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Miscellaneous - 68 FERNVIEW AVENUE 4/30/2018 (3)
68 Fernview Ave. , Unit 4 i BUILDium \,. i i MetLife Auto&Home® Homeowner Operations Field Claim Office Mail Processing Center P.O.Box 2201 Charlotte,NC 28241 (800)854-6011 Mw,m t L I June 4, 2014 North Andover Building Inspection 1600 Osgood St Suite 2035 North Andover, MA 01845 Our Customer: Melinda Ryder Claim Number: JDE36528 8S Date of Loss: May 3, 2014 Dear Sir or Madam: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has —_ been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 3B, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 69 Fernview Ave, N Andover, MA Sincerely, Andrew J. White - DR Metropolitan Property and Casualty Insurance Company Senior Claim Adjuster =_ (800) 854-6011 Ext. 7050 Fax: (866) 947-1856 Email: ajwhite@metlife.com MetLife Auto&Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates,Warwick,RI. MPL MA-REGDEPT Printed in U.S.A 0698 MetLife Auto&Home® dco1» dco2» «fco3» dco4» Oco5» e ife MetLife Auto&Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates,Warwick,RI. MPL MA-REGDEPT Printed in U.S.A 0698 Date. . .��! 3917 x- °f,Nc`°T•1�c TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMus� This certifLe � . . . �a:--+.�t,!. . .u?. . . . . . . . . has permi ,.e<,•. . . 43/!plumbing s o � . . . . . . . . . . . . . . . . . at.le . . . . . . . . . . . . . . , North edover, Mass. f Fee .'�!!. . .Lic. No..BOG/�. . . . . �. . . PLUMBING INSPECTOR Y 01/12/99 14:55 .00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ��' /y.�/�UI/ 'c�/ , Mass. Date 19 , Permit#c� Building Location �� ?5e k-Al w tle, Owner's Name J o4Ati` 4.v - D Type of Occupancy C GD New p Renovation ❑ Replacement 2"'� Plans Submitted: Yes ❑ No 2' FIXTURES z N _z t- NN 0 O z y W x J (a ) V Q N Z W CC N 2 N Q ¢ _ ~ Z 0 z N a J N W y H W y Y Q N W Z ` f. Ix toIA 2 a H U W N d � X V Z O O = N W Q 2 Q 14 W ? O Q dN z Cr a Ir W a c W W' d 0 N � J a J CL e a. a 0 2N QIN z o 0 y z x W o a s I Q o Q j J Q ¢ x = Q O 4 h 3: x j m I Ca0 a J 3 z r- N U. o a a a 3 c to o SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name Fred L. Webster Co. , Inc. Check one: Certificate Address 306 Walker Street 0 Corporation Lowell, MA 01851-1848 ❑ Partnership Business Telephone 453-2891 ❑ Firm/Co. �- Name of Licensed Plumber Stephen Webster 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 indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sggent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi ' for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing an p r 1 2 h Ge eraI Laws. By Title ignature of 116ensed Plumber City/Town Type of license: Master 0 Journeyman E] APPROVED OFFIC S ON License Number 10615 2 BELOW Fon OFFICE USE ONLY . FINAL INSPECTIONS SKETCHES PRO )ES SiNSPECT,oNs FEE 2 q NO, \\\ APPLICATION FOR PERMIT TO DO PLUMBING '\ � } �\ . �\ $ • `y4 NAME &TYPE OF BUILDING / �\ { LOCATION of BUILDING ® m 2` \ `k PLUMBER } . y. { . }«= PERMIT GRANTED } \ DATE 1gm PLUMBING INSPECTOR �}� Date... ............ ... ...... � HORTp °ft"`°:•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��SS�cMus�� This certifies that6�.vic� �-"�� �.... .................................................................. has permission to perform .............erp-. --4w� ........................................ Ale -12 in the building of.........yc.2iT.. . . �...... Ger ��' � at......... ... /.1�/�! ........�........................ ,N rth Andover,Mass. Fee..`�........... ..... Lic.No.�L�7.S ........... . . .�!s. � r � z ELECTRICAL INSPECTOR, Check # 23� 895 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. { Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: g 171 ,0 4 City or Town of: J Aa olk A n yde C To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforin the electrical work described below. Location(Street&Number) � &r n U i P tJ U P2 C 11e,�i TGto P 6 re pn r o tr oxo j2i T Owner or Tenant O LO A p r Telephone No. o I q Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Aa69S i J e t)(, 12 Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Ray In P1)(1 M Re nen Q, 1 Completion o the ollowin table m be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA o. No.of Lighting Fixtures Swimming Pool ❑ n- o Emergency Lighting rud.Above rnd. ❑ BatteKy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etection an Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste DisposersHeat Pump Number Tons K No.of elf-Contained ' Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal f-1 Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW o.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 E uivalent OTHER: Attach additional detail if desire4 or as required by the Inspector of Wires. 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 ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [`BOND ❑ OTHER ❑ (Specify:) �Estimated Value of Electrical Work: (Expiration Date)Q (When required by municipal policy.) Work to Start:_ Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties ofperjury,that the information on this application is true and complete FIRM NAME: LIC.NO.: Licensee: CG1 p�, 4! _-t1 0,5M Signature LIC.NO.: (If applicable,enter "exempt,,in the license n ber line.) Bus.Tel.No.,• 4:,)7 Address: -C g ��� CA )y Alt.Tel.No.: 1-7-92 Iaware-that OWNER'S INSURANCE WAIVER: am aware that the Ltcensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. S Signature Telephone No. p o17, Date. . .. . . . . . . . . . ,aORTq � TOWN OF NORT ANDOVER PERMIT FO PLUMBING ti SSACMUS� 4 ' This certifies that . . . . . . . .`. . `. . . . . . . . . . . . . has permission to perform ... *'. '/ :.:-:'f- -1--'-�-�'. . . . . . plumbing in the buildings of l., ���. . . . . . . . . . . . . . . . . . . . . . . . . . at . . .. . ... . . . . ..,,, North Andover, Mass. Fee . . . .Lic. No �t�l.?�. . {.,. . /44- . . . . . . . . . . . . . . . PLU1413ING INSPECTOR Check ff 8'168 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING r (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Lf/S')67 ,- Building Location ��" kl'4 tew /A4 Owners Name &u4 �����,�s�.. Aecr Permit# vl)l' -4t f Amount Type of Occupanc 040 New Renovation �' ReplacementEl Plans Submitted Yes ❑ No FIXTURES �I z x H W a O a O w w w w z z z ar Z – a p H xO A x a, z A w A a �, x w z o � w O U x � a � A A a 3 x H '� � A04 a w� lASEVENr 1n H ern MOM 3MHJOM 4M>LOCR SMHAOCR 41 6M Hi" 7M It" t sffl 11" (Print or type) --7 Check one: Certificate Installing Company Name ���5 � ✓'►��1�'a .4 �;Ot.( ❑ Corp. Address El Partner. Business Telep one� � 1 � G'5�1 0—Firm/Co. Name of Licensed Plumber: i.,i/'4pyp elvle4 A Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 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 of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State Plumbing Code an 4 Chapter 142 of the General Laws. By: v-r� igna ure 01 LicenseclT,�;Nuer Type of Plumbing License Title City/Town is n 11 e ori E USE ONLY APPROVED(OFFICE se NumDer Master Journeyman ❑ ( C I As The CommonweaUk of Massachusetts k; ! Department of Industrial Accidents ., Office of Investigations 600 TTrashington Street Boston, MA 02111 www_mass.gov/dia . Workers, Compensation Ins4mnce Affidavit: Builders/Contractors/Eiectricians/P A licant Information lumbers Please Print Leaibl Name (Busincss/Drpnization/Individual): Address: . j City/state/Zip: >�, �:�� G )A° Phone Are you an employer?Checkthe appropriate box: I.❑ I am a employer with 4. ❑ I am a general contractor and I Type of Project(requiretE): employees(full and/or part-time).* have hired the sub-contractors 6. ❑Naw coristrvction 2•Ram.a:sole proprietor or partner- listed on the attached sheet= 7. ❑Remodeling ship and have no employees These sub-contractors have working forme in an g• Demolition y capacity. workers' comp.insurance. 9. Buildi [No workers'comp,insurance 5. ❑ We are a corporation and its ❑ nS addition 3.❑ required.) officers haveexercised their 10•0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 152, §1(4),and we have no insurance required.].t -employees. [No work=' 12-E] Roof repairs camp. insurance required.] 13•17 Other "Any applicant that checks boil!#I Homeowners who submit this must also fin out the section below showing their workers'oompensation policy information. t affidavit indicating they am doing all work and then hire otaside contractors must submit a new affidavit indicating each. xConuactors that cheek this box an addition must attached al sheet showing,the name of the sub-contractors and their workers'scup,pc&�•n fonRsuc I am an employer that is provi&ngworkrs'compensation inuaneforinformaton M'empill Below is the Policy and joh site . Insurance Company Name: I-ayelw-f Policy 9 or Self-ins. Lie.#: Expiration Date: Job Site Address: / pr-21/illl� f�1-�- , ers' CitY/Stata/Ztp: Attach a copy of the workcompensation 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 TOP WORK ORDER and a fine of a S 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 here by cernfY under the pains and penalties of perjury that the informationrov' p uled above is true and correct Si tore: Date: Phone#: [1B ot useill Do not write in this area,to be completed by city or town o riaL r Town: Permit/License# Issuing Authority(circle one): rd of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector e'rt Person: Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all empIoyers 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 mom of the'f6mgoing engaged in a joint enterprise,and includirag the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associaborn 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 sucb 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),addresses)arnd phone number(s)along with their certificates)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' cflrnpensation 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,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' CQtl.pensation policy,please call the Department at the number listed below. Self i_ngitreri enmpRrtige a�n�ri�t Pat tn�ir 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 vvilI 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 Depar ment of 13ndustrial Accidents Office of Investigations 600 Washington Street Bosfon, MA 02111 TeL #617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-US www.mass.gov/dia Date. . . . . ... WORTN pf .ao ,ti0 TOWN OF NORTH ANDOVER a • - PERMIT FOR GAS INSTALLATION SACHU5Et This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation .`/. in the buildings of . . . . . .P C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . .I North Andover, Mass. Fee.2,k . . . . . Lic. No:9l . . . . . . q . .E�.':. . . . . . . . . . . . . . . `GAS INSPECTOR Check# 3 70Q MASSACHUSETTS UNIFORM F.PPLICATION FOR PERMIT TO DO GAS FITTING City/Town: C t;C' MA. Date: Permit# �G Q.Y'hV 1Q.a4 S� Owners Name: Q.�' f't � ��Q+� Building Location: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement:,Q Plans Submitted: Yes❑ No Q�©tib FIXTURES vi Z W UW 0 2 N< WW 0 N ~ W m x Z J v w z w 0 U) w 0 ir- p z0 f- O W Lu D w O ¢ F W w UJ m 0 w O a W re _ LL W = Q w w z fn x w ~ U) = Z W w W z W > ai Q m w O z O y > Z Q SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 KU FLOOR 4 FLOOR 51H FLOOR 6 THIFLOOR 7 FLOOR 8 FLOOR _ (7 ! Check One Only Certificate# Installing Company NamSr tn '04 IF cc Corporation Address \�'�h�`<ce CitylTown ��.3�a to State ❑Partnership Business Tel:%-w 403'1 Lk%t-%% Fax: \\ ❑ Firm/Company Name of Licensed Plumber/Gas Fitter:1�F V-9A 94T°COC \N�*X�RqV1^ INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No 171 If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's A ent By checking this box❑;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. Type of License: By ®Plumber ❑Gas Fitter Signature of icensed Plumber/Gas Fitter TitleL Master Q� �G Cityrrown LJJourneyman License Number: `des APPROVED OFFICE USE ONLY ❑ LP Installer FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTI6N(S) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH I PLUMBER.GASFITTER.LP INSTALLER LICENSE NUMBER:" PERMIT GRANTED❑ DATE- f I GAS FITTING WSPECTIOR TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: a IMPORTANT: Applicant must complete all items on this page 2V V (-I LOCATION Com$ 1 e^� -- �'- q Print PROPERTY OWNER_ Qav;A Ak,so., t^� Print MAP NO: PARCEL: 6 ZONING DISTRICT: Historic District yes Machine Shop Village yes �ho TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial teration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: "Cze,nn0A6 )044 aowx . N w cell S , Gr,! <xkl'e.S OA cel'% Identification Please Type or Print Clearly) OWNER: Name: _ ?er-L Phone: q-?F- Address: (OF : CONTRACTOR Name:_ Phone: 9-? , - 1Y Address: t2 6&�J. IL Wsti, Supervisor's Construction License:' C?nFtet ' Exp. Date: 6 Z17616 Home Improvement License:_ /y5`2!Z 0 Exp. Date: 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: $ 1� 1 11©00. av FEE: $ /ZD.°D Check No.: 1.L? Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acceEmped uaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21 A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date ................_-----_.._..__........_......_..........._......----........................_........_...._._...._....._................................................._......................._. Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers-Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 Location i lhtAd No. =L� Date ep- 3 NpRTM TOWN OF NORTH ANDOVER C: .w .•'1hp Y . ° Certificate of Occupancy $ • Building/Frame/Frame Permit Fee $ 1 "~ s�CHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 222 ,- 2 Building Inspector V40RTH Town 0 t 4Andover O'AVT `.�w,_ 'y.'v'4•'. .Y. .;,�, \o• y - T i - - -~ T dover, Mass., ' o T O LAKE /fesCOCHICHEWICK V AERATED P'P�\ �� `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �Q BUILDING INSPECTOR THIS CERTIFIES THAT.... .r�N.� ...........`...:'�,+. ---.................... . ..... . . ....................................................... Foundation .....4......................... buildings on ... ct!!�..... ....L Rough has permission to erect........ g .�..... ............. tobe occupied as.. 4 ...................................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS Rough ...d ............ ............................... Service B ING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. MC#145220 Guerrieo Home Remodeling CS#90899 12 Meadowlark Way Billerica, MA 01821 978-204-9189 Homeowner address: Date: 7/23/2009 David and Alison Peck 68 Heritage Green,Unit 4 North Andover,MA Estimate Description: Full Bathroom Remodel 4 Complete demolition and removal of bathroom fixtures, walls, ceiling, and floor. (Down to wall stud and floor and ceiling joists) • Install 3/e"plywood sub-floor with 1/2"wonder board on top for tile substrate • Install fireproofing material to any openings of cavities to adjacent units • Install 1/2"blue board to all walls and 5/8"fire code blue board to ceiling • Install 1/2"Dense Shield tile substrate to shower walls • Veneer plaster walls and ceiling • File and grout bathroom floor(approx 25 sq ft) • Install medicine cabinet, sink base, and any accessories(Toilet paper holder,towel rods,soap dishes etc.) • Install primed,4"colonial baseboard molding and 2 %"colonial door trim • Permit and inspection fee's included Total for above work: $3,450.00+cost of permit(Estimate$75-150) *Additional cost for priming and painting walls, ceiling, and trim, $375.00 (Includes paint and labor, Benjamin Moore or California,one color for walls and one for trim.) *Additional cost would apply if raving to insulate walls, ceiling, or floor. Cost would be between $SO and $200 pending on scope of area needing insulation and type of insulation needed. Payments would be as follows: Deposit due on starting date: $1,150.00 Payment due after rough inspection: $1,150.00 Final payment due at completion of work, $1,150.00 Estimated time to complete work- Demolition, 1 day Framing for rough inspection, 1 Day Blue board and plaster,2 Days Tile and finish work, 5 Days *Additional time needed if having to insulate, 1 day. Estimated starting date,August P, 2009 Notes: Customer is responsible for supplying allplumbing and electrical fixtures, tile, and accessories. Customer is paying for plumbing and electrical separately, not through Guerrieo Home Remodeling. All work will be performed as specified in a professional manner. Any alterations or deviation from the above specifications would involve additional costs,unless decided on in advance and approved of,by Guerrieo Home Remodeling. Any agreement to begin work based on a written proposal quote issued 6 months or more,prior to actual date of start,may be subject to change,due to higher prices in material cost, premium or additional fee increase. Thank you for choosing Guerrieo Home Remodeling. If you have any questi ns, please,feel,free to give us a call!? 3/051 i tic a;'"o�u ��Sg tcegt�ttrti 5 an HOMEtMPRO VEMENTCONTRACTOR Registr" on 145220 77707 trfton 1212712010 Tr# 2 Exp Type DB6 k&. 't lug REMODELI�IG't GUERRIEO HOR _ PH OER� UE�?R1E0 CHRISTe. ;gyp 12 MEADOWiAR WA fa 0f; :ltlministrat, BILLERICA,MA 0182 :r Nlassachusetts - Depili-tment of Public S.ifet% Board of Building„ Re kihttions and Standards Construction Supervisor License License: CS 90899 Restricted to: 00 CHRISTOPHER E GUERRIEO .12 MEADOWLARK WAY BILLERICA, MA 01.821 Expiration: 6/9/2010 ('ummisiuner Tr#: 27351 Me Comrnonwealtfi ofMassachusetts ' i Departmeiizt of Industrial Accidents• of Investigations 11 600 kTlrrshiRgton Street «, .�a Boston, MA 02111 �c Workers' Compensation I:nsitranee A.fiEida A o licant Informaifian vat BwiderslContractors/Eiectncians/PiQmbers Please Print Leibt Name (Business Drganizatiom4ndividual): (--Pri 5 C�(•�'r�CJ • Addmss: c✓1c,�1C (,J City/,State/Zip: Q I ey;c Phone k.3 7Ereymployer4 Cbeek.ffie aPP�Priate'box:mployer with 4. Q I am a Typeof project(r7addiiti:ons generaleontr:actor and I ees(full and/or part- etrm .* have hired the sins-contractors • New coastram.a.sole proprietor or partner. Iisted on the attached sheet.! 7. �emodeiing ship and have no employees These stris-eontractars have working forme in any capacity. workers, comp.insurance. 8. Q Demolition (No workers'comp.insurance. 5. Q We are a corporation and its 9. ❑Building ad 3.❑ required.] Officers have exercised their 10•[].Electrical 1 am a homeowner doing all work ri rem seI£ of exemption P r MOL l l.[]PIumb- re Y [NO-W comp, .c LSA, §1(4),'and•we have no insurance required.]t .emplo yees, [No workers? 12.Q Roof repairs comp. insurance required] 13 -Other `/+ny appiicarrt tient dmcks boz#I must also MI out the section below showing their workers'oom 1 fiomeowrters who eribmit this a rf davit indicatin th ars dol an P°p Poiky information 4coetractors that check this box must !; wwt and then hire outside contraetots most submit a new affidavit indi attisobed an additional sheet showing.t:he name of the mb-mm-.ours and such' it worl=•�-T.Faiic;ir&mtiou. ernPwyer Pkat is ptovirissrrg:worlrers•'err ersatier� information ' �risurance for rrry.earploy�; Below it the PacJ'andyab site . Insivance Company Name: tie�e rv, Policy#Or Self-ins.Lie.#: Expiration Date: Sob Site Address: /�� /T><tirl-a c� •C ��-r c� Attach a copy of the workers' couipeusafion dot~ ` CitYt> elZip: Policy IzcratiiL page(showing the policy number and expiration date). . fine ue to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cturtinat fine up to$1,500,D0 and/or one-year imprisonm p'-nalties of a- Of up to$250.00 a viol as well as civil penalties in the form of a STOP WORK ORDER and a fine Investigations of the IA orriinsuran e�- Be advised t rion copy of this statement may be forwarded to the Office of I do hereby cel*and the pains and peeaUies afPCd&uY that the information pro lr voted ore is nice and correct sr tur e: . Date: � 3 • Phone#: 7 - _ FI = only. do not write in this a�4 to he comple4nd by&by or town officio! n: Permit'/License# hority(circle ooe): Health L Building Department 3.City/Tawn Clerk 4. Electrical Inspector S. Plumbing Inspector son: Perone#: Information and Instructions Massachusetts General Laws.chapter 152 requires all emp foyers to provide workers' compensation for their employees. Pursuant to this statute,an e►npinyee is defined as"..:every person in the service of another under any contract Aire, F— express or implied,oral or writtzn." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or arry two or more of the'famping engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receivar ortrustm-of an individual,partnership,associative or other legal-,city,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 m do maintenance,construction or repair work on.such dwelling house or on the grounds or building appurtenant thereto shaU not because of such m-aployment be:deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state o.ar-local 6ceusing agency shall withhold,the issuance or renewal of a license or permit to operate a business or ito construct buildings in the commonwealth for any apPficant who has not produced acceptable evidence.o r comprmnee with time insurance coverage required" Additiomliy, MOL chapter 152, PC(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pedbin Brice of public wort-, until•acceptable evidence of compliance;with the ins== requn=n=b.of this chapter have been presented to the carrtracting authority." Applicants Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary, supplysub-contractoir(s)name(4 address(es):amd phone number(s)along with their certifimite(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partri=hips(LLP)with no emplayees otherthan the members or partners,are not tsquired,to carry workers'compensation insruanee. Ifan LLC or LLP does have empioyees,a policy is mquirB Be advised that this affidavit may be submitted to the Depar rem t of Industrial Accidents for confirmation of insurance coverage.. Also Ese sure to sign and-date the affidavit. The affidavit should be returned to the city or town that the application for the peirait or license is being requested,not'the Departmant 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 nusmber.listed below. Self-insured cornpanies should enter their self-insumncic license number on the*approprate tic. City or Town Officials Please be sure that the affidavit is complete and printed iegbly. 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 whicb will be used as a reference number. In addition,an aoplimnt that must submit multiple perrnit/lic M=applications in any given year,need only submit one affidavit indicating current policy•information(if necessary)and under"Job Site Address"the applicant should writt"all locations in (city or town). A copy of-the affidavit that has be=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 f dwe: permits or licenses. A now 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.t a dog license or permit to bum leaves etc.)said pmsnri is NOT.re:quired to complete this affidaviL Thr.Office of Investisdions would lice to thank you in advance for your cooperation and should you have any qu-scions, please do not hesitate to give us a call. The Department's address,telephone and fzx number. The Commonwealth of Massachusetts Department of lzidn'aW Accidents Office-Of Envestigsttions " 600 Washington Street Boston, MA 02111 TeL #617-727-4900 ext 406 or 1-977-MASSAFE Bruised 5-2645 Fax 4 617-727-7744 www.mass.gov/ciia N