Loading...
HomeMy WebLinkAboutMiscellaneous - 73 BRADSTREET ROAD 4/30/2018N , rpn Do I. Q O Igm m 1 P O o s 0 10896 Date : ll`.•!..:.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING P(�(_� This certifies that.........................../��-........ �t....:........r..................................... has permission to perform ... �........ r%. ..........:....................... plumbinth buildings of........................................................................................... /. ........................,,North Andover, Mass. O'�/ V Fee,577!� Lic. Nop..3Y�T ................................:...............:.................. PLUMBIWG INSPECTOR Check # P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY f� v► _ _ _ _ MA DATE PERMIT # 1 JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TEL —� JFAX _ OCCUPANCY TYPE COMMERCIAL Qi EDUCATIONAL © RESIDENTIAL gl NEW: M RENOVATION: [I REPLACEMENT: FIXTURES Z FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN f— PLANS SUBMITTED: YES E{ NO© m10 m SHOWER STALL SM- VICE / MOP SINK TOILET 1 ! _�_..! ! 1 U NAL 1–_j .____._{ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES— WATER PIPING OTHER KA01 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER � AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and and that all plumbing work and installations performed under the permit issued for this application will be in co pli nce (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # MP © JP � CORPORATION F]j#=PARTNERSHIP0# I E::; - COMPANY NAME .� r _ �J f ADDRESS I CITY I S'4 lie, inn 11STATE ZIP L� TEL FAX ¢ CELL g Z3.--/ EMAIL to the best of my knowl p iney)t provision of the TURE LLC _.E PME N ❑ Iii w LL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name (Business/OrganizatiorAndividual): r Address: PN30)(,�6 I? -City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ployer with 4. ❑ I am a general contractor and I (full and/or part-time).* Vm have hired the sub -contractors 2.e proprietor or partner- listed on the attached sheet. ship andhave 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.] 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. T -Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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' information. 4111 Insurance Company Name:. Policy # or Self -ins. Lic. #: Job Site insurance for my employees. Below is the policy and job site Expiration Date: 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. Ido hereby.certiry,uMler thepains pe alties ofperjury that the information provided above is true and correct. 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 Instructiois 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 ofpublic 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-coutractor(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 maybe 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 (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 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 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 offadustrial .Accidents Office of avestigatiom 600 Washington Sirea Boston, NIA, 02111 TQL # 617-727-4900 eyt 406 or 1-877:MASSA.FE Revised 5-26-05 Fax # 617-727-7749 �ww.�ass,go�fdia Location ��3 viy No. C17 Y/ Date � / NORTH TOWN OF NORTH ANDOVER L s Certificate of Occupancy $ a^CMUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ c>� S Check # /(?/ -- 14648 14648 4/ft r(� ----- % Building Inspector TOWN GP NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Buildin Commissioner/I for of BuildingsDate oc 1 avis 1- ,71 l S, Ul P fJAMA I IVA 1.1 Property Address: I 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 2.2 Owner of Record: Name Print Address for Service: 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Not Applicable ❑ �j U Front Yard Side Yard 3.2 Registered Home Improvement Contractor Rear Yard Required Provide ReqWred Provided R red Provided Expiration Date St natureTelehone 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ an%-11or11 /. - rxvrJx i Y V W PI Jft KarilY/AU I11UKLLEI) AGENT 2.1 Owner of Record �1y yy3kP� Name (Print) Address for Service I. Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Sign lure Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construe on Supervisor: lL Address01 '91 _r7s Signature Telephone Not Applicable ❑ �j U License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name V Ck tit Registration Number Address Expiration Date St natureTelehone r il- 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 ....... ❑ SECTION 5 Description of Proposed Work check all applicable= New Construction ❑ 1 Existing Building . it I Repairs) ❑ 1 Alterations(s) Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: N I SFCTTON fi - RCTTMATF.D rnTUCTP1Tr TrnW rnCTQ I Item Estimated Cost (Dollar) to beOFFICIAL Completed b permit a licant� USEbNLY � r �� 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) C: 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number NEL I IUA 7a OWINER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name •fr Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1 ST 2 3 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 IS BUILDING CONNECTED TO NATURAL GAS LINE 0 'own of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM Of NORTH 4 COCINCRIWKR 7 ACHUS���� In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit-# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Signature of Applicant Date NOTE. A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. .a rA W b °o w V) V) a V) O z . Or - -.0 o w o 04 U in a w a O v o cG w a O w W W o w u a cn p w" p H o c� m g i7. w W C a° co cn v cn rA W 0 s sem\ Q O' lI w Ju Q Oo Q o co 01„x* o c o me c 4COS o ` O N O {N C.) C.) G �: .. M CD0 N r0+ c COL 40 )i N 1 om - :cam �mce## E y C Ac: m J N Cc :E co omo �e :��Lco 0 CC CL. m� m Oki col OLD c d m N a �' O N N CD 2CD t COD «LL . +2t .~ ,� a Cc co Z LU —E 0 �C O LU o oomc g V� CL c2Nip m 'O O = c p to C Cn 0 w 0 4 �a o civ .v CL. O ♦O■. ce C Z � C.3 ca c C C C CO2 M 0 U) U) Ir w w U) `o0zat page o======i� f 105 Haverhill Street Free Estimates Methuen, MA 01844 Fully Insured THOMPSON'S ROOFING (978) 691-1355 ` Shingles — Slate — Rubber Roof Single Ply - Copper Work PROPOSAL SUBMITTED TO PHONE DATE 19r: & Mrs. Glenn 6-1-00 STREET JOB NAME '13 Bradstreet Road CITY, STATE AND ZIP CODE JOB LOCATION ti north Andover MA 01845 2- CxJ ARCHITECT IDATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ,strip off all roof shingles on house and g3r3de Install aluminum drip edge around roof line Apply ice and water shield 3 ft. up all.. along edges ane; in valleys Apply 1.5 1b. felt paper on rest of roof area Reshingl.e with a 25 year shinva.le y01117 choice ot: color_ Install new fl-�inges around soil. pi.pcs Change the metal on top front side pfiftiat roof. to MI -11-1 rin�sh Remove all work related debris 25 year warranty an matter i_a 1 10 year guarantee on labor Construction lic. #060112 Improvement #128612 Option: If you decide to ha.ve a 25 yea Arc,Ii_tect sh.i_ngle it will be $300.00 (three huddred dollarsi more** Ut VrOpOgt hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Four thousand two hundred ------ 4 200.00 dollars ($ )• Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. Authorized Signature Note: This proposal may be withdrawn by us if not accepted within days. Z(CCCptanCC Of JrOPOOI — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature work as specified. Payment will be made as outlindd above. Date of Acceptance: Signature CC�tTIFICATE OF LIABILITY INSURANCE CONTRACT OR OTHER DOCUMENT WITH RESPECT, TO 'WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED F'ERE:N IS SUBJECT TO DATE 04.23.01 (MM/DD/YY) PRODUCER _ PELHAM INSURANCE SERVICES INC 1�� BRIDGE STREET THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PELHAMNH 03016- INSURERS AFFORDING COVERAGE 11�,,:-., INSURER A: Liberty Mutual INSURER B: The Maryland :N";','RED Thomas Doyle DBA Thompsons Construction & Roofi 8 West St. Salem NH 03079 INSURER C: INSURER D: INSURER E: 04-11.01 rnvFRnr,Fc THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N6 WITHSTANDING 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 F'ERE:N IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN tiEG!,:E:: 11v A:D CLAIMS. INSP. Ln TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE 11�,,:-., GENERAL LIABILITY B Ex jj COMMERCIAL GENERAL LIABILITY [ J [ ] CLAIMS MADE [x] OCCUR SCP 34865353 04-11.01 _. i1.000,000 04.15.02 FIRE DAMAGE (Any one fire) $ 300,000 MED EXP (Any one person) E 10,000 [[ PERSONAL & ADV INJURY $1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER [ ]POLICY [ ]PROJECT [ ]LOC GENERAL AGGREGATE $2,000.000 PRODUCTS COMP/OP AGG 82.000.000 AUTOMOBILE [ ] LIABILITY ANY AUTO COMBINED SINGLE LIMIT [ ] ALL OWNED AUTOS (Each accident) E ] SCHEDULED AUTOS BODILY INJURY ] HIRED AUTOS (Per person) $ I NON -OWNED AUTOS BODILY INJURY (Per accident) [ ] PROPERTY DAMAGE (Per acu dent) GARAGE LIABILITY I ANY AUTO AUTO ONLY - EA A:CiDENT $ L OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY [ ] OCCUR [ ] CLAIMS MADE EACH OCCURRENCE. $ AGGREGATE $ DEDUCTIBLE $ [ ] RETENTION $ $ $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY WC2.31S-314995-019 04.21.01 04.21.02 [XI WC STATUTORY [ ] OTHER E.L. EACH ACCIDENT A $ 100.000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER ., DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Roofing Job at 6 MIDDLESEX ST. NO. CHELMSFORD, MA CERTIFICATE HOLDER [ ]ADDITIONAL INSURED: INSURED LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FRANK DEAMICIS THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO 1ITTENHOLDENAMED 6 MIDDLESEX ST, TO THHELLEFT.DAYS BUTWFAILURENHE TTOIDO SO CE TSHALLRIMPOSETENO OBLIGATION NO. CHELMSFORD.OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR MA 01863 REPRESENTATIVES. AUTHORIIZED REPRESENTATIVE (7/97)— /L"" 4 '-ou r-, Page 1 of 2