 1000000 dA0ETNT O REED _ COMMERCIAL GENERAL LIABILITY i PREMISES(Ei OccurrirlQel._.,.g_- . 50000 A __ _ CLAIMS MADE X OCCUR�?P-13�2898 9/(7/2012 19/6/2013 MED EXP(Any one pomon), .,S___ 1000 PERSONAL d ADV INJURY j 1000000 GENERAL AGGREGATE I S 2000000 GEN'L AGGREGATE LIMIT APPLIES P@R:I I PRODUCTS-COMP/OP AGG S 2000000 Pa 1 I i POLICY. I LOC I AUTOMOBILE LIABILITY COMBINED Es a donnOSINGLE LIMBS ANY AUTO ---- . ....------- .- ALLOWNEDAUTOS BODILY INJURY $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S NON-OWNED AUTO (Per accident) —_ PROPERTY DAMAGE s .-....... . (Pe,Bnddenl) GARAGE LIABIUTY I AUTO ONLY-EA ACCIDENT S ANY AUTO j OTHER THAN EA ACG S AUTO ONLY' AGG f EXCESS I UMBRELLA LIABILITYEACH OCCURRENCE OCCUR --- CLAIMS MADE ' - AGGREGATE DEDUCTIBLE RETENTION S I 5 WORKERS COMPENSATION WC STATU- ER OTH- I, AND EMPLOYERS'LIABILITY TORY LIM T.S.YIN, ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIOEN7 3 _ 'OFFK;ER(MEMBEREXCWDEDi - - ' - I(MentilOry In NH) rE. .L.DISEASE-EA EMPLOYE 11 yei.d88CAI)e under SPECIAL FROVISIONS 0010W LDISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROYIS IO NS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF IHE.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,1HE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Castricone Roofing & Siding NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 90 SHALL Unit 3A IMPOSE NO OBLIGATION OR UABILfTY OF ANY KIND UPON THE INSURER,ITS AOENT9 OR 231 R Sutton Street REPRESENTATIVES. AUTHORIZED REPRE A North Andover, MA 01845 ACORD 25(2009101) ©1988-2004 ACORD CORPORATION. All rights reserved. INS025)2ooao,I.o1 The ACORD name antl logo are regletered marks of ACORD �i:1`.�arhusctU - Uc11:II-tnlrnt Il PUIlI1C .�;11ct � Bu:1rt1 of Builllin� FZc_ulatiuil. anil tit:1n11;u 11 --- Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,VVS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration: 12/16/2013 ' ( innii..Lncr TM 7924 SCA 1 C.- 20M-05/11 .� Office of Consumer Affairs&Busiess Regulat o/n „ •,40ME IMPROVEMENT CONTRACTOR jaVim; egistration: 104569 ,( Type: Expiration: 7/14/2014 Private Corporation --,.may. DAVID CASTRICONE ROOFING, SIDING& David Castricone 200 SUTTON ST SUITE 226 NORTH ANDOVER, MA 01845 rza Undersecretary ' DateQl . <".0 RT TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING k' ,SSACNUSE� t iS ll / This certifies that . . . .!- G . . . . . . . . . . . . . o has permission to perform. . . . : ./.4 plumbing in the buildings of . . .r1. ! . �. . . . ... . . . . . . . . . . . . . . . . at :.. . 3-r f . . . . ... . . . . . . . . . .. North Andover, Mass. Fee.. . ."... . ic. No..7.�.�. 3 : . . . , . 9- L. . . . . . UMBING INSPECTOR Check It — t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location � �®✓f 57-owners Name ���igIr/eS' r 6 Permit# 2�7 Type of Occupancy ��l�d�� ;�✓,� Amount New Renovation Replacement rM Plans Submitted Yes No FIXTURES W O w x Q O z a U U 0.. O W O a 09 w W Cn w x ax E" U O O rn W U SMBM - &�41VE�1T v BES 11V1 FLOQ2 41H HAOOR 5M FLOOR 6M FLOOR - 7II3FLOOR gm FLOOR (Print or type) Check one: Certificate Installing Company Name yj�jLLO/,Vis✓ ��t�/� ��N ❑ Corp. Address �0, /jpo s-7d- El Partner. 14 14,1xft✓Q'e /14 14- 0/,yyA Business Telephone 4:� S, = 1�1 3710 1�1 El Firm/Co. Name of Licensed Plumber: //—/O�Vl -5 114/-/-0/L�/'��✓ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ 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 insurance Signature Owner El 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 Massachusetts State Plumbing� CQde and Chapter 142 of the General Laws. ;47 — irk By: Signature 31 Mcenseaum er Title Type of Plumbing License ��,Y 3� City/Town License NumDer Master ❑ Journeyman 0 APPROVED(OFFICE USE ONLY �a. ;2 tDate. . . ...... .g pORTM FY. rOya�..ao ,s,�OO 3 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION '1s9SSAC MUSES .. ^s_ ti This certifies that . . .,�j�, has permission for gas installation . . . . . k!p!t. . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . � %. z o :: .. . . . ., North Andover, Mass. Fee. 2 t' Lic. No. `� �. 3. . . . . . 4iAS INSPECTOR + Check# 6440 MASSACHUSETTS UNN ORM APPUCATON FOR PERM TO DO GAS FITTING (Type or print) Date A G �- NORTH ANDOVER,MASSACHUSETTS ' Building Locations S 1JLMQAJ-1 -S7— Permit# Amount$ Z,� 'ti,7i e��I�F�l�".� 512� Owner's Name New D Renovation Replacement Plans Submitted Ed y U a� vi a w m H z O I" F iz z z 0 F v, z u w x y z a p a > x w C7 F z F zzd w W G7 w F W V x C z w < a F' v� m z O z w O Fi S x o v x 3 A ov a > ca a f6- SU B -BASEM ENT B A S E M ENT 1ST. FLOOR ) . 2ND . FLOOR `1 3RD . FLOOR \' 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Name HALL0ifAry P���1'/t.�� Che k one: Certificate Installing Company Corp. Address PP0, i30X G,4c�.►Af�C ' t1.cj1:1 Partner. Business Te ep one 0 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 [0 No® If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Is Other type of indemnity 13 Bond 13 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 0 Agent 0 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 Massachusetts State Gas Code and C a ter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber 2 YF-3-3 City/Town ® Gas Fitter License Number ® Master APPROVED(OFFICE USE ONLY) Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 y�•°•y www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c Please Print Legibly Name (Business/Organization/Individual): n p JI Address: loo Am t�f ke_e_f 3u`i" 2,V. City/State/Zip: t (f 44s.. Uayef MA 61844 Phone#: q 7 (t3 Slid-O Are you an employer? Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employee's (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. I E] Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition k m working for me in any capacity. workers' comp. insurance. 9. [:J Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.El Electrical repairs or additions required.] 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 12.0 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: r, ' +-"• Policy#or Self-ins. Lic. #: y VV C 4OO !4 0 OQ I at_uExpiration Date: O 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 rine up to$1,500.00 and/or one-year'unprisonment, 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 under th pains and p alties of perjury that the information provided above is true and correct: i Signa p ca Date: 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 y. or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the 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 subriiit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would lice 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Town of North Andover tAORTil Q Eo Building Department 0 6 27 Charles Street North Andover, Massachusetts 01845 o� (978) 688-9545 Fax(978) 688-9542 CHUS DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl1, sl 50a. The debris will be disposed of in/at: s hvG s� L4M NCS Facility location Signature of Applicant Az k _ Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. DAVID CASTRICONE ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 10456 200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 D 2S V L5 D 7 HILLSIDE ROAD,BOXFORD,MA 01921 In North Andover 978-683-3420 In Boxford 978-887-6147 JUL 2 6 2006 In Haverhill 978-374-7314 BY:-------------------- Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: Owner's Name....�IQ .r.........G4♦`.A�....'.....................................A..................T hone#.....a.ar .2.2" ...o..... Job Address..�.�e.. .....9 .t .........................city...,l Y.o.... �.th.e ..............State.... ............ Specifications: ...................................................................................................................................................................................................................... ✓trip existing shingles(V 4pply new drip edge to all edges. 1..j................................................................................................................................................................................................................ pply feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane In valleys and bottom edges of any unheated areas of house. ..........................j..................................................................................................... �pply felt paper underla}� ent. ,.I�tall ridge vent to t ..................� ... . . ..... ....................... ........ .........hing........................J. ..................................... ............................ ✓Aeroof using shingles with s Z do year warranty. ...................................................................................................................................................................................................................... Counterflash chimney. -New vent pipe flashing. mal disposal of all debris. Areas)to be worked on: r ` ..... S..t. ....:.... ....................................!...o:�,�r.....�. A............. ns.....� ......1/l e. ... .�... ..��r.. ..........::.................................................. .............................. .......... ........c, . :t> .........:................................................................................ ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... One Year Workmanship Warr ransferable) Manufacturer's Warrapt,, as specifle m nufaiturer Materials and Labor to ost$.... .. ......... Pa able. 7O Payable...................... ..................... Balance payable on completion of job Owner or Owners ale not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces,water stains when roofing shingles have not had adequate time to cure). Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation es requested by contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates. The undersigned warrant(s)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s). There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by Ali parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration One Ashburton Place Room 1301,Boston,MA 02108 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-related permit or deals with unregistered contractors shall be excluded from access to the Guarantee Fund. Approximate starting date of work..................................................................... Completion date.............................................................. Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner has three business days to cancel this contract and incur no penalty. �} IN WITNESS WHEREOF,the parties have hereunto signed their names this.........a�.l..k.....day of / ... y 20... / Accepted: �.... �CSigned.S..l(�k �4K.� ....................................Owner CSigned.........................................................................................Owner .. Per.L ........ Representative L"- '' Location �I° r� -�2= No. � ``f Date i. MORTM TOWN OF NORTH ANDOVER 00 1 i Certificate of Occupancy $ k i. 1'�S'•"°'Eta Building/Frame Permit Fee $ swCHus tr Foundation Permit Fee $ ON Other Permit Fee $ �, TOTAL $ Check # 1,2V4 E 1 192? /---Building Inspecl.er TOWN OF NORTH ANDOVER pORTH APPLICATION FOR PLAN EXAMINATION O`�S�Eo bq�o C OL 10- 2 ` < Permit NO: 0��_ Date Received �1 °NAre Date Issued: 7-c �-06 9SSACHUS IMPORTANT: Applicant must complete all items on this page LOCATION -ails Print PROPERTY OWNER_2Z74 d z c- � FA Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Repair,replacement ❑Assessory Bldg ❑ Commercial ❑Demolition ❑Moving(relocation) ❑ Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED Ski P -f- RE_(H WGz, �- a y �=,� �Nfi Sf19 D FC/n/l�� �� /zva r� Identification Please Type or Print Clearly) OWNER: Name:e1q,44 Q S P-1 0 Phone: Address: � �1 �✓ T �fi /I/� �/(�O U L� CONTRACTOR Name: 19A///2 r 9,4 F_ Phone: 72 bt/20 Address: U S(/f�� Sfi A& &?/,90 V C�2 ! i Supervisor's Construction License: Exp. Date: Home Improvement License: �G y S6 Exp. Date: 7 Yr 6 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 3 6d x12.00=FEE:$ 36„ df) Check No.: Receipt No.: */ Qa 7 Page I of 4 S III Building Setback Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq.ft.: NOTES and DATA—(For department use) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 I� Swimming Pools ❑ TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art Public Sewer ❑ Tobacco Sales Food Packaging/Sales ❑ Well El c ' ❑ 4 Permanent Dump on Site Electric Meter location,tO Private(septic tank,etc. F1 project ` NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund e n Signature of contractor Signature of Agent/Owner ed Plans El❑ Certified Plot Plan ElStam p Plans Submitted El Plans Waived THE N,RDEp gTMEN SECTITAL SIGN OFFNS FOR I ONLY U FORM I DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT El El ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other t, COMMENTS DATE REJECTED DATE APPROVED CONSERVATION El COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ HEALTH COMMENTS _ Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Drivewa Water&Sewer connection/Si nature&Date Permit es_no_ Fire Department signature/date Temp Dumpster on site y 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 n ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 Pape 4 of 4 tkORTH To`111111;m o Andover No. V �-7 % over Mass., 7-co71--'*(o LA COCHICHEWICK C7 0/'�ATED P"Y WARD OF HEALTH Food/Kitchen ............... T D Septic System THIS CERTIFIES THAT............................. BUILDING INSPECTOR . .................. . ........... .............................................. Foundation has permission to erect................... ................. buildings on ...... .......ueea............ Rough to be occupied asChimney ............ ...... ...................................................................................................................................... provided that the person accepti 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 UNLESS CONS '_MON STAR qS_ ELECTRICAL INSPECTOR Rough ;.. iu .... ..... ......................................... ...... ....... Service BUIL UIL SiPP�EC R Final 7 J'n rr 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 Tomm Of 0 10LA o dove, Mass., 7-c,7-O COCMICMEWICK 7B ADRATED 7`s BOARD OF HEALTH Food/Kitchen T D Septic System THIS CERTIFIES THAT.................. BUILDING INSPECTOR......... ................ ... ....................... ................................................................. Foundation has permission to erect........................................ buildings on_ ...... ....... ..... . .... ............................. Rough tobe occupied as ............ ...... ...................................................................................................................................... Chimney provided that the person accepti 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 CONS CTION STAR S. Rough ..... ............�............................ Service BUIL SPEC R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burne Street No. SEE REVERSE SIDE Smoke Det.