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HomeMy WebLinkAboutMiscellaneous - 726 GREAT POND ROAD 4/30/2018\� N I '� � p N W � ' o m � oDi o � z , i o � 0 0 o � This certifies that ......G.�-,,v. 4jk, !?i:e.. .. o has permission to perform .... C .....S.y...! . r'? -t7.......... . wiring in the building of ................... P � at. ... 47VA . , No �h Andover, Mass. Fee;.c. No.. ELECTRICAL INSPECTd Check # "' L � 91032 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule S: 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. 01 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 shat be limited as to the time of -ongoing construction. activity, and mayhe.deemed_bythe dnsp.ector-of_Wires abandoned.and.invalid-if_he—.. or she has determined that the authorized work has not commenced or has not progressed during the.preceding 12 month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the, permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain -permits •and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effector existence" during the qualifying period beginning on August 15, 2008_and extending'through August 15, 2012. AU -1e 8 - PermiVDate Closed: * * Note: Reapply for new per ' ro Permit Extension Act -Permit/Date Closed: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 11032 - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: t9 — (6 , ( 2, Cityor Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) % Q- Cj Are n:r PQ Imo( Owner or Tenant Telephone No. 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 New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: f�J�2P l✓e c..,, /4 C ��5-6P� S dam V --]._ Completion of the following table may be waived by the Inspector of Wires. Attach additional detail ij desired, or as required by the tnspecior UJ rrtres. Estimated Value of Electrical Work: SOO-� (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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSU_RANCE [-I BOND ❑ OTHER ❑ (Specify:) 06----4 G I certify, under thepains andpenalties o perjury, that the zn ormation on this application is true and complete. FIRM NAME: A% IVO PLfiP t LIC. NO.: 90 Licensee: 4A Pp Signature Nk—_ o LIC. NO.: (If applicable, enter "exempt" in he license number line / /�� Bus. Tel. No.: ? — Address: �Q0 61�r G� �"j _Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. of Total No. of Recessed Luminaires No. of Ceil: Sus le Fans P (Paddle) ) TransKVA s No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o cy Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burgers Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Numper Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: .......... .. ......... .••••• Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems:Y No. of Devices or E uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equi valent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail ij desired, or as required by the tnspecior UJ rrtres. Estimated Value of Electrical Work: SOO-� (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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSU_RANCE [-I BOND ❑ OTHER ❑ (Specify:) 06----4 G I certify, under thepains andpenalties o perjury, that the zn ormation on this application is true and complete. FIRM NAME: A% IVO PLfiP t LIC. NO.: 90 Licensee: 4A Pp Signature Nk—_ o LIC. NO.: (If applicable, enter "exempt" in he license number line / /�� Bus. Tel. No.: ? — Address: �Q0 61�r G� �"j _Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. FUM ICA PF - �.'�sseu�-�[ fifr,orian�nre`� G'4crtrafr,rp: ..7tn fnitiaY�'1 r - - Date ,di. �s-1.1t31-t?-lV I-7JC.�+cJ'..I.VJ.g i �,'asse��--[ � ' �i`aiSec��� �' � ate-�ns�ec�.oxtxeo�uixe� (��0.q0)�• [ � . �t5�]eCtoxS' Comm•ex�ts: , (1Cns�iec#ozs',zguaiuze�torizizaTs) date assecT•-� j �'az�et�--j � �Z.e�.s�eetZo�.�•e[�u'rxe�(�s0.U0)�I J fuectoxs' comments. lnspectoxs�,�zgnaiuxe��oias) ]ate secs-C+aile�i--j ienspectionxe�uiYe (O.�D) j oectoxs' eoJm�ne�tfs: ' {�s�ectoxs' zgnaiuxe�1zoinitZals) Data � --- �' ��{,'alier� � � )- ' ate �nsp actioxt xeg�ii'etl (��D.O D) •- [ � lus�eaoxs'Winataze-n.oinitials) date ' r)'PhrAX0AM. rVdDRFYi.'%tffTV,7brCVTAIM T,"'fiWw'7f'o,W"d'M.A7wVA`.t`OB _7SPAC EDTaNOT 't The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 swww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): ��(/ iN0 C Address: /® c> bl- -r t• City/State/Zip: CC 'S (par, ktk TS Phone #: 7 7C3 Are you an employer? Check the appropriate box: llfffam a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I -am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t I employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site reformation. nsurance Company Name: I 'olicy # or Self -ins. Lic. #: ;,,,,,.c/1'!! Expiration Date: Pa/ 23 ob Site Address:__ ? 2 G (S --q I` o� /09 City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 251 of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify tinder the pains and penalties of perjury that the information provided above is trace and correct. signature: Date: 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 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 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 tevised 5-26-05 www,mass,gov/dia 964 ry Date.... '.eV: ....... '3 ,&ORT" Of �«ao {. '14• 06 or ooh TOWN OF NORTH ANDOVER PERMIT FOR WIRING e This certifies that ........... %fib.... M.P.. Z- "`.. ....... sx, t�+ s� �. has permission to perform S fG :3. , wiring in the building of ................ . �. �`' /.}........................................... . ,,� �f —7 Z �-�—� ......... North Andover; Mass. ao 7 Fee.. ................. Lic. No.......325....... .................... .. �� ... ELECTRICALINSPECTOV Check At ' 1�����L4�3�s� . L �.vinrlrclrrw�waaer agr JG?u Permit No. �� T Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS w [Rev. 1/07] (leave blank) M 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.INTNK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address — e CZ a r- OUB Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:' t-,, M iat;„n . ftho fnllnwinv tahle may he waived by the Inspector of Wires. I -Attach aaamuneu uetuu Y ueaucu, u+ uo —1—' —�y J - -- --- 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 coverage is in*force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE � BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee:F-iel, e Signature LIG NO.: 3 Z5%2 C (If applicable, enter "exempt" in the license number line) us. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. No. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In - Ei Swimming Pool rnd. grnd. ❑ No. of Emergency Li-gkting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond.Tonal No. of Alerting Devices HeatPumpTotals: N umber KW ................. No. of Self -Contained No. of Waste Disposers -Tons......... .. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal E] Other Local ❑ Connection No. of Dryers Heating Appliances KW Security Systems,* No. of Devices or Equivalent No. of WaterKW No. of . - No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: I -Attach aaamuneu uetuu Y ueaucu, u+ uo —1—' —�y J - -- --- 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 coverage is in*force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE � BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee:F-iel, e Signature LIG NO.: 3 Z5%2 C (If applicable, enter "exempt" in the license number line) us. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 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: 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 #: Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...."1 ! . �!? N h.`?..�...� ,%� f �.. i:.`7....... . has permission to perform ... 1A- . ��.. . plumbing in the buildings of ..Ucr,.(t,%.................... G <� ' at ....�.?. �.... , n, ; , „�, . North Andover, Mass. Fee ..� o Lic. No.. /��. t J. C. .......4.� � .� ........ PLUMBING INSPECTOR Check # -7 5ro G 8694 0 a 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS /�(� Date Building Location / /�, � %� ' " `Owners Name ar- [�t/� Permit # Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes11 1:1 No FIXTURES (Print or type) Installing Company Name Address Certificate ner. n/Co. Name of Licensed Plumber. t4.fj 16/ Insurance Coverage: Indicat� type of insurance coverage y 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 a Agent 11 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 pe ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach ts-Sj4tg numbinCod/and Chapter 142 of the General Laws. D (OFFICE USE ONLY Type of Plumbing License License u Master Journeyman 0 The Commionwertith of m,,ssachusetts Depariment o f£radusfizal Accidmts Office of £piUestdgatioazs 90 WasAinb on street $ostan, AIL4 02.X.Z1 Www_mass-gov/dia Workers' Compensation insurance Affida.vft: Builders/Con ractorSxlectxicia s/Plumbex s MIicant-Information . x tease rrint .Leuibiy Name (Business/Ord n,zation/Iniiividuat):/� (CC �. Address: ' 3 V City/tate/Zip: Cyt/ Phone #. -Are y an employer? Check the appropriate box: 1- I am employ th 4. ❑ I am a a Type of project (required): bezEeral contractor and I employees (/or p_ time). have hired the sub -contractors 6` ❑ Ne�' construction 2• ❑ I am a sole proprietor orpariner- -listed on the attached sheet. t 7• ❑ Remodeling ship anhave no employees These subcontractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. ' Wo workers' cora . insurance 5. 9. (] 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 p� MGL 11. � bin r airs or additions myself, la y [No workers' comp. c. I52, § E4 )� and we have no 12-Elinsurance required.] t employees. [No workers' Roof repairs comp. 7nsr,rancfPrequired.] I3.❑ Other 1e g�yr it n+mTt__ r_,,ant flyoE .^.�•�yo yJOX.4r ID•�4S also YL oat tut eCII''-^3 RoMeowness who stewnifftiis affidavit indicating they =e dc�- `u " --* an rhea himutside cornizsct_o Tr &-t, g+Contactors that cxec` .._ tox m•rt �i�C a new, afidavit indicating such. additional sheet aamebf the sub -contactors and their workers' co o" mP. P �Y informafiom f anz an employer that isproviding workers' cozrzpensauon .Mszrrance for infor7natzon my employees th Eeloit� is thepolicy and job site. 'n Insurance Company Name: ✓, Policy # or Se1f-ins. Lic. #: K A. 6 / a 9 g �o / . - F�:piration Date:_ Job Site Address: j, f - ���� �� • c I* � -_, � Attach a copy of the wormers' coCity/State/Zip: mpensatior2 policy declaration page (showing the policy number.and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a m nne up to $1,500.00 and/or one-year imprisgnent, as well as c=ven i1 penalties in the form of a STOP WORK ORDER and a nue of up to $250:00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ Ido herebycertify under pa' rs and peizaides of perjury thczr the information provided above is true and correct M2ffia re / .Date,:_. _ ^� ^G Phone W. Official rise only. Do not write in this area, to be completed bar cite or town officzaL t City or Town: Permit/License # Issuing Authority (circle one): X. Board of Health 2. Building, Department 3. City/Town Cierra 4. EIectricaI Inspector S. Pluzabing Finspector G, afher Contact Person;: Location No. / 1 Date ti NO�TM TOWN OF NORTH ANDOVER O: i�ao a,hC L 9 Certificate of Occupancy $ `,ssACHUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #a 7 t' 17551 rr.-�-�-.-- Building Inspector / TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING b ..:. BUILDING PERMIT NUMBER: DATE ISSUED: % SIGNATURE: BuildiECommissioder/IqEeector of Buildings Date SECTION i- SITE INFORMATION '1.1 Property Address: '7"2 (,a,�-CAll 4(� /�cQ 1.2 Assessors Map and Parcel Number - umber:7"2( Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided _+ 154) 1.5. Flood Zone Information: 1.7 Water Supply M.G.L.C.40. Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record hyo arae (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: / Licensed Construction Supervisor: 4�79 ) ` � „/,%vim Address Z111 -KIN" / --IW Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home IImprrov`ement Contractor SDI —7h C Com �any Name /VA lve 1rC �` �� �(� Not Applicable ❑ Registration Number Address Expiration Date Si nature Telephone (Al 1, z M 90 r z G^^ � 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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1. Building Estimated Cost (Dollar) to be Completed by permit applicant1E i 1177 ©� QF'fC�USE (a) Building Permit Fee Multiplier QN[,y�" 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical(HVAC)�� 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERSAGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT - -goy, as Owner/Authorized Agent of subject property Hereby authorizez�w /% o cze/ ! to act on My behaI in 1 matters elative 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/A ent Date INNON" lip, 0:;, NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS OT 2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND j IS BUILDING CONNECTED TO NATURAL GAS LINE ;'. 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: Irle S 7 Y�q�Cx _ocation 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 cAi-6- N.. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #7 Insurance Co. Policv # Company name: Address City: Phone * Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years'.imprisonment.asmell_as_civiLRenattiesin the faun nf-a..STOP WORK_ORDER..and..a.fiine of (.$100.00).a day.against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under, the peips and .Signatu of perjury that the information provided above is true and correct. Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other D: Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax Please print. DATE JOB LOCATION Number "HOMEOWNER Name PRESENT MAILING ADDRESS Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION City Town Street Address Home Phone G-iFtn Map / lot WorK rnone The current exemption for "homedwners" was extend'N to include owner -occupied dwellings of two units or less and to allow such homeowners toage an individual for hire who does not possess a license, provided that the owner acts as ervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides intends to reside, on which there is, or is intended to be, a one or two family dwelling, attach or detached structures ac- cessory to such use and/or farm structures. A person who constrs more than one. home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance w the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of\\\No. Andover Building Department minimum inspection procedures and requirements and tha�he/sh e will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Zip Code Client#: 19_227 JOHNHORA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MW DNYYY) 1 03/30/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION USI New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 6360 Manchester, NH 03108-6360 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 04SBAGQ8654 603 625-1100 INSURERS AFFORDING COVERAGE NAIC # INSURED John Horan Construction LLC 21 EVERGREEN DR - INSURERA: Hartford Insurance Company. 29424 INSURER B: Eastguard Insurance Company 14702 INSURER C: , Hampstead, NH 03841 INSURER D: INSURER E: MED EXP (Any one person) $10,000 COVERAGES 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. SR LTR ADD'L INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS A GENERAL LIABILITY 04SBAGQ8654 04/01/04 04/01105 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE EIOCCUR DAMAGE TO RENTED $300,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $110001000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 PRO ECT LOC 17 POLICY 7 J A AUTOMOBILE X LIABILITY ANY AUTO 04UECTU4440 12/30/03 12/30/04 COMBINED SINGLE LIMIT $500'000 (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) X X HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR E-1 CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND JOWC419749 04/01/04 04/01/05 X WC ORY LIMIT ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - POLICY LIMIT $500,000 SPECIAL PROVISIONS below OTHER )ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Dperations usual to the insured :tK I IhiGA I t HULUtK CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Carl Woekel & Son Inc. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL I n DAYS WRITTEN 853 Ocean Blvd NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Hampton, NH 03842 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR TIVE \CORD 25 (2001/08) 1 of 2 #74379 BAFCA 0 ACORD CORPORATION 1988 STOCK COMPANY COMMERCIAL LINES POLICY WESTERN WORLD INSURANCE COMPANY RENEWAL OF N0. NPP817616 ICGGAIG tUGw HOMPCHIRF Policy NO. NPP882504 COMMON POLICY DECLARATIONS MGA # 216 Named Insured and Mailing Address: (No., sheet, City, state, Zip Code) Producer Carl Woekel & Son Inc Surplus Services Ins Agency, Inc 150 Wells Ave 853 Ocean Blvd Newton, MA 02459 Hampton, NH 03842-2516 Policy Period: (Mo. Day Yr.) From 04/01/2004 TO04/01/2005 12:01 A.M., standard time at your mailing The named Insured Is: address shown above. ❑ Individual ❑ Partnership 0 Corporation ❑ Other Location of Business: (Enter "same" if same location as above) Business Description: various Residential alterations, additions, repairs and remodeling IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGES FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. Commercial Property Coverage Part Commercial Liability Coverage Part Terrorism Risk Insurance Act Other: Forms aDDlicable $ 397.00 $ 2,948.00 M&D TOTAL ADVANCE PREMIUM $ 3,345,00 OTHER CHARGES $ Show number and edition date E s JnjW"awe sem, Bm P.O. Box 7425 Gilford NH 03247-7425 603 293-2791 800-594-9285 Fax: 603-293-7188 TOTAL 3345. 00 TOTAL ADV PREM $ 3,345.00 M&D GRAND TOTAL By 04/26/2004 EB:ns AuthorizeY� r6E nTHESE DECLARATIONS TOGETHER WITH THE COVERAGE PART DECLARATIONS, THE COMMON POLICY CONDITIONS, COVE ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. INSURED r FORMS AND WW230 02/03 Co IL � � V V0e)Lf & <-S-0t4 :1120. AName of Service Since 1897 CONTRACTORS AND BUILDERS 147 Washington Street Methuen, Massachusetts 01844 (978) 682-7901 Fax (978) 688-3413 April 29, 2004 W. F. Holdings C/o Robert F. Worthen 3 E. Spit Brook Road Nashua, New Hampshire 03060 Re: 726 Great Pond Road Dear Mr. Worthen: I am pleased to submit the following price on work as outlined below. 1. Remove cedar sidewall shingles from house. 2. Apply Dupont Tyvex and Maybec white cedar shingles, dipped in Cabot stain, as sections are removed. Color to be beige. 3. All disposable material will be placed in a dumpster for removal from site. 4. We will obtain necessary permits. Cost of permits to be added to price as we are at the mercy of the Town. Total Price -----$42,775.00 a. Removal of any hazardous material not included b. No painting included If Fraser white cedar shingles with 2 coats of Cabot stain, in color that you desire, is used in place of I coat Maybes standard color cost would be $80.00 per square more. There are 4 bundles to a square. Our estimate is based on 34 squares to do the work. L�V �i truly %our L-(/�2'jY Carl Wcekel, President ✓/ze -Parvszauaea�l o��/t/�uoaccctucaetla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 002707 Birthdate: 07/30/1929 Expires: 07/30/2005 Tr. no: 2183 Restricted: 00 CARL W WOEKEL PO BOX 2316 METHUEN, MA 01844 Administrator w � v w w a W o w N cn v C8 A °c � co o w o a: � v U a o c w o Gtko a «� w o Ift rA rjo w O O H p i!' -ACHL CML C A O s oeM i .• ! W W Q O �±� COL 10 Qo E f. C m r G0�� t E O * co :c m c o m O � y rnCD3A. O 0- Q O h i 32 :==MCos y�vo fA m * ? nC m mom 20 ca O N O O Z :o`er S, a c a m `mc •c CD . COL +.o D COD LIJ 0 y" C atNc o H ui = LLJ 93.0 o o C.3 ID o��� g CL o— = cm zCL = � ��� H z $ a.=..m r O 4 IS 0 a., g O L z a O H � C CD cm C CO3 O .COD FE m m CL O O � O M o a v�Q ca cc di C ZCL m �..� N2 O C C •� C cc Go D LLI cl ul C4 W W 19 W U)