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Miscellaneous - 67 CRICKET LANE 4/30/2018 (2)
67 CRICKET LANE f 210/107.A-0217-0000.0 1 ti �4 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.invalidif 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: - 0�4�/ '� Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: /, Date ..Z............................ 014�koftTh A TOWN OF NORTH ANDOVER PERMIT FOR WIRING 3 C14US This certifies that ............. -7 . .......................... ....................................... has permission to perform ...... ...................... ....................... wiring in the building of......Av9..,l ................................ f ovel, j at....4..7......... ..... .............A.... . ..... North And K-0 2- 4 Lic.No ............. ... ...... ...... ........ Fee... . ................ LECTRICAL IwS, C.iTOR Check # 10557 r' Q �j/� �inmonwea[lh o/V133acke13 Official Use Only cc�� cc77 Permit No. 1lepartinent BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1//07]Occupancy and Fee Checked 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 (PLEA SE PRINT IN INK OR TYPE A LL INFORMA TION) Date: I City or Town of: /V, /\t/1 A o LI Q L To the Inspector of Wires: By this application the undersigned gives notice of Ns or hintention to perform the electrical work described below. Location(Street&Nu her) -eirl- Owner or Tenant L ,�Q 9- f= Telephone No. $ (� Owner's Address / Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building M-Q 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: Ps w�U M*Tb C T� "F�eT�[l S�i t ,^ � Com letion o the ollowin table inay be waived bv the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above E] In- ❑ o.o Emergency ig mg rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers Heat Pump Number I Tons KW....... No.of Self-Contained Totals: Detection/Alertin go,Devices i No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection t� No.of Dryers Heating Appliances Kms, Security Systems:* No.of WaterNo,of Devices or E uivalent Heaters KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or,Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:__Qa- aL%- 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 cover,pCis in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under th ains and enalties of perjury,that the information on this application is true and complete. FIRM NAME: �/�►� V Jv �y L LIC.NO.:%6d,4 Licensee: M �•'4✓10{�/ Signature LIC.NO.: (If applicable, to ze t"in the licens umber line.) Bus.Tel.No. I Address: I f t 21� AR H fie►-, �/ 14 �3 �� 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 Signature Telephone No. PERMIT FEE: S G r h The Commonwealth of Massachusetts Ai J Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 9 to LAI) v N I LFCfi���C Address: �AA/q /�1 City/State/Zip: ?,---_,U4" Phone#:_(0 �((j ' /,3 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I oyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.211 am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] 1 employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_�,��'r ;: y (j4, L .Policy#or Self-ins.Lic.#: (2% W C I SyL Expiration Date:" U Job Site Address: '� w/) Z— (v �'- City/State/Zip: Attach a copy of the workers' compensation olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rd udder th ains and penalties of perjury that the information provided above is true and correct. Signature: I Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS ELECTRIAfiB REGI. T R�D M�ST�� ELECTRICIAN ! SS�ft THE-A�dVE LICENSE TO: ' R L :QUALITY ELECTRIC =` HARD R LANGEVIN c I 21 LANE RD ° P.ELHAM NH 0307.6 2. . C.. •. 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 c. 166,§32,an on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.01 electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the d 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-ifhe—__. ._ 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. F1 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 I 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. Ire7 it/Date Closed: "7 Y' Note:Reapply for new permit sion Act—Permit/Date Closed: 9963 Date...._...' . ..... t NOR7M TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMUS� This certifies that ........ has permission to perform ......... P.....``:................................. wiring in the building of.......... .......................... at... ..7 .1.E.k.4'..�... 414,el.. .... ...... . ........�J .. ..�. ..... - orth Andover,Mass. oo o�"Zv/4 Fee............---'... Lic.No.............. ............... ... ...... • ELECTRICAL INSPECTOR Check # SZy / 4A Commonwealth wealth of MassachusettsFOccupancy Official Use Only Department ®f Fire Services No. 13 BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked 7] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (PLEASEPRINTWINK OR TYPE ALL INFO TION) Date. (MEC),52 CMR 12.00 City or Town of: By this application the undersi#eedgives no ' e of his or her intention perforTo m the electrical work dtescribed below. Location(Street�&Number) 67 �rt K _ t C n Owner or Tenant Com.(Ire� /nQ r^U� � �/ Telephone No. Owner's Address SC m Is this permit in conjunction with a building permit? Yes N No ❑ BLDG PERMIT# Purpose of Building 4J, h �� 7z'Aj, > --� � � ��/� I/r`Utility Authorization No. Existing Service Amps _ / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps ---L-Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �UC c Z7-A n ��<Z•/p�C� /tet• C�Pr' r Completion of thefiollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires /3 No.of Ceil:Susp.(Paddle)Fans 1140.01 Total. No.of LuminaireTransformers KVA Outlets No.of Hot Tubs Generators KVA ,i No. of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig tingrnd. rnd. Batte Units No. of Receptacle Outlets L1 No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches S- No.of Gas Burners No,of Detection and No. of es Ran Total InitiatingDevices Ranges No.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons. KW No.of Self-Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems: No. of Water , No.of No.of No.of Devices or E uivalent Heaters Data Wiring: Si s Ballasts No.of Devices or,E uivalent r No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by theowner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER S I cert, render the sins and enadties o ❑ (Specify:) P .fPerinly,that the information on this application is true and complete- FIRMNAME: )-Ccs Z:-/tC�r- Licensee:e` LIC•NO.: a{j o Signature LIC.NO.* (If applicable, ever "ex pt"in th license number line.) r,L-� Address: / iY r $ -� �0 SCcv SvS Bus.Tel.No.: A3i *Per M.G.L c 147,s 57-61,security work requires Department of Public Safe "S"Licen AIt.Tel.No.: g�/v 740/ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabcen LIC.NO.: required by law. By my signature below,I hereby waive this requirement. I am the(check one)El ownerance r Elowner's agent. Owner/Agent Signature Telephone No.' PERMIT FEE: $ l ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGII INSPECTION: Passed—[ Failed—[ ] Re-inspection required($50.00)-[ ] In comments: (Inspectors'Signature-no initials) Date F ECTION: Failed—[ ] Re-inspection required($50.00)-ments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: w (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: Z (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. ELECTRICAL PERMIT NO. INSPECTION REPORT: [� ELECTRICAL INSPECTOR-DOUG SMALL [Passed .ROUGH INSPECTION: — Failed—[ ] Re-inspection required($50.00)-[ ] nspectors' comments: On- (Inspectors'Signature-no initials) Date EFINALSPECTION: Failed—[ ] Re-inspection required($50.00)-omments: -------------------------- ----------------- (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: c (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors'comments: (Inspectors Signature-no initials) Date y F5.INSPECTION-OTHER:assed—[ ] Failed—[ ] Re-inspection required($50.00spectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. Commonwealth of Massachusetts Official Use Only Department of Fire Services � BOARD OF FIRE PREVENTION REGULATIONS d Fee Checked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AJI work to be performed in accordance with the Massachusetts Electrical Code (MEC),s2CMR 12.00 (PLEASE PRIN7'IN WK OR TYPEALL INFO TION) Date: // City or Town of: V' To the Inspe or f Wires: By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below. Location(Street c&Number) 67 Cl-, K et C n�_o Owner or Tenant I' I')') Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ BLDG PERMIT# Purpose of Building -J, 4 Ai, �(,�J�;� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps _ / Volts Overhead❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ' A 0 0 43 A 6S C- /oc Com letion of the following table may be waived by the Ins Rector of Wires. No.of Recessed Luminaires / No.of Ceil.-Susp.(Paddle)Fans No.of Total. Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o.o mergehey ig tinga rnd, rnd. ❑ Batte Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and No. of Ranges No.of Air Cond. Total Initiatin Devices Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons p Totals: ................. ........... .............. ' N o.of Self-Contained Detection/Alertingy Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances , Security Systems:* No. of Water KW No.of No.of No.of Devices or E uivalent Data ata Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent J .4ttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the3ains an"d�penalties ofperjury,that the information on this application is true and complete, FIRM NAIVE: j CG �I,CC Z L LIC.NO.: )-0 �c7 Licensee:, 7 C r,, Signature l .f �.�.�,. LTC.NO.L3 X022 (If applicable, en er "ex pt"in h license number line.) Address: / � iY y /, S cv Jcvs Bus.Tel.No.:2&rvv_ a3� X77 *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"Licen Alt.LIC. O.: 7610� 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts R Department oflndustrial'.Accidents Office of investigations 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation Inswranve, Affidavit: Buildelrs/Contractors[Blectricians/Plumbers Applicant Information / Please Print Legibly Nari1e(B.usiness/Oxganization/Individual): i C G�^�/ L�G ( C Address: /y C k'YS /10r C De City/State/Zip: vs /'7/9 Phone#:_ _4� 02� �' 13 _'2 FOI employer?Check the appropriate box: Type of project(required): employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction yees(full and/or ppaart-t e).* have hired the sub-contractors sole proprietor or partner- listed on the attached sheet.? 7. ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.E1 Electrical repairs or additions required.] officers have exercised their " 3.❑.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.[]Roofrepairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeoymers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew-affidavit indicating such. lContractors 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 and job site information. Insurance Company Name: coo nl 7'P/ L ,LAl S Policy#or Self-ins.Lic.#: t(/ Q 9 go)V 2/14 . Expiration Date: rob Site Address: ,� �!, V_ t L6 t''2 City/State/Zip:_ /), Y9 h C/U1pf'P Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do lzereby cert under thepains andpenaldes ofperjury that the information provided above is true and con ect. Sip-mature: Date Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# -Issuing Authority(circle one): X.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbinglnspector 6.Other C ontactPerson: hone 9: IV AOL Safety insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: WARREN A. MARKOWSKY and ROBIN MARKOWSKY Property Address: 67 CRICKETT LN,NORTH ANDOVER, MA Policy Number: HMA 0319025 Claim Number: BOS00037507 Date of Loss: 5/21/2013 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Brigid Tarpey Claim Examiner 5/29/2013 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5349 Fax: (617) 531-8819 Email: BrigidTarpey@Safetylnsurance.com t Date...... .".Z. -. f NCR7M 1 3?O•`,r�`o�•°_e�ppL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,S$A US� This certifies that ....... .......ST�4rlj/��(/............ ............,..(. ................. has permission to perform ...............3...... ��c!/... ............... wiring in the building of........!" .� �� at........... ... .... !.................................................. ,'forth Andover,Mass. J � Fee ......�........... Lic.NoA.6 ©2........... ....... ..� ��.�..�...�!': ./,. p ELE s RICAL INSPECTOR Check # .Y 825) r f -N t;ommonwealth of Massachusetts70ccupaIncy o�cial use only Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS d Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECT All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527c1 RAL WORK (PLEASE PRINT WINK OR TYPE ALL INFORAM TION) 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) Owner or Tenant S Owner's Address Telephone No. Is this permit in conjunct'conjunctiq with a b 'ding permit? Yes LD-- NO Purpose of Building ❑ (Check Appropriate Boz) " � Existing Service U❑tility Authorization No. APs os Overhead Undgrd El--No. No.of Meters l New Services / �P Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and A rapacity Location and Nature of Proposed Electrical Work: Com letion of the olloud table may be waived b the Inspector of Wires. No.of Recessed Luminaires No.of Cel-Sus No.of p.(Paddle)Fans Total No.of Luminaire OutletsKVAers No.of Hot Tubs Transform Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o,o mergency ig o d. d. Bane Units No.of Receptacle_Outlets No. of Oil Burners FIRE ALAR-ms No. of Zones No.of Switches No. of Gas Burners No.of Detection and No.of N Ranges Ran Devices g o.of Air Cond. °� Tons No. of Alerting Devices No.of Waste Disposers eet �P dumber ons No, of Self:Contained Totals: -" `-"'.. Detecfion/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑Other No.of Dryers Heating Appliances , Security Systems:* No.of Water No.of KW No.of No.of Devices or Equi alent Heaters Si s Ballasts. Data Wiring: No.Hydromassage Bathtubs No.of Devices or E wvalent No. of Motors Total HP Telecommunications P OTHER: No.of Devices or E uivaient Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start; Inspections to be requested in accordance with MEC Rule 10,and upon.co ,INSURANCE COVERAGE: Unless waived by the owner,` mpletion. 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 cove a is in force,and has exhibited proof of ame to the permit issuing office.. CHECK ONE: INSURANCE L� BOND ❑ OTHER ❑ (Specify:) I certify,under the s and enalties o p ) /o��•►�G sP P ofper' that the information on this application is true and complete. FIRM NAME• / 01 c C Licensee: 1,1LIC.NO.: (If applicable, enter"exem "in th nse�umber line.) S�$�e LIC.NO.: Address: �C// �� fty � Bus.Tel.No.: *Per M.G.L c 147,s 57-61,security work requires D {�of Alt.Tel.No.: Lice OWNER'S INSURANCE WAIVER: I am aware that� �ee does not ublics ehave'the Iiabili ara�Kn_ C� required by law. By my signature below,I hereby waive this requirement I am the(check one ce cov ormally Owner/Agent ) ❑owner ❑owners agent Signature Telephone No. PERMIT FEE.$ The Common wealth of Marsachuset& Department of.Industrial Accidents ! Office of Investigations, ..rl g "`' 600 Washington Street iva f Boston, MA 02111 ` wlVW:mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/El Applicant nformation ectricians/Plnmbers I Please Pirint Lem Na lie(Business/OrzeAzabonilndividual); Address: v•-p_ City/State/Zig: ! Are you an employer?Check the appropriate box: 1.❑ 1 am a employer with 4. ❑ I am a gemeral contractor and IF7R= Type offect(required): _ loyees{foil andlor part-time).*. have hired the sub-contractorsconstruction 2. I am:a.sole proprietor.or partner- listed on the attached sheet,f deling ship and have no employees These subi-contractors have working for me m an litiony capacity._ workers' comp.insurance.[No workers'camp.insurance 5. ❑ We are a corporation and ifs . ng addition squired] officers have exercised their cal repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL f 1.❑Plumbing repairs or additions t myself.[No•workers'comp. :..152, §1(4),and we have no � ] insurance ired. t .employees. [No workers' 12.❑Roof repairs comp. insurance required_] 13-❑.Other "Any applicant that checks bole#i must silo fill out the section below showing their workers'nom satin • f Homeowners who submit this affidavit' P� n poli tnfomiati �ndicatin they arc d cY on lcontractors that hook this box mustatieeheQ an additioasi shot showing the trams of the sub-im ouiside oonuactors must submit a naw affidavit indicating such �ctots and then workers comp.policy ittfomiation. I am an employer that.&prPremg.workerx'compensation insurance or infornratlon, f my emp�Y Beiow is the policy and job site Insurance Company Name: ' Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Attach a copy of the.workers'com Crty/Statezip. pensa#ion policy declat abon page(showing the policy number and expiration date Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to$1,500:00 and/or one-year imprisonment,as well as civil penalties in the form of a imposition WORK ORDER penalties of a of up to$2$0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of a fine • investigations of the DIA for insurance coverage verification. I do hereby c under the rns o rY 1har the information provided abov is Si tore: and correct - Date: Phone#: Ofj`iciai use only. Do not write in.this area,to be completed or town officio[ City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing gnspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individualx,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 commenweah�h nor any of its political subdivisions shall enter inw 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 r necessary, supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certific ate(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'cnrrnpensation insurance. if an LLC or LLP does have t 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't[te 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 permitflicense number which will be used as a reference number. in addition,an applicant that must submit multiple permit/licerm applications in any given year,need only submit one affidavit indicating•current policy information(if necessary)and under"Job Site Address"the applicant shouldwrite"all locations in (city or town)."A copy offlie 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 at permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of lnvestiptions 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 andfax number. The Commonwealth of Massachusetts Department of Indusbial Accidents Office of Investigations 600 Washington Street Bastion, MA 6.2111 TeL#617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mem.gov/dia Location C te (C No. r Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ u + , x Building/Frame Permit Fee $ CMUS�"t� Foundation Permit Fee $ P SSAE u` S22ber Permit Fee $ Sewer Connection Fee $ 0 Water Connection Fee $ ^• TOTAL $ =° Building Inspector 9701 Div. Public Works PE&,%i1T NO. Z PAGE 1 a0- APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. MAP d40. `v I LOT NO. -2 / 2 RECORD OF OWNERSHIP IDATE BOOK "PAGE — ZONE SUB DIV. LOT NO. LOCATION �-7 PURPOSE OF BUILDING OWNER'S NAME !/�2r� _� Q 00 P NO. OF STORIES SIZE OWNER'S ADDRESS/ - BASEMENT OR SLAB ARCHITECT'S NAME ( SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME {,6,/� SPAN DISTANCE TO NEAREST BUILDING � ( DIMENSIONS OF SILLS DISTANCE FROM STREET "" POSTS DISTANCE FROM LOT LINES-SIDES REAR '" '" GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION - /1 r! MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. (1!/ PGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND/APPROVED BY BUILDING INSPECTOR DATE FILED NUILDING INSP[CTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT G 04 FEE ��— OWNER TEL.# PERMIT GRANTED CONTR.TEL.# �f�J 19 76 CONTR.LIC.# / 7 G H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY SioR1E5 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY .FFICEs LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- MULTI. FAM RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. ---III PINE BRICK OR STONE HARDw D PIERS PIASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B M'TAREA _ 1/1 1/1 3/ FIN, ATTIC AREA _ NO B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARD"j'0 _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORPOOR ADEQUATE i I NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING j cop, NORTFI Town of Over +{ y zower, Y— I r 19 �6 o o dMass., FSA COC1 CIEw Pam ��.�ARA T E D p `'� ' S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................................4s > ........... .�!z.. . . .C..................................:::...........:.... - Foundation has permission to erect..... 1... ,1 ........ buildings on .......... .. ......... d G.cl� 2`-'.... �........... Rough tobe occupied as.................................................. . .. �`�6. ........................................................ ....4-t ... Chimney provided that the person accepting this permitshall in every respect conform to the terms of the applicatioon 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 t' � Final EXi T.P\ES LN 6 MONTHS 'CONSTRUCTIO?N STARTS ELECTRICAL INSPECTOR Rough .... . . .. ... .... .... .TO .....:....................R Service ... .. ..... ..... G BUILDININSPEC Final Occupanc,DPermit Requinz,,J ro Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Fi ugh Fnal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. i w i y '� aolve�lsirviww aS aTeA uaydxTy t 96/6Z/LO uorag�id 9� ^ Wo low 3N3W3A dl�I> ' _ ,` .; • T� -�om,„�,u��� �✓G�woac/zuaetta DEPA�iNEHi OF PUBLIC SAFETY CONSTRtlCli4i SUPERVISOR LICENSE Nuttier: ' C 053 - fzpires: Birthdate:) ;:°D2/15/1997 01/15/1958 Restricted 00 ,EN M SNOLAK i VIDALE ST NO ANDOVER, NA 01845 ti z " h: Date. . NORTPq TOWN OF NORTH ANDOVER ��pF`4�.•0 ,•1,t,pp PERMIT FOR GAS INSTALLATION �,SSACMUSES This certifies that . . .. . . :-. .. . .. .. . ... !r�. :. . . . . . . . . . . . has permission for gas installation . . . . .. .�. . . . .: . .. . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . .. . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee..;'. . . . . . Lic. No.. . . . .".... . . . . . . . . . . . . . . . . . : . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MAP ' PARI:' � d MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO 'ASFTnING V�o� V '"' S a (Type or print) ate NORTH ANDOVER,MASS HUSETTS Building Locations Permit# 3Y / Amo $ O Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ x w z z m F w O O Eur- O z G �' x w x a d W a w w ° > w a Q 0 z o z o x x o > SUB-BA SEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3R1). FLOOR 4TH . FLOOR 5T,`-1 . FLOOR 6TW . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or k one: Certificate Installing Company Nam Corp. /V Addres ❑ Partner. Business Tel6phoneLj Firm/Co. Name of Licensed Plumber or Gas Fitter G INSURANCE COVERAGE Chib� o I have a current liability Insurancepolicy or it's substantial equivalent. Yes No❑ lea If you have checked yes, se' dicate the type coverage by checking the appropriate b x. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and i tallations T ormed under PermitIssu for this ication will be in compliance with all pertinent provisions of the s Code and Chapter 4 of Kene Laws. By: Signature of Licensed Plumbe O Fitt it Title ❑ Plumber . City/Town ❑ Gas Fitter License Number . aster APPROVED(OFFICE USE ONLY) Journeyman 3L.� 4 Date. /.-.!j. .�.% ....... TOWN OF NORTH ANDOVER pF��.ao ,e,ti0 3? O PERMIT FOR GAS INSTALLATION A ,SSACHUSEt This certifies thatGr c c u?P has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . in the buildings of . r . . . . . . . . . . . . . . . . . . . . . . . . . at . . ./���� . .l%?'t s?: Z7. . .l/ , North Andover, Mass. Fee. ./A Lic. No..`�.`�.1. .3 ` . c .4.- . . . . . . . ' v GAS INSPECTOR i WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIPIG t (Print or Type) C NORTH ANDOVER Mass. Date / QO wilding 'Location. Permit # o _ .� Own s Name Stein Gl�c���,�►-, .r New '7 Renovation D Replacement Plans Submitted D FIXTUPrS N v _ ' N as y cc df m .O O fA = t- W u m j 4 v t- a ?' x o t- °C d m H N a m 0 0 = a W W f- m w t w W �., �, a <r y 4 m tc w z o W as u, 4 '� � a }, z W W C7 .1 < : �' tr Q W W V L7 G = l-. W J H z f, �- to m ? O ~ W O N S Z d W G rt "' d yr y ¢ W O 4 c < Q O o W n: O W t m x o o = U. a ca v cz > Q a t- o SUa—$STMT. BASEMENT s t ST FLOOR { I 2P10 FLOOR 3RQ FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TK FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLBG. & HTG. CO_ INC.Q/Corp. 9199 Address 20 A-EGEAN DR. UNIT 1 10 Partner. METHUEN , MA. 01844 Firm/Co. Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter GFORGF I ARnSF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ©`Other type of indemnity D Bond F1 Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent U I hereby certify that all of the dct►ils and information I have submitted (or entered)In above application are true end accurate to the best of my knowledge and that all plumbing work and InsaUations performed under'Permit itteed for this application will-be in compilanca with SU pertinent provisions of the Massachusetts State Cas Code and Chapter 14:of tho General Laws. - •_. I3 YPE LICENSE:. By rGasf lumber Title itter- Sign ture of Licensed aster Plumber or Gasfi.tter City/Town: ourneyman 9983 APPROVED (OFFICE USE ONLY) License Number Date.'. . i . `. .`. N° 4 0 TOWN OF NORTH ANDOVER d PERMIT FOR PLUMBING ,SSACNUSE� This certifies that '�.4 .�.� . . . !.'. . . . � .�.. . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . !q°.'.`. . . .`. . . . . . . . . . . . . . . . . . . at.,'. .. . . . .'. . . . . . . . . . . . . .. North Andover, Mass. Fee. . . .Lie. No.`. . . . . . . . . . . �._. . .�. .:'��^. . . . . . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer .`•� .,,.-„ ........ ,._.�1, ,,, �ryirvhnn.A��'ly►Si�3�19�-J��-J�'LE�A44�7�-�t�-J�.0 �u��od�t�uv�a ,¢�� . -�._. Ant or T 7” NORTH ANDOVER, Mast. Oali, Building it * Cr;5'G Location - � Cr Owner's�+ Name --Steve New ❑ Renovation ❑ Replacement [� Plans Submitted: Yes❑ No ❑ FIXTUAEd s1 w 0 0 iz 44 K an " M w �y az � � g ; « � � ` : � � � �+ 3' _ 0 s 0 'r r s 0 U • r o p s H M .r a o s l« s i o sua—eaMT. sAGRUENT IST FLOOR 11140 PLO 0R $R0 ►C0011 4TH ?LOON eTH FLOOR eTH FLOOR. TTM FLOOR 1THFLOOR • Installing Company Name ANDOVER PLBG. & •HTG. CO. INC. • Check one: CertificateCorp. 2122 Address 20 AEGEAN DRIVE UNIT# 10 13-Partnership MA. 01844 ❑Firm/Co. Business Telephone 978485-8383 .Name of Ucensed Plumber r,FnRrF LAROSF INSURANCE COVERAGE: ec e I havea current liability Insurance policy or Its substantialequlvalenL Yes © No ❑ If you have checked 3m. please Indicate the type coverage by checking the appropriate box A ItablAy Insurance policy CEJseOther type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WANER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signstuts o at or Owner a an Owner ❑ Agent ❑ I Mraby c*Mfy that all of the detifih u d`h(atnitlon.t have strbrr>ftted tot entstsd)In above` krxnrtadpa and that iA ctumbt crock°:uidtln t llittlons sa And.soarate to the best of my 1 th Pedot »d under the' nM laswd lor°thtf ` pe tinen provislons of a Maisactiui*'tts"-Statit'PKwx �0 tlonlrll b�h compNanq with an binq Code ar�d•a�apt.r prof tt>. ,..,. er . Title ons urs Q s+ um Ctty/Town License Numbw 9983 AF'r XNED (OFF)CE USE ONLY! Type of Plumbing License:Master Journeyman 0 M Location No. Date NORTH TOWN OF NORTH ANDOVER - • O Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s�CMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # ,Oke i 8 '/-' 5 7 �2z� /-�—$uHdingInspector I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: m �xf � X ic SIGNATURE: Building Commissioner/1for of Buildings Date Z SECTION 1-SITE INFORMATION o 1.1 Property Address: 1.2 Assessors Map and Parcel Number: (;)/ 0 // 0 /0 - Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. blood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT IStOrICDistrict: Yes NO m 2.1 Owner of Record IVAAp LO i::�V Cp fc LA-4E N�� J,aName �nt) Address for Service: p/ Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor:ups or. (/J(> P.O.Box 637 License Number North Reading NIA_ .�d; 01864 /�1� Expiration Date Seknature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name ) Duval Rmft 1 ��e m P.O.Box 637 Registration Number r• North Reading,MA Address 0011864 _r Expiration ate z^ Signature Tele hone G) L SECTION 4-WORKERS COMPENSATION(M.G.1. 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 buildinaamit. Signed affidavit Attached Yes....... No....... SECTION 5 Description of Proposed Work check all a h'cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Com leted bypermit applicant 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 to 5 Fire Protection 7 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, t.Js ,as Owner/Authorized Agent of subject property Hereby ad orizeYD , e to act on My be if in all matters rel wor uthorize by this ding permit application. Si a e o Ovaner Date SECTION 7b OWNER/AUTIIORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and informioVa�th� regoing application are true and accurate,to the best of my knowledge and belief 1 K e.0.80X 637 North Reading,MA Print N 01864 Si ature of Owner/Agent Date Oro .' NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IST 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFMvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE C NORTH Town of gAndover ,� o over, Mass., �Z3�� oLA COCHICMEWICK ADRATED PPS` K5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • THIS CERTIFIES THAT........ .............. .......... BUILDING INSPECTOR Foundation has permission to erect........................................ buildings on..:(...�..... Rough tobe occupied as ... inj............................................................................................................................................ Chimney provided that th person acce ing this permit shall in every respect conform to the terms of the application on file in Fid this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIONSTA ELECTRICAL INSPECTOR Rough ....................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I r The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations •� Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: �ity I am a homeowner performing all work myself. Phone # 0 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address P.O. 637 City: 01864 Phone#-. insurance.Co.�"•�J Poli # �7 f 0 �4ds Company name: Address City: Phone# Insurance Co. _ Policy# Failure to secure coverage as required under Section 25A or MGL 152can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment.a4 u¢elt.as_civil,penaltles inthefmn-fe_STOP WOM.ORDER.and..a.fine oQ311)(1.00)aiday.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 certify under the pains and penalties of perjury that the information provided above is bue and correct. Signatu ---�� Date Print name Dit-. V Phone# Official use only do not write in this area to be completed by city or town official• City or Town Permit/Licensi []Check if immediate response is required ❑ Building Dept ❑ Licensing Board Contact person: ❑ Selectman's Office Phone#. ❑ Health Department ❑ Other 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 c 11, S 150 A. The debris will be disposed of in: (Locatio of Facility) Signature of PermitApplicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a `-" 5�� 5�5' CXX/S_ Page No. of Pages Builders License # 58443 Home Construction Reg. # 109288 o o D (9139 944-9994 (9913)) 664-2559 .'I "The Areas Oldest Roofing Company" I; P.O. Box 637, North Reading, MA 01864 III I PR OS LSUBMITTEDTO PHONE DATE - I I ! t C TREET/ I ( r y II ` CITY,STE NO ZIP CODE JOB LO ATION 7 f. of - , , ;', ; `• rt ,, r 1. I We hereby submit specifications and estimates for: Recommended Optional (Included in price) (Not includedin price) Rip& Remove all shingle debris from roof&job site: I d l layer :112 layers ❑3 layers or more ✓ Repair/or Replace any roof decking; not to exceed 50sq.ft. II 11 sl Install 8"aluminum drip-edge/and rake-edge along entire perimeter.Choice of mil wh e r brown _ V Install ICE&WATER underlayment along horizontal eaves,valleys, sidewalls and sky-lights&chimneys �1 ✓ Install premiumTase sheet underlayment between roof deck and roofing shingles t I I 'I d Install 25yr CertainTeed/GAF/Tamko or Owens&Corning traditional 3-tab roof shingles U 30 year I • Install 30yr CertainTeed/GAF/Tamko or Owens&Corning architectural roof shingles U 40 year U 50 year U Lifetime -- I policy for more details See manufacturer warranty I - o/ Install new aluminum vent-pipe flange(s) I - - ---- - - - ------ - - - ------- - Chimney ----Chimney(s)-counter-flash and re-step existing flashing U Cut& Install new lead flashing Ridge-vent/exhaust vent with low profile design, hidden by shingle caps U Soffit-ventilation Goof louver-vents 'I - - - - - - -- - - 1 II I Seamless style aluminum gutters-custom fabricated at job site I 'U downspouts I„ Other ------- - -- - - -- ------ - - - - - - - - - - --- ---- - -- ------ -- - --------------- -- --------- I u II n I I I I I I. I I I . - - - - - - -- - - - - -- - - - - 1 - ------------------ ------------ -- - - - 11 "Please Note:All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear-off I,. _ - - - - -- _'-- - - - - - - - - -- -------- -- ------------------- -- - -- ------ - - _----- Price includes all items above that are checked only/others may be priced separately upon request. I -- 'j We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: f , l Total price not including options. dollars($ Payment to be made as follows: 30%deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 I Late charges of$50 per week for all outstanding bills due upon day of Authorized completion. Signature V.. l -Accepting proposal means agreeing to the terms of the enclosed binder Note:This proposal may be contract. Please sign contract&return top copy(white)with deposit. withdrawn by us if not accepted within�t�days <CN- Commonwealth of Massachusetts \ City/Town of t a System Pumping Record RE CEIVED Form 4 D G„M SV gy`W DEP has provided this form for use by local Boards o e�Ithused, but the information must be substantially the same as that pr � s form, check with your local Board of Health to determine the form they use. ymust be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side o Right side of house, Left front of house, Right front of house, s .- Left rear of house-R rear of h uft rear of building. Right rear of building. Address C #I Ckl bp, City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State/} Code Telephone Number 9 B. Pumping Record L 2�-- -15�-D� 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: , 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L D Lowell Waste Water g to a of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1 � 1 ,. Staple GidejS IIII IIII IIIA VIII VIII VIII VIII VIII VIII111111 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO3��/ Date Received Date Issued: ZZ� IMPORTANT:Applicant must com lete all items on this page LOCATION Print PROPERTY OZXNFR Print MAP NO: a ARCEL: a ION1NG DISTRICT: Historic e hop Village yes '31 VEMENT TYPE OF IMPRO PROPOSED USEResidential Non- Residential ❑ New Building e0ne family ❑Two or more family ❑ Industrial ❑Addition [I Commercial Alteration No. of units: ❑Assessor Bldg [I Others: [I Repair, replacement y [IDemolition ❑ Other 03Flood' am F, OtWetlandsi s '� WatershedDi triet r .l Septic ®W,ell'� , y pl;� i ❑ �'aw�V.r d '4�.� f . � r . .fi:', < _- _ ..E,-:,. 3 _s: �pk._�i.`,s�:,�_.y:.�J.�<d .y.sc��.�:v �i:�:s�.'eee- • .��.��ater/Sewer... >_. �.__ r� .�t.� . .. �_ ._ ---- -- _� DESCRIPTION OF WORK TO BE PERFORMED: S j�vv n. Identification Please Type or Print Clearly) Phone: OWNER: Name: i Address: Phone: CONTRACTOR Name: Address:_ t�`'� 3 I_ �- -- NG w ✓, Supervisor's Construction License: 057 3 e13\1 Exp. Date: aqj; , j N Home Iruprovement License: D\ '1`'� Exp. Date: ARCHITECT/ENGINEER t!" Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ \ FEE: $ 13 `d ,V22 Check No.. y ,2— Receipt No.: 4` rr -�1 (P NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund --- ----- -- -__--- �Y.. -- -_ — - - - t actor•:-=� :.` :��� .:-- - --� - - Sigriatur`e�of�A'ent/Own - _ =•_ �.Sinature`ofcon r _____ - :_. j Location No. Date MOIITh TOWN OF NORTH ANDOVER O f41 A 9 : : Certificate of Occupancy $ s4CMUS Building/Frame Permit Fee $ �J r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23966 Building Inspector Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ [Well E OF SEWERAGE DISPOSAL c Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ ❑ Tobacco Sales ❑ Food Packaging/Sales ❑te(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature (COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature i Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -Temp Dumpster on site yes Locatedno384 Osgoo Street Located at 124 Main Street Fire Department signature/date 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 NOTES and DATA— For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ❑ 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 ❑ 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) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording tust be submitted with the building application Doc. DOC-Building permit Revised 2008mi NORTI.. ® EAndover TO" _0 R.. V 177: o A o lover, Mass., 01- as- S k A- 11 COCMIC MEWICK V� SRATED P`P � BOARD OF HEALTH Food/Kitchen Septic System .PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT e%Ci - ............. .. '.......... .......... Foundation has permission to erect........................................ buildings on ..V4"....... .. Rough to be occupied as...... .. .lMo..O.. ........ ti ..l.S.... .. ....S?a.d ..............�............................. Chimney provided that the person accepting this permit shall in eve 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 lie , PERMIT EXPIRES IN b MONTHS UNLESS CONSTRU NELRT ELECTRICAL INSPECTOR Rough ........................................................................................... ................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT: Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. #CO L7� DATE(MWDDYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/29/2010 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: 9 the certificate fickler Is an ADDITIONAL INSURED,the pol"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). tODUCER NAME: 4 P ROBERTS INS AGCY INC PHONE. Hc -8073 -3147N 97$ 683 A MAI L060 Osgood Street AODREss.mike@Wrobertsinsurance.com lorth Andover, MA 01845 RISUREII(S) AFiORDNO conUal; rulcrr INSURER A. PROVIDENCE T(j 3URED KEVIN MURPHY BUILDING & REMODELING INSURER B:MERCHANTS INSURANCE 169 BOXFORD STREET INSURER c:GUARD INSURANCE 169 BOXFORD STREET INSURER 0: NORTH ANDOVER, MA 01845 INSURER E: INSURER F: OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATB•-MAv BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN_IS SUBJECT TO ALL THE.TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE amWvD POLICY NUMBER MA) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 CLAIMS-MADE LX'OCCUR MED EXP(Any one person) $ 5'000 CPPOO60868 11/22/1011/22/11 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY `Ro LOC $ AUTOMOBILE LIABILITY Ea accident $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED MCA7013608 01/23/10 01/23/11 AUTOS AUTOS BODILY INJURY(Par accident) $ 3 NON-OWNED PR acciden $ HIRED AUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR SMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITSIX E ANY PROPRIETORMARTNEFUEXECUnVE OFRCERNEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 500,000 (Rlandak"lnNN) IMWC109881 07/01/10 07/01/11 E.L.DISEASE-EA EMPLO $ 500,000 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 :SCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) ERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER NORTH ANDOVER MA 01845 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 V I P UX45�_ (D1986-2010 ACORD CORPORATION. All rights reserved. ,0111325(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of/Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers A licant Information Please Print-Legibly Name(Busimess/orpnization/lndividual):_��u .�,� �1.�,,r� �•.t\��., �tiZv.,.,.5^v� Address: City/State/Zip: N► b t 0 t0( Phone#: ya,s - b`"$-S33 Are you an employer? Cbeck the appropriate box: Type of project(required): 4. ❑ I am a general contractor and 1 6 New constriction I am a employer with�... ❑ ees full and/orpart-time)-* have hired the sub-canvacwrs �10 y ( P art-tune}' listed on the attached sheet, t 7. �-Remodeling I am a sole proprietoir or partner- , :.❑ ship and have no employees These sub-contractors have 8. [] Demolition workers' comp. insurance. . 9. Building addition working for the in any capacity ❑ g workers' comp.insurance S. ❑ We area corporation and its (No officers have exercised their 10•❑ Electrical repairs o; additions required.] 3.El am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions myself. (No workers' comp. c. 152,§1(4), and we have no 12.0 Roof repairs insurance required..]t employees.[No workers' 13.❑ Other comp. insurance regetired.) Any applicant that chedm bwc 1 must also 811 out the section below showing their workers'compensation policy information: Homeowners who submit this affidavit indicating May are doing all work and then hire outside contracson must submit a new affidavit indicating such. -ontramn that cheek this box must attaehed an additional sheet showing the name of the subcontractors and their wo*='cony,policy info'rrmtion. am an employer•that is providing workers'compensation.insurance for my employee& Below is the policy and job site Kformation. nsurauce CompanyName: 'olicy#or Self-ins.Lic_ #: fit% Expiration Date: M�.� 1 t ob Site Address: City/State&* L.1a. 0 X814, kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Zai7ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crizttinal penalties of a ine 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 )f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. r do he by certi�er the pains and penalties of perjury that the information provided above is tree and correct. ;i atur Da 7-0 Phone#: �-`1� —S 3 3� Of-tial use only. Do not write in this area,to be completed by eity or town official, City or Town: Permit/Ucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Towu Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• r � 169 Boxford Street North Andover,M A 01845 PH:978-688-335 Building Contractor FAX:978688-720' Proposal To: Warren&Robin Markowsky 67 Cricket Lane All Home improvement Contractors and Subcontractors emag�vtunless Andover, Ma 012845 �horneatr«registration by vernent contracting, i�or chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and Status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place, From: Kevin Murphy Room 1301,Boston,MA 02108.(617)-727 85% CC: Date: 2/20/2011 I Job: Basement renovation Date of plans: None ArChRect: None Location: Same Section I-Work Schedule Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 2/21/11. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 3/30/11.The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11-Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair correct,replace,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. I Section III-Scope of Work Page 2 of 4 169 Bo)d;rd Street Nath Andover,MA 01845 PH:978688-5335 FAX 9786E&XXXX General Proposal is to renovate existing finished basement area. No allowance has been made for any structural changes. Building permit will be obtained by contractor. Demolition Existing ceilings will be gutted,wall between two rooms in rear section of basement will be completely removed. Wall /door at center of basement will be removed and opening expanded as large as possible. Textured wall against garage will be gutted. Other existing walls and closet areas to remain. Building All framing materials required to change openings/remove walls will be provided. Plumbing No allowance has been made for any plumbing Electrical Electrical work required to add twelve recessed lights, relocate plugs/switches where walls are removed, will be provided. No allowance has been made for any other electrical work. Insulation Any insulation required will be supplied/installed. Plaster Ceilings and wall against garage, will be blueboarded and skimcoat plastered. Other areas will be patched as required. Ceilings and walls will be smooth. Interior Trim/Doors Interior trim will be supplied and installed to match existing. No allowance has been made for any new door units. Painting All interior painting will be provided. One coat of primer and two coats of finish will be applied to all painted surfaces. Floor in pool table area of basement, will be painted. Colors to be determined. Samples/information will be provided prior to any floor painting. Flooring Floor at entry area will be tiled. ( area is approximately 8'x10' ) An allowance of$5 per square foot has been included for tile materials. i Page 3 of 4 f�1Ne�■'f�Tiii�.3/NeYi 169 Bo 3ord street North Andover,MA 01845 PH:97MB85335 FAX 978588-X)00( Waste Removal All demolition/construction debris will be disposed of by contractor. Page 4 of 4 KitiitfiRR i�RK1•Y�ifRi�i 169 Bordord Steel Nath Andover,MA 01845 PH:9785885335 FAX 97BaB-)O= Section IV-Price Schedule We hereby propose to furnish material and labor-complete in Accordance with above specifications for the sum of... ... ... ...... ... ... ... ... ... .......$ 11,500 Payment to be made as follows: Percenta alitem Description Amount 1 Demolition complete $3000 2 Plasteling complete $5000 3 Job 100% complete $3500 Total 3 1 $11,500.0-0-1 -Notice:No agreement for Home improvement contracting work shall require a dammo payment(advarae deposit)of more that one-third of the total contract payments which the contractor must make,in advance,to order ardor otherwise obtain dei � total amornt of all deposits or nrery of special order materials and egnripment,whichever is greater Contractor: Kevin Murphy 169 Boxford Street No.Andover, MA 01845 Registration No: 101874 Section V—Acceptance Acceptance of Proposal—I have read this document and accept the prices, specifications, and conditions stated. I understand that upon signing,this proposal becomes a binding contract You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO T SI THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signatu (" Date '7-k'z-6 Signature Date