Loading...
HomeMy WebLinkAboutMiscellaneous - 62 WILLOW RIDGE ROAD 4/30/2018 (2)I O N W N O :Z Z N ( Q -0 0 i• v PO O r O =r m S (1) L CD �: , co `D Ch OD (J1 (o 0- Q 0 0 ool G) m CO (n 0 (D M 0 0 < 0 v 3 O D o G� m 3 C7 00- 0 CD v Z 0 M Z m 3 (p 0 D 0 D D (' 0 Q v Q Q o (� 00 m Z- m Z 0 ° SE 0 O 0 CD z° - n O CD O < 0 7 z _ v z 0 O O < 0 0 m N O O CO O CD L C CD N coN O t �'� 101b -1V vyk 4A. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . Tj CITY �/i P�n•i MA DATE 116 1 PERMIT #r haAq JOBSITE ADDRESSLWT OWNER'S NAME 4� POWNER ADDRESS W\SL_ I TELI FAX TYPE OR il OCCUPANCY TYPE COMMERCIAL ❑CATIONAL ❑ RESIDENTIA PRINT ❑ CLEARLY RENOVATION: REPLACEMEN PLANS SUBMITTED: YES ❑ NO NEW: F-1' 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 GAS/OIUSAND SYSTEM � ° DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM' DEDICATED WATER RECYCLE SYSTEM DISHWASHER I,---- _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I' LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK _ 1 TOILET URINAL' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabili 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 Q 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: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true andagmtrate to,1he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian P i ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Kevin Scott I LICENSE # 13258 SIGNATURE MPQ JP r-1 CORPORATION Q# 2438 PARTNERSHIP❑# LLC❑#[� COMPANY NAMEJ Kevin Scott Plumbing & Heating INC. ADDRESS I P.0 Box 446 CITY I Wilmington I STATE F MA ZIP 1 01887 TEL 978-988-3632 FAX 978-694-9977 1 CELL 978-479-8966 EMAIL I kevplumbing@comcast.net t �'� 101b -1V vyk 4A. :�;�`` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organizationgndividual): Address: 1r.0 City/State/Zip:\ w\` N Phone #: TI 1 'i id' 63a Are yram.aern n employer? Check the appropriate box: T ' e of project re uired ' 1.ployer with= _employees (full and/or part-time).* 7. Q New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for mein 8. E] Remodeling any capacity. [No workers' comp. insurance required.] El In I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9. 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [] Building addition ensure that all contractors either have workers' compensation insurance or are sole I L aBluntrica l repairs or additions proprietors with no employees. 12.,mbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � 13. [� Roof repairs These sub -contractors have employees and have workers' comp. insurance.* 6. ❑ We are a corporation and its , officershave exercised their right of exemption per MGL c. 14. ❑Other 152, § i (4), and we have nq oyes. [No workers' comp. insurance required.] p *.Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who snliffiit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors jhat check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors tave employees, tfiey must provide their workers' comp. policy number. I am an employer that is pi'ovidiiig workers' compensation insurance for my employees.' Below is the policy and yob site information. Insurance Company Name: t, Policy# or Self -ins. Lie. #: e— 3����75 Expiration Date _( h, fob Site Address: U,� WV , 'al*_ City/State/Zipk91,t 4J Attach a copy of the workers compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 thepl"penalties ofperjury that the information provided above if true and correct. 4r8 - 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 #: The Commonwealth of Massachusetts f Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 :�;�`` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organizationgndividual): Address: 1r.0 City/State/Zip:\ w\` N Phone #: TI 1 'i id' 63a Are yram.aern n employer? Check the appropriate box: T ' e of project re uired ' 1.ployer with= _employees (full and/or part-time).* 7. Q New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for mein 8. E] Remodeling any capacity. [No workers' comp. insurance required.] El In I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9. 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [] Building addition ensure that all contractors either have workers' compensation insurance or are sole I L aBluntrica l repairs or additions proprietors with no employees. 12.,mbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � 13. [� Roof repairs These sub -contractors have employees and have workers' comp. insurance.* 6. ❑ We are a corporation and its , officershave exercised their right of exemption per MGL c. 14. ❑Other 152, § i (4), and we have nq oyes. [No workers' comp. insurance required.] p *.Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who snliffiit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors jhat check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors tave employees, tfiey must provide their workers' comp. policy number. I am an employer that is pi'ovidiiig workers' compensation insurance for my employees.' Below is the policy and yob site information. Insurance Company Name: t, Policy# or Self -ins. Lie. #: e— 3����75 Expiration Date _( h, fob Site Address: U,� WV , 'al*_ City/State/Zipk91,t 4J Attach a copy of the workers compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 thepl"penalties ofperjury that the information provided above if true and correct. 4r8 - Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract fte, 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 trustde 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 ar '-tenant thereto shall not because of such employment bd deemed to be an employer." MGL chapter 152, §25C(6) als; .es that "every state , (ocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in tine commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". Applicants Please fill- out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy, please call the Department. at the number listed below. Self-insured companies should•enter their self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant, as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia AC40ROQ' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrr" L� 5/26/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Sturtevant, CIC, CISR TGA Cross Insurance, Inc. PHONE(781) 914-1000 FAX A1C N Ext : No)'. (781)224-S777 401 Edgewater Place ApD�.ksturtevant@tgacross.C:om Snits 220 PERSONAL & ADV INJURY_ S 1,000,000 {GE_N'LAGGREGATE LIMIT APPLIES PER: PRO- Lx I POLICY [::1JECT L-1 LOC OTHER: INSURER(S)AFFORDING COVERAGE MAIC# Wakefield NA 01880- INSURERA:The Netherlands INSURER B FXCelsior 124171 11045 INSURED _ INSURERC:Peerless Ins Co Kevin Scott Plumbing IF Heating Inc. 124198 PO BOX 446 INSURER D: I BODILY INJURY (Per person) S Kevin Scott INSURERE: C Wilmington MA 01887 INSURER F: — — 1 1-uvEKAGES CERTIFICATE NtIMBE97'CL1552639530 GCVNJnkt wl1U0=0. 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR I TYPE OF INSURANCE ADDLISUBR POLICY NUMBER POLICY EFF MM/D POLICY EXP I LIMITS A X I COMMERCIAL GENERAL LIABILITY �(i CLAIMS -MADE OCCUR I.._� _ I %C8P31B5448 1 I I I 5/15/2015 III ; 15/15/2016 ( EACH OCCURRENCE S 1,000,000 PREMISE$ EaEocwrU 15 300,000 MED RT (Any one person) S - 15 , 000 PERSONAL & ADV INJURY_ S 1,000,000 {GE_N'LAGGREGATE LIMIT APPLIES PER: PRO- Lx I POLICY [::1JECT L-1 LOC OTHER: GENERAL AGGREGATE 5 2,000,000 PRODUCTS - COMPIOP S 2,000,000 AGG �- C005 5 B AUTOMOBILE LIABILITY ANY AUTO ; ALL OWNED% !SCHEDULED AUTOS 'AUTOS X HIRED AUTOS X I NON-OWNEDI AUTOS i i i ! 1 BR31OS446 i 5/15/2015 I j 15/15/2016 I C MBINED ANGLE LIMIT 1,000,000 I BODILY INJURY (Per person) S - BODILY INJURY (Per acaderd)I S PReOrac�cidentDAMAGE S is C —Xjj UMBRELLALIAB OCCU LAS R EXCESS CLAIMS-MADE 1 j i I COB777929 +( ! 5/15/2015 5/15/2016 OCCURRENCE $ 1 000,000 �EACH ::JS=, 000, 000 1 X I RETENTION 5 10,000 S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y! N ANY PROPRIETORIPARTNER/EXECUTNE�I (Mandatory In NH) If Yes, describe under !D ESCRIPTION OF OPERATIONS below I N!AE.L..L ( I I I WC3185445 j ( 5/15/2015 ; 5/15/2016 jj PER I STATUTE I ER EACH A 500,000 CCIDEOFFICERIMEMBEREXCLUDED? EL DISEASE _ EA EMPLOYE S 500,000 --- _ E.L DISEASE - POLICY LIMIT S 500,000 � I I II DESCRIPTION OF OPERATIONS I LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached S more space Is required) ACORD 25 (2014/01) INS025 (201401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gregory/SP3 +1 F46-- ; U 19BB 2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Location—` u�-�-�..�-' �c�� � .r,' f �,:� No. .?3/ � Date /Z NORTH Of TOWN OF NORTH ANDOVER • OL . - 1 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ O `� 'Check # IZ-6 �U r ' PI. - 15 2 I. - 15L 2__3 % Building Ins or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 97, BUILDING PERMIT NUMBER: DATE ISSUED: 2 SIGNATURE: 4a4iW p7rA� Building Commissioner/I for of Buildings Date -Z- Z JL�I:liVPl 1-J11E 1PI1'VK1VlAl1V1V 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ap 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 Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ` Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 L,ipcensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: .3 S V A104T/1' 1-2%G*044r License Number Address S LSS 0 0 7 7 17.' Co 3 z Expiration Date Signature Telephone —LL C)9 / „2 oU 3 3.2 Registered Home Improvement Contractor Not Applicable ❑ arc e- �-� �� -5- Company Name �le-2 6P 3 S 'K Registration Number Address �/ l -" e. 6� �� �1 �—c� � S / Expiration Date Signature Telephone SECTION 4 - WORKERS 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 building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 DesciA tion of Proposed Work check av applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify 4 ! Brief Desc 'ptibn of Proposed Work: ' SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant O ICLALIUSE ONLY x 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO AE C MPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, „ /-/�!/� /Ij A:—L L , as Owner/Authorized Agent of subject property Hereby authorize /fav A -e "r to act o My beh ; ' -19TH afters rel o uthorized by this building permit 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 Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 sT 2ND 3 SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMI IEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Visit Our Showroom At 354 N. Broadway Salem, NH 03079 Weds. - Fri. 12 - 4 Sat. 9 - 12 Tel. (603) 898-2259 Fax (603) 898 - 2816 PELLERIN Famous Brand Names CertaVINYL SIDING Mass nteed • Mastic P , Alcoa 111C. Andersen Harvey Proposal -Agreement Therma-Tru PROPOSA} SUBMITTED TO (PHONE DATE Y STREt=T % / JOB NAME CITY. STATE d ZIP CODE JOB LOCATION fL/ / I L'L1/v l /'7 We hereby propose toJurnish all materials and labor necessary for the completion of the following products in accordance with the specifications and drawings ^'19)j.{!eG, ✓ �.2' Cj ��/>.�.� µ:.L,� �`l7C �.� (,(/ i. If -1 G -L t L ii✓t / ✓l LMt et��`/`"�. J `�Iii�C�-- l".'l� �/� 7 1 �i.�. \ � _,1J �-.�� S L.✓ Iu� !� mac. � �<_. S LLc" cj , ,. �l � cam. �� . � :� c� , . l � 1 �:z .�, ,.r. :�� �v�C w . L ,� s �.� l.� It •� /�< �� s �� , �n� � , s� << t r` /o l_s < tl�kece 6,'gce!� j/,',j'Zk 5 rt,6'� f;7 4 (a a'�'l GU), P14"11_"k_ Total contract price is L .L%1 '✓� �`"`� `�Y '"- dollars ($ r -T PAYMENTS TO BE MADE AS FOLLOWS. ^ 3 del., A v'7 S t /�✓T � �3 / � µ. l Q `'� Li (L � � �e'i�1a-r - �:1"1 ` 3 vbL'�^ L l -�-�✓J � +�I�,-� Ltd ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED ALL WORK TO BE COMPLETED IN A AUTHORIZED WORKMANLIKE MANNER ACCORDING TO SPECIFICATIONS PER STANDARD PRACTICES SIGNATURE ANY ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS INVOLVING EXTRA COST WILL -�r BE EXECUTED ONLY UPON WR(rTEN ORDERS AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE ACC E PTANC E OF PROPOSAL - THE ABOVE PRICES. SPECIFICATIONS AND CONDMONS ARE SATISFACTORY AND ARE HEREBY ACCEPTED YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED PAYMENTS WILL BE MADE AS OUTLINED ABOVE CUSTOMER HAS THE RIGHT TO CANCEL THIS CONTRACT UP TO THREE (3) DAYS AFTER DATE OF ACCEPTANCE SIGNATUR c� �(::�,% DATE OF ACCEPTANCE /C /J %1,I / SIGNATURE -,- -- Y ✓�17f' C/IILAl07dU�fl�r!/1. O�� '(CGJ1G,c�!!.� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 037603 i Birthdate: 04/17/1951 Expires: 04/17/2002 Tr. no: 18687 Restricted To: 00 KENNETH W PERIGNY 5 MCGRATH ST SALEM, NH 03079 Administrator BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 033077 Birthdate: 08/13/1950 Expires: 09/13/2003 Tr, no: 2831 Restricted: 00 PAUL A PELLERIN�- 29A HOBBS RD («a v —e _ PELHAM, NH 01,076 Administrator _ — HOME IMPROVEMENT CONTRACTOR I W ' Registration: 100286 - Expiration: 6/15/02 Type: Private Corporatio PEIIERIN VINYL SIDING Kenneth Perigny (��, _ ;, i; s a•� 354 N. Broadway A[WINAHATI C — Salem NH 03019 StateLine Container Services P.O. Box 2063 Salem, NH 030"1 BILL f� r" LA 5 Pelleru , " 354 Nc Salem, `G �° 6s a 63bAL, Invoice DATE INVOICE NO. 11/15/2001 1599 v TERMS DUE DATE Job Location Due on receipt 11/30/2001 14 Kyle St. Salem ITEM DESCRIPTION QTY RATE SERVICED AMOUNT Can; location A 15 Cu. Yd. up to 2 tons 1 325.00 11/6/2001 325.00 Thank you for your business. Invoice Total $325.00 Payments Received $0.00 Balnce Due $325.00 ..__ T .//{I f' l!'O llAiltOltUivfil�/1. b`J.. '!/,ClJSI1.Clt.116P.�,Q BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 037603 Birthdate: 04/17/1951 Expires: 04/17/2002 Tr. no: 18687 Restricted To: 00 KENNETH W PERIGNY 5 MCGRATH ST SALEM, NH 03079 Administrator BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 033077 Birthdate: 08/13/1950 Expires: 09/13/2003 Tr. no: 2831 Restricted: 00 PAUL A PELLERIN� 29A HOBBS RD PELHAM, NH 03076 Administrator `ir.er-I/' HONE IMPROVEMENT CONTRACTOR j -i Registration'100286 ,41 Expiration: 6/15/02 Type: Private Corporatio PELLERIN VINYL SIDING Kenneth Perigny 354 N. Broadway ADMINisu,nTOR Sales NH 03019 G U A R Dr INSURANCE �r GROUP Workers' Compensation and Employer's Liability Policy NorGUARD Insurance Company Policy Number PEWC224950 Renewal of PEWC120802 NCCI No. [25844] [1] Named Insured and Mailing Address PELLERIN VINYL SIDING INC. 354 N. Broadway Salem, NH 03079 Federal Elmployer's ID 02-0507229 Risk ID Number 280007536 Agency POLLACK INSURANCE AGENCY Towne Square Office Park 12 Paramenter Road Londonderry, NH 03053 Agency Code: NHPOLL10 Insured is Corporation [2] Policy Period From June 29, 2001 to June 29, 2002, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: New Hampshire B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: WC OOOOOOA - STANDARD POLICY WC 000001A - INFORMATION PAGE WC 000308 - PARTNERS, OFFICERS & OTHERS EXCL. END. WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR WC 000404 - PENDING RATE CHANGE ENDORSEMENT WC 000406A - PREMIUM DISCOUNT ENDORSEMENT WC 280601 - NEW HAMPSHIRE SOLE REPRESENTATIVE ENDT WC 280604 - NEW HAMPSHIRE AMENDATORY ENDORSEMENT [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 6,837 Total Surcharges/Assessments N/A Total Estimated Cost $ 6,837 1N I LKNAL USt cm CCD Page - 1 - Information Page MGA : PEWC224950 Date : 06/14/2001 WC 000001A P.O. BOX A -H, WILKES-BARRE, PENNSYLVANIA 18703 co O A o . c c m c c �3 O u o w v cn 04 o U z ,.a C Or- -v C O w x O w v a U G x pG W z � a�-0 O w G x W U W O u: u w G w x O a z d O w —Cis C w z d a ;L4 v r 7 cra u z cn o E v) Q _ H COD W H m W ca COD 16- 0O3 H O C `. vV �t •d C 0c :s o O 40 0 Ea c r V CD a N 0 0 C N _A N14: v 0 o Z 3 N :0. c 0 C � a ` H A E N Z r N O N C 0 C: cm C 3 m `2 a c 'c N 0 O Z 0 cm CD O G3 Z O D CO2 h E L C O i7 CO) 0 0 v .Q CO2 O C.3 ft _cc Q. CA L 0 v co C. CO) C 0 CM C Q C O� m m 0 W (r LLI cr W U) CO W0 ac.� LA 0 ; C O Q C Z cO2 'w o :0� Z CL 0 c o 0 N 0 C O 0 d� rO+ N 0 0 0 rN MCD .y C r Z A C .E 0 0 •N 100 OOOa CL O.O O a mm rO. H O $ a� m E N Z r N O N C 0 C: cm C 3 m `2 a c 'c N 0 O Z 0 cm CD O G3 Z O D CO2 h E L C O i7 CO) 0 0 v .Q CO2 O C.3 ft _cc Q. CA L 0 v co C. CO) C 0 CM C Q C O� m m 0 W (r LLI cr W U) N2 2 167 Date ... CZ::r ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING '-�' ......................................... This certifies that ............ ................................ . has permission to perform_....:. ............. / ell wiring in the building of ........ i ............................................... at North Andover, Mass. ..... r7 .. . ....................... Fee .`7 ........ Lic. No . .............. ......................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer nW C0W0NWE LTH4FMAS5AC.f&MM ofonly DEPARTIKFNT0FPUB1ICS4FM Permit No. BOARD OFMEPREVEMTONREGMTIOASS27CMR 120 Occupancy &Fees Checked APPUCATION FOR PIRMIT TO PERFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE W[TH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat 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) 4 J W j t L1J,/ Mr Owner or Tenant g1d T I( & e /yam f Owner's Address artm L Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overheada Underground No. of Meters New Service Amps / Volts Overhead r--1 Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work STi9-GZ u / /,i tit, 1vry1 Tet9 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA and ound No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total -► Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local = Municipal Connections Other No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• htVdreCa� RnuattiDthem4ma»atsofMassadtta�CtnaalLays lha%eaomtttLiabihtyhtL==PohcymdLdmgCurpl&CovaageoritsmigmMoWh-Aa* YES ED NO a Ihaw%hnittedvaWpoo(ofsmne1othe0ffi=YES F1 NO Ifjwha,,edrdWYES,pleaseadc*thetWcfcowa bydakigthe INSUR.ANiM a BOND OIIER ftmSpe*) WadctD&W Est m;*d VahaedEk1id We k $ >;tial FIRM NAME r Z L46,7- I==- � ✓� � I fW Sigr mae ° �_ LiomseNo G � BLsixssTd% U 7 Al 6-r—J' Iii% G(/4AkTel. Na OWNER'SIIWRANCEWANER,Iamaw=ftAtheL.im nse to I gtheit>SLraneoL oris >balegt> ItastecpmedbyMtls�cfiseltsGeoaalLaws a4dthatmys�eonthspt�appGcationwate�this te�nali (Please check one) Owner a Agent 17 Telephone No. PERMIT FEE $ Location No. ' -3 a Check # /a'/ —" Date /-j , / TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $'�/ Building Inspector LA N 70 2, _ y Y w i 2 z � - j Y .T, n A m 6A Y = LA N S Y Ln i 2 T. V: - j w m 6A = S m Fn � 2 .G i �o n RI IA c ,y a Z 7D m 'Si f�1 Nfin LA N C N /R m ✓. m N T. V: - j = Fn � .G �o n RI IA c ,y _ Z 7D m 'Si f�1 Nfin Z O •Z r A n Ar p % H ++r• N d 1 LA N C 2 2 � = Fn � .G n RI IA c _ Z 7D m 'Si f�1 Nfin Z O •Z n Ar p \ � H ++r• N d LA N a \ � k � n T. •Z n H N LA N FORM W - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. a&1/IAm4_ APPLICANT FILLS OUT THIS SECTIONAPPLICANT &46i"4" PHONE -W- - 3Zo LOCATION: Assessors Map Number, 17 PARCEL SUBDIVISION LOT (S) A9A STREET Ch1 lGr! O&I 94 f7&,2__ �D, ST. NUMBER OFFICIAL YSE ONLY***��((*****\\****** I co Ps r,REZO"MENDATIONS OF TOWN AGENTS: ATION ADMINISTRATOR DATE APPROVED DATE -REJECTED TOWN PLANNER DATE APPROVED r1� DATE REJ9CTED COMMENTS 1 FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED _ OR -HEALTH COMMENTS G /; ,_:.._�'�; _".9 DATE APPROVED /T DATE REJECTED PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT U LI /� • G Z _�� FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE 12/02/1999 15:19 9786886008 GREENE PAGE 01 . vA4 To:A niti a y L t _ 5 AVIJIA N +C ------------------------ 1 WAY certify that the above Nortgagt Inspection Plan was prepared for ase to connection with a a" Nort%agt ad is sot intended or represented to be a property line or 1409 surveJ. It cannot be Used for establishing ftsct, hedge , villa of building lines. No responsibility is elttndtd herein to the land Omer or occupant. The location of the crigisal bailding(s) as shoes herein was in cosplianct with the local applicable Tonto% bylays in effect when constructed. with respect to horizontal disenste»sl requirements, or is #wept fres violation enforcement action onder Mass %.l. Title P11, Chop. 40A, S". 7, unless othtrwist shorn herein. Subject buildia%(s) lits 1H a flood Tont designated lone:_ C- _ and shown on FIRM nap co.rwlity-rant/%_ _ 0�2�_Px_� a-! ------------------- JCD, D CWMTED, LAND USE E OE9EIDPNENT CDNSULTAM 4 AUTUMN LANE, MTipl I M 01844 M-683-9932 William Barrett Homes DIV. OF COLONIAL VILLAGE DEVELOPMENT CORP. '. (5013)682-2320 1049 Turnpike St. No Andover MA 01845 (508)682.2397 fax CONTRACTOR AGREEMENT THIS AGREEMENT made the 25' day of October, 1999 by and between Colonial Village Dev. Corp , hereinafter called the Contractor. 1049 Turnpike Street North Andover, MA 01845 and Cathy Greene, hereinafter called the Owner. 62 Willow Ridge Rd North Andover MA 01845 Witnesseth, that the Contractor and the Owner for the consideration named agree as follows: Article 1. Scope of the Work The Contractor shall furnish all of the materials and perform all of the work shown on the Drawings and/or described in the Specifications entitled Exhibit A, as annexed hereto as it pertains to work to be performed on property at 62 Willow Ridge Rd Article 2. Time of Completion The work to be done under this contract shall be commenced on or about January 5, 2000. Time is of the essence. Article 3. The Contract Price The Owner shall pay the Contractor for the material and labor to be performed under the Contract the sum of $31,269.00 Dollars , subject to additions and deductions pursuant to authorized change orders. Article 4. Progress Payments Payments of the Contract Price shall be paid in the manner following: 1st. At signing of Contract $9,381.00 2nd. At Rough Inspection $9,381.00 3rd. At substantial completion $9,381.00 4`''. At completion $3,126.00 MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.0 CITY: Lawrence STATE: Massachusetts HDD: 6235 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 11-30-1999 DATE OF PLANS: November 30, 1999 TITLE: Third Floor Shed Dormer Alteration PROJECT INFORMATION: Cathy Greene 64 Willow Ridge Road North Andover, MA 01845 COMPANY INFORMATION: William Barrett Homes 1049 Turnpike Street North Andover, MA 01845 COMPLIANCE: PASSES Required UA = 107 Your Home = 98 Permit # ; Checked by/Date ; Area or Insul Sheath Glazing/Door Perimeter R -Value R -Value U -Value UA CEILINGS 1175 38.0 0.0 35 WALLS: Wood Frame, 16" O.C. 550 15.0 3.0 37 GLAZING: Windows or Doors 75 0.350 26 COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date the Commonweafth of 9Kassachusetts [Department of IndustnafAccidents Office of InvenVations 600 Washington Street Boston, 5W 02111 Workers' Compensation Insurance Affidavit APPLICANT INFORMATION Please PRINT Legibly Location: ��% !l,��L%rx,�) Llj�,L- QI&D City. 14ND6t/e,K (•/4.A,– —Telephone #: 10�178-lolfh`11,04- 5 O I am a homeowner performing all work myself. I am sole proprietor and have no one working in my capacity )�I am an employer providing workers' compensation for my employees working on this job Company Name: ti 11(1 Y1(11 '(1 r Ci/ �"1rn£ Address: tL Np SVVTa} City: 1 � ' ` of 4 oo�q n Telephone #: Insurance Com an : h Polic #: O I am (circle one) sole proprietor, general ntractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City' Telephone M Insurance Company: Policy # 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 $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby ceryy under the pa'n and penalties of perjury that the information above is true and correct. Signature: Date: �/l�✓ereng�,i^t �, Print Name: O Phone # _ &Sz- 230-z) Official Use ONLY - Do not write in this area City or Town: ❑ Check if Immediate response is required Permit/License #: Contact Person: Telephone # ❑ Building Department ❑ Licensing Board o Selectmen's Office ❑ Health Department ❑ Other BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: DLLW'p-5� o0 b Location of Facility 4addre of Permit Applicant [bad NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector :.$'U6EWA U E - °I�iPOPoSED :.E:�or �TRAt)�NG • O&AS•T C'©, - LOCAr�ow: Goi'-. RDiv W 4 'rho Aro 11.E;zZ, Alol` s 4S� a IZ G� . _TYPE OF : �UlGQfiVG 9 d EA ROOArj - � r GARA(:;E`CEGG,gR_PCUA%I/�c/C, iAGl4/T/ESS" 'GDW ;e!;T1A-f,4 rk ¢DP:1a AV - R14 2 A 7 i9BSD.eoT%ON :i4�E.4' �G.Yi t.S:f' i9.50:pT/G�'.T� . , r. } -`'�' *y.-1 :�'` �PERcoGAT!'O�ll TESTS a,;Jt �. t�"i'"' '•r- mr'Z .� �� t'� -. .,�¢ T4P,• EL"Et/RT'�oh! y , . ��.�-.Q �, '`� ' r � .� � 4�, SATU�MOA41 xa /Yt•tJ. `r` r? - 6 t F`,3 a BDTTOiW1 VAT � 4 , BY tl0 AA11.)6VE-i' dF z , BY tl0 AA11.)6VE-i' dF vt P �3d EL f 38. f (o /�' � � ', 9 '�Csi� ; ` � f �'�.� i,,,� .< �,�, �� .,�,/'/y `•�.�.;,r-';�,. /fj� �s n 74a;d Q t Nt 12/17/1999 12:20 9786886008 GREENE PAGE 01 12/17/1999 12:23 9786886008 V GREENE PAGE 01 64. 5�,e! tf z Ti 047' Jp�, �L a dP—Z 3N � N w 4 f GREENE PAGE 01 64. 5�,e! tf z Ti 047' U) m m Cf) 0 m C •f CO) 10 C z co O a r- CO W d D� O o p CL t= CD o EK O CC CD CA CD O 7 im d CD O r+ CD CD V�' CD y O 0 CCD 0 co c ?- O d =_ 0 a0 m N CD CO'f m n N m Q C 7CD h -1 O m N C y C2 m m mCD n CA O A N O rw O ZL•n O O Lon. Cf � o m y x n � a Q o 5 5 CD CDm N 0 0 3 N rte„• d CCD_ C N N �� 47 m wN `a 5 a C., O cn oOQ Z (� 1r Ova < ^n ;o ° TS Ito o a O Z �. o �r.: 7o 0 _ p �� m CD OiQ n CD n a 0 .T N Ct7 n O rri CDCD r a cmm V ^ `1 tC C d ate• f "C, " f N o._ CO) CD C) o 0 � CD � zo C.5: O n: O c ?- O d =_ 0 a0 m N CD CO'f m n N m Q C 7CD h -1 O m N C y C2 m m mCD n CA O A N O rw O ZL•n O O Lon. Cf � o m y x n � a Q o 5 5 CD CDm N 0 0 3 N rte„• d CCD_ C N N �� 47 m wN `a 5 a C., O cn oOQ Z W O : ^n ;o ° TS m 7 o �r.: 7o 0 _ p �� .•« m • n CD n a � 0 .T N Ct7 n O rri CDCD :e A ate• f "C, " f o._ 0 � CD z 0 4K cn ? cn oOQ Z m ^n ;o ° TS m 7 cn 7o 0 Crz ^n 7 0 n ^n a n a � 0 Irl 0 Ct7 n o o rri W L- L- P� �� PWY-Cf ; 62 mL rb Ems ' PATE: � R f \� �rg�r MHOM2 \ �R�E �A& �9� � �U�� PU OF |NU HOM� [ VAIIU\ ANP �/fU\ NCAA . . 2 b u D I 1-n Q EY15TWMN srAlEs o Z d 713 - n c Q" Z5 1 i i j r. } 1 r k 62 W WOW p1196� POAl2 scw E, A5 NOMn NOM, ANf70\U, / i3 U I L P F-12F r- N F- H HEEr nnE: VIM FLOM 5HW Paver AnnmoN � I 01V1�5 i 0