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HomeMy WebLinkAboutMiscellaneous - 65 BEAR HILL ROAD 4/30/2018 65 BEAR HILL ROAD 210/064.0-0080-0000.0 1 I � t Date... ... .. ........... CF NOwrh,� 3i; oo� TOWN OF NORTH ANDOVER PERMIT FOR WIRING gBACMUS� y , This certifies that .... ..N Q..0 M��� .................I................ . .................................................................... has permission to perform ............................................................... wiring in the building of......`�.�..0/�? f'�?., .............................................................. -sat ...... . C5...... 'P -.f�`�\.:..4` �!j.................N h ndover,Mass . ................. Fee. �!~"""�..,........Lic.No�,......��. �� .......... .................. .................. .. .... .. ELECTRICAL INSPECTOR Check# 2— U�- �: z0q 5 13 0 &\ Commonwealth of Massachusetts Official Use Only • Permit No. i Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTWINK OR TYPEALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noticef his or her inton�perform the electrical work described below. Location(Street&Number) /��'X" Owner or Tenant U Telephone No. Owner's Address 0-7-1-1 Is this permit in conjunction with a buildinpermit. Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed EIectrical Work: -e �- Completion of thefollowing table may be waived by the Ins ector of Wires. No.of Recessed Luminaires G No.of Ceil:Susp.(Paddle)FansNo.of Total ` Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 1:1 o.o Emergency Lighting O rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No. of Switches No.of Gas Burgers No. of Detection and InitiatingDevices No.o g Tons g No.of Ranges No.of Air Cond. Total Nf Alerting Devices No.of Waste Disposers Heat Pump NumberTons KW - No.of Self-Contained Totals: "'" "" .................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent i P s No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eq uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5-6� (When required by municipal policy.) f� Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless S the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covers is in force and has exhibited roof of same to the permit issuing office. g p P g CHECK ONE: INSURANCE EVBOND ❑ OTHER ❑ (Specify:) X certify,sander the pains and penalties ofperjury,that the information on this application is true anal complete. FIRM NAME: LTC.NO.: Licensee: SignatureLIC.NO.: �/ U j L�L (If applicable, nter"exem in the license nber line.) Bus.Tel.No.• Address: CCS jI C,��� ,/o(Gw S� Alt.Tel.No.-• *Per M.G.L c. 147 s.57-61 securi work re uires De arhnent ofl?ublic Safe "S"License: "c.No. > q P tY OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed r on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the r y notification of completion of the work as required in M.G.L.c.143,§3L. i Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written ' application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Q Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: y ROUGH INSPECTION: Pass❑' Failed 0 Re-Inspection Required($.) ❑ Inspectors Comm ts: - 3 Inspectors Signature: Date: FINAL INSPEC YON: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Com s: 0 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i The Commonwealth of Massachusetts - Department of Industrial Accidents i 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 Legib Name(Business/Organization/individual): 7WIr-, Oz,,�r_e Address: City/State/Zip: (,/7�/fps C� - Phone#: Cj1/ z 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 emyees(full and/ox part-time)* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. �• El Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, El 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 1111 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' 1311 Other y comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they hire doing all work and then hire outside contractors must submit a new 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. lam an employer that isproviding woYkers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required-under Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yearimprisonment,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 c -tinde l_- ns andpenadties ofperjury that the information providedab a is fru and correct. - Si e. s��//� � Date: Phone#: ' Official use only. Do not write in this area,to be completed by city or town-offsinl. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing�Inspector 6.Other - - ` Contact Person: _ Phone#: r r _ 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 beenpresented 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 number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the - members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have t 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 in any 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 r town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox 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 ComjAomwealtl ofMossachvsetfs Department ofladustrial.A,ccidants Office ofIavestigations 600 Washingtoa Street Boston MA,02111 Tel,#617-727-4900 est 406 or 1-877:,MASSAFF, Revised 5-26-05 Fax#617-727-7749 vttVW_mace OFA-uli;a • Date................. ! ................ NOwTiy °� •�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACHUS� This certifies that ...K ` �� has permission to perform V e qY\0.J.c..1...C�(.,s2A ........................................ wiring in the building of.. A ............................................................................................. at��.:J....l .Q.. '. 1.........................................>..N... Andover,Mass. Fee....:- ! .........Lic.No3h� .. ..rl. ...... t....t. ........ LECTRICALINSPECTOR ^heck# 19 T) r F�)W�16 V. �Izcql ,q Commonwealth of Massachusetts Official U ly e � Permit No. 12A Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 10 S C7 yf*L �t t LL. r<C . Owner or Tenant U N A "kl N r E(L. Telephone No. Owner's Address \oS ykE:uR wtu-- (LN Is this permit in conjunction with a building permit? Yes '® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters t New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: #j ALL. �N Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA 1 No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 2 Swimming Pool Above ❑ In- ❑ o."Emergency Lighting rnd, rnd. Battery Units No.of Receptacle Outlets k No.of Oil Burners FIRE ALARMS No, of Zones No.of SwitchesNo.of Gas Burners No.of Detection and kP 2 Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained .................._. Totals: ��� .. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Connection El Other Connection �. No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IlP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (aoa.06 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C RAGE: 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 V undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify,tinder thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: - E LA - tLIC.NO.: 2 a 2 A Licensee: Ib LE LrcAAIA-- Signature LIC.NO.: \S�,nLot, (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- Address: :7-7 �® -;T. U-oUts nIP4 030411 Alt.Tel.No.•X1-7$-490—2 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$b Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with-the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an yi 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.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-tern economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Commen Q Inspectors Sign ure: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 12- Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ti The Commonwealth of Massachusetts , - Department oflndustrucl Accidents Office of Investigations 600 Washington.Street .Boston,MA 02111 vmmass gov/dia Workexs'Compensation Insurance Affidavit:BuUdersfContractors/EIeclricians/Plumbers Applicant formation Please Print Le�itbly � Namo(Businessiorganization&dividual): f-GI.A�Q EuF�cfL�f Address: —7-7 i City/State/Zip: �_Aqu t s r`)g czo H!? Phone If: q-?,q-49 r, tL9 7 Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with 4. ❑ I am a general contractor and I 6. [1 New construction employees(full and/or part-time).* have hire dthe sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ship and1aveno.employees These sub-contractors have 8. ❑Demolition working for me in.any capacity. workers' comp,insurance. 9. �Building addition rKo workers'comp.Xnsurauce 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised.their 3.01 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing,repairs or additions myself.[ffoworkers'comp. c.152,§1(4),and we have no 12,QRoofrepairs insuraacerequired.j t employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicautthat checks box#t must also RU outthe section below showingtheirworkers'compensationpolicy information. Homeowners who submitihis affidavit indicating they ki doing all work and then hire outside contractors must submit anew affidavit indicating sueb. 1'Contractors that checkthis 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 Bellow is the policy and job site inforination. Insurance Company Name; Ak r^ rn.sry At Policy##or Self ias.Lic. kon-•L o S k9 cl Expiration Date: S/I S rob Site Address: I S K ti,\e- 1A it,k- City/Statelzip: J1 iwL�.0.,E 0-- Mq� Attach a copy of tie workers'compensation.-policy declaration page(showing the policy number and expiration.date). Failure to secure coverage as regynedunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a tine u to 1,50 0.00 and/or ones- ear im nsonment as well as civil penalties in the form of a STOP WORK ORDER and a fora p $ � y p a o u o 250 00 a da a airlst the violator. Be advised.that a co of statement be forwarded to the Office of fpt $ yg copy Y I� Investigations of the DIA for insurance coverage verification. I do hereby cextM under the pains and penaltles ofperfury that the information provided above is true and correct. - Si attne• Date: h - -k Phone##• 9 IR -y'ir, - 8gzC Oficial use ox1y. Do not write in this area,to be completed by city or town official City or Town: Permit/License 0 Issuing Authority(circle ane): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone M Information and Instructiol.s Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuarit to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express or implied,oral or written.." An employeiis defined as"an individual,partnership,association,corporation or other Iegal entity,ox any oxmore of the foregoing engaged in a joint enterprise,and inoluding the Iegal 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 notmore than three apartments and who xesides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction orrepair work on such dwelling house or on,the grounds or building appurtenant thereto shall not because of such employment be deemed to bean 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented 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)andphonenumber(s)along with theircertificate(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 thatthis affidavit maybe submitted to the Department of Industrial G 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 OMcials Please be,sure that the affidavit is complete andpxinted legibly. The Department has provided a space at the bottom of the affidavit for you to fffl out in the event the Office of Investigations has to contact you regarding the applicant: Please be-sure to fill in the permit/iicense number which will be used as a reference number. In addition,an applicant thatxnust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necess axy)and under"Job Site Address"the applicant should write"all locations in (city or towir)".A.'copy of the affidavit that has b een 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 lice-uses. Anew affidavit must be filled out each year.'Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: `l.'.he CQm- �onwaft of MassafihuSetE� - Depari.ent offndusWal AccX e t Moe Qf JAVestfgA-Roma 6bQ WakkgtM ft��t Boston,UA Q.2X X x - Revised 5-26-05 WWW.Mass.g¢ dia � r li MI-TH OF MoSSACHUSET MONWEATS �':CO o e • - o o BOAR. 1 CTRI C'1 Arls F1-= L:ILfNSE 'AS FOLLOWING HE ELECTRIC {SSUES T.­9 IAN. MASTER � R:�GISTED KYLE A LECLAIR 29 LAK0 I EW DR I <SH I.RLEY MA 01464-2 ;3 COMMONWEALTH OF M/�►SSACHUSETT:S 4: B©Af3U`O¢ ELE "°RICIAiNIS C sdin ISSUES THE FOLLOWING LICEN5� AS A REG JOURNEXMAN ELECTRFC,IAi' az � r 4Z l KYLE A LEC LAIR t 2�, LAKEVI E'WDR � !� 511RLEY MA 01464-2143 j 13617 . 07/31/;lb 54664 s Date.... q ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU This certifies that ................4eCIA-..I- E&c-rKic- ..................... ..................................................................................... has permission to perform ........ M. e..(.................................................. wiring in the building of............ L......I.......IAO. ..-re ....... at .....A&. P-8..... ..............North Andover Mass Fee....... ......t...... ...Lic. No. C FytECTRICAL INSPicTOR Check# 2 r Commonwealth of Massachusetts Official Use only Department of Fire Services PernutN°' /2— Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS a e .V 7 M L" 1/0 J leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATIONS Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) tpl,!, 3r ra(Z "k LA 20 . Owner or Tenant L l N A, V, _ Telephone No. Owner's Address \Qr,, QG pg- t-k t- et-, Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 2Ewc a� 2u C)y �24 E(z r_,I,"r r i AtAN V W ecN ECL C t r-C"t-)\4 At'SA (Z��� �=p,Pt A r 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 Above In- o.o Emergency Lighting Pool rnd. ❑ rnd. ❑ Battery Units � No.of Receptacle OutletsNo.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "' "''"' ' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wtres. Estimated Value of Electrical Work: 48 o Q .Gu (When required by municipal policy.) Work to Start: 1.-< -l %I Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME - LIC.NO.: Licensee: kL,,A�E l.�t i,A�lt, Signature LIC.NO.: Zi��-�. (If applicable,enter "exempt"in the license number line) JV Bus.Tel.No.• `i"7e-moo o-Sri ZS Address: kca— (aLcw Alt.Tel.No.: `Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:,$ Signature Telephone No. S S ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the _ permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the,' notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass[N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN TION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: L_ 1 lZ., %`_ Date: FINAL INSPECTION: Pass �4 M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comm Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts = Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe(Business/Organization/Individual): l,&,t.A\YL ag-qLk Address: 2'% t.A,_Fv ew �,(2 . City/State/Zip: kz:�LLc31. „r\N Cy„gkA k-k Phone#: q 75.4 .0-6g-1-s Are you an employer?Check the appropriate box: Type of project(required): 1.0 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. �• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name:. A k NA M v V n\ Policy#or Self-ins.Lie.#: Q\, c, - c v - o\S S Expiration Date: S - 7 okS Job Site Address: S Cir oa_ N\%. . MD, City/State/Zip: N oa-r-kA tAA 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: Phone#: g 76- %0 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.PIumbing Inspector 6.Other - - - Contact Person: Phone M 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 in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The ConuAonwoalth of Massachusetts Department ofIndustrial Accidents Office of Inivestigations 600 Washington Street Boston,MA,0.2111 TeX.#617-727-4900 ext 406 or f-877«,MA.SSAF& Revised 5-26-05 Fax#617-727-7749 WWW-Mass,govldia Jun. 6. 2014 10: 28AM Russo Insurance Agency No. 5117 P. 2 AC-C>J?J,Jr CERTIFICATE OF LIABILITY INSURANCE FDATe 16/2/DDfYYY� /6/2014 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 pollcy(les) 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 Ileu of such endorsement(s). PRODUCERNTACT t$OU9A NAMe Russo Insurance Agency, Inc. PHONE (508)533-3000 F fb051533-5999 92A Main Street EMAIL P. 0. Box 637 INSURER(S)AFFORDING COVERAGE NAIC0 Medway MA 02053 INSORERAMe:rohants Insuranae Group INSURED INSURERB:Safety Indemnity Insurance 33618 Leolair Electric LLC INSURERC:Aesociated Industries of 29 Lakeview Drive INSURER D: INSURER E: Shirley MA 01464 INSUReRF: COVERAGES CERTIFICATE NUMBER:CL144203532 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN 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 POLICIE=S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL POLICY NUMBER POLICY EFF MMIDD LIMITS POLICY EXP D OENERALLIABILI7Y EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE PRE «once $ 5001000 A CLAIMS-MADEFx OCCUR aop1042094 9/30/2013 9/30/2014 MEO EXP oneperson) 8 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2 r 000,000 X POLICY DPR 40C $ AUTOMOBILE LIABILITY COleaMBINEDISI ELIMIT 1,000,000 8 ANY AUTO BODILYINJURY(For person) $ X ALL OWNED X 8CHEDULED 6220194 10/11/2013 10/11/ AUTOS AUTOS 2014 BODILY INJURY Poraocldenl) $ HIRED AUTOS X NON OWNED —PROPERTY DAMAGEAUT $ (Por aorldon[I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ BXCESB LIAR II CLAIMS-MADE AGGREGATE $ DED RETENT10N$ C WORKERS COMPENSATIONWC STATU- DTH- AND EMPLOYERS'LIABILITY �N �, ANY PROPRIETOR/PARTNER/EXECUTIVE E.L,EgCHACCIDENT 8 1O0 000 OFFICER/MEMBER EXCLUDED? N/A (Mandalory In NN) C-100-6015659 /19/2014 /19/2015 E.L.bISEASE-EA EMPLOYE $ 100,000 IfIn d®scribe under DESGIRIPTION OF OPERATIONS below E.L.DISEA8E-POLICY LIMIT 1 8 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORO 101,Addl(lonal Remarks Schedule,If more apace IB required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Att: Building Department 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 III C .Russo/KA-REN . = a ACORD 26(2010105) ®1888-2010 ACORD CORPORATION, All rights reserved, INS025(201005).01 The ACORD name and logo are registered marks of ACORD 3 COMMONWEALTH OF M CH . n o c . o BOAE3i2 OF FL1=cTaICIA,N;S ISSUES THE ;;FOLLOWING 'LICENSE AS Aa REGISTERED MASTERLECTRI-GIAN KYLE''A LECLAIR f = +z { ' Pc� 29 LAKs"v EW'DR SHIRLEYt MA 01464-2143- 21 - 1464 214"21 - 2 A : 07/31/16 54663 . . 4 I i Location No Date " /? • TOWN OF NORTH ANDOVER . , Certificate of Occupancy $ Building/Frame Permit Fee �0 $ Foundation Permit Fee $ Other Permit Fee $ IdED TOTAL $ Check# Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO- Date Received � zo l Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION .. _ _ Print _. PROPERTY OWNER . .���✓✓� ___ Print 100 Year Old Structure yes n MAP NO: PARCEL: ZONING DISTRICT: Historic District yes rw--- Machine Shop Village yes ne--,*, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building B'One family (Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: _,Bn a,a, k v i9-ec_t. �ke­- &)Adp zu ouwd /;y�n e A-S z'o&,A x x /eV Identification Please Type or Print Clearly) A OWNER: Name:_ L,;,,vA �qK"--le Phone: Address: (�S `�t! A2 CONTRACTOR Name: Jv,-_ !Jv1,10(11r21 Co,u.57= Phone: I Address: V3 14c-&-o10a 4'S /ZcI . )ywY- Pn t Supervisor's Construction License: C5-00 o c Exp. Date: Home Improvement License: /.55,F 7 9 Exp. Date: ARCHITECT/ENGINEER `^ Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3-7Slip .�� FEE: $ qzp s Check No.: Receipt No.: NOTE: Persons cont acting with unregistered contractors do not have access to the guarantyfund .Signature of Agent/Ovuner ' � cam- 'Sig-nature of contractor i �(Jvn�ov-•�. Plans Submitted Plans Waived ❑ Certified Plot Plan � tamped Plans ❑ Building Department The fohiowing is la list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Li"'-.Flo �sect�ion/E�Ievat�io �an Of Proposed Work With Sprinkler Plan And Ions pplicable) ❑ , pliance Report (If Applicable) ❑ Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) a Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Building Permit Revised 2012 _ I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP&OF.SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ Tobacco Sales Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED IC N G & DEVELOPMENT ❑ 1,9 //3 , � ENTS h� 5 �d-�er� e ��t3 , T 1 Cr GG 4D Zb GP CONSERVATI Reviewed on Signature COMMENTS CAJ0 aQ �_ /'3 { � � 100' e� HEAL ;H Reviewed on Signature C MENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConnectioniS_ignature& Date Driveway Permit DPW To-*,v;2 Engineer: Signature: -- Located 384 Osgood Street (FIRE DEPARTMENT" -Temp Dumpster on site yes no Located at 124 Mair, Street Fire Department signature/date t k COMMENTS 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 I NOTES and DATA— For department use 6 1 i ® Notified for pickup - Date f I. Doc.Building Permit Revised 2010 i 4 I i � NORTIy Town of A p " - 0 No. dolt- 14 41 4 Z � o h , ver, Mass, COC NIC HI WICK y1. U BOARD OF HEALTH Food/Kitchen PERMIT TD II II Septic System THIS CERTIFIES THAT .......1. o.%...................`.... ., BUILDING INSPECTOR G•► � `.I....... Foundation has permission to erect .......................... buildings on .... .......................... ............ 00� � tough to be occupied as .1Wr ......... iwo.......�r*VO4.........eA.0'.sk..+..... .�j 4 Chimney Provided that the person acdepting 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 CONSTRUC N S TS Rough Service .......... . .... ..... ........................................... 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. SEE REVERSE SIDE .r � '"'� /r , �r r r� ✓ r1� 'kms r E 1 . II 1 1 I f I E ! I m r � r .r i { I r _ - r, �' �. �, ,. `�"'`� ' �� �.� �.z, . .<„ s __. Rightfax N1-2 8/12/2013 7:40:28 AM PAGE 21002 Fax Server CERTIFICATE OF I. ABILITY INSURANCE DATNc nVJIDDFiCATE IS ISSUED AS A MATTE O NFORMATION ONLY AND CONFE S NO RIGHTS UPON THE CERT ICATEITOCERTIFICATE DOES RIOT•AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY TIME POL THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED VE OR PRODUCER-AND THEF AT IMPORTANT*if tho certifit:ate holder is an ADDITIONAL INSURED,the policWies)must be endorsed. It SUBROGA71ON IS WAIVED.subject to ho tormx and condRions of the policy,certain policiw may require and endorsement. A statamesrt on this certificate does not Confor rights to he certif ate holder in lieu of such amforsement x. PRODUCER CONTACT NAME; DANIEL ORCO11R"_INS AGCY PHONE FAX 429 HIGH ST INC.No,Ext); IAtC.NO). N MDFORD,2MA 0215$ E-TMtARt ADDRESS: 1$57[V IWAM9 IS)AFFORQWO COVERAGE MAIC R { INSURED RMRER A: TRh TEr&pS iV ?MMNi',Y CO. DONOV.W JOSEPH.DBAJOS.:.PH DONO-VAN CONSTRUCTION INSURER s: RNSURER C: 43 ACROPOL S RI D iNSURER R6i E: LOWELL,ANA 01854 rl+tsURFR F: COVERAGES CERTIFICATE NUNSM, R>EVI3ION NilIYMEtt tiliseliXt'6E13Er.713buUE TO III: Ari TNEP - - - ORGA ERI. gOTWITHSTA01110 AaY 0WOUIRENMIT.TOM On COMXY OR OF ANY CONTRACT OR OTHER OOCUMM WITH RESPECT To VAMN THIS CERT MATE MAY SE Ism OR MAY PERTAK THE"WRAME AWORDED BY THE POUCIES E}ESCFMED HMM iS 8MECT TO All THE TERMS,EXCLUSWNS AND CONOITKMS OF SuCN POLRf."RM UWS SNOWIN t%Y NAPE SEEN Rs3?IRC BY PAID CLAIM MR ADD SUD POLICY EFF OATS OLICY EXP DATE LTR TYPE OF OISURANCE L R POLICY Kft3 7t 'ImU'm%YYyY) W-IAMYYYY) I MTS GENERALLIABJUTY .ACHOCCURRENCE I5 COM MERClAL GENERAL L'A9'Lit f ...Y.... CLAIMS MADE M OCCUR. AMAGF TO RENTED S FM-.-SES(Ea a=wemc) i t FENER ED F..XP(Ary one person) !S CENt.AGGREGATE LIMIT API !F-S MR £MAI_&A0V IMURY i S [� AL AGOWCAFE S POLICY £'ROJECT E..�l LOC LRC iS•Gt3M1OP AGG Is AUTOMOBILELIABILITY OM8INED S:NGLE �S AW AUTOIhFrr(Fa amidwt) T ALL O HIED AVi OS BOCILY INJURY ( SCNEpULE AUTO iPerCerstxo is "EDAUTOS BODILY W URY $ NON.0WgEO AUTOS (Per accirlam) PROPERTY(DAMAGE. S (Per a>it derR) f UMSi2ELLALIAS OCCUR EACH OCCURRENCE S EXCE5SLiA9 CLAIMS-MADE ,AGGGREGA7E S i RET E\r ICN S S j A MRKETt'SCO ISATTONAND vres'At11'4°xr OTS EW7�LOYERSLIABILITY YIN tr9•EE90P$3A-2 1-=V2012 1Q21.�3 VI Sr OFF 0FRNC 8ER EXCUDEC7 y NIA F L.EACH ACCIDENT S t a�c�anr'c, R Ex.Ctu�? � 100,000 (►Sa+daorf+an HH► E.L.L48EASE-EA EMPLGYFE S 100,000 TYb.L1QtiT•°J2 iR��."r DESCRtF 10Y OFOPERATJON$Wrew F.L.DISEASE-POLICY L!M;T 5 500.000 DESCRIPTION OF OPERAMUSCOCA TRICTIOtNSSPECIAL ITEM TMSRWT—kCSS SWY PPJ01Z t:GPTM.ATE L4SL7FSJ TO THe Cra7ree—CAT:'r"OMER.AMe_jW0 WMKSRS COMP CGVMAlS r TIS:WORKERS,CONIPIDISAT[ON P011CY WFS NOT P OtgDE Co',IERACZ POP.DONO VAN.JOS i_ r k CERTIFICATE HOLDER CAHCELLATTON { L.INA Ht1NTER SHOULD ANY OF iHEASOVE DESCIP48M POLICIES BE CANGELLEQ BEFORI 65 BEAR FULL N AEROANC£iMTH T1#THE EWIRATIONE POLICY OVTE 15fdt TICE L 8E DELIVERED AUTHORIZED RS'RFSSNI NORTH ANDOVER.MA 01345 ! MUS(MIM) TRIC50 name=and logo are reipsUereg marks of A D 1988-2010 ACORO CORPORATION. All r tS reserved. I i The Commonwealth of Massachusetts Department oflndustrlglAccidents Office o fInvestigations 600 Washington Street Boston,MA 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): -tiNy IM;L1 C)-.5 Address: Y3 City/State/Zip: z_.0 k-,e_ In A Phone#: 77f a'a 6F V1 5-- Are pu an employer?Check the appropriate box: Type of project(required): 1.IJ 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.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Domolition 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 10.11 Electrical repairs or additions 3111 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' comp.insurance required.] 13F]Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they 2're doing all work and then hire outside contractors must submit anew 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 th at is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:. �iz`t v-e,1eo_S Policy 4 or Self-ins.Lic.4: U 13 Expiration Date: %© i 3 rob Site Address:_ &f City/State/Zip: 44o • Ab.,&I,)u - 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$250.0 0 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. Ido hereby certIfy under the pains andpenalties ofperjury Aat the information provident above is true and correct. - Si ature: <:�_ �D^"��— Date: Phone [F0fJ1e1a1only. Do not write in this area,to be completed by city or town official.n: Permit/License# ority(circle one): 1.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and ffastructions . 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 employei is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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 ofpublic 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 number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. B e 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 Blease be sure that-the affidavit is-complete-and printed legibly: The D apar[inerit leas provided a space at the boom of the affidavit for you to fill out in the event the Office of luvestigations 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"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 ox permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Coxnxr�or�woa t o 1�Tassa�husPtts Dep.arUmmt ofladustdal.A.ccideats Office offll, Aigatio.ns 6QQ Washingtou Street Boston}MA 02111 TOL#61,7-727 4900 eA406 ox 1-877-MASS.AFE Revised 5-26-05 FaY,#617-727-7749 BUILDING CERTIFICATION PLAN SS �ZZ �Z N �- UTILI TY EASEMENT \ \ � I POOL UTILITY EASEMENT LOT 6 LOT 5A o� 44,357 SF �+\ ROOF— 31' \ OVER DECK 22.1 /i DRI VEWA Y /27 EX o 0 EASEMENT TOHSE BENEFI T L 0 T 5A 36.3" N. - PROPOSED \ p' PRH co 41.4, !q,20k 150.00' BEAD MILL COAD SETBACKS ON THIS PLAN ARE FOR THE DETERMINATION OF ZONING REQUIREMENTS ONLY. OFMAss, REFERENCE I CERTIFY THAT THE BUILDINGS AND/ O JAMES G OR STRUCTURES ARE LOCATED AS SHOWN. DEED: BOOK: 6894 PLAN: No: 9492 D. a AHO w PAGE: 246 35383 °gyp P" STREET 65 BEAR HILL ROAD •�►. �qbo suRvo CITY NORTH ANDOVER, MA �•'•�••••` APPLICANT MICHAEL HUNTER DATE _8/26/2013 SCALE 1"=40' JOB# 8080_ CRICKET62 L P.L.S. 1 o ,�SL7RVZ7711VG" DRACUT, MA. 01J 4826 .�,� '"` ; �,� I 1r�I ,/ I�G` ``,,�� y; � i. ,� i.� .�. f. .... .� r� ! } .�.� { `,�a o • _ Unrestricted-Buildings of any use group which } contain less than 35,000 cubic feet 991m3 of UMassachusetts-Department of Public Safety ( ) � Board of Building Regulations and Standards enclosed space. Construction Suptn icor License. CS-002604 • z : JOSEPH E DONOyAN 43 ACROPOLIS RD ~� LOWELL MA 01$54 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Expiration For DPS Licensing information visit: www.Mass.Gov/DP5 `✓�,�.,.. J1./r_�C... '„" Commissioner 05/23/2014 .r. `�%f�c•�crr;r��rrtc-ca�.t/,-c� �c�zW�crrt!.t;cll; Office of Consumer!affairs&Business Regulation License or registration valid for individil use oid ';Y glfC3.orr fMPROVEMENT CONTRACTOR before the expiration bate. If found.return to, s!i �egistration; 15f,879 Type: Office of Consumer Affairs and Business Reguic ion '„Expiratlon: 5/15/2015 DSA 10 Park Pima-Suite 517G `'✓ Boston,MA 021.16 JOE DONOVAN CONSTRUCTION JOSEPH DONOVAN 43 ACROPOLIS RD. ---- LOWF_LL,MA 0 i 854 LissderseeretarY Not valid without signature Page: 1 Joe Donovan Construction Co. Quote 43 Acropolis Rd. Lowell, MA 01854 Number: E102 Date: June 12,2013 Bill To: Ship To: Lina Hunter Lina Hunter (978)975-8877 ( (978)975-8877 65 Bearhill Rd. 65 Bearhill Rd. No. Andover ( No.Andover MA, 01845 MA, 01845 14 Date description — Amount 06112/13 Contract to build wrap around farmers porch 44'x X x 8'deep -Provide Insurance Certificates �Irr -Provide Building permit and electrical permit I-Relocate AC unit, sillcock and sprinkler feeds -Sona tubes 12"diamteter,48"below grade -Frame to be pressure treated lumber i -Decking to be Azek 5/4"x 6"with blind fasteners or equivalent -Square porch posts 5"x 5"structual FVC -Vinal rails and ballusters Vinal lattice and skirt boards(Azek trim) f-Vinal ceiling -10 recessed cans in ceiling, 1 switch -Asphalt shingles to match existing roof -Deck and roof flashed against house -Any siding removed to be replaced � '13 Page: 2 Joe Donovan Construction Co. Quote 43 Acropolis Rd. Lowell, MA 01854 Number: E102 Date: June 12,2013 Bill To: Ship To: _ Lina Hunter Lina Hunter (978)975-8877 (978)975-8877 65 Bearhill Rd. 65 Bearhill Rd, No. Andover No. Andover MA, 01845 MA, 01845 — - Date Description Amount �-Stairs to be wrapped with Azek boards and decking Complete Job 37,500.00 -Approximate timetable for work 2-3 weeks, begining in early Sept. 2013 -Job to be cleaned daily -All debris removed from jobsite -Payment schedule$12,000 down,$12,000 after frame is inspected and $13,500 upon completion Total $37,500.00 'I i 0 'i3 X14- -P)yw�o� � v 3—akFt tt,Z ��k� rr r� S4-rtLkCtv,A �k I /Styr d vi+ aur �r tt ff � ►q S'�"�N�� W i`}'�-, ��M 3'C�.�"G a 1t S �� 1'd s+ P�t•)C-�1 o r'Z. rr V f e aUaOzs \ c4.)cw i LILILLLIIJ Not scwle Outlook Print Message Page 2 of 2 .:1 C. U U..:.:.� ULi { t r Til 04 ,�,�����"JJJ717 VVV 111...1111 1' Fwd: Hunter design renderings From:Lina Hunter(bombitas29@me.com) This sender is in your safe list. Sent: Thu 8/15/13 8:34 AM To: lina hunter(cakesbydesignedibleart@hotmail.com) a L EEO N 12 r � L } https://snt l46.mail.live.com/mail/PrintMessages.aspx?cpids=66c75047-05af-11 e3-9dfd-00... 8/15/2013 Home �m -ovement �� e ®imlr�.e� FIRng_ua_ge form,satisfies all basic requirements of the state's Home Improvement Contractor Law to protect homeowners. SeeIc Iegal advice if necessary. (MGL chapter 142A),but does not include standard Lachusetts Consumer Guide to Home Improvemerrt"before agreeinto any worlcon your residehome nce.You may obtain free co a b copy callir� the e of Consumer Affairs andllusiness R,egulatiorl.'s Consumer7nformaiionHotline at 617-973-8787 or 1-888-283-3757 ox on pyb ebsite.g HOMeONMelr WoR7lIlilagio]nour "Contractor 7�nniF®>llona.�(;ion Name ��'� u�✓�2�� Company Name ••..l U e- `.J c'�I.lf>✓/�j�/ Ccs n/.S/ Street Address(do not use aPost Office Box address) &-5- h.'// r� Contractor/Salesperson/Owner Name , �,�,� s� City/Tov'm' State Zip Code JCN o U IA/ rgo�. / Busess Addrees►C,20 ��s(must include.a street address) c'cilz°iL "T <S Daytime Phone EveningPhone 7 City/Town State Zip Code MailingAddress(It different from above) oa , Business Phone I ederal ElnpIoyer ID orNumber c HomeImpmvement cantmctorlteg:Number xnw regnires that most lame xpiradan date improve mentcontractorslmvc / n valid rcgistrntion mtmBcr J S f 79 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the worlctocompleted ec' in ,sp liy gthe type,brand,and grade of materials to be used,use additional sheets if necessa .) ' /4/Lm��a-S 'f02 c / Lv Required Permits-The following building pewits are required Proposed Start and Completion Schedule-.The following schedule will and Will be secured by the.contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will,be excluded from the Guaranty JFnwrnd provisions o ra,zl - ' fi ao/3 MGL chapter 142A,) -- V --_Date when contractor will begin contracted work. -3 Date when contracted worlc will be substantially completed. Total Contract Priceand Paym ent Schedule The Contractor agrees to performthe work,fumishthe material and labor specified above for the total sum of-T-3—z t7 0 Payments will be made according to the following schedule: t ( ) � - upon signing contract(not to exceed 1/3 of the total contract price Ar the cost of special b / p older items,whichever is greater) y / or $_ uPon Completion of yotyn e by ' —c— / / or upon completion of Go $ •� upon completion of--�-- p he contract, (Law forbids demanding fun payment until contract is com feted to bo The following material/equipment must be special g pP3''SSatisfaction) . to be paid for ordered before the contracted work begins in order to meetthe completion schedule.(**) to be paid for NOTES:(°i°)Including all finance charges(*=i')Law requires that an deposit or down- Payment req not exceed the greater of(a)one third of the total contract price or(II)the actual cost Of auired ny s the ee special equipment before workbegins may which must be special ordered in advande to meet the completion schedule. y p or custom made material x renswarran -Is an e..Tress W1 rl,,Infy behilT provided by the contractor? ✓ • '` Sub contractors-The contractor agrees to be solelyresponsible for completiioon of h woxlc descr bed regazdless ofthe actio s of anythird ontract pa renals a ntractox utilized by the contractor..The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this a cement (Contract Acceptance-Upon signing,this document becomes abinding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the o carefully before signing this contract. f llowing cautions and notices ° Don't be pressured into signing the contract.Take time to read and fully understand it: Ask questions if something is unclear. ° alce sure the contractor has a valid Home I'm rovement Contractor X eidstration. The law requires most home improvement contractors and subcontractors to be xegistered w�.th the Director of Me Improvement Contractor Registration, you may inquire about contractor registration by writing to theDireetor at 10 ParlcPlaza,Room 5170,noston,MA D2116 or by calling.617-973-8787 or 888-283-3757. ° Does the contractor have insurance? .Ask the Contractor fox his insurance company information so that yon can confrlm coverage,or aslc to see a copy of a°`proof of insurance,document. ° I�now your rights and responsibilities. Guide to the Home Read the Important Infoxm,ation on the reverse side Improvement Contractor Law: of tlis foam and get a copy o£the Consumer You may cancel this agreementifithas been signed ataplace otherthauthe contractor's norm contractor in writing at his/her main office or branch,office by ordinary a•place of business,provided you no ' the third business day fonowin �Y mail•posted,b tele g the sighing ofthis agreement. Y gram sent or for do e not , gr nt. Seethe attached notice of cancellation form for an explanationto£thism g midnight oftlte D®�T®7[`SIGN 7C13�[� �®NT7?CONTRACT ZC Two identical copies of the contract must be completed and signed, one c s 0 Id �` ��' &�SYAC {'S 111 op should go to the homeowner. The other copy sltotddbe icept bytbo contractor. xlomeownex s Signature 4CMICtOes Signature 13 Date cConnixactor A rbitr tion The Home Impi ovement Contractor Law provides homeowners with the 37ght to initiate an arbitration action(as an 'alternative to court action)if they have a dispute with a contractor. The same right,is not automatically Zoxdedto a contractor,however, The contractor wotiid have to resolve any dispute he/she has with a homeowner.in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby inutaally agree in advance that in the event the contractor has a dispute concerning this contract;the contractor may submit the dispute to a private arbitration ffim which has been approved by the S ecxetaxy of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to lbmit to such arbitration as.provided In.Massachusetts General Laws, chapter 142A.. Homeowner's Signat.ire C actor's Signature N®TJ[CIE:The signa rtes of the parties above apply onlyto the agreeme t of the paides-to alternative dispute resolution initiated by the contractor: The homeowner may initiate alterative dispute resolution even where this section is not separately signed by the patties. Romeowner's Rights A homeowner's rights under the Flome Improvement Contractor Lew(MGL chapter 142A)and other consumer Protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded'from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and wort manlike manner, Homeowners maybe entitled to other specific legal rights if the contractor guarantees or provides an express warranty;for worlananship or materials. In addition to guaxantees or warranties provided by the contractor, all goods sold-in Massachusetts carry an implied warranty of merchantability and fitness for a pat ticular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you.have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in dulicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties axe also advised not to sign the document 111d1011 blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification cat ion to the.original contract must be in writing and agreed to by both parties. Contracted work may not begin=-ffi both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the•payment schedule in oases where the homeowner deems hirn/herself to be financially insecure. However,in instances where a contractor deems him/herseIf to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j of t escrow accotm-t as a prerequisite to continuing the contracted work. Withdrawal of hinds from said•accoumt would require the signatures of both patties. .AA.d ditiorlal Information .If you have general questions or need additional information about•the Dome ` coer rights, r Law or other or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Imp ovement" contact: Consumer Information Hotap, Office of Consumer Affairs and Business Regulation 10 Park Plaza.,ROOM 02116 617-973-8787, 888-283-3757 or'vxisittthe OCABRwebs tatatlit //w vmass. ov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specTacally about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration O:Ece of Consumer Affairs and-Business Regulation Id ParkPlaza,Room ostonMA 617-973-8787, 888-283-3757 Or Visit the RIC website, bsite'at 02116 211 �,Y nass.eov/ocabr/ Go online to view the status of a Home Improvement.Contractor's Registration: lttt r.//db.state.ma.t2s/ho7neinnvrovement/aicenseelist.as For assistance with informal mediation of disputes or to register formal.complaints again st a business, mess, calx: Consumer Complaint Section- OfRce of the Attorney General 617-727-8400 .AND/OR Better Business Bureau 508-652-4.800,50&755-2548 or 413-734-3114 Version 2.1-17/�.�.i�n n Location �� eep alz No. Date 3 �S'd MaRT� TOWN OF NORTH ANDOVER + s + ; . Certificate of Occupancy $ ��ssAC" <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # _ :�-20u4 - - Building Inspector E TOWN OF NORTH ANDOVER i APPLICATION FOR PLAN EXAMINATION0 .Of MO sTh'�,y 0 b n Permit NO: �p4 S Date Received 0' +' s Date Issued: CHust� l IMPORTANT:Applicant must complete all items on this page ' LOCATION Print Si PROPERTY OWNER 4-e4 J Print MAP NO.: 6 PARCEL: Q ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building 0 One family ❑ Addition ❑Two or more'family ❑ Industrial 0 Alteration No.of units: ❑ Repair, replacement 0 Assesso Bldg g ❑Commercial ❑ Demolition ❑ Movingrelocation ❑Other 0 Others: ❑ Foundation only DESC ON V/ORK�T BE PREFORMED S1 r liar o�- r-� ,�- � da,r ' Identification Please Type or Print Clearly) OWNER: Name: G Phone: Address:_ �S JS kK r- 1 ( a CONTRACTOR Name: .S a.�,.S CAS 11h42 10 Phone: �r 6 I � P A SS Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHIT ECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER SF. Total Project Cost :$_ J-41 it FEE:$_ / �- Check No.: t � � Receipt No.: Page W4 4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing,Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned)to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:81'FORM03 Page 4 of 4 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools ❑ � Tobacco Sales El Well 11 Tobacco Packaging/Sales ❑ Permanent Dumpster on Site ElPrivate(septic tank,etc. El Permanent Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty Jund � Signature of Agent/Owner { Signature of contractor Plans Submitted ❑ Plans aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPME T ❑ [� 3 D 19 COMMENTS A4 `" AV x t t f X-b QZv(/" ;C/1 0&4e w.f to , � �11� _ ATE REJECTED DATE APPROVED CONSERVATI COMMENTS�P,N �i'1 1 �1�1 I V1 l�G�l'�, GV1(tC —,4I'�J�S lardTG1'� a� � 5 j N' PW 1 mU{b RP I I t`s "Kr OYl ptmof�7 DATE REJECTED J DATE APPROVED HEALTH ❑ ❑ � COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no I Fire Department signature/date 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 �I Building Setback ft. Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use I I � i i Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Ln.2006 tAORTH Town of Andover 0 VO No. om-P- W 10, + over, Mass., • Ps 0 .= LA 0 COCHICHE WIC ORATED BOARD OF HEALTH Food/Kitchen . PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT......... ...............//..................................................................... Foundation has permission to erect....... rect........................................ buildings,on .........k4..............&. 4r/ ....001tw............... Rough tobe occupied as.........gb�.Of......A7 A0.4.0..I........................................................................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS S S - U 11TU Rough Ur T Service ................... .............................. ........................ BUILDING, IN�SPEC�R*** 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. �N•TS.� UTIu11E�j , \ k ti16 0——� 13 DAVI c' \ w�,►.A9 '.1�d fir.rte.*, u;t' D snv 0 s F 41614, 4 \ \ .3 e w ' Z --3F THE LOCIATION OF PROPERTY LINES SHOWN HEREON IS BASED ON PLANS BY OTHERS AND ON INFORMATION FROM VARIOUS SOURCES AND IS TO BE USED FOR MORTGAGE PURPOSES ONLY AND NOT FOR ESTABLISHING LOT LINES, LOCATION OF FENCES, DRIVEWAYS ETC. 7T7RSTRUMENT-SMVEY HAS NOT BEEN PERFORMED. AN INSTRUMENT SURVEY IS ADVISABLE IF STRUCTURES ARE LOCATED WITHIN ONE FOOT OF A LOT LINE OR ZONING SETBACK LINE. CAIAEP,ON—BISHOP ENGINEERING CORP 90 MONTVALE AVE, STONEHAM 02180 (61»: 3 o,,.E f} (0143 aoe No. •1573 wr sa : -�rrt ooat IS95 PACE z33 PLANA9z voreorER(O I�obe2T R F%Q6PZP �a1FLtESZ ,X,� fo5Lt-- A).TITLE WWRER9 BASED ON MY KNO'NLEDGE, INFORMATION AND DELIEF, I CERTIFY THAT: — THE BUILDING CONFORMS TO THE FRONT, :SIDE AND REAR YARD SETBACK REQUIRENiENTS AND THE LOT CONFORMS.TO THE AREA AND FRONTAGE REQUIREMENTS OF TIIE ZONING DY—LAWS OF TILE y0'Rd OF 1'.`HICH WERE IN EFFECT AT THE TIME OF CONSTRUCTION. f' — THE STRUCTURE IS K16VIN THE SPECIAL FLOOD HAZARD AREA AS SHOWN ON THE /F".'tiZ i. DATED(o „tRrt, TONY OF NORTH . .. ANDOVER OFFICE OF Vw BUILDIv GD EP� • �,•►�, , � RV*IENT 1600 Osgood Street Bu' 2 Building to 264 "•ACNu`,t��. North,kndover, Massachusetts 01845 Gerald X Brown Inspector of Buildings Telephone(9'8)684.95 HOMEOWNER LICENSE EXEMPT Fax (978)6S8_y5t' IOiv DATE:-4 i JOB LOCATIO tiumber Street Address H0,1�IEOW t►',' ER +�-1�Ft� �I�wh � `� Name Home Ph one S� S Work Phone PRESENT MAILING ADDRESS—6 City Town State Zip Code The current exemption for"homeowners”was extended to include owner-occupied dwellings to two units or 1 Provided that the own to allowsuch homeowners to engage an individual for hire who does not possess a license,prov acts as supervisor). .State Building (Code Section 108.3.5.1) and weer DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there i be,a one or two F imily structures. A person who constructs more that one home in a two-year period shall not considered a homeowner. s,or Is intended to � he The undersigned"homeowner"assumes responsibility for compliances with the State Building Applicable codes, by-laws, rules and regulations. ng Cede and other The undersigned"homeowner"certifies that fie,she understands the Town of North Andovcr minimum inspection procedures and requirements and that he.'she will comply with said coca requirements. Building Department Procedures and HOMEOWNERS SIG,NAFLRE APPROV.xr.OF RC'rr.DING 0FFIC1,\L ----- r,,. L; •.m Hnmu,.n,'r.,t?�. ,cl-iir.n —_---- ;; I-,... 1:: • . ,.- ."ir1 c.al.rH•. .'.iii 1 CUSTOM BUILDINGS ' .--�r�• Country Barn,Monarch ....................page 5 OPTIONS&UPGRADES.............Daae 6 SSPECIAL SERVICES CUSTOMER INVOICE Page 1 of 7 NO. 2685-13918, e 2685 METHUEN Phone: (978 ) 989-9025 VALIDATION AREA 72 PLEASA7r­ • A, EY ST Salesperson: MXC948 METHUEN, MA 01844 Reviewer: This is onl at000TE for the merchandise and services printed below. This becomes an Agreement upon paymentand an endorsement by a Home Depot register validation. 0 0,i-:_ Name Home Phone or f - HUNTER MICHAEL (978) 975.8877 AddressTOOK THE TRUCK TO DO HI Work Phone Company Name -�!.:..-. .J`. LIED TO US ON THE LAST R - City NORTH ANDOVER Job Description State MA Zip 01845 c°""ty ESSEX fi(MOTE is valid for this date: 0210312007 MERCHANDISE AND SERVICE SUMMARY Werc�ianXise soOt0 customers, quantities of 111fiS`TALLATIONREF#10177 _. BASIC INSTALLATION LABOR: 1 ........................................................................................................................................ 471-8971 SHEDS USA .00 EA Y $0.00 $0.00 OPTIONAL LABOR SELECTED INCLUDES: .fIR:...:...::.::::::::....:...................:::.::::.::::.;:.;:.;:.;;:.;:.;:.;:.:;..;... ............................. .....::::::::::::::::.:::..::::: ............... .... 05 ...6 FOOT WALL HORIZON -VINYL CLAPBOARD/12x16 1.00 EA Y $4,299.99 1 $4,299.99 24 ...ROOF STYLE CHOICE- REQUIRED - CHOOSE ONE (6' WIDE SHEDS lt 1.001 EA I Y 1 $0.01 1 $0.01 PEAK ONLY)/GAMBREL 26 ROOF SHINGLE COLOR CHOICE- REQUIRED FOR ALL - CHOOSE ONE/BLACK 1.001 EA I Y 1 $0.01 1 $0.01 29 ...VINYL CLAPBOARD SHEDS ONLY- I OLOR CHOICE- REQUIRED/WHITE 1.001 EA I Y 1 $0.01 $0.01 '•'GDNTINUED ON NEXT PkG�`�" .......:. . Check your current order status online at www.homedepot.com/orderstatus >s, Page 1 of 7 NO. 2685-139182 . , - Customer Copy (9801) 0100228631 X : Date. . TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING ,SSACMUSE� Ja / (This certifies that . .� . • .. . • . �• • �• . . • . . . • • • • has permission to perform . !.l plumbing-+n thebuild'! �s of- at . �.� . : . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee,./. !//f.Lic. No.. .�� 5-1--;. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4• PLUMBING INSPECTOR • Check # ' 5993 � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 1633 �\ (Print or Type) C� --f-� t Z /2&/ , Mass. D e /1 { •7_c;e � 3 z{- _ Pe it # : _ r o Building Locat' n Owner's Name Type of Occupancy 1'i S 17 E N Ti t=)(.._ V New ❑ Renovation ❑ Replacem t [H� Plans Submitted: Yes ❑ No ❑ FIXTRES t y N O -4 Z > W W Y J N Q V ~ N O • z N 0cc x a O Z W N W N ~ V W N Y Q H W = d d X V = Q m Q N W } Q ~ H Z O Q N O .cC a z C rt W W' a N G Q J N J — O D -A W !- V >, 1- O S CL j H Z Y O d O O N = X a �„ k W W a z v� m a a a ¢ ac Q o a 0 4 J W f=- �• Y J m N C a J W O SUB—asMT. BASEMENT 1ST FLOOR 2N0 FLOOR 3R0 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing.Company Name f'�O r3E�T • -gym m 14 TA�°7 Check one: Certificate Address �r, t�`c,/-}L W/Yt fin) s-1+j ❑ Corporation l P E%N i Fn)- yo A 01Tc1�1 ❑ Partnership Business Telephone 9-7 1 9-f1rm/CO i Name of Licensed Plumber 5A,iaditI r- ,ec l INSURANCE COVERAGE: I'have ayes current,flabillity Insoura ce policy or Its substantlal equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy Ad 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner C1 Agent ❑ 1 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 nerformed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral LawsSV1M . � "Ltc-d re o cense Plum er Cittyy/Town Type of License: Master % Journeyman C]API'RONED OFFICEONL License Number 133 � BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR