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Miscellaneous - 68 BEAR HILL ROAD 4/30/2018
/----�-68 BEAR HILL ROAD 210/064.0-0096-000().0 r I f F i k �I I 4 k �I C i � - - - - �� f{J 1 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_bythe-Inspector_of-Wires abandoned.and_inyalid-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. El 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. ule 8—PermWDate Close . ` z / *°k*Note:Reapply for new permit..K 0 Permit Extension Act—Permit/Date Closed: �i. .Date....4�. ......� , ................. CF powrot .0.. oo� TOWN OF NORTH ANDOVER PERMIT FOR WIRING til °+;,.o•''t� 83ACHU3� This certifies that ............... .... ... ... `. as permission to perform ....... [P.. !)�!: ...... ` �� �.. ..................... j wiring in the building of....................................'..C'-= �j :......................................................................... Aat .......�.� h `...............n,North Andover,Mass. a Fee..............................Lic.No. l . b...........P . -1 :............. G ELECTRICAL INSPECTOR Y Check# Z C, 1 12 ` 7 Commonwealth of Massachusetts Official Use Only Department of Fire Services r0ccupamcy rmit No. oo q0b BOARD OF FIRE PREVENTION REGULATIONS andFee Checked ctrician s cell#;contract#&bld permit#ff applicable) .I/o7] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordmea wittlte Massachusetts Electrical Code X-C),527 0dR 12.00 (TL4SEPB1ATINI KORT-P?.EAL.LMMILiTTON) Rafe: City or TovsA of: �:� 1/Q,�� To the Inspector of Fires: By this application the undersigned gives notice o or leer intend n to perform ectrical work described below, Location(Street ccs Numbe �. l� OwnerorTenant ��e,(' TelephoneNo. Owner's Address , Is this Permit in conjunction with a building permit? 'yes ❑ Nra (Check Appropriate Bot) Purpose of Building Utility Authorization No: ExistiugService Amps / Volts Overhead❑ Undgrd❑ N'o.of Meters New Service _T _— Amps / Volts Overhead❑ Undgrd❑ No.of Meter, Number of Feeders and Ampacity Z Location and Nature of Proposed EIectrical Vi'ork: Cmnpl`et?onof the following table maybe waited by the Inspector of tires No.of Recessed Luminaires No.of CeiL-Susp.(Pa.ddle).Faus No,of Total Transformers KyA No.of Lumznaia e Outlets No.of Hot Tubs Generators KVA Na.of lC nminaixes Swimming Pool Ahave [] In- El o.o mergency ag tang nd. d. Battery Units No.of Receptacle Outlets No.of Oil Burners iP AJ,ARIIS Nro.of Zones 3 i No.of Switches INo.of Gas Burners No.01'Aetection and p Inidatina Devices No.of Manges No.of Alt•Cond. Tons IN of Alertinb Devices No.of Waste Disposers HeatPrznnp Number T,'ous KW ;No.of Self-Contarne, TO : Detectionwertin Devices i No.of Dishwashers jSpace/Area Heating R Local I.'Tuaicipal Other Connection No.of Dryers HeatingAppliances I(, Security�ystexos:-. No.of'6�'ater . No•of Devices or E uivalenf No.of No.of Heaters I Si s BalIasfs Data Wiring: No.of Devices or E trivalent i No.Hydromassage Bathti bs No.of Motors )70W In,, Telecommunications Wiringg OxHE:E$: : No.of De•cices or E uivilent . r Taft additional detail ifdesire4 or as required by the Inspector of Tires Estimated Value of Electrical Work: 0 (when required by municipal policy.) \ Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. 1 NSURANCE COVE1 Cl :libless waived by the oWner;no permit for ttte performance of electrical vlork 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. S X CBECK 010: INSLaANTCE ❑ BOND F1 O= (Specify.) -- ( p fy:} SeLfIusured � 1 certify,under the pains a7td petralties of perjury,that theinformation otz this applicailon is true and complete. � FIRM NA E. ADTLLC DBA ADT Security -1 —2_ LIC.NO.: C-172 Licensee: Thomas J.Lee SiS�na mire / /125 G�l.�2f- LIC.NO,: C-17 (Ifopplicable.enter`exempt"in Lbe license mnnber line:) �� / - Address: \ � 4.3_\��� (' ��q Bus. _ � C.1 1 Alt.Tel.ltio.: `Security�ysu s..onsacror ui�r .,,:mac r, A ,,,, orl�: applicable,enter the license number here: 001779 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurauce 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 Signatuxe Telephone No. .PEAWT. 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PROPERTY OWNERJ _ Print iob Year Old Structure yes rt MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes o .TYPE OF IMPROVEMENT- PROPOSED USE Residential Non- Residential ❑ New Building it One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial -Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/,Sewer DESCRIPTION OF WORK TO BE PERFORME : AGS o. d' ( Wo w Z✓� Identification Please Type or Print Clearly) OWNER: Name: Phone: 508 -412V,368s Address: CONTRACTOR Name: 62Lecar �c��av�S!-moo S Phone nn /n� // '�I rr Address� � � r5 i � /Cc aL �v�tla�� V4A-- U. lir 16 Supervisor's Construction License:_( s_- J 72=aE o l _ Exp. Date:- l S2 ,�96l Home Improvement License: lOV49 Exp. Date: /g 2-© L( ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED.ON$125.00 PER S.F. Total Project Cost: $ /O � _"—" FEE: $ Check No.: z ZS Receipt No.: NOTE: Persons contrac ing with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner'~ nature.of contractor Plans Submitted �� P n Waived ❑ Certified Plot Plan ❑ Stam ed Plans ❑ Building Department ' The following is-a-list of the required.forms to be-filled outfor:the appropriate.permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. 'And/O'r 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 pp din 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo,,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buhding Permit Revised 2012 . 1 Plans-Submitted ❑ Plans Waived ❑- _.Certified Plot Plan ❑ Stamped Plans ❑ .._ . .. -.TYPE OI;:SEWERAGE DISP_OSAL • . _ Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑ ; Well ❑ Tobacco Sales 0 Food Packaging/Sales ❑ Private ,septic tank etc- . o `:.-Permanent Diinpster oil-Site ❑ r THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM f I DATE REJECTED DATE,APPROVED PLANNING & DEVELOPMENT ❑ ❑ f COMMENTS _CONSERVATION Reviewed on—.., .- Signature COMMENTS HEALTH Reviewed on Signature "COMMENTS z Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ .. Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit _ • f DPW Tow2 Engineer: Signature: a 8 -- Located 34 Osgo, od Street FIRE DEPARTME-NT Temp Dump' on site yes , n Located-at.124,Mair,Street �'� 'Fire Departme►if signature/date w: _ :� .. COMMENTS '' Number of Stories: Total square feet of floor area, based on Exterior dimensions. TotaI-land area; sq. ft.; - ELECTRICAL: Movement of Meter IocatFnn, rriest-or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: -Yes No MGL-Chapter 166-Section 21A-F and G min.$100-$l000.fin.e NOTES and DATA— (For department use I i I ® Notified for pickup - Date Doc.Building Permit Revised 2010 i � y The Commonwealth of Massachusetts - Deparfin nt of Indicstrigl Accid nts Office oflnvestigations 600 Washington Street Roston,MA 02111 -www.mass gov/dia Workers'Compensation]insurance.Affidavit:Sudders/ContractorsfElectricians/Plii mbers Applicant Information Please Print Let=i , Name(Business(Organizationftdividual): (C-re�� C_I eL✓�Slil� � Address: S L' (rck � City/Stato/Zip: "0(9'10 Phone#: / ' ��S `�f g L 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 6. [l New construction F employees(full and/or part-time).* have hire dthe sub-contractors 2.[ I am a sole proprietor or partner- listed on the attached sheet. 7• Remodeling ship and'have no.employees These sub-contractors have 8. ❑Demolition worldng for me in any capacity. workers'comp.insurance. 9, Building addition [No workers' comp.insurance 5. ❑ We are a corporajion and its 10.❑Electrical repairs or additions xequired.] 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 insurancere iced. employees.[No workers' a 13.❑Other comp.insurance required.] 'Any applieantthat checks box01 must also fill outthe section below showingtheir wbrkers'compensationpolicy information. 'Homeowners who submit this affidavit indicating they hie doing all work and then hire outside contractors must submit a new affidavit indicating sirbh. (Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees Below is the policy and joh site information. Insurance Company Name% Policy#or Self ins.Lia#: Expiration Date: S Job Site Address: City/State/Zip: Attach a copy of the workers'compensationpolley declaration page(showing the policy number and expiration date). k'ailme,to secure coverage as requiredundex Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue 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 fmo of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of. Investigations of the DIA for insurance coverage verification. X do lierehy cert&undqr file pains and penalties ofperjury that the information provided above is true and correct. - Si atare• - 7 r GDate: y 4� L/ Phone#• �`�`5- / / L Official use oply. .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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express or implied,oral or written." An employeils defined as"an individual,partnership,association,corporation ox other legal entity,or anytwo ormoxe of the i"oregoing engaged in a joint enterprise,and including the legal representatives of a'deceased employey,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced•acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority," Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphone number(s)along withtheir certificate(s)of insurance, Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than,the members or partners,are notrequired to carry workers'compensation insurance. If au LLC or LLP does have employees,apolicyisrequired. Be advised that thisaffidavit maybe,submitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ` of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure,to fill in the pemilt/Iicense number which will be used as a reference number. In addition,an applicant atm thust submitmultiple permitllicense applications in any givenyear, need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in. .(city or town):'A copy of the affidavit that has been officially stamp ed 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 ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitate to give us a call. The Department's address,telephone and fax number: The Ganimonwuealth ofMassa..c�hvse#s PoPartment ofZudwWal A;ccide�ts Qfoo ofTmsfrga-iona 6bG Wastdag%j S17re�-f< Boston,> A02111 T01#61.7-7.27-4900 OA 406 Qx 1-877- Revised 5-26-05 Fax 0 617-727'7749 wt�tv.�ass,gc�v�cla`a, NORTk F Town : _ , ver No. h ver, Mass, A_ COCHICHEWICN 7�pDRA7ED S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System 1 THIS CERTIFIES THAT el&4*40BUILDING INSPECTOR has permission to erect g ' w.r. �.� , Foundation .......................... buildings ............... ......... A. ...... Rough to be occupied as .:...... .... .. ...........P.O. ... ..... �r ....................................... Chimney provided that the person ccep g this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR W • UNLESS CONSTRUCTIV T S Rough Service ................. . ........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough i Display in a Conspicuous Place on the Premises - Do Not Remove Final I� No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Customer:Zalanskas Construction Project Name: Bellanger--N.Andover,MA Order Number: 185BD3276 Quote Number: 5515678 Line# Location: Attributes 25 None Assigned Pella Brand, Inswing Entry Door Right, 33.5 X 81.75,Vanilla Cream,6 9116" Item Price Qty Ext'd Price i $747.35 1 $747.35 1:3280 Right Inswing Entry Door Frame Size: 33 1/2 X 81 3/4 PK# General Information: 20 Minute Fire R ed Panel,20 Minute Fire Rated Frame,Clad,Wood,Pine,7 7/8",1 5/16",6 9/16",Standard` ,Sill, Bronze Finish Sill, 1 ,+ Oak Threshold — 12 624 Entry Door Panel: Solid,Fiberglass,Smooth,Smooth,6 Panel 33 Exterior Color/Finish: Standard Enduraclad,Unfinished,Vanilla Cream Viewed From Exterior Interior Color/Finish: Unfinished,Primed Hardware Options: Latch Bore with Deadbolt,2 3/8",2 1/8",No Handle Set,Standard Steel,Brass Unit Accessories: No Bang Panel Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,6 9/16",7 7/8",Factory Applied,Pella Recommended Clearance, Perimeter Length=231". Rough Opening: 341/4"X 821/4" Line# Location: Attributes 30 None Assigned Architect, Double Outswing Door Active 1 Passive, 71.25 X 80.125,Vanilla Cream Item Price Qty Ext'd Price —�, $2,638.29 1 $2,638.29 1:7281 Active/Passive Double Outswing Door Frame Size: 71 1/4 X 80 1/8 PK# General Information: Standard,Clad,Pine,5 7/8",4 9/16",No Certification,Standard Sill,Bronze Finish Sill,Standard Frame Stops 1 j c Exterior Color/Finish: Standard Enduraclad,Vanilla Cream _ t 624 Interior Color/Finish: Unfinished Interior Sash/Panel: Standard Viewed From Exterior Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Order Handle Set,Bright Brass,Multipoint Lock Grille: No Grille, Wrapping Information: No Exterior Trim,No Interior Trim,4 9/16",5 7/8",Factory Applied,Pella Recommended Clearance,Perimeter Length=303", Glazing Pressure=205. Rough Opening: 72"X 80 5/8" Line# Location: Attributes 35 None Assigned OBLT5001 - Keylock, Brass, Random Item Price Qty Ext'd Price ' $11.99 1 $11.99 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com r Printed on 3/24/2014 Contract-Detailed Page 3 of 6 Customer: Zalanskas Construction Project Name: Bellanger--N.Andover,MA Order Number: 185BD3276 Quote Number: 5515678 Line# Location: Attributes 40 None Assigned OBLT5002-Keylock, Brass, No Key Item Price Qty Ext'd Price $11.99 1 $11.99 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/24/2014 Contract-Detailed Page 4 of 6 Contract - Detailed Pella Window and Door Showroom of Concord Sales Rep Name: Dombroski, Brian ® 341 Loudon Road Sales Rep Phone: (603)568-9194 Concord, NH 03301 Sales Rep Fax: (603)428-3551 Phone:6032251953 Fax: 6032253169 Sales Rep E-Mail: DOMBROSKIBJ@pellaboston.com Customer Information Project/Delivery Address Order Information Zalanskas Construction Bellanger--N.Andover,MA Quote Name: 3/20/14 Entry&Patio Door Quote 34 Birch Road Order Number: 185BD3276 ANDOVER,MA 01810 Lot# Quote Number: 5515678 Primary Phone:(978)835-5194 NORTH ANDOVER,MA 01845 Order Type: Non-Installed Sales Mobile Phone: 9788355194 County: ESSEX Wall Depth: Fax Number: (978)4699461 Owner Name: Payment Terms: 2%10/Net 30 E-Mail: seghezzi@comcast.net Zalanskas Construction Tax Code: MA TAX 6.25 Contact Name: Owner Phone: (978)835-5194 Cust Delivery Date: 04/15/2014 Quoted Date: 3/15/2014 Great Plains#: JJZALANSKA Contracted Date: Customer Number: 1003040220 Booked Date: Customer Account: 1000556078 Customer PO#: Line# Location: Attributes 10 None Assigned Pella Brand, Inswing Entry Door Left,37.5 X 81.75,Vanilla Cream, 6 9116" Item Price Qty Ext'd Price T. $707.20 1 $707.20 1:3680 Left Inswing Ent Door 3 9 ry Frame Size: 37 1/2 X 81 3/4 PK# General Information: No Fire Rating,No Fire Rating,Clad,Wood,Pine,7 7/8",1 5/16",6 9/16",Standard Sill,Bronze Finish Sill,Oak Threshold lEntry Door Panel: Glazed,Fiberglass,Smooth,Smooth,Twin Colonial Light _37 t, 624 Exterior Color/Finish: Standard Enduraclad,Unfinished,Vanilla am _ Interior Color/Finish: Unfinished,Primed Viewed From Exterior Glass: Tempered Low-E Hardware Options: Latch Bore with Deadbolt,2 3/4",2 1/8",No Handle Set,Standard Steel,Brass Unit Accessories: No Bang Panel Grilles: No Grille Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,6 9/16",7 7/8",Factory Applied,Pella Recommended Clearance, Perimeter Length=239". Rough Opening: 381/4"X 821/4" For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 3/24/2014 Contract-Detailed Page 1 of 6 Customer:Zalanskas Construction Project Name: Bellanger--N.Andover,MA Order Number: 185BD3276 Quote Number: 5515678 Line# Location: Attributes 15 None Assigned Pella Brand, Inswing Entry Door Left, 33.5 X 81.75,Varma Cream,6 9/16" Item Price Qty Ext'd Price r $734.27 1 $734.27 f 1:3280 Left Inswing Entry Door Frame Size: 33 1/2 X 81 3/4 ! PK# General Information: No Fire Rating,No Fire Rating,Clad,Wood,Pine,7 7/8", 1 5/16",6 9/16",Standard Sill,Bronze Finish Sill,Oak Threshold Entry Door Panel: Glazed,Fiberglass,Smooth,Smooth,1/2 Light 33 tt2 624 Exterior Color/Finish: Standard Enduraclad,Unfinished,Vanilla Cream Interior Color/Finish: Unfinished,Primed Viewed From Exterior Glass: Tempered Low-E Hardware Options: Latch Bore with Deadbolt,2 3/8",2 1/8",No Handle Set,Standard Steel,Brass Unit Accessories: No Bang Panel Grilles: Grilles Between Glass,3/4"Contour,White,White,Traditional,3,3 Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,6 9/16",7 7/8",Factory Applied,Pella Recommended Clearance, Perimeter Length=231". Rough Opening: 341/4"X 821/4" Line# Location: Attributes 20 None Assigned Pella Brand, Inswing Entry Door Right, 33.5 X 81.75,Vanilla Cream,4 9/16" Item Price Qty Ext'd Price $524.35 1 . $524.35 . V 1:3280 Right Inswing Entry Door G Frame Size: 33 1/2 X 81 3/4 i PK# General Information: No Fire Rating,No Fire Rating,Clad,Wood,Pine,5 7/8", 1 5/16",4 9/16",Standard Sill,Bronze Finish Sill,Oak Threshold t Entry Door Panel: Solid,Fiberglass,Smooth,Smooth,6 Panel 33 V2624 Exterior Color/Finish: Standard Enduraclad,Unfinished,Vanilla Cream Interior Color/Finish: Unfinished,Primed Viewed From Exterior Hardware Options: Latch Bore with Deadbolt,2 3/8",2 1/8",No Handle Set,Standard Steel,Brass Unit Accessories: No Bang Panel Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,4 9/16",5 7/8",Pella Recommended Clearance,Perimeter Length= 231". Rough Opening: 341/4"X 821/4" For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/24/2014 Contract-Detailed Page 2 of 6 ZALANSKAS CONSTRUCTION 34 BIRCH ROAD ANDOVER MA.01810 978-835-5194 GREG.ZALANSKAS()COMCAST.NET QUOTE# 14 Order# Date 3/20/2014 QUOTE SUBMITTED TO: WORK TO BE PERFORMED AT: �. Name Peter&Lynda Belanger Name SAME Address 68 Bear Hill Rd Address city-state N.Andover MA Planned Date Phone Phone Job Description: Replace front entry door with a two lite Pella door(see Pella contract for details)match custom exterior trim with pvc materials,match trim for interior. Trim cost$325.00 /Labor to remove old door and trim,Install new door and match custom trim$925.00 Rot repair additional. Replace front side door with 9 light Pella door(see Pella contract for details).Match trim inside and outside. Trim cost$90.00 /Labor cost$575.00 Replace garage door with 6 panel Pella door(See Pella contract for details).match interior and exterior trim. Trim cost $90.00 /labor$575.00 Replace door from garage into house with a 20 minute fire rated Pella door(see Pella contract for details.).Match interior and exterior trim. Trim cost$90.00/Labor cost$575.00 Replace slider into screen with a Pella two wide outswing French door.(see Pella contract for details.) Trim cost$90.00 /Labor cost$650.00 Does not include any painting or rot repairs. Pella entry doors cost$2715.00 and the two wide French door cost$2800.00 Please read Pella contract for details. Home owner needs to pick up door handle and dead bolt for the entry doors.Need to verity staying with Brass? Disposal $250.00 /permits$175.00 /The Bronze sills changed the price by total$157.00 more All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $10,x132:00 PLEASE MAKE CHECK OUT TO ZALANSKAS CONSTRUCTION with payments to be as follows $6,000.00 to order product $2,000 at start of install Submitted by: GREGORY ZALANSKAS $2082.00 at completion. OF ZALANSKAS CONSTRUCTION Acceptance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work specified above. Payments will be made as outlined above. Accepted by: Please note: Thlif-proposai'makJ6 withdrawn by us if not accepted within 30 days v�ao/a0 � i ce,.v -- C'U�'✓I I . r tTJI�moi_ North Andover MIMAP 68 Bear Hiil Road July 5, 2016 64. 0048 ,. '. 4P64.tD-0101 `���•, � #�� , ' > 4+ O BEAR ILL R. 4 y x 56 BEAR HIUL-tj�D �> " GiF iC 'i ILL`RD •.,.,,� i 064.0-0096 _µ W " r _ Y m�hq a .s i .p Vit. ✓� .2 .. �'� `�;" fir,• 064.0-0094 _ " a r• , rtes� .�•, -_ j ,;� � .. � =-; _ ;_ _":+,f1b4.0-0f1 s 9' 0 MVPC Bo Interstates l` Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, — I 1 Meters Data Sources:The data for this map was produced by Merrimack —SR Roads �/ i /1 f NORTH q Valley Planning Commission(MVPC)using data provided by the Town of "t 1 � D O �t�p r� North Andover.Additional data provided by the Executive Office of Easements q/'� �}NYJJ ,r e� •e 00 Environmental Affairs/MassGIS.The information depicted on this map is �l Parcel /•C, �ff" V1 ' � 3 L for planning purposes only. r may not H adequate for legal boundary �y �j(i�oP4. O P definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER y N ~ 1 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING it * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT i ASSUME ANY LIABILIN ASSOCIATED WITH THE USE OR MISUSE OF .(�,S•wrau'fit THIS INFORMATION SACH 1"=58ft ��° North Andover MIMAP 68 Bear Hiii Road July 5, 2016 rA ,. 10'BEAR+HILL R • > � F, 0�640-�102 JIF i 56.BEAR HILL�RD 064.@-0@'3.7 110 00 0 00 .17 00 011 01 p . . BEAWHTt LRD @64.0—0096 t . r s OF 0 01 Jr 011 14� 01P @64.0 0095 IOO BEAR HILL�RD io 064.0 0081 00 +t �, 064.0=04 64.0-0082 064.0-009 E3 MVPC Be Zoning Overlay Zoning �l Municipal Boundary 0 Adult Entertainment Dist6c Busine s 1 District 0 Machine Shop Village Ove q Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Rail Line 0 Watershed Protection Dist O Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates 0 Historic Mill Area O Busine s 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of _1 ©Medical Marijuana O Genera Business District OE t`1O '1ti North Andover.Additional data provided by the Executive Office of —SR Downtown Overlay District O Planne Commercial Dev 2 e++ E�•6 00 Environmental Affairs/MassGIS.The information depicted on this map is Roads 0 Historic District Corrido Development Dist 3 _ L for planning purposes only.It may not be adequate for legal boundary (j Osgood Smart Growth(40 13 Corrido Development Dist O --- M definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 17,Easements S:Hydrographic Features @ Corrido Development Dist MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑ParcelsIndustd I 1 District s THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY --Streams Industri 2 District _ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Wetlands Industri 3 District #o _ �+ ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Q Industri I S District �+ Exempt Lands Reside ce 1 District THIS INFORMATION Reside ce 2 District SSACHUSE Reside ce 3 District dei ice 4 District 1"=58 ftde ce 5 District Ede ce 6 District .9e a, ential District Town of North Andover, MA July 5, 2016 # I " - t= a � ■ 'e 'may, � �� h v A ° h OL ,. �� � -'�` t• � 1 1• 1 - 66 ft Property Information Property 210/064.0-0096-0000.0 ID Location 68 BEAR HILL ROAD +s Owner BELANGER, PETER MAP FOR REFERENCE ONLY NOT A LEGAL DOCUMENT Town of North Andover, MA makes no claims and no warranties,expressed or implied, concerning the validity or accuracy of the GIS data presented on this map. Map Theme Legends Aerial Photo, 2011-2012 • •TOWN BOUNDARY PARCELS Aerial Imagery© Digital Globe, Inc. All Rights Reserved and c/o MassGIS, USGS Color Aerial Photo, 2014 •TOWN BOUNDARY PARCELS Imagery- USGS Color Ortho Imagery, Date.......... .. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that has permission to perform ..../ - (, ,.J f!LP ..... wiring in the buAiding of....-,,. 8e/ . ..... ........................................................ .......... .... ........ 4,at ..6.6�...............Z-'�..4.....e...a...... ...../z. ................. NOl:th Andover,/Ma -0 Fee 7.�...........Lic. No. .............. .............. .. .. ......... . .. ..... 4� �2C�/� /L ACTIR�IC�AL INSPECTOR Check'/660�/ 3 - - Commonwealth of Massachusetts Official Use OnlyROMP - Department of Fire Services Permit No. Occupancy and Fee Checked \ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank Q APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 Q (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1� City or Town of: NORTH ANDOVER To the Inspector of Wires: v By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 611Sr �✓�I r� j Owner or Tenant ��•� `Q,u� Telephone No. S Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity ll Location and Nature of Proposed Electrical Work: ( ,y ale1Ji c,eg Zt1 �w Completion o the ollowin table may be waived by the Ins ector o 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 Emergency ig ting nd. rnd. Battery Units No.of Receptacle Outlets Zl No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating DevicesTot � No.of Ranges No.of Air Cond. Tons No.of Alerting Devices �I No.of Waste Disposers Heat PumpNumber .Tons KW No.of Self-Contained Totals: `. _.""'"'""'""'••"•"•. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal Other Connection No.of Dryers Heating Appliances KW Security Systems:°' No.of Devices or Equivalent No.of Water �, No,of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 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 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEABOND ❑ OTHER ❑ (Specify:) I certify,under the a. nd nalties ofperjury,that the information on this application is true and complete. FIRM NAME: zi LIC.NO.: (ala a�o Licensee: Yo1H &A.4-e— Signature LIC.NO.: (If applicable' pt"in the lic se na+ ber line.) c ��nn Bus.Tel.No.:?fig ��320$' Address: 5 CLtbcJ!` �! Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departmen of Public Safety"S"License: Lie.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: $ �p _ )MECTRZCA.L PERMT I�T0, ELEC7CMCAL INRECTOR•-. x.ROUO SP CTION Passed= Failed--j ] Re-inspection required($50.09)•-r ] hspectors'co)n meufs: (Xnspectoxs zgna a nonftiaTs) Date 2.FMALNS C'TION-, )Passed-[ Failed—[ ] c Re-3mspection required($50.00)•-[ Inspectors'commie)afs: (inspectors'Signature -no initials) Date 3.•UNDER GROUND INSPECTION- Passed—r ] Failed—j ] Re-inspection required($50.00)-•[ ] Inspectors'comments: • 1 (Inspectors'Signature--no initials) Date 4.INSPECW0N--SER fCF: - DATE,E CA L L>ED NATIONAL CP-Pi NA-=—.. Passed—[ ] Failed—j Re-inspection xequired($50.00)- [ ] bspectbrs'commons: (Inspectors'Signature-io initials) Date 5.INSPECTION-OMR:' Passed—[ ) failed [ ]_ 'Re-inspection required($50.00)-[ ) Inspectors'conim.ents: cisp ectorsSignature-•no initials) Date l)®OR TA G,5.,ARE TO BE FH T,ED OUT AND LEFT ON•SITE IF TBE AMA.TO I3E INSPECTED ISNOT � T ACCESSIBLE AND ARE INSPECTION OF 550.00 IS TO DE CHARGED. - The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,ALL 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. A licaut Information Please Print Ledb Name(Business/Organization/Individual): ti Address: � c vuS City/State/Zip: Cc,xc,o % 06V3 Phone#- 160el— 3.2& Are you an employer?Check the appropriate box: Type of project(required): 1.FJ I am.a employer with employees(full and/or part-time).* 7. ❑New Construction 21 a sole proprietor or partnership and have no employees working for me in 8. Remodeliing any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. r]Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. • 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its of�cers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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. II' 1 #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they,must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'.below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce der the pains penalties of perjury that the information provided above's tF a and correct. Si nature: f 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#: 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-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 sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia J w' Commonwealth of Mas usetts, Division of Registrati Board of Electri RYAN M £ 45 ADA LAWREN Master Elec 'a �' •a �O V��W 21726-A 07/31/2016 �M. SJO.UC�8835 License No. Expiration Date. Serial No. Date........... 11129 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING gB�CHu This certifies that......... has permission to perform...... ....... ................ ............ .................. ............ plumbing in the buildings of...... -e�................................................... ........... . ........ ... at......tal.......( r \\ Vd. ....... North Andover, Mass. .. ........................................................... Fee..7 Lic. No. ..... ................................................................................. PLUMBING INSPECTOR Check# d MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOR CITY Or��-h ,A,.-/��✓�"r- MA DATE W [ PERMIT# ____ ✓� OWNER'S NAME �' JOBSITE ADDRESS Gib &--jAr [ TEL FAX [ P OWNER ADDRESS EDUCATIONAL ® RESIDENTIAL TYPE OR OCCUPANCYTYPE PRINT COMMERCIAL Q PLANS SUBMITTED: YES® NOD CLEARLY NEW: E] RENOVATION:® REPLACEMENT: 4 5 6 7 8 9 10 11 12 13 14 I FIXTURES-1 FLOOR- BSM [ 1 2�[ _3 [ __j BATHTUB BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL 1 -�._.___I _.J __._:_I .-...__ ► � ___.� ___.._1 __ .____.J __J __._.l ._:____� ____J I,r SERVICE/MOP SINK TOILET URINAL. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER - - f ( l _.� INSURANCE COVERAGE: 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESNO �1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW OTHER TYPE OF INDEMNITY EI BOND Q LIABILITY INSURANCE POLICY fired b Chapter 142 of the e coverage required y p ' nsee does not have theinsuranc g CE WAIVER:I am aware that the licensee OWNER S INSURANCE 's requirement. waives thl q d that m signature on this permit application Massachusetts General Laws,an y 9 CHECK ONE ONLY: OWNER F--11 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the de'nsltaila d Ins rmati medhunder he ave u itt issued ed or enter for his applicationIg 111is pwill be n compliance with all Pertinent provision of the edge and that all plumbing work andpermitL Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S faflJ [LICENSE# la-`16; � SIGNATURE MPJp 0 0 CORPORATION #=PARTNERSHIP E3#�[LLC .1 �I t I [ ADDRESS �✓` '" S ' - COMPANY NAME (� R rS��) ' ' STATE rw�► I ZIP CITY TEL FAX _ � CELL � `1a.3. � EMAIL ._____----- ROUGH PL ING INSPECTION NOTES BELOW FOR OFFICE USE ONLY -T FINAL INSPECTI N TES _ THIS APPLICATION SERVES AS THE PERYes No MIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 m Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib, Name(Business/Organization/Individnal): r 6 Address: 3 +J`TJ'" c. ,-- City/State/Zip: ►M e-T N�-c,� `'�✓� D/b`(y Phone#: 5 7 V �� I Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with I.. : employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3_❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. ,dumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.F-1weare a corporation and its officers have exercised their right of'exemption per MGL c. 1.4.E]Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check-this box must'attached an additional sheet showing the name of the sub-contractors and,stgte whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer ttiat is providing workers'compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: M 2 TC 11 S ( rJ j C �o '� c Policy#or Self-ins.Lie.#: �� Z�.D Expiration Date: 1 Job Site Address: ` City/State/Zip:/1)0rT+l 0;—b 01/2- ✓`)A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: L1 ' 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#: 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 oPhire, 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." I 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 Depattment of Ifidustrial Accidents foi•confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town.that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Oiw ME • • • ��H.OF MASNS., BARD PLUl'95E � rSUES THEGw$FL T�:p L i FOLLoWi. C,11S AS A MASTE t f CEtaS�; A p pgRSpNS RPL^UhiB� rI1LTU{� ST J ! r 'E MA 01844- 1010 t-' I I