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Miscellaneous - 742 WINTER STREET 4/30/2018 (2)
N r A O N D � z o o m m co M Q o g ; o m o m 6-1 N° 9643 Date. I7' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that. Q-.`Q�e-........... . has permission to perform ..... ..0 �. ................. plumbing in the buildin sof ..�' ��..w.,r ................. at ..... .k.1J 1-Z- Jq e si .......... , orth And v r, ass. Fee.? . Lic. Nt 13.. i �J... ...... . Check # PLUMBING INSPECTOR 2�yZ"'1��??-1�1� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer } MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 190Vcr I MA DATE /O'_ ' I _ ( PERMIT # JOBSITE ADDRESS ''Al c� S� OWNER'S NAME POWNER ADDRESS _ i TEL _ _ �__ N I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL � EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY �—�/ NEW: 0! RENOVATION: REPLACEMENT: 2J PLANS SUBMITTED: YES NO FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM { .._._.._..._) _I _...__ .._..___ 1 I --__-.._ DEDICATED GAS/OILISAND SYSTEM ! DEDICATED GREASE SYSTEM 1 I —( i 1 � f _. _..J f ___f _._.___l DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I 1 ..__..._._I _...__ .._._ J -._._.._I I I , _..__I ._ ___._! ._.____I ____1 _I .__.___I DISHWASHER DRINKING FOUNTAIN i ....._.....1 f __.-...' I (! i 9 ._.._ _-_._...E .__ _J == --,j _....._i FOOD DISPOSER I ._._._f _ I __....__( l I ' ! f i ._..___I ._.___.1 ._--1 { FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) i i ....__._._I i ...____I i I ._1 _.___I _.__. _.._.__.__I ._._.._ f { _% .....___-i KITCHEN SINK ! _..._._.__.i 1 1 I _._._.._.i I _----- __.__.._E LAVATORY ROOF DRAIN I SHOWER STALL SERVICE / MOP SINK l 1 J _._._f I � 1 ._..._1 .._�i ______.f ._ _ TOILET _i ._ _._ _I i � � J ._ __.I —A URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I i OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES -1 NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY DI BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F AGENT 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 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 co I' ce wi all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME t s�v 3 DvC�-¢ J LICENSE # I I x SIGNATURE MP 0 JP �] CORPORATION 0# PARTNERSHIP P# LLC COMPANY NAME d, ADDRESS hi xi CITY �..���v���,_� .__._-._..._..__ _._.._..__..i STATE ZIP TEL FAX _ = CELLj EMAIL H z° 0 H U W W of z p W o u W z w F- U) w 5 0 - co co a p z a � w a � U J CL IL a 66 � w x w 1-- LL rA H z 0 H U a 44. 00 C9 z as � a a p a !t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):�q'�C1`� Address: a City/State/Zip: W9 6%J4('ell0_ OA 6179 ? Phone #: 978-6 3 -,071 Are you an employer? Check the appropriate box: 1. E I 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. [1 We are a corporation and its required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] 1 officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am 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 hivestigations of the DIA for insurance coverage verification. 1 do hereby certify uder the pans andpenalties ofperjury that the information providu ed above is tre and correct. Si pnatnre- l.)atn- 10- --? i - S D, 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 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass,gov/dia x -•— a�njeu6ig �. - 4, Z J r.:. y -•— a�njeu6ig �. - 4, Z r.:. y O � I to tli l 0 an c ` LL>- w c Z 0 Ei w W c. r✓ r�. tfi. (i V) ; cn h toul• < u�w tl) p p tn. }o U N LU . 1 This certifies that ...... Tel-I.... `,C?.iJ./�1 ,,,,,,,,,,,,, has permission to perform .... Of :f. >, E�:F.fI . . . .. . ........ . wiring in the building of ..t�L . - .l-<J. t tv.7 . .. . . ............ . . at .. T1 t t,0 7 , , , ..... ,, North Andover, Mass. Fee . .f?. b- . Lic. No.........�Zz ,� - ELECTRICAL INSPECR� Check # U Sa 7- % ,�L 577 11188 (,1rnnwjzvreah4 o f f addachzcdemd Official Use Only p cc�� Permit No.:. , . l % % ` w 2yadrn4d 0 31re serviced ; , Occupancy afl 1, ee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) ;. APPLICATION ION FOR PERMIT TO PERFORM ELECTRICAL. APPORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CLr(R 12.00 (PLEASE PRINTItVJJX OR TYPE ALLINFORIV-1TION) Date: ' pC-t -2q — 2012- City or Town of: djotZTl� 1�1'�l ER "ISI /� To the Inspector of Wires: By this application the undersigned gives notice of.his or her intention top erform the electrical work described below. Location (Street & Number) !142. W =.NT E—R STAC—CT Owner or Tenant MC EW13,46 Telephone No, q7JR 787(1:3 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Buildin Utility Authorization No, Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters New Service Amps / Volts Overlie❑ Undgrd ❑ No;,of Meters Number of Feeders and Ampacity B Location and Nature of Proposed Electrical Work: K�b tl rBZN6 oNLy ) Completion of the following table may be waived by the Insvector of Wires. No, of Recessed Luminaires No, of Cell,-Susp, (Paddle) Fans No. of Total . Transformers.. KVA No. of Luminaire Outlets No. of Hot Tubs ' Generators KVA No, of Luminaires Above In- Swimming Pool arnd. ❑° ¢rnd.o Q o.or mergency rg hng Batter Units No. of Receptacle Outlets No. of Oil Burners ' FIRE ALARMS No. of Zoaes ' No. of Switches No. of Gas Burners No, of Detection and Initiatin Devices No, -of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Disposers i p HeatPump Totals:. Number Tons Ii1V...._. "' " " No, of Self -Contained Detection/AIertin Devices No. of Dishwashers Space/Area Heating KW Locnl ❑ Municipal Elother Connection No. of Dryers Heating Appliances ,': KW Security Systems:*. No. of Devices or Equivalent No. of Water, Heaters No. of No; of Sins Ballasts Data Wiring: 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 desired, or as required by the Inspector of Mres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: tp —Zq— Q_ Inspections to be requested in accordance with iviEC 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 ;orovides proof of liabilityinsurance 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 the pains and penalties of perjury, that the information on this application is true and complete. FMI NAME: LIC, NO,: Licensee: WnMNjz Signature ��m+ LIC. NO.: -5E (If applicable, enter "exempt'' in the license number line.) VBus. Tel. No,: Address: J,JQfn ?AkCAflW IOL�J LIAVe121:111�{MA ©l g$'2 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 laws. Ty my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑ owner's agent. Owner/Agent Signature Telephone No. � 11 0 0 r The 01,9MMonwean of Mm�sachuse u Department o, f Ind�Accidenls LW Qfflce of1"tdgniioirs . . � - 600 A�ashecgtot� Sweet Boston, MA 02111 , c i www marsgov WOi'I{6PS. CAII PMatioD �nghmee l�L�aVit Bufld dCant1'actoTBi ectliciaaVplambers Ato&=t Wormation Please Print Leah Name(Bmineslo�geo;�atonitnaivietnal):� TZ. t�/1 W `1 � r�1 I� • Address:_ City/StRWZ.iP: Phone.#:. 9?8 5n �? 1 Are you an employer? C.heek.tbe appmpriste-box: —' 1. Q I tion a employer with 4, ❑ I loth a gcrlaral corhtrac0or and I Type of PrOled Oquiri�: emp oyes (full arhd/or— l part time).s have !sired the stdi-aonnactars � �, ❑ N0H' conshucdon 2. I am -seoie Prnpriarar. or partner- Iistnd on dhe attadted i ?• 0 Mocleligg Ship and have no employees These sub-eontraatms have S. (] Demolition . working for me in any cq)it, ty, [No workaes' comp, inauan� workers' comp. iasuhancs, 5: 0 We are a corporaf im and its q, Q Building addition required.]- 3. D I am a homeowner doing offtc:ethr have exer+cisad their MOL11.�] to.Q EleaWcal repairs oz• additions all work myself [No•workiml comp: insuhattce right of exemption per c, t52, § 1(4); mhd we have no. Plun4bing „el alts or additions 12. Roo f rcom ❑ required,]:t employees. [Nawarkeih3' . t3.Q.Other comp. insumce,rqubt&] 'My N PROM dw dwckeb.a#I must slso fill cut the scatioR below tdhowing their wkst' �nPenenion pej�y mforaurtion t Homeowee � Ww submit this affkk t hfthing they see"g all wank and thm him outeido connacbom must lardnnita now ATWw indmiog sash. i 4conuactocs duduck this box naw m additional sheet i. shows'ha the Ana aftliea6van0vow.Jow do* .- cmqx policy iatornmtift r0 o�loyerthat iS-vry * tt--Wvrk=t campensadon s�stuanceforffv-�tipiloyeru i efow fr thePi° 7-, ske Inshtaanee Company Name: Policy # or Self -ins. Lic. Job Site Addrow., ''y 42 o &Te ST Wa24% a 4r)1)) © t $ 446 . �1�1��.. City'/State/ZrR: Attacb a copy of the workers;': coalPensatiun policy declartif3oo page (showing the policy number and expirmdm dgbe� Failure to sgcure coverage as required under Section 25A of MG.Le.-152= lead to the imposition of criminal Pia of a fine up to 1,SQQ.t)Q aihcUor one-year imprisonmaht; as welt as Civil penaiiies in the form of a STOP WORK ORDER and a fine of up to $25Q.00 a day against due viols or. Be advised chat a csopy of this shtsttement may be forwarded to the Off= of Investigations of the DIA fbr instir = Wveiage verificaEion. 1 as kerwby certify ander Nu pains and paraNc ofpedwy thatstkei,¢ommWon pmv4* d ;abovr isme`and coned Doc: 0C Q, fIchd we ontj . Do not were in this WW(4.90 br caeapp41W4.. by aliy.or town OfflCiaL City or Towu: PerndVLkm&e 9 Issuing Authority (circle one): . I. Board of Health 2 Bedding U 6. Other epartmew. 3. CIWTown Clerk, 4. Electrical Inspector 5 Plumbing inspector J Cotrrbct Person: Phone #: Date...3.-. ..C�... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........R .`Z< <-- �� ............................................................................... has permission to perform.. 5 1/1 C- lo��? ................. ^............................� ,.... wiring in the building of .........' .:.1.G. �e(1..w.-.................................. .......... —7 v at .................................................. `S North Andover,,Mass. ...............r�1-7 ..... L` Fee ....... .............. Lic. No.96 b Z,!9 .. ... ............. LECTRICAL INSPECTOR ' Check # 9262 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. . Z� Occupancy and Fee Checked :ev.1/07] 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 IIV INK OR TYPE ALL INFORMATIOM Date: City or Town of: NORTH ANDOVER To the Ipector oBy this application the undersigned gives notice of his or her intention to perform the ele trical worries described below. Location (Street & Number) _79a Vv i ll�- — S+ Owner or Tenant Al C j I AJ ; A/ Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building 1,/1,.� ? (Check Appropriate Bog) Utility Authorization No. Existing Service UJ Amps Volts y Overhead I�-Undgrd ❑ No. of Meters New Service Amps —Volts Overhead 11Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1'h:1 i -e— '� UL K -e+ -41)A IhAc-+-. r►I OAM No. of Recessed Luminaires No, of Ceil.-Sus V p. (Paddle) Fans No. of Luminaire Outlets No. of Hot Tubs No. of LuminairesSwimming Pool Above ❑ in_ grn. — . No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burners No, of Ranges No. of Air Cond. Ton No. of Waste Disposers Heat PumpTons Number Tons I Totals: No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances KW No. of Water Heaters KW No. of o. of Signs Ballasts Hydromassage Bathtubs OTHER: ❑E table may be waived b the No. of KVA KVA ALARMS !No. of Zones 0- Of Alerting Devices ti_on/Alertin& Devices ❑Munic COIInecipalfinn ❑ Other No. of Dei Data Wiring: No. of Dei o. of Motors Total Hp I Telecommunications No. of Devices or � Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start p, (When required by municipal policy a= a- - / () 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 coversin force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER en I certify, under the aims andpenalties o � (Specify:) . �p fP�lur1', that the information on this application is true and complete FIRM NAME,e LIC. NO.: CSG Licensee: o • �G ✓eta -Q L� e1 Signature LIC. NO.: (If ap Address: e, enter "exempt " in the license number line.) Address: P -CL 144/-, Bus. Tel. No.40. *Per M.G.L c 147, s 57-61, security work requires Dty Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licens a does not hav1e'the liability Lic. No. required by law. B m signature y q ty insurance coverage normally By y gnature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ t 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Tfilashington Street Boston, MA 02111 www nnus.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Aicant Information Name (Business/Organird6on/Individual): Address: LA /I- SID City/State/Zip-P_ 14q, Phone #:.6U Are yo an employer? Check the appropriate box: ` I • am a employer with �_ 4. Type of Pretest (regairet(): employees (full and/or * ❑ i am a general contractor and I 6• ❑New construction part-time), have Faired the sub -contractors 2.E3 I am .a.sole proprietor or partner. Iisted on the attached sheet $ 7. ❑ Remodeling ship and have no employees These sub -contractors have working for mein any 8. ❑ Demolition y capacity. workers, comp. insurance. [Tao workers' comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition 3. ❑required.] Officers have exercised their 10. ectrica) i am a homeowner doing all work rcPairs right Of exemption per MGL 1 I.❑ Plumbing or additions rr/yself. [Noworkers' comp. C. 152, § 1(4),'and we have no repairs or additions Insurance requrred ] t 12.[]Roof .employees. [No workers' repairs COMP. insurance.required.] 13.M Other 'Any applicant that cheeks bo> t must also fill out the section below showing their workers' bo � t Homeowners who submit this affidavit indicating they ars doing all work and then hire outside c�usctom policy information ;Contractors that check this box must attached an additional sheat showing the "me of the sub must submit a new affidavit indicating such -cortr_eactors ^.a �ti. • . ,., r,, I arc an employer that is providutg:workerscompensaiian insurance or information. f my employees: Below is the policy mid joh site Insurance Company Name: M A k' _ Policy 4 or Self -ins. Lie. #: l Expiration Date: ✓lit t a6 .. Job Site Address:_ /�� Failure to Attach a copy of the workers' compensation policy deciaratioo page (showing City/Stste/Zip: /a the policy number and expiration date secure coverage as required under. Section 25A of MGL c. 152 can lead to the imposition of criminal penalfies 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 fi 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 ne Investigations of the DIA for insurance coverage verification. I do hereby c =,penaU perjury that the information provided above is true and corned Sienaiure: Date: L71ctaD only. Do not write in this area, to he completed by .rill, or town official n:Permit/License # ority (circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone #: Date .. t� . J /� ....... � TOWN OF NORTH ANDOVER 9 o PERMIT FOR GAS INSTALLATION This certifies that ... v ' . • .. .� / . ......... has permission for gas installation ...f�n�.� ...P��.... . in the buildings of ...,��%�/f�.�r�t ��. ................. at ... ?. ..... ! :n ...... !� .. , North dover, Mass. Fee, a�.. Lic. No.. �C/... s. � r"A1 . -.11 � , GASINSPECTOR Check # 2.30 7 • i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) a J0 An&V t , mass. Dat0q1 etic 0q City, Town Permit # Bonding / ' � (l l -e r_� Namer.�_� AT: Location '-f t NamerEwi n'q Ce Type of Occupancy: -emikp", New1A Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No 0 SEEMS on 0 MIN K MKIMMEME so �IMME#N NEEM sommossommm,m swum MEN MEN OMENS EX (Print or Type) nstalling Company Name (1 E' ii Qom( IncI Address q I_ i A n r) ! P-' f (�, 6Tk 'e Business Telephone '11-0 - n,) Check One: Certificate 21 Corp. —Jj ❑ Partnership ❑ Firm/ Company Name of Licensejdlumber or Gasfiuer I hereby certify, that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. By - Title City/Town APPROVE® (OFFICE USE ONL FORM 1243 A.M. SULKIN CO. 1989 - TYPE LICENSE: ❑ Plumber Signature of Licensed Gasfitter Plumber or Gasfitter El Master p l d 7 / ❑ Journeyman License Number z to c n m m m N X m -a n x m 0 T w O 0 m N CO) Z N V m A 0 z w m r 0 O w 0 In m 0 m e N m 0 z r The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations r 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �( Name (Business/Organization/Individual): S L P CAI 0 11— A/C. Address:" 91 l YIVA/ Ei& Lb '1.3°T6EF_-r City/State/Zip: � 4 A o 3y Aq o l 11^(oJ Phone #: 1 7LX63 1-d Are you an employer? Check the- appropriate box: 1. [M I am a employer with q5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors !. ❑ I am a sole proprietor or partner- listed on the attached sheet I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] f These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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 #I must also fill out the section below showing their workers' compensation policy information: f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContracton that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy inforrnation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:M/&Lrs'A - Re—r,,gfz J,W E e &-yes Cawlaa, sa7a Policy # or Self -ins. Lic. #: (' ()Oo s'/4/ - Expiration Date: 01 0 idc0 q— 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 andpenalties of perjury that the information provided above is true and correct. Signature: t 4:ea Date: Phone #: 17k. 5a I' a9 E Oficial 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 6r 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 afthe bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations 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 2evised 5-26-05 www.mass.gov/dia N° 2 J 8 Date ...3..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that P e R` F has permission to perform ..... ��.h." 1.......�c P r . %r? ............................... wiring in the building of ....... C J.. k ! a o .. ............................................... at ..4 .....L -.j:.: !.Ji7...� .............❑..........North Andover, Mass. geeU,%j�. `.`......... Lic. No. I.I VOII Jl................ ................................ f ELECTRICAL INSPacrox Check # o�9-3 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer It Cloyn tuireaUho�l�l%a��aclucesj� ti ID in V . �0119a-kno c 45-M sefvicsi BOARD OF FIRE PREVENTION REGULATIONS For Ofticy,4lsa Only (Rev. 11/99) Qy\ Permit Number. Occupancy & Fee APPI1CATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS EIWMCAL CODE 527 CMR 12.00) PLEASE PRINT IN iNK OR TYPE ALI: INFORMATION Date:J City or Town of: AIIANDovp To the Inspector of Wires: By this application the undersignec I gives notice of his or her intention to perform the electrical work described below, Location: (Street & Number) NN Owner or Tenant: _ I G 14E /Z (� O C H P AIM ._ Owners Address: A/t/ Is this permit in conjunction with a .wilding Permit? Yes o No fif (Check Appropriate Box) Purpose of Building_,S/ /1IGz£ _F,9M/ iJtility Authorization M / U / 13& i - Existing Service: _Amps IL_L:: QVolts Overhead 0-' Undergmund.0 # of Meters_ New Service: Amps,/ZO /�Vo� Overhead 11 Underground. # of Meters:_ Number of Feeders and Ampacity:_ /`%p.S Location and Nature of Proposed Electrical Work:_ 41.ZA r zyc y REI Pll2. . = R I E No. of Recessed Fixtures No. of Cell.-Susp. (Paddle) Fans No. of Transformers Total KVA i No. Of 1.)ghting Cutlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground a In Ground a # of Emergency merge cY U ghting Battery units No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of Zones No. of Switches No. of Gas Burners # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained No. of Ranges No. of Air Conditioners TOTAL TONS: Detection/Sounding Devices No. of Waste Disposals Heat Pump Totals: Local a Municipal Connection v Other a curity �or Equivalent Number. TONS: KW: No of. of Devices No. of Dishwashers Space /Area Heating: KW Data Wiring, No. of Devices or Equivalent No. of Dryers ..:_. Healing Appliances KW Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydrp Massage Tubs No, of Motors Tota) HP INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of Ole work may Issue unless the ffcensee provides proof of liability insurance +nckidirkg completed operation' cove or it t substantial equlwtlenL The undersigned certifies that such coverage is In force, and has exhibited proof of some to the permit issuing office. CHECK ONE: INE URANCE 0 BOND 0 OTHER 0 Please specify: Estimated Value of Electrical Work S (When required by municipal policy) Work to Stag Q, (�fy P/z7kn 3 —7- 0 + Inspections to be requested in accordance with MEC Rule 10, and upon completion. II caroly, Un lha pains and pena/ties of perjury, that the information on this application is true and complete. Finn Nam�� /� LIG. # / '7 UV 17 Licensee:ITZ ` Signature: ��// /1 (if appflc�a/ble, enter'"exec pt' in the license number line) LiC. # � 52100 /9 Address: /l%F%..A— ?b CL /y 2� Bus. Tet. # v Ah. Tel. # O 3 ` Lf OWNER'S INSURANCE WAVER: i am.ewart that the Licensee dea: nnf h.,.a tih—. r,„�:��.. Location Gl No. _ Date o�°oT;�ti TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ �+s "'CH ESQ. s�c►,us Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ _ Water Connection Fee $ TOTAL w ding Inspector 05/22/% II:49 43.95 PAID 9303 . Div. Public Works w � a �Ia _ 00 m t . ❑ 0 N - W N dl � a N � N ` p� W W z �O 0 W Z W m f Q 0 3 F N 0 0 0 0 H J z Wm w 1. 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CA «.. _ ._. oC= .E o •N O W U m ca -0 cm p - =CL Q CD -F. 0 N •O _0cc = ` � =, ca w coH .co CLL co C O co v Q /_ ii CO) O O V .CL CO) C O C) Q CA 0 0 co CL CO) C CO CM C O O m m 0 CD ev � 3 -a O Q O a CL cma c cc CO O z CD CL CO) C t �ToWII_ Of o main`scieet -NORTH ANDOVER ivorthAndovet•. MassdchliSetts O I845 M SIOY OF PLANNING & COMMUNITY DEVELOPMENT KARE:` H.P. iNEL..SOK DIRECTOR In ac;.^rdance with the�rG7 g c - C ' t c cor,dircn of Build ::^ ing Peit Number s that �e ris resulting re:n this work shall be dispose,: CC :n a omper:V .... '$� sClid ';'aSc.i'�'�^^sa, ^C'Ei," S •(: by .`IGL il., s u:a - . . i ne debris will be disposed er ire_ f—_ac:iwo Sfe:+a ..e of Pc:mit Applicnt Date NOT_: Demolition permit fr= the Sown of North Andover must be obtained for this project through the Office of the Building Inspector. • OFFICES OF: -.�.. RPPF—AJS BUILDING CONSERVATION HEALTH i t �ToWII_ Of o main`scieet -NORTH ANDOVER ivorthAndovet•. MassdchliSetts O I845 M SIOY OF PLANNING & COMMUNITY DEVELOPMENT KARE:` H.P. iNEL..SOK DIRECTOR In ac;.^rdance with the�rG7 g c - C ' t c cor,dircn of Build ::^ ing Peit Number s that �e ris resulting re:n this work shall be dispose,: CC :n a omper:V .... '$� sClid ';'aSc.i'�'�^^sa, ^C'Ei," S •(: by .`IGL il., s u:a - . . i ne debris will be disposed er ire_ f—_ac:iwo Sfe:+a ..e of Pc:mit Applicnt Date NOT_: Demolition permit fr= the Sown of North Andover must be obtained for this project through the Office of the Building Inspector. • Date........ ; ........ ....... TOWN OF NORTH ANDOVER 0 0- PERMIT FOR WIRING This certifies that../&,�L/(#6�j A, ........................................... has permission to perform .... . " ...... wiring in the building of.!..�!......... .. ........................ at ... ....... / ... .............. , North -Andover, Mass. Fee ... �/Zt41.. Lic. No.X&3.�A..... k . .. . .. .. ................. ..... .... . .. ,?.7 -:7 ,-- (/// — ELEcmicAL INsp Check # 3 5436 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PEF All work to be performed in accorc (PLEASE PRINT IN INK OR TYPE ALL IN City or Town of: North Andov By this application the undersigned gives notice Official Use Only Permit No. �73 Occupancy and Fee Checked [Rev. 11/99] (leave hlank) IT TO PERFORM ELECTRICAL WORK with4he Massachusetts Electrical Code (MEC), 527 CMR 12.00 TION) Date: 11/18/04 To the Inspector of Wires: or her intention to perform the electrical work described below. Location (Street & Number) 742 Winter St Owner or Tenant Audrey Malin Telephone No. (978) 689-2607 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Existing Service New Service Utility Authorization No. Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Wiring and connections for a 4 -Ton AC Split System Completion of the following table may 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 No. of Lighting Fixtures Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total 4 Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Totals Number Tons KW ........ .... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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:) Appleby & Wyman 4/23/05 (Expiration Date) 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. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: D&D Electrical Contractors, Inc. LIC. NO.: Al 1933 Licensee: Douglas P. Lynch Signature, Qr ��.n,�.0 _ LIC. NO.: 24594 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.•781-932-0707 Address: 247 Salem St. Woburn, MA 01801 Alt. Tel. 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: $40.00 Signature Telephone No. Location �Ll a tL,, e !1 No. Y Date % �'�3 a TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 15 -49 --- Foundation 5. -49 --- Foundation Permit Fee $ Other Permit Fee TOTAL s y , Check # % % w (y 177u9 i/w (I"e(- ,.— Building Inspector c TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: r!� Building Commissioner/Ins for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 7 y2 �✓�h�- S�. 1.2 Assessors Map and Parcel Number: -(� Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frans fl 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Reqtiired Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 �Owner of Record � IrN Name (Print) Address for Service re -e Signature Telephone 2.2 Owner of Record: N4tme Print Address for Service: Si azure Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: (Axa aG" Lice ed Construction Supervisor: 7i V- +l1 GC 3Z Address Sig atu Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor --r/ ls// A (�t�tlf Not Applicable ❑ 12-f 7? y CoAnany Name // e -(5 � d �� , z��-2�L+�.t 1 / �� oc b 3Z f- r Registration Number Address Expiration Date i mature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .....X No ....... ❑ SECTION 5 Description of Proposed Work check aII 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 Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HVAC)_C6 5 Fire Protection 6 Total 1+2+3+4+5 S ` Q 9, n` Check Number Gs SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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, S �'� /4 G!�/ dc� ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are .rue and accurate, to the best of my knowledge and belief 1� / Print Name ^Si tue of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS is 2' 3 SPAN Dl]vIENSIONS OF SILLS DRV ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND 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: 4%S - (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector pntican=, inromatI lame: ob LccZtion: Ci"': The Commonwealth oj',Vassachuserts Department oj'lndustrial Accidents Dice of Investigario,:s 600'VashMgtott Street BOstofi MA 02111 Workers' Compensation Insuranrr, ,a mA; . nsurancc—��--►� i 0 r r, Phone = Phone= ?00 -4no - %M 'r,nt Vamc SG:_�T-1 �Ot�r2 — 11 WOW Official use only. Do not wT;te s, tris area. to be compieted by city or town ofticiai or Town: Permit/license 9 Crecy _-=eC=IP mmnnse :s reouued Contaa person: — Phone ar: a- 866-M76 C2 Buil ne Department ❑ Licensing Board ❑ Selectmen's Office D Health Department 0 Other Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 DPS-CA1 Co 50M -04/04-G101216 ✓le �amm�yn� a� ,�aac`zuaelld Board of Building Regula:ians and Standards V HOME IMPROVEMENT CONTRACTOR Registration: 129774 Expiration: 11/2/2005 Type: Supplement Card PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 Registration: 129774 Type: Supplement Card Expiration: 11/2/2005 Update Address and return card. Mark reason for change. Address J Renewal Employment Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 �r Administrator Not v id withoutsignature ✓ize �omvnzonuieall/ a� . �aasacizuaella BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 081843 Birthdate: 02/06/1966 Expires: 02/06/2006 Tr. no: 81843 ' Restricted: 00 STEPHEN T DICKINSON 17 BURNSIDE LANE MERRIMAC, MA 01860 Administrator co m x m mcm cn m y m CO) C° z CD O CLc ==r Q. Be a� � o o p a� c� CO O CA CD 0 d O CO) O CA d CD CD P. CO) y O st CD 0 CD C IM 0-0 �� o d ceo= o _Q N d • ,� y m�m� z N��C 9 0 =10 to —4 ft gn-►n Er 10 m 0 y b or m _ 0 0 o a+: a 00 0 n o Z� M oo 0 o :' V C W N � oma X m o rrOc �:A :c ►� c �om� n C� y s Cos Go ca ti y 7 �IL A b O to 0�"`�' y � o n z CD ��' O N� O cl) !r H . . . 0 r � m IM0 Omq 0 0 Zi I� cn(n ° w Z C17 �T z x w:3 0 "x n pd q 00D. r+ n 4 0 HIC Registration #129774 Federal ID #04-3277886 Pella Windows & Doors of Boston nn "Viewed to be the Best" WINDOW CONTRACT Sold To: " 7. r i Address: `- - f Wit. — State: p: '. City: zip: site Address (If different): Approx. Start Date: Pella Windows & Door: 45 Fondi Road Haverhill, MA 01832 PH: (800) 866-9886 Service: Ext. 124 Fax: (978) 373-7274 Sales: (866) Pella06 Date: --1 Phone (Home) L, 24 Phone (Work) L'`• 3``� Phone (Cell) Approx. Completion Date: Pella Boston Will Furnish and Install: PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED Remove Windows from the opening where they noyv exist on: FIRST LEVEL: # Openings -.' # New Window Units ...r • ` SECOND LEVEL: # Openings -:' i # New Window Units THIRD LEVEL: # Openings # New Window Units fti3 t?i6 t+L d�T itiTviaN�ac Ui CAIaIilft-V lIUUVva ei IU/UI 0LU1111 UUUIJ All workman's compensation and liability insurance maintained Warranty mailed to customer upon completion when full payment is received Total Project Amount $ Financed if Yes: Ampunt Financed $r�—~ ' (Reference # ) Deposit Received $ Balance on Substantial Completion $ - �;�` (Payment is payable to installer at completion of job) Additional Comments: PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. PLEASE REMOVE ALL SHADES. VERTICALS. BLINDS, CURTAINS. DRAPES OR WINDOW MOUNTED AIR CONDITIONERS, PRIOR TO THE INSTALLATION OF YOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE REi11oVAL OR INSTALLATION OF THESE TYPES OF ITEMS. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A WARRANTY PROBLEM. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMEN': AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OF RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETEL` FILLED IN DUPLICATE OF THIS AGREEMENT. CONTRACT SUBJECT TO FINAL INSPECTION BY PELLA CONSTRUCTIO1 DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. NCES WILL This contract is a legal document. Your Pella THIRucts will be BUSINESS DAYally made-to-order for you. UNDER NO AFTER THE CONTRACT HAS BEEN SIGNEDUANDAD POSIT PAIDEBYISIGNINI CANCELLATION BE POSSIBLE BEYOND THE THIRD BELOW YOU ARE ACKNOWLEDGING THAT THE ABOVE SPECIFICATIONS FOR THE PELLA PRODUCTS YOU ARE ORDERING ARE CORRECT. Pella Rep. Signature: � j^. `-' `n,. `�-•( �� Date: � � •� � i Jay Customer Signature: Date: White - Original Yellow - Customer Pink - Store vv-- �, l\ 11 )i�) �10 0 v�-Do YES NO 1. ❑ , ❑ 2. '❑T ❑ 3. ❑ ❑ 4. ❑ 0•. -.5r-I " 24. ❑ ❑ 25. ❑ ❑ 26. 1 ❑ 27. ❑ ❑ - 28. ❑ ❑ 29. ❑ ❑ 30. ❑ ❑ Pella Windows & Door: 45 Fondi Road Haverhill, MA 01832 PH: (800) 866-9886 Service: Ext. 124 Fax: (978) 373-7274 Sales: (866) Pella06 Date: --1 Phone (Home) L, 24 Phone (Work) L'`• 3``� Phone (Cell) Approx. Completion Date: Pella Boston Will Furnish and Install: PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED Remove Windows from the opening where they noyv exist on: FIRST LEVEL: # Openings -.' # New Window Units ...r • ` SECOND LEVEL: # Openings -:' i # New Window Units THIRD LEVEL: # Openings # New Window Units fti3 t?i6 t+L d�T itiTviaN�ac Ui CAIaIilft-V lIUUVva ei IU/UI 0LU1111 UUUIJ All workman's compensation and liability insurance maintained Warranty mailed to customer upon completion when full payment is received Total Project Amount $ Financed if Yes: Ampunt Financed $r�—~ ' (Reference # ) Deposit Received $ Balance on Substantial Completion $ - �;�` (Payment is payable to installer at completion of job) Additional Comments: PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. PLEASE REMOVE ALL SHADES. VERTICALS. BLINDS, CURTAINS. DRAPES OR WINDOW MOUNTED AIR CONDITIONERS, PRIOR TO THE INSTALLATION OF YOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE REi11oVAL OR INSTALLATION OF THESE TYPES OF ITEMS. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A WARRANTY PROBLEM. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMEN': AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OF RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETEL` FILLED IN DUPLICATE OF THIS AGREEMENT. CONTRACT SUBJECT TO FINAL INSPECTION BY PELLA CONSTRUCTIO1 DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. NCES WILL This contract is a legal document. Your Pella THIRucts will be BUSINESS DAYally made-to-order for you. UNDER NO AFTER THE CONTRACT HAS BEEN SIGNEDUANDAD POSIT PAIDEBYISIGNINI CANCELLATION BE POSSIBLE BEYOND THE THIRD BELOW YOU ARE ACKNOWLEDGING THAT THE ABOVE SPECIFICATIONS FOR THE PELLA PRODUCTS YOU ARE ORDERING ARE CORRECT. Pella Rep. Signature: � j^. `-' `n,. `�-•( �� Date: � � •� � i Jay Customer Signature: Date: White - Original Yellow - Customer Pink - Store vv-- �, l\ 11 )i�) �10 0 v�-Do