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10731
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that........./a11h4 I
............................
has, permission to perform ......... 11.7.14 .. I
plumbing in the buildings of
at ..... ......
b Andover, Mass.
'::.� � " .... 4
Fee.-.� .-4�?Lic. No. 11,� I .... ........... �::�
PLUMBING INSPECTOR
Check #
-CN-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Ur'
CITY North Andover MA DATE 811512014PERMIT #
JOBSITE ADDRESS 6 Water Street OWNER'S NAME[Rennie
P
—
OWNER ADDRESS TEL
_ _. T _._ FAX ---
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL E]
PRINT
CLEARLY
NEW: ® RENOVATION: F-1 REPLACEMENT: E] PLANS SUBMITTED: YES[] NO
FIXTURES -1 FLOOR- BSM 1 2
3 4 5 6 7 8 9 10 11
12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _—M
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK_-
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK -_ ._ __-
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING---__-- -_� _ _ .__ .._. .—_
OTHERMain Drain-
70
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej 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 reciuirement.
CHECK 0 ONL OWNE 0 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this ap lication are true a d ccur et th st rriy knowledge
h II P t is%n of the
and that all plumbing work and installations performed under the permit issued for this application w e in com rtin pro
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Timothy A Giard LICENSE # &KNATURE
MPD JP® CORPORATION# 3443 PARTNERSHIP[J# I LLC#
COMPANY NAME Timothy A Giard Plumbing & Heating_ _ ADDRESS I PO Box 782 _
CITY North Andover STATE MA ZIP 1011845 —� TEL 978-689-8336
FAX CELL978 490 7108 EMAIL TGiardplb yyahoo.com
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T e ronnnonwealth o) [t1a,-;sac1&.f?Seid'S
Depart€nett'i of Indushrial Accidents
pce of Invesdigations
600 Ulasltinalon Street
Boston, l'LI 02111
111"WIV.t11ass. f o1ldia
CI
Workers' Compensation Insurance Affidavit: Bisildei-s/Conte-actoi-s/Electi-icians/Plumbers
-
at Information
Niame (B"usiness/Organization/Individual):_ yu �
address.- , n. 4 ter, c `Jl�c
_lty/State/Zip:.j� ���
� Phone #: O
ou an employer? Checic the appropriate bOX:
7re
I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.'
required.]
5. ❑ We are it corporation and its
] I am a homeowner doing all worlc
officers h3Ve exercised their
myself. [No workers' comp.
right of exemption per iv1Gl_.
insurance required.) t
c �15?, J('1); and we. have no
employees. [l,io workers'
comp. insurance retluired.l
Type of project (required):
6. ❑ New constniction
7. ❑ Remodeling
8. (] Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Y applicant that checks box #i must also fill out the section bdov., showing rhetr «•orkers' compensation policy uiformation.
meowners who submit this affidavit indicating they are doing all -oak and then hire outside contractors must submit a new affidavit indicating such.
htraetors that check this boN must attached an additional sheet shotviq the name of the sub-conhractors and state whether or not those entities have
`.oyees. If the sub -contractors have employees, they must provide their ':•orhers' comp policy number.
E; an employer that is providing workers' compensation insurill;ce jor a;�i emplQuees. Below is Zlte policy andjob site
>Yr;EfIfE01a.
trance Company Name:—�)yc)y f _ -_- 'L— ---
icy ',,' or Self -ins. Lic. b:
Site Address:
l-I'wration Date:
City/State/Zip:
ach a copy of the Workers' compensation policy declaratiori page (showing the policy number and expiration date).
ere to secure coverage as required under Section 25A of JJMGL c. 152 can lead to the imposition of criminal penalties of a
U p to �; �9 0 and/or one-year imprisonment, as well as civil penalties in the town of a STOP WORK ORDER and a fine
Ipto ?50.00 a da against e viol ar B ad d that a copy of this statement may be forwarded to the Office of
esti ations of 1�I r ins ranc cover e veri cation.
r hikeby certify EtrEdL the Ji;js air
/1:
rjury that the iir%ormation provided above is Prue and correct.
h
t?f,�iaal rise only. Iso not write irr Mis urea:, to be comph-1-d by city or tIow ; ojftcael_
City or Town:
Pe:-mit/Licetmse H
issuing Authority (circle one):
1. Board orflealth 2. Buildiag Dep:ari-i ent 3. City/Toa•;n t ilerlc gib. Elecuical 1wipect-or 5. Plumbing lnspector
I
Location /t> - 8 W A +e S �
No. 6—C20 Date
Of
NORTIy TOWN OF NORTH ANDOVER
3?•,t`•O ,•,hO
O
A
•
Certificate of Occupancy $
Building/Frame Permit Fee $ o _
s�CHU
Foundation Permit Fee $
1. Other Permit Fee $
' TOTAL $
Check #
17110
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
A k^sig.,^s e�_-�__ ,�+s.`�` �.- r¢&t}x„„ •:
-y^t„ .�t ,� 1 _ ..was ..=reri .. $4.,
, „..., .. _ . , „ .. ,.. ,_
BUILDING PERMIT NUMBER: DATE ISSUED:
3—lc�-o
SIGNATURE: AIM C
Building Commissioner/lEEpector of BWIdings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parol Number:
v
Map Number Parcel Number
/L K
1.3 Zoning Inf�ormation:y
Zoning District Pr osed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Re aired Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private 0 Zone Ontside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
D (�6F P.�7 F— 5 Y� S' a
Name (Print) Address for Service
S"
Signal�tre Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Addi'i.ss
l !
Sigt&ture Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
D—At p L14 5IR1 c�WF-G-
Not Applicable ❑
o L/
Company Name I
-t00 S a M �� S LkY z
Registration Number
-A
Address
Expiration Dat?
Si nature ---.Telephone
X
SECTION 4 - WORKERS COMPENSATION (NLG.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 building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work check
a Hcabte
New Construction 0
Existing Building
Repair(s)
❑
Alterations(s) 0
Addition ❑
Accessory.Bldg. 0
Demolition 0
Other
❑ Specify
Brief Description of Proposed Work:
SnC F- R bio
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
C leted by permit a licant,
11j�iFFICIA L'
USE ONLY,"
1. Building
/ ' !
(. 7 b 0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
D
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
D
Check Number S�
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building pen -nit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I,�% % As Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief r
D-AV 1 P c—A,--s
_
Print) 1��
01
Signature of Owner/Agent
NO. OF STORIES
gl /b b 54
Date
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 s
2ND 3KD
SPAN
DRyIENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
APPLICANT INFORMATION
The Commonwealth of Wassachusetts
Department of IndustrialAcaents
Office of hzvestzgations
600Washington ,Street
(Boston, A(A 02111
Workers' Compensation Insurance Affidavit
Please PRINT Legibly
Name:
Location:
City:A /D n `% F/e, Telephone #: 9 L e�""_ C!
❑ I am a homeowner performing all work myself.
D I am sole proprietor and have no one working in my capacity
13 I am an employer providing workers' compensation for my employees working on this job
Co any Name:
/Jfri%I'15�:,�7/lC�iiL3llrr
Address: -U-11Q Ir
410k r L)i trig i
Insurance •u.. i t '. 'Z k`
I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
workers' compensation policies:
Company Name:
Address:
City: Telephone #:
Insurance Company:
Policy M
Company Name:
Address:
City: Telephone #:
Insurance Company: Policy #:
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment 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 hereby cnder tl pains and enalties of perjury that the information above is true and correct.
Signature: . _ l !� J, �,. ,�� Date: '31 % 6 6 T
Official Use ONLY - Do not write in this area
City or Town: Permit/License #:
o Check if Immediate response is required
❑ Building Department
o Licensing Board
❑ Selectmen's Office
C) Health Department
13 Other
INFORMATION & INSTRUCTIONS
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation
for their employees. As quoted from the "law" 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation
and supplying company names, address and phone numbers as all affidavits 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.
City or Towns
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. The
affidavits may be returned to the Department by mail or FAX unless other arrangements have been made.
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
Fax # (617) 727-7749
Telephone # (617) 727-4900 ext. 406', 409, or 375
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of. Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in: C -- 9
P n r�- z
(Location of Facility)
Signature of Permit Applicant
ho z 0
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
f , .
�..� , _...� _.���_ ✓�e �anvrreoou�eccl/,/ a���aaoac�ivaP,lla�
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR '
Registration; -,104569
Expiration 14/2004
Typex _Private Corporation y
DAVID CASTRICONE_ RO�OFI
�41a - astricone
7 Hillside Road
Boxford, MA 01921
Administrator
it
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' DAVID CASTRICONE
ROOFING, SIDING & REMODELING . REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
7 HILLSIDE ROAD, BOXFORD, MA 01921
In North Andover 978-683-3420 In Boxford.978-887-6147
In Haver)t111978-374-7314
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 describe
Owner's Name...... .a 3 ..9. ................................................... Te hone #.......i�.Z-�.. ./!•• ..........
Job Address ...... 6.1 ... g....... 4 ................ city ... 40,. ... A . Zt:cc! a'rrf ............... State...:... ..............
Specifications:
/Strip existing shingles. t/" pply new drip edge to all edges.
/Apply C'r� 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. '
.........................................................
L�Apply "ielt paper undLrl ent. IiG�i�ll�■1i1� p $ .....................................
1 �}•.
Aeroof using I L� [ � shingles with a �3 year warranty,
..................................................................................................................................................................................................................... .
t -Count rflashhimney. ✓New vent pipe flashing. ✓Legal disposal of all debris.
.w�'..............................��.................................................................................. ................ ...........; ..............
Area(s) to be worl(ed on:
................................................... ........a� ..... �........... ::. ..,� ..........
..................................... ..:..........�.....:......
........ .�
� .I...
............................................: ..... .... ... ..` .....:................................... .. .
.......................................... F. ...... .......�-;....C....�...........
....
......................................................................................................................................................................................................................
One Year Workmanship Warrant Not Transferable)
Manufacturer's WarranChu ecified by man cturer //Materials and Labor to co............................. Payable ...........1.............. on .....
Payable......................... on ....... ............................ i/Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability whilejob 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 as 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 all
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.
7
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 thisL . day of ... .:..� ani..., 20..19.`./.....
Accepted: t • .ff�
Signed.. `:�� .......................Owner
Signed......................................................................................... Owner
Per................................................................. / ' 0 Y `
Re resentntativeve
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