Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 55 FOXWOOD DRIVE 4/30/2018
55 FOXWOOD DRIVE / �c7 210/065.0-228-0000.0 �7 J b l Of pOR7ry 1 x� 3?O�';r``� TOWN OF NORTH ANDOVER PERMIT FOR WIRING .�,SS�1CkUS j' This certifies that .` �n ....... �s� ....... 7- f......... has permission to perform ...2. .I. .... � .*-- .. ............................ wiring in the building of... 9 ?1�1..y........eft./Z. . at..4.?...... Aa?w................... .;NNh Andover,Mass. Fee..../.�........ Lic.No. �� ..�......... .............. ....... ELECTRISPECTOR Check # �'! '❑ - 2012 Massachusetts Electrical Code Amendments 527 01R12.00§Rule 8: In accordance with thepxovisions of M.G.L,c.143,§,3L,the permit application form to provide notice ofinstallation of wiring shall be,uniform throughout the Commonwealth,and applications shall be filed- bn the prescribed form.After a permit application has been accepted by an Inspector of Wiresa appointed pursuant to M.CT.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G,L.c.I43,§3L. Permits shallbe limited as to the time of ongoing construction.activity,and maybe deemed_bythe.Inspector_of_Wires abandoned_aad-invalid-Zhe_ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. ❑ The Permit Extension Act;vas created by Section 173 of Chapter 240 of the Acts of 2010 aM ektended 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 fiuthers this purpose by establishing an automatic four-year extension to certain permits-and licenses concerning the use or development ofreal property With limited exceptions,the Act automatically extends,for four years beyond its otherwis a applicable expiration date,any permit or approval that was "in effect or existence"during the qualifyingperiod beginning on August 15,2008-and extending through August 15,2012. tyle 8—Permait/Date Closed: Note:.Reapply for new per ' ❑. r,�rt� 0 Permit]Extension Act—Peranit/Date Closed: � T� Department of Fire Services Permit No. '7r Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEf),527 C tIR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l� J City or Town of. NORTH ANDOVER To the Inspector f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) <::�7 Owner or Tenant �iLj'TJ� ( (�%G�' Telephone No.'2� V5206V E I r=: Owner's Address i I Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Serviced Amps /Z-46-/p Volts ` Overhead ❑ Undgr - No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Wor L TTc4f�� U Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In ❑ o.o cy Lighting l rnd. grnd. Battery Units Units l� No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 Tons No.of Waste Disposers Heat Pump I.N! KW - No.of Self-Contained Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKW No.of .,No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value;771,VZ Work: ����® (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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: INSURANC99 BOND ❑ OTHER ❑ (Specify:) I certify,under Ili epains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: �z P LIC.NO.: & Licensee;.. �...0 y'K.�G Signature LIC.NO.: ,,������- (If applicable, enter "e empt"in the license number line.) us.Tel.No.. �'CJ644i � Address: k1 - (tel.{ OUA l Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security wor 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. .r� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 °'� s�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: iY,`77,-C. G. City/State/Zip:�il� 1CCf4WC /�hone#: "13 �C� � 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 I�am a sole proprietor or partner- listed on the attached sheet. E]Remodeling 'ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its "r 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.]i employees. [No workers' 13.[_1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 1 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 ofperjury that the information provided above is true and correct. Signature: 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#: Date...( ............ .(..� 10649 TOWN OF NORTH AND o �tio * PERMIT FOR PLUMBING ( !� I This certifies thate��VA .� has permission to perform.......... .......js?g.,v l... "`—.. } plumbing in the buildings of.......... ...1 .L - -.........................................:.. at.....:6K.... X. ?. ?. '. -� ...:......................... North Andover, Mass. Fee.... Lic. No. . ...........:...........:...................... a............. _ PLUMBING INSPECTOR Check# i j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _tel///�7_ _�1!c� /d MA DATE�3 J PERMIT# JOBSITE ADDRESS OWNER'S NAME ,9,✓ ,./] .�, �, �,� OWNER ADDRESS TELE: FAX TYPE OR OCCUPANCY TYPE COMMERCIAL�]J EDUCATIONAL © RESIDENTIAL 5f PRINT CLEARLY NEW: M RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES D NO© FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASI)IL1SAND SYSTEM ! I —-__C `�I DEDICATED GREASE SYSTEM [ DEDICATED GRAY WATER SYSTEM __-J __._._] __ -C=I __ - -____1 __..._J1 -� -- DEDICATED WATER RECYCLE SYSTEM I J ! ! l ! ` 1 ___I ._..._--C DISHWASHER _! .__._� DRINKING FOUNTAIN FOOD DISPOSER .--_-.....; -_______E -__-___.0 .__.—.� _..__._I ".__.__.0 _.___1 FLOOR/AREA DRAIN ._.�..._I __._.._.1 � INTERCEPTOR INTERIOR KITCHEN SINK �! ._.._._I ,..� _--_—!_---_� LAVATORY ROOF DRAIN SHOWER STALL I F:7--i ____1 ..___-_.� __ C __.__. _ _T _► I SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION ..C WATER HEATER ALL TYPES WATER PIPING - I - -C C .. _ C .------- OTHER _ ( -- ! —! --- -----I ---C ! --.._i ._.... - - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESE]-I NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2r OTHER TYPE OF INDEMNITY Pj BOND M! -i qj- OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT IF-1j SIGNATURE OF OWNER OR AGENT C hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# ® - SIGNATURE mpg?/ JP 0 CORPORATION 01#=PARTNERSHIPQ#®LLC a= COMPANY NAME ADDRESS CITY �._.__.I STATE ZIP TEL FAX L=CELL _:s3i- . I L r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NO tES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I y r . I Acx The Commonwealth of Massachusetts - Department of lndustrialAccidents 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/Organizationlfndividual): Z� �JAl Address:_ ,1 City/State/Zip:/�/� �.✓/�u 2y'�' Phone �7 ���f-,02 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.Tam a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El 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.❑Roofrepairs insurance required.]t employees.[No workers' 13.[1 Other comp,insurance required.] xAny 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 ire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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. 00 Insurance Company Name:. 7 ��✓� Policy#or Self-ins.Lie.M Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. Ido hereby certify under the vpins and penalties of ' ry that the information provided above is true and correct. Simature: 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): Y.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 5.Other - - /Lontact 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 anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 submit multiple permit/license applications"Many given year,need only.submit one affidavit indicating current Policy information(ifnecessary)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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orpermit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho GowjAonwoalt�of 114assoc?zv.,sPi s Depaftent ofJndustdal Accidents Office of Investigations- 600 Wash Voii Street Boston,MA 02111. Tel,#61.7-727-4900 ext 406-or 1-877:MASSAFF, Revised 5-26-05 Fax#617-727-7749 I • `COMMONWEALTH OF MASSACFtUSE7-TS, • -• EL PLUMBERS AND GASFI • � J LICENSED,qS q ITERS MASTER PLUM.BfR j ISSUESABOVE LIbENSE TO: s RONALD J -BAKER 20`. CHARLES ST Sp !. NE`kl-BURY--PORT MA 01950-3012 .10.-603 05/01/14 , 177028 l C MONWEALTH OF'MA$SACHUSETTS PLUMBERS AHD. GASFITTt~RS< ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTERf�PLllhYBER RO:JALD J BAKER... 20. CHA'hwSTLu ., : . 1 NEWBURYPORT M'A 01950 30.1 `z r 10 05/0 fly 23 .1,1.4 aaal�•r -. 746 Date. .f .1.� �.�. ... .. r pORTM ( "rq °F 3� TOWN OF NORTH ANDOVER FO p PERMIT FOR GAS INSTALLATION, �9SSAcMUS6 This certifies that . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . in the buildings of a fir r) 2 .� . . . . . . . . . . . . . . . . . . . . . . . . . . at . �� .Fqn v. ��. . . !� ... . . . . . .. North Andover, Mass. Fee 3°. . . . . . Lic. No. .. . . . . . . . . .11-:NI-1.1. ... . . . . . . . GAS INSPECTOR Check# � ) P MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: ./l1ooL�'/7 �✓ ��°s*'/�—MA. Date: p Permit# J� Building Location: �..J �"� � �✓'-/4 S Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [L� New: ❑ Alteration: D Renovation: V Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES ad LU LU U) ZH W U = W W O� _ N vi = O O J } W ~ V) O W IX Z F- Z W W Z lz Lu It O Q H N N w W w m O Q d F W W W X W ' V) V z W Of Z = w OH Q W = � > v w z 0 -� H 1- 0 z -i C7 LL N = to I.W.. w w z W } y '' Q Q m W O z 0 ~ SUB BSMT. BASEMENT 1 FLOOR j :r —Pu--FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR —iFLOOR /J Installing Company Name: Check One Only Certificate# �.�/ ,G./C.� � �/7 ❑Corporation Address: 14/ City/Town /lu✓� /f�':,ay� State ❑ Partnership Business Tel: 799- i Asp Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [Dl Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner 1:1 Agent , By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By [I Plumber TitleElGas Fitter Signature of Licensed Plumber/Gas Fitter .2 Master Cityrrown ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer Date. M4 NORTH TOWN OF NORTH ANDOVER f 11, PERMIT FOR PLUMBING ,,` 49 ,SSAGNUS� -�`This certifies that . . . . . 6 .�.6.�r. ±-� .l.l t: . . . . . . . . . . . . . . has permission to perform . . . . C iv.Q P...... ... . . . . . . . . . . plumbing in the buildings of . .�. l7. . L?. . . . . . . . . . . . . . . . . . at . . S. .�.'. . G:X/!t-!U c: . . . . .F.) �. . . . , North Andover, Mass. Fee 4 """. .Li c. No..,li/.' . . . . . . . . . . . . . . x PLUMBING INSPECTOR Check # 3 Z MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:/%Ar/r /JN�a���! , MA. Date: o Permit# r Building Location: I -Owners Name: i��J' Type of Occupancy: Commercial ` Yp ❑ Educational❑ Industrial❑ Institutional❑ Residential[v]- New:❑ Alteration:[2� Renovation:g Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED z SYSTEMS W f W N x � M LLJ Z > in = v' w o 0 H a � Z Y Q of J cQ W �7 W cc cc Z W W Z WX V) LU OC Z Ln ZA- W Z h In N L N d = i H ~ Q H 0 Q Z 0 W Z W J Z O n' LL. = J Q LL � 3 p OC 3 W G 1. H J a z oe W oi! 0 W 3 W LLS LLI 'A LU a a L o o > > o° o O Z R a a a z W a a m m o o LL x x g 3 3 3 3 o a 3 SUB BSMT. BASEMENT 1N FLOOR 2ND FLOOR ao FLOOR 4r"FLOOR 5r"FLOOR 6r"FLOOR 7r"FLOOR 8r"FLOOR y Check One Only Certificate# Installing Company Name: �>,/ ❑Corporation Address: ?,0' sj City/Town:///.�' �.�i lState• ❑ Partnership Business Tel: �J� '7/�i y`" ���� Fax: It Firm/Company Name of Licensed Plumber: /�'4'o;;xv INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application on waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 11 Agent E] I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed Plumber City/Town .:.Master APPROVED OFFICE USE ONLY ❑Journeyman License Number: _./� J�(1:1 �' Ccmmerce InsuranceSM Aw The Commerce Insurance CempanysM �C Citation Insurance Company SM SM Members of The Commerce Group,Inc.1m CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500 www.Commerceinsurance.com October 25, 2010 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall N ANDOVER MA 01845 RE: Our Insured: RANDAL A MURDZA/DENISE MURDZA Property Address: 55 FOXWOOD DRIVE Policy#: TV7456 Date of Loss: 10/22/2010 File#: WCM578-RVM60 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, 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 my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. JAMES NOWAK Telephone: (508)949-1500 Ext: 15581 CLAIM REP SR,PROPERTY Toll Free: 1-800-221-1605, Ext: 15581 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. October 25, 2010 water damage to exterior wall CcmmCrc Ccmpanies ....COME GROW WITH US CIC 254 (Rev.4/95) MAIL H01 tAORTH ® o Ando* ver No. 6 41 - LA, dower, Mass.,O COC MIC ME WICK SAO TED BOARD OF HEALTH Food/Kitchen ERMIT D Septic System j BUILDING INSPECTOR THIS CERTIFIES THAT............:.. Z°g.! �-e.� ........ �/, �,�.` ��/� ................................................................................. Foundation has permission to erect........................................ buildings on ....a..O '� IA<�......ry .................................... Rough to be occupied as........... ....'. ...L �.��c �..l..�G ,G'c.....�........ ...��.`�1.�'4r.�. 6�0:►�.+r,..................... Chimney provided that the person accepting this permit shall in every respect conform to the terms f 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 CONSTRUCTION -STARTS Rough 000 ................ 4000 .......�.... ............................................ Service �/]3UILDING 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 S 1 D E Smoke Det. z x NORTH oAnfdover 0 ." No. , /[ v o A K -dover, 1Vlass., co CMICKEWICK ORATED PPS �� . U BOARD OF HEALTH Food/Kitchen tg F 4 RMIT TSeptic System BUILDING INSPECTOR ' ► : � f s .': `�16....................... �.......V. f.................... ................................................... hit pUrtnlsar tr.t �^ Foundationnon 0 . ..... ................ buildings on . .. ..... Rough ........... y g V e Y :do be occuP- �.4; i�r ,/f.....:d ey proWdedmthtth person g thispermit shall n very respect conform to the terms of the application on file in F' al ``this.Mflce�aind$toFthe pro Isions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of V Bulidli►g ;lithe Town of#Nbttt Andover. PLUMBING INSPECTOR -VIOLATION of the Xoning;or Bullding Regulations _Voids this Permit. Rough Final PEAMt. rl' EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TIO S } TS = Rough ............................ ..... Service. BUILDING INSPECTOR Final Occupancy Permit Required to OL-upy 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 Date.0.6/:2-2.../--)3... 6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that e-P'7-./-5Ck....4...0.1-...z 4��r r.............. 'f has permission to perform Fa-.r....1'.1 e................................................ wiring in the building of.... .................. at................14 .................................................../1164'-z North Andover,Mass. Fee..26,07)... Lic.No.../�:�,?........../1",_1....�.. .......... ELEMICAL 19spEcroR Check # / 312- 4692 Official Use Only Permit No. qy&C0W-W09VWE,4Lq9fOT91'r,4SSAMSE9TS Department of ftb&safety Occupancy&Fee Checke� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT{ .AO'work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all irtformabon) Date ^O To the Inspector of i Town of North Andover The undersigned applies for a permit to perform the electrical work describelow. Location(Street&Number d Owner or Tenant Owner's Address Is this permit in conjunction with a building it Yes 0 No tf (Check Appropriate Sox) Purpose of Building � ' C 0 Utility Authorization No. Existing Service �� Amps Voits Overhead 0 Undgmd&i No.of Meters '.New Service Amps Voits. / Overhead 0 /Undgmd 0 No.of Meters Number of Feeders and Ampacity - 6t4" 4 o� � 6� l�A51-0Z3=-b e %Location and Nature of Proposed Electrical Work Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above 0 In 0 No.of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No.of Emergency'Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers SpaWArea Heating KW Detection/Sounding Devices 0 Municipal 0 Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases W— a No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Comp1Red Operations Coverage or Its substantial equivalent YES NO P have submitted v4d proof of same to the Office YES QF NO 0 if you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE Or BOND r' OTHER 0 (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Worts to Start Inspection ate Resquested Rough' Final Signed under the Pe as pf erjury: FIRM NAME LIC.NO. Licensee 0&1 714 Xe Signature LIC.NO. Address C�D cJ Pr rG L k) AR Tel.No. No. ev'� �b p�f OWNER'S INSURANCE WAIVER: 1 am'aware that the Ltcenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ ° (Signature of Owner or Agent) Location No. Date �3"Q MORTM TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ I his', Building/Frame/Frame Permit Fee $ � s�cMusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I Check # I 14768 /f Y tBuilding Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building CommissioneLfld for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O s S /--0 X VV 00 o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Regilired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service � 7F0 Signature Telephone QS 2.2 Owner of Record: Name Print Address for Service: O Signature Telephone M SECTION 3-CONSTRUCTION SERVICES 00 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construct-�iipervisor: C Q 3 Q r/ �w-ro A/ A V y M4 l4 Vr ! /) License Number Address / 00;L—�- '� 7$ --5 7 3 5 3 Expiration Date 3 D - Signature Telephone ro 3.2 Registered Home Improvem/�ent Contractor Not Applicable 0 re / Company Name I �L 9 4 g G Al r w 0 GU A V�. I-1,n U c E^� �� Registration Number r Address r Expiration Date Signature Telephone SECTION 4-WOREERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bui ing permit. Si ned affidavit Attached Yes...... No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C k/ '67 X c It To Mx /� { SUp R&&M, xl5j f SECTION 6-ESTIMATED CONSTRUCTION COSTS 'w Item Estimated Cost(Dollar)to be „ �OFFICI ►LUSE QNLY Com p feted b y Ermit a p p Iicant e 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of 000 Construction 3 Plumbing © Building Permit fee(a)X (b) 4 Mechanical(HVAC) 0 0 t 5 Fire Protection . 00 6 Total 1+2+3+4+5 / 5-00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT V I, n Iti f7 y C1i/ 61. as Owner/Authorized Agent of subject property Hereby authorize A X'-Td o t'--1 D' §C' to act on My behalf,in all matters relative to w rk authorized by this building pen-nit application. 0 Signature of Owner Date SECTION 7b OWNER/AUTH nnORIZED AGENT DECLARATION Lf e ,y-o S S 0 as Owner/Authorized Agent of subject I, o+r v� / g j property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief �t Print Nans m Si 6 atuure of Owner/A ent Date NO. OF STORIES SIZE 10- BASEMENT 'OBASEMENT OR SLAB SIZE OF FLOOR T ABERS 1 / 2ND 3 KD SPAN /v DIMENSIONS OF SILLS DIMENSIONS OF POSTS 14- DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING '50 P-6 7'v -e l' X MATERIAL OF CHIMNEY IS BUII,DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that allnecessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT ✓l PHONE' W-3 ):3 `6 6 5 ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER STREET_ S K Go cs"DA STREET NUMBER �5 OFFICIAL USE ONLY RECONEVIENDATIONS OF TOWN AGENTS .. .■own.Now■ ..............■r■■■■■■■■■■■■■■r■■■■■■■r........17ilwon.■■ DATEAPPROVED C NSERVATION ADMINISTRATOR DATE REJECTED COMMENTS DATE APPROVED TOWN PLANNER DATE REJECTED CONBAENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED CONSAENTTS PUBLIC WORDS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE llni ;c �0 � DATE APPROVED DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Town of North Andover �tUI° N Building Department o Z 27 Charles Street North Andover, Massachusetts 01845 i 7 688-9545 - (9 8) Fax (978) 688. 9542 Acnus���� 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 cl 1, s150a. The debris will be disposed of in/at: Facility location Signature of App icant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. orrice orinvesugavons Boston, Mass. 62111 Workers'Compensation Insurance Affidavit Please Print Name- �� Location 1v w 7-0 lU /a V City Phone 3 7 3 L-3 am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name. Address Phone# Insurance Co Poliw.# Company name- Address City Phone#: Insurance Co Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'impris6nment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is bye and correct Signature u Date Print nameN7✓�� �`-y �����°SSO -Phone R7F 373 L6S 3 Official use only do not write in this area to be completed by city or town official- E]' Building Dept ❑Check if immediate response is required Building Dept I] Licensing Board El Selectman's Office Contact person:_ Phone#: I] Health Department 0 Other FORM WORKMAN'S COMPENSATION r ✓he"t�o�n�n�urea%�nf',.,�lr�aefic�u;le�/d ONE IMPROVEMENT CONTRACTOR Registration: 129428 Expiration: 8/31/01 Type: Individual Anthony P. Delgrosso 7� Ba An ho ton Ave.Delgrosso ADMINISTRATOR Haverhill MA 01830 ✓�ie i�an�irrw�uuea� o�✓�,aaacu,�zuoella 1 BOARD OF BUILDING REGUL/t7tS . License: CONSTRUCTION SUPERVF y;. Number:CS 032669 Birthdate: 06/30/1940 Expires: 06/30/2001 Tr. no: 10251 Restricted To: 00 ANTHONY P DELGROSSO �i 26 NEWTON AVE G�.1 HAVERHILL, MA 01830 Administrator O NORTH 0 fdover O No. = L A o dower, Mass., COCHICKEWICK RATED i'9 S H E � BOARD OF HEALTH PERMI Food/Kitchen Septic System T T D BUILDING INSPECTOR THIS CERTIFIES THAT.... �N......t_� .. ... ''V/.��. ........ v/! Z/4.......:............................. Foundation Ne/has permission to erect.�p*x.�•'�..... buildings on ... o� ..................... Rough �0 ! w ip'01� 0110r. A I" s S/A/P 00 J" Chimney to be occupied as... ..................................................... . . .............................................. .. ........................................ . . 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, Altera ion and Construction of F[, Buildings in the Town of North Andover. �001� PLUMBING INSPECTOR °.Y VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough We. 4 ......... .. .. .... ..........................'......................................... 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. MORTCACE INSPECTION PLAN AOORESS. otot✓ CITY/TOWN at: H+—rl,4 Atm V0V E*_ nab►- SCALE: I"- DATE: 2-8 -95 DEED AND PLANREFERENCE �� ESSFX No��H Registry of Deeds Deed Book Page Pion Beek 0-to• 12 37( pak;e Certificotion a hereby mode to: L o�f 3 The aermonent structures are opproximotety iocated on the ground os shorn and they either conformed to the setback requirements of the !ocol zoning ordinances in effect at the time of construciion or are exempt from (�l enforcement action under WG.L.. Chooter !OA. t}• Section 7. unless otherwise noted. -� VEct< tq Certification is hereby mode that the structure N shown oo this pion is not located within a �+ 22 t 2 �Y- 6.�t Special Rood Hazard Area as delineated or th rncp o/ QD Community Panel Vo: 50 048 Etfertive / revised Date: Jupe 2; 1q9q ti 0 3y the U.S. Deportment of Housing & tlrtwn t.V)j Devefoomeht. Federal Insuronce Administration. ! rids?.rche 41. �a ,W.27WNEPONSET VALLEY 0 ass, S VTto. '� SURVEY ASSOC., INC. 95 'MITE SMEi.7 QUINC' MAS ACHUSETTS 021169 TELE..OHMNE: ;617) 472-4867 I ' N2 94 Date.6..- 30 TOWN OF NORTH ANDOVER 0 I- 9PERMIT FOR WIRING 4L SS CHUS This certifies that ...... . ...................................TR(..o.......................... has permission to perform ....7 e2ce7Z.,=-7............................................... wiring in the building of......4 .'�q....IHAIl.e.6!-1 v —................. ..................................... .North Andover,-Mass. r Fee//d":.?.G_e_X_C�� Lic.No�� /.Y.C �b ............ ....... ELECTRICAL INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer r ®` Il1C UU1VVV1U1 vrYGfil.11l Ur JVVIJr"LnuaEl 13 viuce use omy DEPARMENTOMBLICSAFETY Permit No. �JO�-00 - MARDOFFIREPREVEN_I70NREGMTIONS5rCMR12 VAPPUCATION Occupancy&Fees Checked cou FOR PERMIT TO PERFORM aE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 / / 0e,(PLEASE PRINT IN INK OR TYPE ALL.INFORMATION) DAA, y 7 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) Owner or Tenant 101-(Ao y 1&0 A Owner's Address r g OaX Is this permit in conjunction with a building permit: Yes�No M (Check Appropriate Box) Purpose of Building ��� Utility Authorization No. Existing Service �� Amps / Volts Overhead Underground No.of Meters New Service �� Amps / Volts Overhead l:3 Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Ro.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA li9o.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets 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 Pumps Tons KW Initiating Devices 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 Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER IrstaartoeCo�aagtr Pt�uarttodieregt>eare�ofM�da�GaleralLaws Iha%eaaxratL bkyh&rd=Poby,mduIgC ffgA le CoAro�aritssubstitale*kdat YES NO Iha%esubmitadvalidptocfofsmnebtheOffmYES r-J-NO lfjcuhaedxckedYES,pkm theWcfwmaWbydrdargthe UsNURANICE BOND MER a (1? =SPoffY) EVirAmD,* j� Fstim&d VAxd Wak$ WotkbStatt ~'7©�... hgactirnD*Raqucsted Pcugh G //` I Feral Sign�under�ieP��of -T FIRM NAME G' !� 0 s'o �� Business Td Na '�f>.�/C'�Sow ���yi°OI ,► ��O� /r/it'� Qcj OS^� AkTUN6 OWNERS MMANCEWANFR;I.ammvmhatlheLxa=dcesc d�eitistraroeco�aageoritssu ler�riva asset dbyMassadxst CMU-lLaws andfivinysgtmanonthispesm4t my i,sdasm mmnenL (Please check one) Owner a Agent Telephone No. PERMIT FEE 625 "� .r- r,.�•r y�.^a'>k �'�'!-r'wd`y,`y�n� ;74�"ta:.Y :�"v�+'�-.t�"�'=:t`�'..+.agW;.` ..-1+`T'��;�. r• LocatJV 3 zC _: oil Date `Z TOWN OF NORTH ANDOVER = F p Certificate of Occupancy $ s; Building/Frame Permit Fee $ Foundation Permit Fee s�CHU ' Other Permit Fee $ �� r Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �t 7 �a Building Inspector y 7795. Div. Public Works Locat!on x No. Date }Y{q TOWN OF NORTH ANDOVER � L ' p Certificate of Occupancy, $ Building/Frame Permit FeeJ. $ _ .. cMusEth Foundation Permit Fee $ Y C 'Other Permit Fee $ Sewer Connection.Fee $ is Water Connection Fee $ TOTAL $ ' �y s ,Building Inspector 11/23/94 16:4S, 1 141.SU MID ` 7745 Div. Public Works Location No. 3 Date "0RT1y TOWN OF NORTH ANDOVER - Z. p Certificate of Occupancy $ Building/Frame Permit Fee $ A Foundation Permit Fee $ too — emu Other Permit Fee $ , Sewer Connection Fee ; $ Wafer Connection Fee $ TOTAL 5-Z) ' uiiding inspector 751 -� ' Div. Public Works fQ tocation X L3�CL t No. Date o M°�tM TOWN OF NORTH ANDOVER" . 3j 0.=t,�ao a1ti�OL - A }.. p Certificate of Occupancy $ Building/Frame Permit Fee $ �saAcNustth Foundation Permit Fee $ Other Permit Fee $ tb Sewer Connection Fee $ awater Connection Fee $ _�'� TOTAL $ r BSI i g Ins for H >b AN©V � Div. Publi .Works + 8427 PER11IT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP i-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE K`{ONE I SUB DIV. LOT NO.4ory :F LOCATION gPURPOSE OF BUILDING e ;;OWNER'S NAME NO. OF STORIES o- SIZE , Y _ OWNER'S ADDRESS 9 BASEMENT OR SLA13 .�1 �y„ _ ?r ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD _ .& r. �`fCC� BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING /!® ` DIMENSIONS OF SILLS DISTANCE FROM STREET t�pl '�i POSTS C.7 DISTANCE FROM LOT LINES-SIDES it REAR "7iR'ii 0 "' GIRDERS °�.. AREA OF LOT Ct /;L ; FRONTAGE//, !7 HEIGHT OF FOUNDATION THICKNESS a IS BUILDING NEW y7 4 lam. SIZE OF FOOTING X IS BUILDING ADDITION e) MATERIAL OF CHIMNEY IS BUILDING ALTERATION 1v 0 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GA 5 LINE ye INSTRUCTIONS 3� , PROPERTY INFORMATION LAND COST ` L I bob SEE BOTH SIDES run f+.-�vm, l - ���5����,jv EST. BLDG. COS ���?��{ �/� s" PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.��_] PAGE 2 FILL OUT SECTIONS 1 - 12 y f8A1V`'� .' EST. BLDG. COST PER ROOM IVA ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO.4 APPROVED BY GtI/ ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR - • DATE FILED BOARD OF HEALTH SIGN OF NER OR T RI A T F E E 6 OWNER TEL.H I; PLANNING BOARD Pn',RMIT GRANTED CONTR.TEL. �' I 1114. 19 ct4 CONTR.LIC.t9- t . _ s BOARD OF SELECTMEN PERMIT FOR FOUNDATION ONLY REGULATED BY PARA. 114.8 S. B.C. PERMIT FOR FRAME IeUItDiNG DATE: BUILDING INBPECTOR DATE FEE PAID 1G. FEE PAID.._.___,.._., I _ _ B..UI,,LDING RECORD 1 OCCUPANCY 12 ` SINGLE FAMILY S.ouIES` 'THIS SECTION MUST SHOW, EXACT,DIMENSIONSOF LOT ANp,DISTANCE FROM k� MULTC"',.RAMIE( -,OFFICES _ LINES AND EXACT DIMENSIONS OF' BU1LcDINGS:,:1NITH' PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED:THIS REPLACES PLOT PLAN:, CONSTRUCTION k 2 FOUNDATION 8 INTERIOR FINISH r CONCRETE 3 1 2 I3 - - CONCRETE BL K. PINE BRICK OR STONE HARDW D —_ j \ PIERS PLASTER _ DRY WALL-- ,V — ' UNFIN. `• '' •" _ 3 BASEMENY`•.. AREA FULL IN. BMT AREA FIN. ATTIC AREA ©T f NO BMT FIRE P,LAGES i{ ,-' �% HEAD ROOM 'MODERN KITCHEN 4 WALLS 'I `9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDY D _ ASBESTOS SIDING _ COMMCN _ VERT. SIDING _ ASPH. TILE _ STUCCO OWMASONRY STUCCO ON FRAME- = BRICK ON MASONRY '- i ATTIC STRS. 8 FLOOR I_ (,1•.��.j BRICK ON FRAME CONC. OR CINDER"BtK. STONE-f, MASONRY.. WIRING STONE ON FRAME-' _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING t;^II X11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM \ STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR \' WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS A 17 d 1,10g19� ,10 �'i�$ ' �MI MI OIL td 6 :',��'., .G-Ull .Ohl `I�� GRAJUAR B'M'T 2nd _ ELECTRIC 1st .I 3rd NO HEATING }} -.1011 own of or, over No. 5 0 3 45, 1`_-=Northdover, Mass., 9@4 B BOARD OF HEALTH PERMIT TO " UILD Food/Kitchen Septic System i n BUILDING INSPECTOR THIS CERTIFIES THAT 4lJA4?1 ... �.....�. Q,. .............................""..... ...3.................... Foundation has permission to erect. 0.....�PAn&buildings on ...�&.3.............S5......fe.40 Rough to be occupied as 11`441 .... ?!!!i(1.1. .. .. e r��10.4�........W/..-Z....LAlt...� t................................. Chimney provided that the person accepting this rmit shall in eve re4 conform to the terms of the application on file in P P P 9 P'e every P 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. (PERMIT FOR FOUNDATION ONLY + PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. (REGULATED BY PARA. 114.8-S. B.C. , Rough Final ,, DAIE FEE PAID ELECTRICAL INSPECTOR UNLESS CONSIIZt l t{ Rough ...... ... .. .. .... .... . . . ... .. . .................. Service BUILDIN SPECTOR - Final Occupancy T'e nit Required to Occas f)y BuiLling1l GAS INSPECTOR Display Conspicuous Place on the Premises — Do Not Remove Rough P Y in a Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT FORM U — LOT MM7,IM FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction :' ` ; have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state, law, regulations or requirements. ****************Applicant fills out this APPLICANT: r0rV Phone W/'d LOCATION: Assessor' s Map Nu.�ber - ` Parcel Subdivis ion Lot(s) T Street- ��[.ClU `` � ��tr� St. Nu:zber >� ************************Official Use only*******************x**** RECOMMEN TIONS OF TOw AGENTS: Date Armmoved onsat_on A '~inistrater Date Resected Date Approved !� f Town Planner Date Re;eczad Cc=erts Date Approved Fcad _nszec-„_- ealth Date Re;ec,::ed Date Approved Data Re;ect__ C omr.armP FV Pub__c works - seaer,'water connect_ans Ml k - dr_vewa:r pe=--liell t Fire Demar-men= Recaived; by Building Ir,=_pec--or, r `; Data NOV - 41994 e=/zs cap' L�On OO' i 3 o soy Ate. N o 0 / V `` /a 7..OD�. S .�1ERF�Y GE.�T/FY TO TyE T/TGE 1A1SU.eOrC ANO /pi- or Jb 7f/E OW Mr THgT THE GPCATEO O.V T1/E LaT.lS AND Tf/AT?OAFS GO,(/FGtPiYf AIV T.dE 7vwN' OF,VO.�9 voovER ZON/�vG c�E6�/LAT.I�.c/S �l �FL�6vI.P0/.t/!s SETB�IC�t'S F•POM ST.PEG'TS�GOT L/.aES.'' �.27�,�/ /yNLn�E.e/ /�RSS, S F(in-yE,C GE.�T/FY T//.4T Tom'/,S OM'ELL/N6 /S�t/OT Q�A�N FD�' LOG4TE0/N THE F G FGOioO H.9ZA.�0 A.PEA. o=� JEF BOU.</O.PS�G�ETE•P/�/�/•4T/Oif/ BOU.VOA.PY AT/O�(/ TA,c'E.S/ F,PO,t4 Exrsrivc ,eEL•o,Pps. 6� f'.4.P,f� ST.rEET A.t/DDYE.C, if1.4S.S.vG%//SETTS O/B/O ORTr"'"' ° Town ® / � E ' < Andover No. 503 � L yy tort dover, Mass., NKK A- 1914 T 0 a- LAKE COC HICHEW ICK 7vO� TED PPS\ RC-1.: 1 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System Bq!LDING INSPECTOR THIS CERTIFIES THAT . ....... Sli .�.................. .. ... ... k ,I?►?.......... ... .................... Foundation has permission to erect.4=0.....�A!`�.&buildings on ...lr&.3.......�.SS7......ek 41�aa4 E.... I Rough �s�� g to be occupied aS 211''ESU....�:1!!!n.1. .. .. �kv%).*.........W�....Z....��...�M�................................. Chimney provided that the person accepting thi4s'permit shall in ever reP4 conform to the terms of the application on file in y p pp 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. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. Rough Final PERMIT EXP 6 MO � EEE PAID ELECTRICAL INSPECTOR UNLESS CONS TR . Rough PERMIT FOR FRAME/BUILDING ......... .... . Service BUILDIN SPECTOR DAT E: FEE PAID: Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rou Display in a Conspicuous Place on the Premises — Do Not Remove Finagh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner i PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT Ii�1R£N H.P.°\ELSON �+ Town of 120 Main Street, 01845 °fr`°' , , NORTH ANDOVER (508)X82-t#�3 h BUILDINGt'y;'^'•'' CONSERVATION DiVI510\OF HEALTH PLANNING & COMMUNITY DEVELOPMENT PLANNING CHIMNEY APPLICATION AND PERMIT DATE / PERMIT # 3—C LOCATION lorwvop d� OWNER' S NAME cam' i BUILDER' S NAME 6 4,11 MASON' S NAME MASON' S ADDRESS �O� D c �✓i/./� MASON' S TELEPHONE r, MATERIAL OF CHIMNEY14 , INTERIOR CHIMNEY `��,-P� EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES '7e4.z D(� �' THICKNESS OF HEARTH ZA -- Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: DATE -1c Ole / # r7J raw SIG2IATURE OF MASON CONTR. LIC./l EST. CONSTRUCTION COST/CONTRACT PRICE— PERMIT GRANTED FEE ROBERT NICETTA, BUILDING INSPECTOR INSPECTED REMARKS • ,i t + SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES ,i",r £#�' .r�"•' t+':1 `"e1 d,t ;y�{'° .?F ^fir 4 q_ ,Ja�+i s� `i:'M1'{t� .e xl'tw ,;,^z?K1 �".S!� ''S �' ?y n+ ��`"�t�i, �. � '. °��- � a fYc ,�.. w r� .�*it , -'�,r�{•�' * rn`; FSs t'f fir, y " e '� " .",r t _ k'e'pt r 7F+j "'• a ..3f'#,,�it +Y P .ps;dr �i7, fs 4 •' W '�Zs$'� �( r' ,•pp la4 �t AT �n"a .4' 1' - "�t }y' may.. r2,:iri.yr'+ , ,fid M 12 •>f.'���,^ 441 m 1 r k u r ^r7 r MIQUELLE M.Z.O. GROUP ARCHITECT'S FIELD REPORT r 'ect: Foxwood Project Field Report No: 02 Salem and Summer Street No. Andover, MA Architect's Project No: 4190 Date: 1/4/95 Time:8:30 AM Weather: Sunny Temn.: 25 degrees Prv.cvnt at,Cite T� ,^,lc Tn1-,i >�� rrra ?+� r,i.+. T1 ir7 r,�S�,.t1; p, Architectural Group Work in Pro ess: 1. Lot 3 - The exterior siding is in progress,the framing is substantially complete Observations: Lot3:(Type 3alt house) 1. The steel beam over the.dining should be diagonally braced to the roof rafters to the front of the house and braced to the adjacent structure at end toward middle.of home. 2. The steel beam.at Living to be diagonally braced back to wall by chimney. 3. Provide additional and continuous studs under microlam valley to left of fireplace. 4. Provide thickened wall at entry/living wing wall. 5. Provide proper attachment for microlam valley to adjacent rafter over upper stair landing. 6. Additional stud needed at post to rear of first landing. (It is four studs above landing and only three below.) 7. Wing wall needed between dining and kitchen to end cabinets of kitchen under front of upper landing. 8. Build out soffit in kitchen to match wall along back of stair. 9. M. Bed - Provide better nailing of roof rafters to floor joist along back wall. ... . bra r Report David H. O'Sullivan Vice President M.Z.O. Architectural Group ' `' ,JAN -- 5 r APPZOVED " 'NG INSPECTOR, Town of vft1i An @+A@F M.Z.O. ARCHITECTURAL GROUP, Inc. 67 Montvale Avenue,Stoneham,MA 02180 617-279-4446•Fax 617-279-4448 ..... � K> ��� ,, _ a".aaesa ..._u•u¢,a�°",,"-e.'—'—`o"td':iY'C '�''m.4w�i'wWk��:w.:��I�XeuW_vir�w.`RtaE>_:-rx...._„4:_ .. ...... ... ........... .. ...:r .. _... _., .. ... _. .. .. ... J , 14 CERTIFICATE OF USE & OCCUPANCY Tolm of NoRID, P� f= . y/,f��r lti•...�r Fri 1l . kgg s' Building Permit Number 5d3 Date q-%FTS; THIS CERTIFIES THAT THE BUILDING LOCATED ON` 5 C'�C > �-�`�� UA 3 � ' MAYBE OCCUPIED AS S�PlGLE �n11�t wFW IN ACCORDANCE c h f~{ WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. ,=ns 14ORTN ` CERTIFICATE ISSUED TO 0 ADDRE uR.KPtK� S-r ... ur! rng nspector 7.. °Wa.Y1. > C T-t"A L 62AD t 1.� 'pPr.CIL '�c�'hl°tG�1 "tA 6E CoMPt ct0 -SPR xbb-noe — �p�.tr f I ''•'�O RTP w �xTowno FSE ' over � � ' O cn o = 5 0 �� r y VA dower, Mass., 96( 199,4 T LAKE COC NIC ME wiCK � Pa. � TED BOARD OF HEALTH Food/Kitchen Septic System }y ,, ': BUILDING INSPECTOR THIS CERTIFIES THAT4+�?S?4?►�.......... f 1� 3.•.. ' ........................................ Foundation Baa g Lbr3 ��..... aC.t 4 VAC...... l ` �G as permission to erect. >�?..............!'jl�..buildings ... ... .......� .. .. ..... Roug t� (.M...�N1Y11. ut7���l�l.. LA)/... ....0 ...C:�?��o .......................... C imney �o be occupied as�i 4.. .... . . �.....• �-• �lq provided that the person accepting this iej rmit shall in every respdct conform to the terms of the application on file in in ct q , • "this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Z1 1s Buildings In the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INSUEck t - . REGULATED BY PARA. 114.8-S. B.C. la � 9 y VIOLATION of the Zoning or Building Regulations Voids this Permit. oug Final t PERMIT EXP 6 �O N 1 FEE PAID _ ELECTRICAL INSPECTOR r UNLESS CONSTR iON ARTS PERMIT'FOR FRAME/BUILDING .................. ... .. . Servi ......................... BUILDING I SPECTOR DATE: Z FEE PAID• tl Fina GAS INSPECTOR Occupancy Permit Required to Occupy Building/" ... ---- - Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done r FIRE DEPARTMEt4j Until Inspected and Approved by the Building Inspector. Burner o - PR. Street No. _ PLANNING FINAL CONSERVATION FINAL Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT T)�i f T Y TT h ' `Gvt' C -(d�r�- .��� f . A tic .4 V�<� Cib Ab CQAW- Y i r } idle V - Date. 7. . .... . OF NORTH 1ti o� TOWN OF NORTH ANDOVER ti D 41PERMIT FOR GAS INSTALLATION �..,rte..• �4s,9s q...o .�qh -- y SAOHUSE This certifies that . . .e��/��C(`?l?.!�. .s, . . . . . . !?l has permission for gas installation . . . .r� . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . .. North Andover, Mass. Fee. Lic. No.. . . . . . (` . . . .. . . . VGAS INSPECTOR Check# 4328 MASSACHUSETTS=.tlIV1FOR"M APFUCATiON F0WPVIITT' O DO GASFITTiNG- �d (Print ix Type) P rola✓�d� , Mass. DateL-jjA 20cs Permit BuadingiocatIon. "u, Owners Namelri,/ti// 97F /Flo � �C�� ,Type of Occupancy New-❑ Renovatlon p Replacementijo Plans.Submitted:- Yesp No p N- W NW V = ¢. W W 0 C o' z■. ems- __ ,�. �' p r to dM- Z O" > ICU- lcvIL C_ is W 19a W = V W Wlm. W < ¢ ~` C ~ _ J <- x' W L ¢. d C W 1Y V ?Q:: z < W2 .. < ¢. .. E' ).. 1e m: Z. O. Y_ O ._ . SUB—aSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3R0 FLOOR. 4TH FLOOR STH FLOOR aTH FLOOR TTH FLOOR 8TH FLOOR Installing CompanyWame• AOAc a�n pl u cv.d'x . Check one: Certir>cate:.. Address 5�l4 (2e,,.��.e �4- . p Corporation _u lu rn A . n 1 l Q Partnership_ Business Telephone �76 i- _-,I&-q - ?)S-_ 11,0 A Firm/Co, Name Of Ucensed Plumber or GasFitter �4Le eh -7:T' �T Q , I�c��;*.e:�`:'::�'r°��mr'+►ice° I have aY liab�ity-insu a.polky or-its,substantial equivalent which meets the requirements of.MGL:Ch: 142. es JK No 0 If you have zheeked-3tMlpmm Wksttthe.tAm fcovemge by-checking the zappropriatii box. A liability insurance policy Othecaype ofindenv*p_: Bond p. OWNER'S INSURANCE WAIVER 'I am-aware that the:licensee does'not,have the lrisurance coverage.required.by- Chapter 142 of the-Mass.General.:Laws.-and Mat!my signature-on this permit-application waives:this-requirement . Check one: p Ownerp Agent, Signature of..Owner. Agent_Owners Age .. . 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 ail plumbing work and installations peAomted_under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter•142 of the General-Laws. Tvna of License:Plumber gnat ber or Gas itt. Title M".M'.' dterr License NumberCity/TAPPP4 VE O 1 N eyman BELOW FOR OFFICE USE ONLY` FINAL, INSPECTION SKETCHES PROGRESS INSPECTION r FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME R TYPE OF BUILDING LOCATION OF BUILDING , PLUMBER On GASFITTER LIC. NO. ! PERMIT GRANTED - A DATE_20 ,, p�S INSPECTOR Z .Is'i N )$ f» " oZ BSOSOOSO c WATER.CLOSETS j- KITCHEN SINKS 0 LAVATORIES w� BATHTUB SHOWER 3YALLS ` s � � � z t' g Is �o � C w. LAUNbRY TRAYS ' 3 j VhWBH. I ACH. CONN. i % q $ r ' HOT WATER TANKS m r O t O a g TANKLESS SLOP SINKS ro FL.�OR DRAINS CI ami (SAS T APS ry o s O DR;NKINO FOUNTAIN � Z m a a �_ c AREA DRAIN b WATE rl !0 5 0 ER PIPING S fv c O Cl ti00F DRAINS O M BACKFLOW PnEv cl o �' OTHER FI?TURES: r �; DOILKR STK 7 GREASE IT ; 5( m SCULLERY SINK " SHOWER VALVE 01. S EW, c Z --8i:kvF FOR OFFICE USE ONLY PROGRESS INSPECTIONS CHES FINAL INSPECTIONS SKET. FEE -_.-- NO. APPLICATION FOR PERMIT TO DO PLUMBING UNDERGROUND ROUGH COMPLETE ROUGH FINAL INSPECTION PERMIT GRANTED DATE PLUMBING INSPECTOR Date.�F- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,t ,SSACMUSE� This certifies that �/. . . . . . . . . . . . . . . has permission to perform . . .V�-. h . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing`.in the buildings of B.D.7/1 . . . . . . . . . . . . . . . . . at . :K .L,4,-.q . . . . . .. North Andover, Mass. Fee 3 . . .Lic. . . . . . . . . �. . . . PLUMBING INSPECTOR Check �"J^e; S 5695 MASSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING L (Print or Type) Mass. Date 20 �� Permit # Building Location (� Owner's Name U�` '��* Type of Occupancy New B` Renovation❑ Replacement❑ Plans Submitted: Yes❑ No 0 FIXTURES �.P. # 'SEWER# SEPTIC # to N z z In — Ln uJ Z to < w }q = ��. z = z M0 J-4 W V) w cn _ F U '� cn 2 z a z w O m w Q W ¢ w Z ° a z a p Ci I— U a = a. z Y a 0 z z • LL Y w m v=i 1 01 o = a o o o a °� m o 1 o SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR' 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name !C Check one: Certificate Address (00 PL11-1/70c-rd ❑ Corporation �►IFTdu lt.,� h SSS 61k,44 0 Partnership 2�2Business Telephone �� J Name of Licensed Plumber or Gas Fitter O—Firmlco. INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes No 0 If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity 0 Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ 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 he permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Cha _,r1420 f the General r 13y Title f LicenSI sed lumber City/Town APPROVED(OFFICE USE ONLY) Type of License: ❑Master 01=rrneyman License Number �� � Date. . :. ��.:�..3... . . NORTH '6. 411 X? 4. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACMUSEtSya ., This certifies that . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation tr c f�% . . . . . . . . . . . . . . . . in the buildings of . . . 7 lY. . . . . . . . . . . . . . . . . . . . . . . at . ...5. ,�. . . �"°. . .. ... .. .tet. . . . . . . . . . Y North Andover, Mass. Fee. .�:.,..�. . Lic. No.. . `! f�. . . . . . ` :!�Oy�-,, . . . . . . S INSPECTOR Check# 4419 MASSACHUSETTS UNIFORM APPLIOATi N F®R'PERMIT TO DO GASFlTTING < ,` (Print or Type) j Mass. Dates 6 t� 30 Permit# er y 1`�- Bultding Location J S F�i., ,,-)A - - Owners Name /7 ul? Type of OcCUpancy iP New Renovation❑ Replacement:❑ Pians Submitted: Yes❑ No❑ IV LuLD in uJ er o m in O OLu a O W .52 9 M Z 0 SUB BSMT > BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR. i 4TH FLOOR . STH FLOOR 6TH FLOOR TrH FLOOR 8TN FLOOR 1 -Ins tailing Company Name Address— �, Check one: Certificate; �� � /`-�"� a—Comaration G C � SS Business Telephone ? .❑ Partnership Name of Licensed Plumber.or.Cas Fitter d CAZL7,,4�- t3--Firmlco. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial e Yes-�` No quivalent, which meets the requirements of MCL Ch. 142. ❑ lf.you have checked yes, please indica to the type of coverage by checking the appropriate box. A liability insurance policy a----'Other type of indemnity ❑ Bond OWNER'S INSURNACE WAIVER: 1 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 s perm appilcatins waives this requirement Signalure o Owner or Owners Agent Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted for entered]in above application are true and accurate to the my knowletlpe and that all plumbing wort and installations performed under the permit(esuepp for his a Icau will r in compliance with all pertinent provisions of the Massachusetts state Gas Code and Chapter 142 of the General Laws a best of Type of license: V By ❑Plumber Tidy ❑zaa tter er Signa re of L sensed Plumbor Cas Fitter CiryRown - J 'I APPROVED(OFFICE USE ONLY) Easter license Number_ cj17 ❑.journeyman BUILDING PERMIT of NORTH qti _ 7 �, TOWN OF NORTH-ANDOVER02 /y APPLICATION FOR PLAN EXAMINATION - �` Permit No#: Date Received ATEv�gSSACHUs���� Date Issued: I PORTANT: Applicant must complete all items on this page LO:CATi10Nr _.w _ —r_ O e Print PROPERTY O_ WNER k�iN_�1� '> r�C --j-CD _ - � Print .. a 100 Year Struetu�e'� ��;'y."es�� MiZP =FARC.EL L - ZONING ISTRI,CT: _ ,Historic ®istnct= es o ��. Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Q-Orfe family ❑Addition ❑ Two or more family ❑ Industrial C�1�ration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 'Septic, 1Nell!! ❑¢Flopdplan -7701etlands ❑ 1Naters_hetl�®%stncfTM r ��erlSewer� � A s DESCRIPTION OF WORK TO BE PERFORMED: ►9-r �2Y+Aa�t L i S ria a�Je./ �S ei t7(- I –tc):Ie.T eSSc "(ol 1� l•J I ao� i Ide tification- Please T e or in Clearl OWNER: Name: Phone: $- Address: Od A. I ContractoriName co r' Rhone ? �( 7 — - -- Address S -71 upe_rvisor's`Construction%License C55� ! .7 Exp �Date:_ d l _� Horne lrnprovement'License: �f % -j �_- fExp Date- a� 5 ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESQED COST BASED ON$125.00 PER S.F. :Li-1,71�� ,Icyo Total Project Cost: $ / ,x-75`� '� FEE: $ �-� y� Check No.: eO2-O Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu anty fund SSignatuM of Agent/OwnerE- _ Signature of contractor__ __ _ i i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swinnning 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on _ Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: _ Located 384 Osgood Street !FIRE iDEPARTMENTTemp.PDumpster on site es _ no _ _ �-- t eet 4Ma�n�S r � y IFirerRepartment ignature/date _ ICOMME 4 NTS + y F rr t. ,n - --_ _. : r...A•.-., �.'. i_=;} _w�. �e�i— �»-..ALL,y;d 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) I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 ii I 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 L3 Building pp Permit Application u Workers Comp Affidavit L3 Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract a 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 a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) D 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) o Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 - Copy of Contract u Mass check Energy Compliance Report u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit i 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 2014 i l Location No. D(f_ P3`�� Date 1 1 I i o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee ?' r 0 Foundation Permit Fee $ ' -Other Permit Fee•, $ TOTAL $ 4 Check 27790 'f ` ' Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 171775.00 m $ - $ 213.30 Plumbing Fee $ 26.66 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 26.66 Total fees collected $ 366.63 55 Foxwood DRIVE 063-15 ON 7/18/2014 Bath remodel I r -I ' L NORTH - . W. 0 40 0. c ve . 0 No. �iy - • yah ver, Mass, �. CONIC Nl WI[N � s V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. ..... , %IL..PAM dk.&0..:...................... BUILDING INSPECTOR has permission to erect . .......... buildings on �. d.0�. .�.N. Foundation Rough tobe occupied as .......... .... .. . .:. ...... .C14.I............................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ................................ Service .......... .... .'��s�� Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until. Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 07/1112014 09:34 7813223719 ADMIRAL* PAGE 01 0R& CERTIFICATE OF LI D16/ roonYYYI LIABILITY INSURA 'CE 7116/Zo14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP `IN THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVE AGE 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 ,JBROGATION IS WAIVED, subJect to the terms and Conditions of the policy,certain pollcles may require an endorsement. A statement on this ',rtificate does not Confer rights to the certificate holder in lieu of such endorsement e . PRODUCER NOMGA Commercial Lines r Admiral Insurance Agency,Inc. PHONE (781)599-2000 IAtCFAx 70 Munroe StreetE-MAIL Suite D INSURERs)AFFORDIN COVERAGE NAIC A Lynn MA 01901 INSUReRA:Arbe1la Protect: 45n Ins Co 41360 INSURED -- INSURER B: Eagle Building Company, Iris INSURER 0:- 2.3R Gr®e11 Tres Lane INSURER D; INSURER E B field MA 01922 RERF: COVERAGES CERTIFICATE NUMBER:CL1471618999 RE :ISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE: INSURED N'MED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC[ME:NT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE l'ZEIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR im TYPE OF INSURANCE POLICY NUMBER POLICY EFF POJ ICY EXP LIMITS GENERAL LIABILITY EA I. OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY UA�PR �* $ 50,000 1811 169 occurrence) A CLAIMS-MADE FOOCCUR 8500054969 /21/2014 /21/2015 K)-;XP An onsperson) $ 5,000 PEA IONAL&ADV INJURY $ 1,000,000 GEIS RAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PR I UCTB-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY )INhU SINGLE LIMIT -LEEI,cldentl w A ANY AUTO 90 j Y INJURY(Per person) $ 100,000 ALL OWNED r—yl SCHEDULED 1020008600 11/14/201-1 1/14/2014 00 o Y INJURY(Per accident) $ 300 000 AUTOS AUTOS HIRED AUTOSNO pgWNED PROS ERTY DAMAGE $-ft 44021— 100,000 PIP.(Ialc $ 8,00 UMBRELLA LIAR OCCUR EAC!OCCURRENCE S EXCIESt3 LIAR CLAIMS-MADE AG )EGATE $ DED RETENTION $ WORKERS COMPENSATION VC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOWPARTNERIEXECUTIVE E.L. kCH ACCIDENT $ OFFICER/Ml;MBER EXCLUDED? N/A (Mandatory In NH) E.L. <SEASE-EA EMPLOYE $ If S6 descrlDe under DESCRIPTION OF OPERATIONS below E.L. ;SEASE-POLICY LIMIT $ DESCRIPTION OP OPERATION$r LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESC (9r;D POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREO:, NOTICE WILL BE DELIVERED IN Toxon Of North Andover ACCORDANCE WITH THE POLICY P VISIONS. Attn - Bryan Loathe North Andover, mh AUTWORIZED REPRESENTATIV@ i s scholnick/WHITE ACORD 25(2010105) ®198B-2010 ACORD ;ORPORATION. All rights reserved. INS026(201005).01 The ACORD name and logo are registered marks of ACORD Rightfax N2-2 7/17/2014 7 : 57 : 37 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T 1'IFICATE 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 IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: ACADEMY INS AGCY PHONE FAX 67 RIVER ST (A/C,No,Ext): (AIC,No): E-MAIL HAVERHILL,MA 01832 ADDRESS: 76B9L INSURER(S)AFFORDING COVERAGE NAIC a INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY EAGLE BUILDERS CORP INSURER B: INSURER C: INSURER D: 23R GREENTREE LANE INSURER E: BYFIELD,MA 01922 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE �OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ ENERALAGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-448OP458-14 02/21/2014 02/21/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT 1 $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER BUILDING INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED — BEFORE BRIAN LEATHE BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D IN ACCORDANCE WITH THE POLICY PROVI 1600 OSGOOD ST BUILDING 20 SUITE 2035 AUTHORIZED REPRESENTATIVE N ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP RA rlg is reserved. EAGLE BUILDERS CORPORATION 23R Greentree'Lane Byfield,MA 01922 (978)463-3110 NAME: DATE: Randy&Denise Murdza 7/17/14 55 Foxwood Drive North ort Andover MA I Bathroom renovation description: 1:Remove tile floor, sink,toilet,vanity,tub&shower. (all debris to be put in dumpster) 2.Electrician to install new GFCI outlets above countertop, install(1)5"recessed(LED)light, install(2)5"recessed(LED)lights over sink. (recessed lighting supplied by us) Floor heating w/timer switch. Wire bath vent. Wire heated towel bar. 3.Install new R-21 Kraft faced insulation to exterior walls that are stripped to bare studs. 4. Install blueboard w/skim-coat plaster(smooth)on all,repaired walls&ceilings. Shower walls will have hardi-backer cement board w/2 coats of Red Guard waterproofing.. 5.Plumber to install drain for shower base,replace shutoffs(sink&toilet),install sink, toilet, sink faucet and shower valve(supplied by Owner). 6.Install tile on shower floor&walls.(tile,grout and adhesive,.supplied by owner) 7.Install anti fracture membrane install tile on floor.(tile,grout,thinset and threshold supplied by owner) 8.Install bath cabinets. 9.Vent ceiling exhaust through roof 1.0.Install new trim,to existing bath window,bath door&new closet door. Install base moulding to bath&closet. 11.Install towel racks,toilet paper holders,-etc. 12.Paint Bathroom, 1 coat primer&2 coats finish(color tbd.Material supplied by us). i I \ i 13.All labor is guaranteed for one year.All materials are guaranteed by their individual Manufacturers warranty. 14.All trash to be removed by contractor. PAYMENT SCHEDULE Total contract price is$13,275 i 1/3 due upon signing of contract($4,425) I j 1/3 due at halfway(bath gutted,plumb,elec rough complete sheetrock installed.($4,425) 1/3 due upon completion($4,425) Price includes labor only(unless specified). Building permit is included in price(limited to pricing of contract). One 10 yard dumpster is included in price. Note: Any additional fees imposed by the city of North Andover are not included in the price,(except the building permit). Installation or upgrading of electric panel is not included in price. By signing this contract: Eagle Builders Corporation,Randy&Denise Murdza agree as above. Randy Denise urdzaDake Eag uilders Corporation Date 6 Glen Lewis vnoOffice of Consumer Affairs and Business Regulation r 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 139211 - ( Type: Private Corporation Expiration: 6/24/2015 Tr# 243244 EAGLE BUILDERS CORPORATION; GLEN LEWISvi -` 23R GREENTREE�LANE BYFIELD, MA 01922 Update Address and return card.Mark reason for change. Address ❑ Renewal [:] Employment Lost Card SCA 1 ip 20M-05/11 �e�po�minaa�arveall�a�C�/l/�i+aaae�rcaeCG3 _Office of Consumer Affairs&Business Regulation License or registration valid for individul use only = OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistratlon: ; y The Commonwealth ofMassachasetts ,- - DepaYtmentoflndustrialAccrkks Office of Investigation 600 Washington Street Boston,.NIA 02111 vww.mass govId a workers'compensation bsuurance Affidavit:Builders/Cod.tactor$)Electricians/Pl*i ers ApplPlease Print ant Xv adividuai: �/��l� O4 S U 1 1 Name usiness(Organiz t'�onlPn ) ��� ( �cr/ Address: d3 Z ��e•J 112 e .Jc City/State 1 `��i��L1 A `Z�l �i��Phone#: �'- 3-7 j Are you employer?Check the appropriate box: Type of project(required.} a employer with 1 4. ❑ I am a general contractor and 1 6. [J New cOnstraction em to ees have hiredthe sub-contractors p y iull andlar listed on the attached sheet.I 7 2.El I am a sole proprietor oxr art time partner listed emodeling ship and`havena employees These sub-contractors have 8. E]Demolition worldug forme in any capacity. workers'comp,insurance, g, El Building addition [No workers'comp.insurance 5, ❑We are a corp oragon and its 10 fj Electrical repairs or additions required.] officers have exercisad.their 3.[I Z am a homeowner doing all work right of exemption per MGL 11,E]Plumbingxepairs or additions Myself [Noworkers'comp. c.152,§1(4),and wehaveno 12.QRoofxepairs insurancexe ed.� i employees.[Nb workers'~ comp.insurance required.] 1311 other xAny applicantthat checks box#1 must also fdl outthe section below kowingtheir workere compensationpolicy information. 1_,cmeowuers who submitthis affidavit indicatingthey are doing allworlc and then hire outside contractors must submit a new affidavit indicating such. TContractors that checktbis bo*must attached an additional sheet showingthe name ofthe sub-contractors and their workers'camp.policy information. I am an employeN that isproviding workers'compensation insurance formy employees Bet 0w as the policy anrijoh site information. Tusuxance,Companyblame: ti -e->' '(4-1 S ✓A�C� �`� Policy##or Self ins.Lic.#: �O oZ t - g 4�`f S- -13 Expiration Date: a I 1"r Yob Site Address: )(Wooh �b e-,-vs, f v1state/zip: A C) n(��V c(,� V&.4 Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequ4 dander Section 25A,of MGL o.152 can lead to the imposition of crhohalpenaltzes of a fine up to$1,500.00 and/or one-year MPI so�nent,as well as civil.p enalties in the form of a STOP WORM ORDER and a rine ofup to$250,00 a day against the violator. Be advised that a copy of this statem,entmay be forwarded to the Office of: Investigations of the DTA for insurance coverage veriliication. I do hereby Bert& title lie linins axd penartde s ofpeYjury t}iat the ire formation ppoviclecl a7 ove rs true andeo�a eet, - si atare• Date: n 1 Phone#• 1Y- 1) 5 6 77 Oficial use oPly, .Do not write in this area,to be completed by city or town official, City ox•Town: PermitlJGicense Issuing Authority(circle one): 1.Board of Health 2.BuildingXDepartment I City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Information and Instruction - Massachusetts General Laws chapter 152 re p quires all employers to provide workers compensation for their employees. Pursuant to this statute,,an enriployee is defined as",..every person in the service of another under any contract o�bixe; express or implied,oral or written" Au employdis defined as"an individual,partnership,association,corporation or otherlegaI entity,Or an two ormore of the#oregoiug engaged in a joint enterprise,and includingthe,legal representatives of a:doceased em to ex.or the receiver or°trusfee of an individual,parhrership,association ox other legal entity,employing employees However the owner of a dwelling house having n otimore thau tbxee apartments and who resides therein,,or the occupant of Me dwelling house of another who employs persons to do maintenance,construction or repair work on such clwelfing house or omthe grounds oxbuilding appurtenant thcrefo shallnot because of such employment be deemed to be an,employer" MUL chapter 152,§25C(6)also states that"every state or local lie-easing agency shall withhold the issuance or renewal of a.license or permit to operate a business or to construct buildings in the commonwealth for•awry applicant who has not produced-acceptable evidence of compliance with the insurance coverage irequl geed. Additionally;MOL 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 complianco.with the insurmco requirements of this chapter have beenpresented to the contracting authority." Applicants Please fill out the workers'compensatzom affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphonenumbex(s)alongwiththeir certificate(s)of insurance. LimifedLiabilityCompanies(LLC)or Limited Liability Partnerships(Up)mdthno employees es oth etth anthemembers orpartners,arenotrequirelto c�Yworkers compensanoninsurnce. if nLLCorLLP dosshaveemployees,apol e,yisrequired. Be advisedthattbis affidavitmay be submittedto the Department of Industrial Accidents fog confirmation of:insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be xetuxnedto the city or town that the application.for the perndt 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 insurancece h ase number on the appropriate,xo xiate line. City or Town officials Please be sure thatthe affidavit is complete andpxinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the appRcant. Please be-sure to fll.in the permit/license number whichwill be used as a reference number. In addition,m applicant thatmust submit multiple prmit/license applications in any given year,need only submit one affidavitindica&g current Policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in , (city or towim):'A copy of the affidavit thathas been ofCcially stamped ox marked by the city or town may be provided to the applicant as proof that avalid afCdavitis on file for f iturepermits orlicenses. .Anew affidavitmust be filled out each Year.Where a.home owner or citizen is obtaining a license ox permit not related to an business o c Y x omm.erc'a rl e i.e a v n e do tar license( g h ase orpermitto burn leaves etc.)said Person is ) p NOTxequ7red 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: TN,CQm-.mor wo-altilofMaa -U opaxxaerat o£XxtduxlX Accdc $ • 69��a.��in�an��re�� BWQn, 02111 W 406 Qr-X-87-7;M �M Revised 5-26-05 FRY, �l taSs,go.V/Ch