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Miscellaneous - 67 RALEIGH TAVERN LANE 4/30/2018
767�ALEIGHTAVERN LANE /107.=_��'0 1 i DRMSIVED C9 1 : 011 September 12, 2017 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Mr. Darrell Hamann 67 Raleigh Tavern Lane North Andover, MA 01845 RE: Maintenance and Service Contract for the Recirculating Sand Filter System located at 67 Raleigh Tavern Lane, North Andover Dear Darrell: Clear Water Industries proposes to provide service and maintenance for the Recirculating Sand Filter(RSF) System at the above referenced address. The following maintenance and service schedule is for the next two (2) years of operation commencing upon receipt of signed contract and Annual Cost received in full. Scheduled Annual Service: Cost: 1 inspection and 1 field effluent test = $305 (Note: Access cover for all components must be at the ground surface.) 1. Check sludge, scum depth and clean the effluent filter in the septic tank. 2. Check panel and alarm system. 3. Check ejector pump and float switches in Recirculating pump chamber. 4. Flush each lateral in the RSF. 5. Check ejector pump and float switches in the Dosing Tank. 6. Flush laterals in Pressure Distribution SAS. 7 Take effluent sample as required by Massachusetts D.E.P. Sample will be analyzed for the following: *Dissolved Oxygen, *Turbidity, and W. 8. Notify Client verbally of any problems encountered. (Note: There may be instances when the high water alarm will sound. In the event of an alarm condition, you are requested to silence the audible alarm and contact (978) 356-0779 for instructions and/or a follow-up field visit by an CWI representative. See unscheduled service costs.) I have read and agree with the above Scope of Work: 1 , CWI's initialsqrri Owner's initials �4 PO Box 825, Ipswich, MA 01938. 978-356-0779 - Fax 978-356-5500 •www.clearwaterindustries.com i e � 4 Page 2 Mr. Darrell Hamann September 12, 2017 Unscheduled service: 1. Unscheduled emergency service calls will be billed at the following hourly rates: *Monday through Friday lam—5pm: $90 *Monday through Friday 5pm—7am: $150 *Saturday and Sunday: $150 with a minimum of a 2 hour charge. 2. If results of field effluent testing for pH, Dissolved Oxygen or Turbidity do not comply with Massachusetts Department of Environmental Protection limits, additional testing for Total Suspended Solids and Biochemical Oxygen Demand would need to be done at a certified laboratory. Owner would be contacted prior to additional testing. Additional testing of effluent would be $105.00 per sample. Certified technician: The service technician shall be a Massachusetts Certified Operator. The certified operator will be David F. Clark, George F. Norris, Mark Cottrell or Mario Rosa. Reporting requirements: In accordance with DEP's Title V Regulations, CWI will file an annual report transmitting the data from the annual inspection, as noted above, as well as a review of any unscheduled service. CWI will also file an annual report with the home owner and the local Board of Health. Sincerely, Clear Water Industries David F. Clark Manager Acceptance by Owner: Darrell Hamann Date i PO Box 825, Ipswich, MA 01938 .978-356-0779• Fax 978-356-5500 •www.clearwaterindustries.com 0 RECIRCULATING SAND FILTER SYSTEM ROUTINE INSPECTION ADDRESS: 67 Raleigh Tavern Lane,North Andover OWNER: Hamann DATE: January 3, 2017 OPERATOR: Mark Cottrell SYSTEM STATUS �- Septic Tank Effluent Filter: O.k., cleaned Scum Depth: 115/4855 Sludge Depth 655/48" Recirculating Pump Chamber Pump H-O-A Setting: Auto Pump Cycle Timer: 2 minutes on, 15 minutes off Alarm Selector: On Level Alarm: Normal Exercise Pump: Yes Test & Clean Floats: O.k., cleaned Tank Condition: Good Dosing Pump Chamber Pump H-O-A Setting: Auto Pump Cycle Timer: On Demand Alarm Selector: On Level Alarm: Normal Exercise Pump: Yes Test & Clean Floats: O.k., cleaned Tank Condition: Good Sand Filter Sand Condition: Clean Diffusers Condition: Clear, flushed all (3) laterals Effluent Quality Visual Inspection: Clear, no odor Sampler pH = 6.8, Dissolved Oxygen= 10.0 mg/L, Turbidity = 6.50 NTU Comments: Flushed all five (5) laterals in SAS on January 3 2017. �t- x z% Signature: �l-� � Certificate # 11739 PO Box 825, Ipswich, MA 01938 . 978-356-0779 - Fax 978-356-5500 - www.clearwaterindustries.com Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 RSF System Operation and Maintenance Inspection Checklist A. Installation & Service Information 67 Raleigh Tavern Lane January 3, 2017 Facility Street Address Date of Service North Andover Mark Cottrell/Clear Water Industries City Operator/O&M Firm Inspect& note if B. Septic tank(s) pumping is required. Sludge Pumping Required: Yes ❑ No ® ® Sludge Depth: 6" Inspect& clean effluent tee Effluent tee filter: Yes ® No ❑ If yes, inspect® &clean at least yearly filter. Clean as C. Recirculation tank necessary. Inspect for ❑ Check if sludge accumulating Pumping required: Yes ❑ No sludge. Odor problems: Yes ❑ No ® If yes,description Inspect for D. Equalization tank (if installed) sludge. ❑ Check if sludge accumulating Pumping required: Yes ❑ No ❑ Inspect pumps E. Pumps, switches, floats, alarm system &electrical switches, test ®Pump Inspections (all units) as necessary. If problems,describe Run pumps in ® Test pump alternator, or record hours Not applicable for this system manual mode. Hours of operation Record ® Float switches 0.k. readings from Check all switches for operation meters& ® Test alarm counters. If non-functioning,corrective action(s) Note if weeds &F. Recirculation Sand Filter debris are present on bed. ® Inspect for ponding Ponding Present: Yes ❑ No Clean/maintain bed surface to ® Clean bed: Yes ® No ❑ allow proper operation of the ® Distribution pipes Flush: Yes ® No ❑ Brush: Yes ❑ No system. ® Check head loss in pipes 0.k. Headloss and comments G. Sample Collection (Field Sample) Yes ® (Field Sample) No ❑ If yes: ❑ BOD ❑ TSS ® pH ❑ TN ® Other— Dissolved Oxygen, Turbidity rsfcheck• 1/24/17 Page 1 of 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and 0&M Form for Title 5 I/A Treatment and Disposal Systems A. Installation Important:When Darrell Hamann filling out forms Owner on the computer, use only the tab 67 Raleigh Tavern Lane key to move your Facility Street Address cursor-do not North Andover 01845 use the return key. City Zip Mailing address of owner, if different: Street Address/PO Box: City State Zip ( ) - ext. Telephone Number B. Authorized Service Provider Clear Water Industries 0&M Firm P.O. Box 825 Street Address Ipswich MA 01938 City State Zip (978) 356 - 0779 ext. Telephone Number Mark Cottrell 11739 Certified Operator Name Certification Number C. Facility/System Information DEP ID Manufacturer ID Model Number Installation Date Start of Operation Approval Type: ❑ General ❑ Provisional ❑ Piloting ® Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information January 3, 2017 December 9, 2015 Inspection Date Previous Inspection Date 6" Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes ® No t5aiom.doc•rev. 11-07-05 Page 1 of 3 Massachusetts Department Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and 0&M Form for Title 5 I/A Treatment and Disposal Systems E. Field Testing Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other(specify): Odor: ❑ musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ❑ no ❑ some pH 6.8 SU DO 10.0 mg/L Turbidity 6.50 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: Notes and Comments: Field sample was clear with no odor. t5aiom.doc•rev. 11-07-05 Page 2 of 3 Massachusetts Department of Environmental Protection 71 Bureau of Resource Protection - Title 5 I` DEP Approved Inspection and 0&M Form for Title 5 I/A Treatment and Disposal Systems H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachusetts certified operator in accordance with 257 CMR 2.00. January 3, 2017 Operator Signature Date System owner must submit this report, technology 0&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use— by January 31 s'of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31'h of each year for the previous 12 months General Use—by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6'h Floor Boston, MA 02108 t5aiom.doc•rev. 11-07-05 Page 3 of 3 J MORTGAGE PLOT EK SURVEY INC. t 17 ROYAL STRIXT LAMENM MA, (}1B41 TQl- 30&-975-1413 4ORTGAGOR .. OECD REF' �r ADDRESS OF P€ fN; PLE BUiLDiNGAdz PLAN REF. 1'Q, .--a� o4 GATE 4F {NSPEC7l4N ! � y OA do, D o; ce C, l� 0 � f a J� � J• 40 �t X 4� Thb �ag, ti YforME In ortgo tp t��' t FtJRTHER SA'": tRAT ftt to T. WHONIN wy PiiQ'} g 06 c P" �� MY top �� Ocespta� um �D�%uldav a �1�_ and ac sas y Jt 3�a v%or than tht said nt+t# *0a � tiro ssl3►4d 1l� �cori�Q +adt�ono ��rt�►b a! �i loect oetQog® l�rtvts�� #a said ma.{ +' '�f�iitE� + at ' md Ao wx*wuwhm wax ►tstz haw a s p k�►rA� est y !hM�� seats ahl�r "► oomag � �t s♦r . evolimflaea In basad aA a � at t3Z Ppftpwty tact.6t s flt Hazard athsrte, and doea not sant a � t�tcplcsnr WIN � o�d tkaard � ► may. ttasrolbr,s D� � �+wl�:c �►t 3+0 • RoM Date../ .� .nl....... HORT11 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUS� This certifies that tip t. Y�11/LQ ............................................................................................. has permission to perform .................... wiring in the building of....... ........................................... at.1. ........� c? r..-...tNorth Andover,Mass. t Fee'.,-�..3..... ........ Lic.o. ... .3S �............ . ..... . :J ELECTRICAL INSPECTOR! Check # � �/�- 9 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.1433L 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 as deshalltermined limited as to the time of.ongoing construction activity,and may be_deemed_bythe_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 completi%n of workshall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or-the installing entit�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 Purpose by establishing an automatic four-year ext ension to certpermits and lowth and icenses conceeconomic rning the use orovery and edevelopment of real t Extension crothe her Wtth 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"Burin the ual' p p �' g qualifying period beginning on August 15,2008 and extending"through August 15,2012. le i�—Permit/Date Closed: **Note:Reapply for new perm ❑Permit Extension Act—Permit/Date Closed: \\ r-, ' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked '/ [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 112ooORK (PLEASE PMT INTAW OR TYPE AU flNFO)?MATION) Date: City or Town of: NORTH ANDOVER To th - U enspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �e '] �� .�/I f l��nti Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building /.) I NO ❑ (Check Appropriate Box) `S / ��'� `� Utility Authorization No. Existing Service ,�9 d1/ Amps J1 G /,2o Volts -.—_ Overhead ❑ Undgrd 1� No.of Meters New Service Amps / Volts ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Overhead Location and Nature of Proposed Electrical Work: - �_L_c�_G6 Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus No.of Total p.(Paddle)Fans Transformers KVA No.of Luminaire Outlets 2 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ in_ o.o mergency d. d• ❑ Batte 119 g Units --, No.of Receptacle Outlets a No.of oil Burners FIRE ALARMS No.of Zunes No.of Switches No.of Gas Burners No..of Detection and No.of Ranges Inifia Devices No.of Air Cond. Tot Nal. Tons No.of Alerting Devices No.of Waste Disposers eat Pump Number Tons KW o.of Self-Contained Totals: ""-� `-'-- `� Detection/Alerting Devices { No.of Dishwashers Space/Area Heating KW Local[] Municipal Connection ❑ Other No.of Dryers Heating Appliances , Security Systems:* • No.of Water It! of Devices or E uivalent Heaters No. Si KW No.of Data Wiring; Si s Ballasts No.of Devices or E uivalent ILI No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring- OTHER: No.of Devices or E uivalent io Estimated Value of Electrical Work: Attack additional detail if desired,or as required by the Inspector of Wires. i Work to Start (When required by municipal policy.) Inspectons 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,g ,office. CHECK ONE: INSURANCE El BOND ❑ OTHER ET(Specify.) G t�1i 7„ szc.c-.�.�. 01 -/..J_/0 I certify,under the pains and penalties of perjury, that the information on this application u true and complete- Licensee: omplete Licensee: FIRM NAME: Oro /YI. /YI e lv * LIC.NO..3 J 8 h Signatur (If applicable, enter"exempt"in the license number line) ' LIC.NO.: -- i Address: Bus.Tel.No 7�F1 S 8 7 7u 7 *Per M.G.L c. 147,s. 57-61,security work requires D „ „ Alt:Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Le Licensee does nothavethe liability Lic.No. e normally required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑ owner cover ❑rance owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. The Commonwealth of Massachusetts �} Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, llLA 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name (Business/Organization/Individual): 6 m , /fie 6 Address: City/State/Zip. v/A--SL Phone 7 SP- 72� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I a employer with 4. ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6 New construction 2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. g ❑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 required.] t employees'.ees. [No workers' comp. insurance required.] 13-El Other 'kraIiy app.i=,that checks box 41 -'so fill out the section below showing their worker;'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. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their worker;'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: AAtach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town official VA 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#: �a 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 an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or'license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials R 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. R r 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 bum leaves etc.)said.person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us`a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 600 Washington.Street Boston,SIA.0:2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-72.7-7749 NAr"r,A?.mass.govf dia E uhe Cf omuwmalth of + ,��iM 011109 u aw o. Er tuttnrtti IJf Public $nfriq Occumlicy A Fie Qwckea„�, -- r BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Mo Pom blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CHAR 12.'00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dae _4 — q& or Town of NORTH ANDOVER To the Inspector of Wires: I � The udersigned applies for a permit to perform the electrical work described below. Location (Street & Nu nr) Owner or Tenant 2 ( /1 Owner's Address Is this permit.in conjunction with a building permit: Yes _ No C (Check Appropriate 80x Purpose of Building Utility Authorization No. —'0 Existing Service 160 Amps �L J Volts Overhead _! Undgrnd of Meters _L •'i New Service Z6-0 Amps/Lu �L�J Volts Overneadlk-- Unogrno No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WOrK i�01 1/J �r'�r/c_ ('P���?,,�� •` 1,2 571 P!�V No. of 1.4ting Outlets I f y : No. of %:S 1 I - I No. of Transformers ransformera TotalKVA I No. of Lighting Fxtures i Sw mm,ng P^o, aocve.— In- r 1 grno. _ grno. '_ I Generators KVA t t' II� No. of Receotacis Outlets I No. of Oil corners No. of Emergency Lighting I Battery Units I No. of Switch Outlets I No. of Gas =_rrers FIRE ALARMS No. of Zones No. of Ranges I No. cf Air Czrc. otai No. of Detection and W. :cns Initiating Devices N0. of Disoossis No.ol Heat dial -otai ures .ons KV1 No. of Sounding Devices No. of Soft Contained ; No. of Dishwashers I SoaceiArea Heatmo Kwi 0•action/Sounoing Devices No. of Dryers I Heating Cevices KW Local i— Municioai —Other ._ Connection � ;i No. of No Jt Low Voltage i No. of Water Heaters KW I Signs ?ailas:s Wiring No. Hyaro Massage Tubs ' I No. of Moicrs Total HP OTHER: 'i t.. INSURANCE COVERAGE. Pursuant :o the reou,remenis at '.tassac-users general Laws 1 have a current Liaol6ty Insurance Policy including C;,mc-,elec Ocerations Coverage or its substantial equivalent. YES NO = I have suomtneo valid proof of same to the Office. YES = %40 = If you nave cnecK•a YES, please inoicate the type of coverage oy; ` checxing the apprconate oox. I. . INSURANCE = SOND = OTHER = (Please Scocay) Eanrt'taad Value of E!ectncal work S 2,f."o d �- (Exaltation Dalai Worx to Start Tr�—�� Insoec:ion gate Aacues:ec: Rough ^,"e'fZ Fina( Signed unser the Penalties of • ury: FIRM NA f k- Licensee S� r/ UC. NO. // J� �? � Sig,a:are UC. NO. 2 eus. Tel. No. �7 Ali. Tel. No.�e2lr ? ✓ OWNER'S INSURANCE WAIVER: I am aware that the Licensee toes not nave the insurance coverage or its suostanttal equivalent as re• guinea by Massacnusetts General Laws. ane that my signatwe on :nIs -arma aopiication waives this requirement. Owner Agent tPlease cnecx onel• (Signature at Owner or Age :steonone No. PERMIT FEE S! . - nti i D ate 1275 NORTH TOWN OF NORTH ANDOVER 0 $- PERMIT FOR WIRING SSAOMUS This certifies that ....................... has permission to wiring in the building ofc?..... .jg.A�............................ . ............... .......... at...Z%.7.Z6�1& '7tz�- 4-It..... North Andover,Mass. FeC40--.1 Lic.N04.&`:�!"o- .... ..... ....... ELECTRICAL INSP ECMR 11/11/97 10:36 WHITE: Applicant CANARY:BuiIding%5jpqD PRIPINK:Treasurer Date. . X�. h.U... . .. . F NORTH • pf .ro ,tip TOWN OF NORTH ANDOVER ° 9 PERMIT FOR GAS INSTALLATION SACHUSES This certifies that . . . . ., . . . . f. . has permission for gas installation . . . . . . . �!?'' ' w.I. . . . . . in the buildings.of// . . . .f?��?.f. . .f : rf r!y?�h .d . . . . . . . . . . at f?. t . . . . . . . . . . . ... . /.,.NN0 h Andover, Mass. Fee¢(3 G . . . . Lic. No PECTOR Check# 13 72 ;' 0" t MASSACHusETTS UNIFORM AppLICATON FOR PERMIT TO DO GAS FITTING Date m (Type or print) NORTH ANDOVER,MASSACHUSETTS I � -7a kt� !� Permit# - Building Locations Amount$ Owner's Name . New Renovation 0 Replacement � Plans Submitted w vi z p w o. a oz°. ❑ w d w F O w W W � � Q 7'+ W � (Wj �pqq � W W �U •� F 01 W W � z 0 a Q d O O W ❑ O W F ° m W ° 3 ❑ .a U z > ❑ a. F O NALEM ENT NT 0 0 R OR OROOROOROOROOR 8TH . •FLOOR Check one: Certificate Installing Company (Print or type) /,i �- ❑ Corp. Name �U Partner. Address j 0 Firni/Co. usmess Te ep one U Name of Licensed Plumber or Gas Fitter G 6Q f1A Check P11g. INSURANCE COVERAGE Yes 0 No 0 I have a current liability Insurance policy or it's substantial equivalent. If you have checked yes,please in cate the type coverage by checking theappropriate box. ' Bond Liability insurance policy Other type of indemnity 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 Check one:requirement. Signature of Owner or Owner's Agent Owner ❑ Agent 0 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas C de and C 2 of the General Laws. Signature of Licensed Plumber Or Gas Fitter BY 0 Plumber /LM Title as Fitter ice a Number City/Town9 Master APPROVED(OFFICE USE ONLY) 0 Journeyman f The Commonwealth of Massachusetts Department o f industrial Accidents Office of Investigations 600 Washington Street .IF Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informatioa Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I 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. [No workers' com . insurance 5. 9 [1 Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑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' comp.insurance required.] 13-El Other ;.Any applicant that checks box l must also fill cut these—tion below,shon^;:b tL"--work—ms>compensation policy i^forma„E:on. 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 ann employer that is providing workers'compensation insurance for my employe information. es Belowis the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: 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 c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date; Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitUcense# 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#: . r Information as d 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 orother 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 apartuzents 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 appurtenantthereto shall not because of such employment be deemed to be an employer." 6 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 coxnpliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone 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. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sxue to sign and date the affidavit. The affidavit should be ret'arued to the city or town that the applicafion:for the permit'or licens e:s 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 m 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations wouldIike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 60.0 Washington Street Boston,MA 02 1.11 Tel. # 617-727-4900.ext 4406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-OS vc vm,.mass._govfdia Date. oT: TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that ✓.� . . . . . . . . . . . . . . . has permission to perform ��1 ,lf»!1-.fid?`... . . . . . . . . . plumbing in thebb 'Idings of .�pd�. . .s !!` t�� . . . . . . . . . . . atTf'J.S.'.1./.7 . .a-!.ell A-fX. 7?_7. . . ., North Andover, Mass. Fee 3.3!.5-0.Lic. No.. . .d 5Q�'. . . . . . . . . . . . . . . . . . . . . . . . . Check # PLUMBING INSPECTOR ��� 8364 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS 7 -��'— o/a • Date Building Location � ��'"'^S H` �� Owners Name �`' S f • � �2���c 91Aermit# Amount _ Type of Occupancy �t Q S New Renovation 0 Replacement ® Plans Submitted Yes ® No FIXTURES Z rn oH a W0 9 w A SA En W a H A a a H H sr� c Maw ernH = 1 4 3MHOCIR 5IRHmtz M EBM 71HFL CIR MBJOCR (Print-or type) Check one: Certificate Installing Company Name �y✓9 e SI �/� ��`Ns `'�� HSf rut ® Corp. a S&G Address 01,J �t""�9 // �� Partner. TyNs� ►� �✓c vac d /k7 S Business Telephone 7 �y - /S - 7F C 3 Firm/Co. Name of.Licensed Plumber: �"� ff"`Sr r5 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one ofthe above threeinsurance ignature 7, Owner Agent E I hereby certify that all ofthe details and information I have submitted(or entered)in above application are.true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach s�Plumbing Code and Chapter 142 ofthe General Laws. By: Signature ot 37censeaum er Type of Plumbing License Title J/ I.4 I.City/Town icense Number Master El Journeyman El APPROVED(OFFICE USE ONLY The Common wealth of ll,Tssachusetts Department o fIndasdrial Accidents df lce O-frAvesga ations 60.0 Washington Street • G• . Boston, 1L4 0211- wWW-•rncLssgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectri"-ins/Piwnbers Au iicant•Tnfonnafion Please Print Lea-ibiy Name(Business/Organization/Individual): OU ✓SVq `e f S Address: ' ' O /W zt, City/State/Zip:_t7''q,�.5 40 0/J'7 ' Phone#: G -Are you an employer?Check the appropriate box: I.❑ I ant a employer with 4_ ❑ I am a� ctor Type of project(required): employees(full and/or part-time).* have hired the subcontrac orands 6. 13 New construction 2.®'I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub—contractors have working for mein any capacity. workers' comp,insurance g' ❑Demolition [No workers'comp, insurance 5. ❑ We are a corporation and its 9' ❑Building addition 3.❑ required.] ofacers have exercised their 10.El repairs or additions T am a homeowner doing all work right of ex myself Per MGL 11.®Plumbing repairs or additions Y [No workers comp. c. 152, I(4),and we have no insurance required.] t employees- [No workers' 12.❑Roof repairs c6mp.insurance;required.] 13 0 Other FIomeowners who submiftais affidavit en do hgon•W o fg w�c� . indicating they ^xs comY,,...��cu....r.,....., g ey a,e dopa all w , Y +Contmcbrs that cheek tai:box m•-' t �`�d then hirenutside eon'-ctors 4ds-t rabmit a new amdavit indicating such. atta;.hed an addirioaai sheet showing the • o same of the sub-contractors and theirworkers'comp•policy information. f am an emplrryer that is providing workers'compensation the for my employees. Beloisr is the policy and job site informatwn. Insurance Company Name: / Policy#or Self-ins.Lic.#. l10 e a o 1 o A Ex-piration Date: Job Site Address: Ll S VP V, ' City/State/Zip: Attach a copy-of the workers'compensation policy decIarati.on 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 o$1,500.00 and/or one-year imprisonment,as well as civil penalises in the form of a STOP WORK ORDER and a n"ne 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 certifjv under the pains and penalties of perjury than the informationn provided above is true and correct. Si2:iature: . X(d .D Phone#. F6. O use only. Do not write'in this area, to be completed bar city or town official a Town: Permit/License# Authority(circle one): of Health 2.Building Department 3. Citp/Town Clerk 4.EIectrical Inspector 5.Plumb Inspector Inspector Person: • Phone'#: Information an- d 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,•associattion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including tine I-gal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association og other legal entity,employing employees. However the owner of a dwelling house having not more than three apar nz ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintr--m nce,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 Iicensing'agency shall withhold-the issuance or renewal of a license or permit to operate n'business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cor3inpliance 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.perfomnance of public work um-til.acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." A-PPlicants 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 Liaith Liability Partnerships(LLP)iv .no employees other than the members or partners,.are not required to carry workers'comp ensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should •be re uu t '- c that l i.._r_..i Iermait'or*1. C in £Bless'.:!d,*not the Department of iF t `vd t0 elle vi��yr�C1wTt�lta�the cisme ttcauut V-11 tl2E pP �nrn•ee i He. r� � Industrial Accidents. Should you have any cnuest;ons rega'dintgg t e lira or if you are ice;;iced to cbtain a worl.'ers' compensation policy,please call the Department at the numbe=r listed below. Self-insured companies should eater their self-insurance license number on the appropriate line. , City or Town Officials Please be sure that the affidavit is complete and printed Ieg1bl3,. The Department has provided i 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 stampe=d or marked by the city or town may be.provided to the applicant as proof that a valid affidavit is on file for future pedants or licenses. A new affidavit must be filled'out each . . year.Where a home owner or citimn is obtaining a license or permit not related to any business.or commercial venture U.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit- The ffidavitThe Office ofInvestigations wogld him to thank you in advance f6r your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone.and.famnumber._.. Tle COMMOnwealh of Massachusetts. Department ofFndu&tcial Accidents •0-flice of Inrestigateons 6 o Wishington Street Boston.,MLA 02111 Tel. 0 617-727-490.0 ext 40..6 or 14 77-I-LSS.SARE Revised 5-26-05 Far:#6.17-727-7749 '9rVfM1=as&-o ov/dia i / t Date. ... /, ... .,.......... f NOR7p ?°•+ ``°-,' "�o� TOWN OF NORTH ANDOVER o PERMIT FOR WIRING SSACNUS� This certifies that )� ....�G1/v •` . has permission to perform ......................... wiring in the building of.....L.�`/�`*� �T'I.!''�a n / .. ....... ..v... .. ....................................... at.....(A..(......../ Gf.....1� .. ... Nort Andover Mass. Fee ..... Lic.No...... .�,9 .... LECTRICALINSPECT R Check # 906 Commonwealth of Massachusetts - Official Use Only Department of Fire Services70ccupancy 96 BOARD OF FIRE PREVENTION REGULATIONS d Fee Checked - [Rev. 1/07] Oeaveblank APPLICATION FOR PERMIT TO PERFORM All work to be performed in accordance with the Massachusetts ElectricalCLECTRICA ELECTRICAL (PLEASE PRINT INNK OR TYPE ALL WO RMA Date: C City or Town of: NORTH ANDOVER o `o 6 ` 7 By this application the undersi ed To.the Inspector of Wires: gn gives notice o his or her intention to perform the electrical work described below. Location(Street&Number) AA�e Owner or Tenant L Ah Q A A h Telephone No. Owner's Address S� Is this permit in conjunction with a building permit? Y Purpose of Building No ❑ (Check Appropriate Box) Qi c i 4A es h Existing Service o Utility Authorization No. p�O t Amps O / vZ 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: Com letion of the ollowin table maybe waived b the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus No,of p.(Paddle}Fans Transformers Total No.of Luminaire Outlets No.of Hot Tubs KVA Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o,o mergency lg g No.of Receptacle Outlets d rnd. ❑ Batte Units No.of Oil Burners FIRE ALARMS No.of Zane.- No.of Switches No.of Gas Burners No..of Detection and No.of Ranges Total InitiatingDevices No.of Air Cond. No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons ns of Self-Contained No.of Dishwashers Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers gestin A Connection � Other Appliances KW Security Systems: o.of Water Heaters KWNo.of NoNo.of Devices or E uivalent ,of Si s BallastData Wiring; s No.of Devices or E uivalent No.Hydromassage Bathtubs No.of MotorsTota!HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Work to Startections (When required by municipal policy.) d in INSURANCE COVERAGE.—Unless waived by the wnerto be e o permit fo the performance of electrical ce with MEC Rule 10,and upon completion. the licensee provides proof of liability insurance includingsta work may issue unless complete operation"coverage or its substantial equivalent The undersigned certifies that such coverage is in force,and has e CHECK ONE: INSURANCE d proof of same to the permit issuing office. ❑ BOND ❑ OTHER (Specify:)�t{.�.e.N-P (_ o�' O I certify,under the pains and penalties of perjury, that the information on this application is true�nd edmpletf FIRM NAME: Licensee: m LIC.NO.: A I applicable-, enter exemp— ttiin the license numbe line.) Signa LIC.NO.: (f PP Address: a L..ewe ty 11 Bus.Tel.No. 7�Q� *Per M.G.L c. 147,s. 57-61,security work requires D Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee doles noSaft have the liability insurance Lic.No. required by law. By my signature below,I hereby wive this requirement I am the check one acoverage normally Owner/Agent ( ) E-1 owner owner's agent Signature Telephone No, pE �RMTl The Commonwealth of Massachusetts kf Department of.Industrial Accidents ; r Office of Investigations 600 ArashinaWn Street Boston, MA 02111 www anus gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri Applicant nformation tasns/Plttmbers I Please Print Lesibl Name (Business oigmization/Individual) -�()� `,1.� („o Address: City/State/Zip: Z-1-1,11-11111,,, G //SS.- Phone #: . ?e 4l5T4r--- 7 9 d Are you an a player?Check the appropriate box: 1.❑ I employer with 4. ❑ 1 am a general contractor and I Type of Pref(required):. Pto Yems(full and/or part-time).* have haired the sub-contractors 6• ❑ New corist�•uction t�•uctiona:sole proprietor or partner. listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These suis-contractors have working for me.in an capacity. g Q Demolition Y capaci workers' comp.insurance. g, Building [No workers'comp. insurance 5. ❑ We are a corporation and its ❑ addition 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 myselt[No-workers'comp, c. 152, §I(4),'and we have no insurance required.]t .employees. [No workers' 12.❑Roof repairs comp. insurener required_] 13.0.0ther 'Any applicant that checks bo>L#l must also fill out the section Homeowners below showing their workers'compensation policy information. t who submit this affidavit indicating they am 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- cvrttractors and their work=,comp.policy information. 1 am an employer that is providtng:workers'compensation insurance or e information, f mJ' mplvyees: Below is the policy mid job site 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 g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and r the pains and en t' o erjury that the information provided above is ruse and carred Si lulu Date: Q Phone#. Official use only. Do no[write in this area,to he conrplene—d 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 ES 6.Other Contact Person Phone#• Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp l oyers 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'foregcaing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver ortrustee 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, VOL 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 eompliaince 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 toyour situation and,if necessary, supply ) ( P � ) g certificate(s)of necess s sub-contractor(s)name s),address(es)acid hone numb salon with their 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' cornpensation insurance. lfan LLC or LLP does have employees,a policy is required: Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please-call the Department at the nurnber.listed below. Self-insured companies should enter them self-insurance"lieense 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 permitllicense number which vvilI be used as a reference number. in addition,an applicant ` that must submit multiple permitilicense 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would Ince to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Depart nent of?ndust W Accidents Office of Investibations 600 Washington Sheet Boston, luiA 02111 Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Fax 4 617-727-7749 Revised 5-26-05 wwwmass.gov/dia Date. 7 .!/- K -1.1. TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING ,SSACMUSE� Y � This certifies that . . . . . �.`. . . . ... . . . . . . . . . . . . . . . . has permission to perform . . . . . f`'.`'° . .. . . . 5. .Jr. . . . . . . . . . . . . . plumbing in the buildings of .�XX!''�' . at . . . . '. .1. .�. . . . . . .. . . . . . . .. North Andover, Mass. Fee.4/. ?. Lic. No..l. . . . . . . . . . . . . . . .�.-. . . `j. . . . . . . . . . PLUMBING INSPECTOR Check # l / 8212 ALL PERMITS MUST HAVE LICENSE & INSURANCE MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:-IJ-4- W'�A MA Date:-01'i ---- Permit# y Building Location:_bi--A kjitTOM 4 Owners Name: Type of Occupancy: Commercial ❑ Educat' nal E] Industrial E] Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES z z o/ Y ° U Z cn N WQ, Z Y Q N J x F- W U W O cn Q 0 � z W w z O a ►_— O m 0 w o Q z W W m z N (7 v a �X�, -1 � Q Q ° o W W z Q Y = ° 0° P x Z Q u_ o. Y Q = W W W U a U) U) ° a o a 'a 0 z ° a 2 a a a Y -j -1 to cn ° SUB BSMT. BASEMENT 1 FLOOR 2 NuFLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7r':'-FLOOR 8 FLOOR �,, r� Check One OnlyCertificate# Installing Company Name: _ _� `lam�--� — — -- ---------------- ��� 4/9� `_ orporation �_ Address: _ _____ City/Town:W�____________oleg State:^ _ Gam@ --- El Partnership ________________ Business Tel: !/U_4�� _ Fax: _____________________ // ❑ Firm/Company ________________ Name of Licensed Plumber: G INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes❑ No ❑ If you have checked Yes, please indi a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only --------------------------------------------- Owner ❑ Agent ❑ Si nature of Owner or Owner's A ent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By------------------------------- Zm�b ense: --------- ---- ------------------------------ Title_____________________________ er Si icen ed Plumber Master City/Town_________________________ License Number: l Z� 3 APPROVED OFFICE USE ONLY ❑Journeyman ------------ Location L?A (/,P03, s No. Date MORTM TOWN OF NORTH ANDOVER F• ° L9 + Certificate of Occupancy $ cMus E<� Building/Frame Permit Fee $ l� s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ s Check # G3C-��--•-- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATfo OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: !� DATE ISSUED: /a Y U3 X Com' SIGNATURE: Building CommissionerqRq.Wor of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property A ess: 1.2 Assessors Map and Parcel Number: 07A 11-7 Map Number Parcel Number o j 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO m 2.1 Owner of ,Rd lecor Name(Pri ) Address for Service i Signature Telephone C 2.2 Owner of Record: Name Print Address for Service: -a� Z rn Sipt ture Telephone M SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ L✓G+-1 *0 4wY- CS -75 0l0/ Licensed Construction Su o Supervisor: O C3- 1p S �L � /��y D�,p�u` License Number Addres 1 rG 6 7 7 7b 05 Expiration Signature Telephone r 3.2 Reg stered Home Improvement Contractor Not Applicable ❑ 0 Compa6 Name rn Registration Number Address r Z Expiration Date A Signature Telephone Y SECTION 4-WORKERS COMPENSATION(KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......❑ SECTION 5 Descri tion of Proposed Work check au applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OCL ,tTSE(3N .Y Completed by permit applicant 1. Building S� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x 4 Mechanical HVAC 5 Fire Protection / 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AG NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner Authorized Agen f subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si afore of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS i DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 4 HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERL4L OF CHIlvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE a The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations o� Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity N I am an employer providing workers'compensation for ,PIoY P 9 Pence ifi/�'►PIa'Yees working on this job. Com name: *61,o9w S' ,address `• `� city: 1�/ )VlyPhone#:/V1� >r C S $ Insurance,Co. '2�-;r�t L f� Polipy# VS L 9//7(o(ol oo Comoanv name. N Address UPhonek Insurance Co. Polis # PaiAne to secure coverage as required under Section 2M or MGL 152 can leedtathe Ili .itbn ofaima�al penalties cfarfine up to X1;50 and/or one years'bWnsorrnent.as s 1 naltIes�olhe�nrm a S7DP fiae�f�,S1ta0.0Dy t>a��9 m� understand that a copy of this statement may beforwwded to the Otfice of imesdiations d the DA for coverage verification. /dohereby certdy under the pains and penalbes ofpe�jwy that Me mfum abba provided above is&w and const Signature Date Print name PbonE-# Official use only do not write in this area to be completed by city or town offkW City of Town Per"Wicensim. --� Bttitrfitn3 f3pt ❑check d immediate response is required Lkenafn_q Boa ❑ Selectman's O Contact person: Phone# ❑ Health Ueparti ❑ 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 c11, S150A. The debris will be disposed of in: 1�-J -(&-,/ (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector L WILLIAM ROWE BUILDING&REMODELING, INC. PO BOX 995 MEMAN, MA 01844 978-794-0494 LICENSED INSURED Daryl&Patty Hamman October 7, 2003 67 Rowley Tavern Lane No. Andover,MA 01845 978-975-7947(H) 978-697-8452(cell) CONTRACT 1. Remove& dispose of the two old decks. 2. The new decks to be constructed in the original footprint, roughly 14x 14, and 6x 12. 3. The stairs are to be constructed in the same size and location as the original. 4. Construct two new decks with a new pressure treated frame. 5. The new decking will be grey Timber Tec composite decking. 6. The rail system will be new Weather Best composite railings. Notes: 1. Permits will be obtained by the builder. 2. Paint, stain, and finish are not included in the scope of this bid. 3. Final payment due immediately upon completion of any punch lists. 4. Finance charge of 2%per month 24APR will be added to accounts 30 days old&customer will be liable for collection costs and attorney fees. 5. Work is expected to be continuous with few exceptions. 6. Change Orders will be written and payment is due prior to the work beginning, Payment Schedule: 1. 7500.00 Deposit on materials 2. $2000.00 Prior to start 3. $25000.00 Upon completion I PROPOSE TO FURNISH MATERIAL AND LABOR--COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF: ). Payment to be made as follows: see above outline DOLLARS($ 12,000.00 AD material is guaranteed to be as specified All work to be completed in a Atuharized ��� 1(� wodmunl ke mwmw according to standard practices Any alteration or deviation SignaUue fan above specifications involving extra costs will be meted only upon written j�resdent orders,and will become an extrse over and above the esEimate All agreements Note This prat mny fie withdra if not accepted contingent upon stnkes,accidents,or delays beyond my control. withne : 3vv AtaLB DfOWPOSaf The above prices,specifications,and conditions are Signaturez� .:_ satisfiectory and are hereby accepted. You are authorized to do the work as specified Payment will be made as outlined above. Date of Acceptance: • t WILLIAM ROWE BULDINCI 4 REMODELINQ. INC. PFJ BOX 995 . MEMM,MA 01844 978-794-0494 UCENM INSURED Daryl Hamman Rowley Tavern Lane No. Andover, MA 01845 978-975-7947(H) 978-697-8452(cell) • September 9, 2003 CONTRACT 1. Remove&dispose of the old windows. 2. Prepare openings with Tyvek house wrap strips. 3. Install 13 new Anderson tilt wash windows with fine light grills in top sash of glass. 4. Trim the exterior with the same as original(no paint). 5. Insulate the space between the jamb and the rough frame. 6. Trim the interior with new stool and 2.5"clamshell casing(no paint). Notes: 1. Permits will be obtained by the builder. 2. Paint, stain, and finish are not included in the scope of this bid. 3. Final payment due immediately upon completion of any punch lists. 4. Finance charge of 2%per month 24APR will be added to accounts 30 days old& customer will be liable for collection costs and attorney fees. 5. Work is expected to be continuous with few exceptions. 6. Change Orders will be written and payment is due prior to the work beginning. Payment Schedule: 1. $4500.00 Deposit on windows 2. $2550.00 1 week before job begins 3. $3000.00 Upon complete installation of 10 windows 4. $1000.00 Upon completion of job I PROPOSE TO FURNISH MATERIAL AND LABOR—COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF: DOLLARS(S 11,050.00} Payment to be made as follows: see above outline All material is guaranteed to be as specified. All weak to be completed in a Autborized s.— workmanUo manner according to standard pmatices. Any atteratian or deviation Signature —la from above specifications involving extra costs will be executed only upon written Presided orders,and will become an extra charge over and above the estimate. All agreements Note: This proposal may be withdrawn if not accepted continged upon strikes,accidents,or delays beyond my control. within da U j�tGE�7$ti "o f'�I he above prices,specificaztioas,and conditioffi are Signature / satisfactory and are hereby accepted You are authorized to do the work as specified Payment will be made as outlined above. Date of Acceptance: ' �� G_ ; ORTH Town of R over O ' . .',• ° dower, Mass. /d COCc wic 1 1 H �t ORATE D PP�t-`� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System iW Awwf .,1/... BUILDING INSPECTOR THIS CERTIFIES THAT......... .4 � �.� ..........Y................................ Foundation ........................... oun ation has permission to erect. I4044ACS ........ buildin s on 0 .................. g � � � Rough 3 g ................... ........ ' .. ..... .. # A^u Lvto be occu ied as � � 4 0C 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, A eration and Construction of Buildings in the Town of North Andover. /070 / /J&V MOW- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS 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. Location I 17 T-A Ler U `N No. 3 6 Date ods "D 3 ,.ORTM TOWN OF NORTH ANDOVER r- 9 ' Certificate of Occupancy $ ��s'•^�'E<� Building/Frame Permit Fee $ ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 36 Check # `J 0 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ., for Kleist,usi tJnl BUILDING PERMIT NUMBER. `� 6 ,7/ DATE ISSUED: f _ D 3 X s//7'' SIGNATURE: (Sty Buildin Commissioner/Inspector of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �� Map Number Parcel Number W � 1• r' 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 Regired Provided v 1.7 Water Supply M.G.L.C.40.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record \rl Dd,41 All-)OeI7 i�7 4-A/t57 Na a(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ icensed Construction Supervisor: O 0 (�r /S License Number wn Address C 7 0 �iJ ✓ f�� � 7�as 7 a7 ic Expiration ate s gnature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v ompany Name M05 rn Registration Number Address /* ajr r,, /� �il.[ A 7 7 7 Expiration Date Signature Telephone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check allapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: M 0U"a- AC'e a (9 y 'eC) SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by perniit applicant 1. Building a (a) Building Permit Fee 2� Multiplier 2 Electrical (b) Estimated Total Cost of © ^� Construction V 3 Plumbing Building Permit fee(a)X tbl 4 Mechanical HVAC (.� 5 Fire Protection 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 I, as Owner uthorized Agent f subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2ND 3 PW SPAN DM ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS f[EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Client#: 25387 rUSI D� LAWREPAR CERTIFICATE OF LIABILITY INSURANC . DATE(MM/DD/YYYY) O7/O2/O3 England THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 6360 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDET AMEND,EXTEND OR ster, NH 03108-6360ALLTER THEHCOVERAGE AFFORDED BIS CERTIFICATE DOES OY HE POLIC ES BEOW. 1100 INSURERS AFFORDING COVERAGE NAIC# PARKERS ELECTRIC SERVICE LAWRENCE PARKE INSURER A: Peerless Insurance Co 24198 4A REED ST INSURER B: Londonderry, NH 03053 INSURER c: INSURER D: COVERAGES INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION A GENERAL LIABILITYDATE MM/DD/YY DATE MM/DD/YY LIMITS CCP9295316 03/23/03 03/23/04 EACH OCCURRENCE X COMMERCIAL GENERAL LIABILITY RENTE $1 000 000 CLAIMS MADE X OCCUR P EMISEMAGE TOEa o u Dr nce $50000 MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $1000 OOO GEN.L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY E 0 LOC PRODUCTS-COMP/OP AGG s2,000,000 A AUTOMOBILE LIABILITY BA9226043 X ANY AUTO 03/23/03 03/23/04 COMBINED SINGLE LIMIT $1,000,000 ALL OWNED AUTOS (Ea accident) SCHEDULED AUTOS BODILY INJURY X HIREDAUTOS (Per person) $ X NON-OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE GARAGE LIABILITY (Per accident) $ ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ A EXCESS/UMBRELLA LIABILITYAUTO ONLY: CU945517 AGG $ CLAIMS MADE X OCCUR 03/23/03 03/23/04 EACH OCCURRENCE $1 000 000 AGGREGATE $1 000 000 DEDUCTIBLE $ X RETENTION $10000 $ A WORKERS COMPENSATION AND WC9692073 EMPLOYERS'LIABILITY $ 03/23/03 03/23/04 X WCY TATO- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE OF EXCLUDED? E.L.EACH ACCIDENT $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-EA EMPLOYE $500,000 OTHER E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Daher Companies SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 235 East Street DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I_ DAYS WRITTEN Methuen, MA 01844 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHO'IZED REPRESENTATIVE ACORD 25(2001/08) 1 of 2Q #S63360/M63359 XKAL 0 ACORD CORPORATION 1988 ACORD 25-5(20011u01 - [- North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: L (Location of Facility) AZ.,f L", 4� Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector S M a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _< Boston, Mass. 02111 9� `''� Sy•'' Workers'Compensation Insurance Affidavit Name Please Print i Name: (Owt Location: (amps S-7 Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my empl wmking on this job. Company name. &L A1= ' Address city: AAle /+ Phoma* 17;-- 75Y-GK4 Insuran6eco. ✓✓I al t t`-Gi h Poli # aZ I)v(p Lo 3 Comaarn name: , Address Phone* Insurance Co. Policy# Failure to segue coverage as required:under Section 25A or MGL 152 can lad to"kwaifon 4 Mimi nat Penalties ofarfine up to S'f•.s0a and/or one years'Improonment-as-walLas a�ies� Sams ��]9P fiaesiF i11QOD��a �9�ainsRme. . understand that a copy of this statement may beforwarded to the office of Investigations of the DIA for coverage verifrlcation. 4 l do hereby candy under the pains and penalties of perjury that the inlarma#W provided above ins&w and conrect Signature--/4r/Q e:L:J. Print name Phone-# 971. 7- �,"YV V . Official use only do not write in this area to be completed by city or town afticiar City or Town_ Perrrot/Licer►sina. 0 Bkfiftng Dept [jCheck I immediate response is required 13 Licensing&k-u St*/eGttnart'S d contact person: Phone# E] Health Depart; Other �s t. x .. 1 k W ;f } 3" 7. `L CUSTOM VIEW CUSTOMER -- DATE 09/03/03 REI` DeckO3246 6��<< 3 (o" t JACKSON LUMBER 215 MARKET ST LAWRENCE,MA. 1-978-686-4141 WILLIAM ROWE BVILDINC4 &REMODELINCG, INC. PO BOX 995 METHVEN, MA 01844 978-794-0494 INSLMM LICENSED October 7,2003 Daryl&Patty Hamman 67 Rowley Tavern Lane No. Andover,MA 01845 978-975-7947(H) 978-697-8452(cell) CONTRACT I. Remove&dispose of the two old decks. 14x 14, and 6x 12. 2. The new decks to be constructed in the original footprint,roughly 3. The stairs are to be constructed in the same si treand ated camen as the original. 4. Construct two new decks with a new pr 5. The new decking will be grey Timber Tec composite decking. 6. The rail system will be new Weather Best composite railings. Notes: 1. Permits will be obtained by the builder. 2 paint, stain, and finish are not included in the scope of this bid. 3. Final payment due immediately upon completion of any punch lists. 4. Finance charge of 2%per month 24APR will be added to accounts 30 days old&customer will be liable for collection costs and attorney fees. 5. Work is expected to be continuous with few exceptions. 6. Change Orders will be written and payment is due prior to the work beginning. Payment Schedule: 1. 7500.00 Deposit on materials 2. $2000.00 Prior to start 3. $25000.00 Upon completion I PROPOSE TO FURNISH MATERIAL AND LABOR—COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF. DOLLARS($ 12,000-00). Payment to be made as follows: see above outline All material is guaranteed to be as specified. All work to be completed in a Authorized — wa wanhke manner according to staWa rd practices. Any aheration or deviation Signature eat from above specifications involving extra costs will be executed only upon written Note: This may be withdra if not accepted orders,and will become an extra drarge over and above the estimate• Ali agreements within t pyx ,t " a. ,l 1 contingent upon strikes,accidents,or delays beyond my control- ons, / .X= pf l�osd The above prices,spectficatrand conditions are Sitpiature satisfiectory and are hereby accepted You are authorized to do the wok as specified D i l.,,._—E Daft of Accepta�e�Ce 'a_t_z—' Payment will be made as outlined above. ! FORM U - LOT RELEASE FORMS-� 03 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fry Boards and Departments having jurisdiction have been obtained. This does not retie the applicant and/or landowner from compliance with any applicable or requirements. ******"**'`APPLICANT FILLS OUT THIS SECTION APPLICANT �)4- y�l rG�J/n01� PHONE ? LOCATION: Assessor's Map Number 7,4 PARCEL_//7 SUBDIVISION LOT(S) STREET__&7 ST.NUMBER USE ,4MMENDATIONS OF TOWN AGENTS: -----------RVATION AD NISTRATOR DA PPROVED 6 ATE REJECTS COMMENTS new .sbne,4u. g fin TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS ' FOOD INSPECTOR-HEALTH DATE APPROVED 1\ DATE REJECTED w e-, S .�C SE IC INSPECTOR-HEALTH DATE APPROVED. Z DATE REJECTED COMMENTS PUBLIC WORKS-SEWERAWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm MORTGAGE PLAN EK SUR V EY INC. 17 ROYAL STt M LAWfiENCE, MA. 01841 Tel. 30&-973-1413 MORTGAGOR � .�,���O K D REP. _.__.lt`�� PG, ADDRESS OF PRfNCIPLE BUILDING PLAN REF. . --gyp{�+�`&AJ "4 OATS O�fi/ INSPECTION a V' {l os °Ce f9 44raI E � /i� s/ �@ ! s LAi,�� 10M This mwtsa s hap.cUan m prrpwvd ,1tT` I FURIHER SA'M IUAT IN My pRopT.SS=NAL P�t�► mwica4s Pi+�B and b not to T', �, cp*4" the W.coo stmet wo/s and Quo a 1 etisd upon as d st ""s ESC 'st RWY •" � for qq oc�PV At,it�El. -. oc�lhuQdRgs. .,_. ► 'iN ..r.._....�. 2MG4 by anyone other the, raid rmoet a t+o �� � +ettll lbs .stbad� toQ�s"0300% of the local eq! !b crssfp�u h oarur eA trtth as �. sarthff aeetttorra� and umt no wAmfth,,.,,. aar%"e thalcins to said martga9or. �.�� f�isttt �.. of trw�a' ittptot eatspis shlac "y ilayst �WTM`AIPON Tit �M'� tAi�s P Y lbes srmot ai thoarlr. &OdALr PRAk a1. Ptopirty is not_ h a Rove Hazard Jbsv, thpb csttllttvt3on #a based an Ahs fo�ion of wr+ayy mark" CIL Pt+apst�y tt i► a no Mamord Ar,46 'I Qlhtes, and doss not rspr*sent d prop.r{,y ,ngw,r. the lbn Qn ta�1a�ma�liar tt-9umtl I'dult 14 tnhs Flood e pza po5�i.7 �Gi�'�cJG,4T�N 6� i �jq N D �lLr6g N C44)01-7009 �KOPogE�D �BOO �f1 t�o� A 100 o OI -E7 91L7E'f- P DoT � � LGLLlNG :gyp 7 J . PoQ GH 0, ao a fo Ar 49 LJ ; Cam-- P�P/ 40 fAi(. L►uE� b L � � CaNN. GTy P qCn OP3 Fq6 15 qy1 W eLL u , Vol 6 .1 RALe16H 1:2L� � . 1 o� No. 3 ` y LAK dover, Mass., COCMICKEWICK ?9S0RATED P'P�,��� U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........�A... ... .... .......... ..I!�l...ff�Ml� .... . ....................................' Foundation Q.AC buildin son ...... . . ....... ..... / . / Vl�has permission to erect.. . . .... /9!,..... !v... ou h to be occupied as.. .... D e .K.-S....... '...7. .� • ...�.`r..1ly 6.W.y..r....5A40't 50-/j Y 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-Law relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. /�� #07 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONT AR S Rough .... ....... ... ................. ..C...........:........:.............:: 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 S 1 D E Smoke Det.