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Miscellaneous - 77 COURT STREET 4/30/2018
B This certifies that ,.�. Date ... e)y/� .. �.V ............. I TOWN OF NORTH ANDOVER PERMIT FOR WIRING e- 1p e-/,,, C has permission to perform.....:.................................................................................................... wiring in�the building of...........`-.�f..�`................................................................:.. ]} ...../...... C....G�!'....................l�'rrc'..... ...... , rth Andover, Mass. % Fee........... Lic. No./... q..'...!. ............ ......................... ELECTRICAL INSPECTOR . Check# M � 1,24 Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. Z I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: t o - 4'— I t f 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) -) I C-&—�- lu,� Owner or Tenant Lu Telephone No. 9-18, Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building �6hc_ Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity No W (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposjed� Electrical Work: ,r,,t,4� k L 85 V.,j a TJ Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators ` KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd, grnd. o. of Emergen-e-y-Ei-ghting Battery 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 Tons No. of Alerting Devices No. of Waste Disposers Heat Pump 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 Wfres. Estimated Value of Electrical Work: C 12>4CZ, (When required by municipal policy.) Work to Start: I © -I a-- I V 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 2 BOND ❑ OTHER ❑ (Specify:) I certify, under the FIRM NAME: 4 and penalties ofperjury, that the information on this application is true and complete. ...9.n -e4-,V( LIC. NO.: a/,Sp2q I Licensee: °�, ��_� b.--Ayg, Signature � �,(�-�� LIC. NO.: A15-52-5 (If applicable, enter, \"exemp j) in the license numb line Bus. Tel. No.: Address: F.r��s .zLL S�- �% o�v� S Alt. Tel. No.: (4G? . 237- 14' f - *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. $ &-r-111— Signature Telephone l�jo. 6yy I1C_4A-A%t- wl 5 0kn� p4e i- ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the a permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the �. notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector 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 effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass (] Failed r Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Com Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com lcx The Commonwealth of Massachusetts Depathnent of IndiustriglAccidints Office oflnvestigations 600 Washington ,Street .Boston, MA 02111 www.mass gov/ctia workers, Compensation Inisurance Affidavit: Builders/Contraci Name (Business/Oxganizaivon/Ti (Wilud): .Address: City/State,01): S,PW 1>367i Phone M "3 -10— - of (4 - Are you an. employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6• Q New construction employees (full and/or part time) * 2. [l I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. g• Building addition [No workers' comp. insurance 5, ❑ We are a corporation and its 10.Q Electrical repairs or additions required.] 3. ❑ i am a homeowner doing all work officers have exercised.their right of exemption per MGL 11•[] Plumbingrepairs or additions myself. [7.loworkers' comp. c.152, §1(4), andwehaveno 12•Q Roofrepairs insurancere ed. i �' a employees. [No workers' 13.❑ Other comp, insurance required.] 'Any applicant that checks box#I must also fll outthe section below showingiheirworkers' compensationpoury information. T'Homeowners who submit this affidavit indicatingthey a're 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' compensation insurance for my employees .Below is the policy and f ob site information. Insurance Company Name: Policy #or Self ins.Lic.M V So L 2— E41rationDate: Job Site Address-, -7 City/state/Zip:_ Attach a copy of the workers' compensation-polley declaration page (showing the policy number and expiration date). Failure to secure coverage as regniredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a flue up to $1,500.00 and/or one�year imprisonment, as well as civilpenalties 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 statementmay be forwarded to the Office of Investigations ofthe DIA. for insurance coverage verification. Ido Hereby ceT`t rider .ams aandpenalties ofperjury Mat the informationprovidedabovee is true andeorrect. - ^--�------ Ili,-. n � l � SL., data• �C� -'7.17`- . Phone #• (_ao � - �- )- — L-hc(' (- 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 Pers Phone U Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an erawloyee is defined as "...every person in the service of another under any contract of'hire,• express orimplied, oral orwritten.,, An employer is defined as "an individual, partnership, association, corporation or other legal entity, or anytwo ormore of the Foregoing engaged in a j oint 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 employes." 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 ofpub& work until acceptable evidence of compliance with, the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your sifiza 0 and, if necessary, supply sub -contractors) name(s), address(os) and phone number(s) along with their certificate(s) of insurauce. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other thanthemembers or partners, are not required to cavy workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised thatthisaftxdavitmaybe. submitted tothe Department of IudusWal Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be reta med 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 *orkers' 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 Towns 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 iu the permit/lzcense number which will be used as a reference number. In addition, an applicant thatmust submitmultiple 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 £or 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 orliermit to burn leaves etc.) said p erson 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 Com monweaIttLofMos afihvsP s - DopaxIment offndu,,'TWd Acddazta Qfte ofI Rvestzga-Uona 6bQ Wa8biagQn ftet Boston, MA021XX Revised 5-26-05 Fax W.Mas,q,ggv c a e Date ...... ` 9- .... ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r y) A4 (s,(, S C) H✓ tlrnr G� Thiscertifies that................................................................. ...... f........................................... has permission for gas installations . �.a�.'............. 'in the buildings of ....L, ............................................................................................... -TI at.......d^.'.......!"............... North Andover, Mass. Fee(_p.6....... Lic. No.. P I'A.......... tio .......................................................... 1 r GAS INSPECTOR Check #'1_ "J� 9bu0 Ej 114 m (�- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ MA DATE ©^ '� PERMIT # OF JOBSITE ADDRESS �/ (�l�� OWNER'S NAME/7 — OWNER ADDRESS c 1 TEL AX - TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIALP--' CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑` PLANS SUBMITTED: YES ❑ NOR ' APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE / GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 21'10 ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Rr' OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application aret e and accurate to the est of my kno dge and that all plumbing work and installations performed under the permit issued for this application will be in co p ance P rtine � vision the ril Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #<®/� SIGNATURE MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI� CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # -- �f11/1' 9�-4 COMPANY NAME % / (V ADDRESS CITY STATEZIP TEL FA _ CELL —' EMAIL r N 0 C C7 A a z b A y 0 z z 0 m m m m v+ V n � � b a -a z G� C � � z X m 0 t m in O # m p. ❑iD z El oz h ® z a r z b A . y z 0 y The Commonwealth of Massachusetts - ' Department of IndustrialAccidints i Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: City/State/Zip:, Phone #: ;cl1 -,32 Are you an employer? Check the appropriate box: , 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (fall and/or part-time).* have lured 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. wo rs' comp. insurance. [No workers' comp. insurance 5. VWe 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.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation 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 re repairs 13. & Other Cj9_ AL11,0,1) nolicv information. t Homeowners who submit this affidavit indicating they aie 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.- lam nformation:Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy anal 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. Ido hereby e ify u er ie p ins a d pen Iti ofp fury that the information provided above is true and correct. Cirrnaf�rra• ! i �/� (el f'f Tata• /� ���� i 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 r 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 loeal 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate Eric. 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 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 Co onwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 6.17-7274900 ext 406 or 1-877-MASSAF Revised 5-26-05 Fax # 617-727-7749 ww.mass.gov1dia IVBURl North Andover MIMAP October 8, 2014 O'S8i0'�©22 X095:0-0004 :058 AO�Q009 058.0-;0.004; 59 GQU#2T :STREET ;058.0'0008 095.0-0-060 601C9,URT STREET A s7j :,q R3T°STi Q5 P,)4q U58„1001"3U ' -8104010F 058'. ,:9006 058;0-0032 0 � N �o;�couRT:s,T osso-0o23 COURT sT' 0.58w0L002$ \ \ \ \ 08.0-0027 80fCOU,RTS7, \ 058 0=0005 \oric Distc ic(, 058.0-Q021 � 100'ICOURT:ST �\ � Rail Line '« Wetlands Zoning Interstates C: Exempt Lands , - Bu in s 1 DiaMct — 1 C Busine 5 2 District Horizontal Datum: MA Slaleplane Coordinate System, Datum NAD83, — SR Ill Busine s 3 District ®Busine s 4 District H0111 - Roads 0 Genera Business District Ot a� q� r Easements D Planne Commercial Dev �s� ra• O L" j ba n O Corrido Development Dist 3' L O MVPC Boundary Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this ma is p for planning purposes only. It may not be adequate for legal bounda boundary y 13Corrido Development Dist O -- - A [3 Municipal Boundary 17 Corrido Development Dist F A definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING Induslri 1 DisMct Zoning Overlay M THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY Ki Induslri 2 District O Adult Entertainment f t ,^, * O Industri 3 District � OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT 0 Downtown Overlay District o i O Induslri I S District �q �1 Historic District o+���u ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Reside rict ce 1 Dist„'.``,fig ®Water Protection Reside ce 2 District 7S 8t SACNUS ❑ Parcels 0 Reslde ce 3 DDistrictrict O Hydrographic Features d dei ce4 District — streams = 75 ft wd }rde ce5District YYY de ce 6 District '00 esidenlial District 1� DATE: /0 -- J-16 LOCATION: OWNERS Nj GENERATOR kw 6a� NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* ICOTOtk IT"rola PHONE NUMBER: V��— ELECTRICAL RESIDENTIAL G S COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �ee PL�6 *ZONING DISTRICT: PLANNING APPROVAL IF IN WATERSHED oo , *CONSERVATION APPROVAL` PL-6pbl�J c 5 9297 Date . Z./ ��'.. . TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING This certifies that .... ............ //......... . has permission to perform .. /..!r� . E'hay.914 !1 plumbing in the buildings of ......�y�C ................... . at ....�... G6G� `Sf%-............. . . . N�Andover, Mass. Fee. Lic. No.. PLUMBING INSPECTOR Check #� •{ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE Fz / '" ao 1 � PERMIT # JOBSITE ADDRESS % C a v -i S i OWNER'S NAME A V_ V2 LY" OWNER ADDRESS TEL FAX 1 TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: ® REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER / FOOD DISPOSER / FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) ` KITCHEN SINK / LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilityinsurance 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 S OTHER TYPE OF INDEMNITY ❑ BOND ❑ , OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME Y11 9 /3 L' V'.9 t' f f SIGNATURE- LIC # MP 51 JP ❑ CORPORATION © # a s F ! PARTNERSHIP ❑ # LLC ❑ # jJ D- li ,D �� ^ 0I a� U S S COMPANY NAME �rS Y S +� Kf ►,ADDhRESS: CITY 1 yo . .9 d o Yo STATE ZIPGlo2� EMAIL 18u vl� e xS 10 ✓Y7c TEL pl 9 YS - �'// 0 CELL % 2 L� _ $/S ' %� 2 FAX % o- 6 Yi ' 5TA The Commonwealth ofMassachusetts Department oflndustrial Accidents Office oflnvestigations 600 Washington Street s Boston, MA. 02I11 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors[Fiectricians/Plumbers ►plicant Information Nal]ac (Business/Organizationllndividual):�U ✓ `� f S Address: CiC/ Ciiy/State/Zip:5 S v3 o v a Phone #: '92,3— Are you an employer? Check the appropriate box: I. I am a employer with 0 • 4. ❑ I am a general contractor 2. ❑employees (full and/orpart-time).* I am a sole proprietor or and I have hired the sub -contractors listed partner- ship and have no employees on the attached shget. These sub -contractors have working ,for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its 3. Erequired.] ]I am a homeowner doing all work officers have exercised their right of exemption MGL myself. [No workers' comp, per c. 152, § 1(4), and we have no insurance required.] r employees. [No workers' comp insuranc Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10. El Electrical repairs or additions I L El Plumbing repairs or additions 12.E]Roofrepairs erequired.] I3.❑ Other I *Any applicant that checks b Homeowners who submit thiox #1 must also fill out the section below show ings affidavit indicating they are doing all work their workers' compensation policy information. 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, policyinformation. -lam an employer that is providing workers' compensation information. insuYance foY my employees Below is tlae policy and job site Insurance Company Name:d U> c, v k µ.J Oe A ,, Policy # or Self -ins. Lie. #:_ w e C), 1. p (" / p • Expiration Date: 3 - / Job Site Address:_' Cov.f- S4 City/State/Zip: /V — A �o(o v -e v 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 ofIVIGL 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 ofthis statement may be forwarded to the Office of Investigations of the. DIA for insurance coverage verification. r do hereby certify under thepains andpenalties ofperjury flzattlie infornzationProvided above is true and correct. 3i ature:� Date: a 'hone #: 7- v/jiC[ui use Only. Do not write in this area, to be completed by city or tow n official City or Town: PermifffJ ense # TssuingAuthority (circle one): X. Board of Health 2. Building Department 3. City/To 6. Other wn Clerk 4. Electrical Inspector 5. PIumbing Inspector 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 "everystate 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 -contractors) name(s), address(es) andphone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' 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 PIease be surof Investigations has to contact you regarding the applicant. e 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOTrequired 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. ".40 Gomu �.oAi` mefth Of A%assachusetts Uepa ,eut o£Trtdustrial Accidents Ogee ofInvestigations 600 Washington S`4reei Boston; .M& 02111, Tel. # 61.7-727-490Q ext 406 or 1-877-MASSAF13 Revised 5-26-05 FRY, # 617"727-7-749 t w.manmvfdia Date........"-.....�. 2 - TOWN OF NORTH ANDOVER PERMIT FOR WIRING D�9vr U �G�T ' This certifies that ............................................ ....`�'��. �.............................. has permission to perform ........! t..< <�'�'��� ................................................................... wiring in the building of ................. :................................................................. 7 at ............ 7.. 7 ........ a .....4... ...7-....—S....,North Andover, Mass. �o Fee........... Lic. No.. Y 6 3................ ..................................... ` ELECTRICAL INSPECTOR. Check # 3 63 4 10646 Commonwea(tfr. of RamacAwdb Official Use Only Elm c:� nn . Uapat�fi>iant ol.tcc7/ im Jarvicaa Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR TION) Date: / r % � City or Town of: &992 r/,Z6, i✓�. To the Ins ector 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 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: Cmmpletinn nfthe frittnwino tnhtn ,nm, A. ,.. i—i A,. ,),. t ......... r w:.,,. No. of Recessed Luminaires % No. of Cell.-Susp. (Paddle) Fanso. 2 o otal Transformers KVA No. of Luminaire Outlets 3 No. -of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ grad. rnd. o. o mergency Lighting - Battery Units No. of Receptacle Outlets 13 No. of Oil Burners FIRE ALARMS* No. of Zones No. of Switches 8 No. of Gas Burners o. o Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers f eat Pump Totals: Number ons o. o e - ontaine Detectioa/Alertin Devices .__.____�. No. of Dishwashers r Space/Area Heating KW Local ❑ Munlcipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of ea KW Heaters o. o al o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications Winng: No. of Devices or E uivalent OTHER: r�✓� 'Z Attach additional detail ijdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Stan: 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 the pains and penalties of perjury, that the information on th' a licat' n is true and complete. FIRM NAME: -28\110 Q�C,-rRi CA L. CON- 1�AC,`rl LIC. NO.: Licensee: DAV tE> -4A 66AA - Signature LIC. NO.: d 4 9 (93A (If applicable enter "exempt "in the license number line.) Bus. TeL No.•C47B' bat -10��� Address: IiYit?�`r' 67- tyt7R ND�uI (z 4 Alt. Tel. NoR79- 37=-5734 *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 11 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Location 77 No. 2� Date _ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 3,2. <1-C) Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 3/9b 12:45 Building Inspector 32.50 PAID Div. Public Works WI I a Y 0 0 m 41 W W ^� N_ y N a_ d' W z 0 z z U. 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C m5o.5 = O N CD c. m `— W O co L 0 0 0 co CD Z � O y D O C C cn 'd w M� T An co W W co ow co O i O co i CC O Q CMQ ca •C 'O o +0--' C tC O V J .C_ O CO c Z m 0 CL L± H �C C V! 0 4 - •wy U3NOi NO(1Vdn300SIH1N1030VO "-N3 N3HM U3010H 3H1 1NiUd eV4MUlH�JIU,' SU3H10 • d0NOS83d3HLN0031UUV0 3NI13tl0.1VN04S 3AOBV Tfld NI 3WVN NOIS ! 33M01-13tl(ll ro Ism1N3Wf1000 Silil • 3E 1S - �t :r 756 L/ZO7i^ :eoa - MJF fi 6l`1F !� U3NOISSIWWCO 3H' 403UIUVNO,'S- U`-''-C3dW-S - AIWI3Idd0 ONV 33SN3ZC AE C3N051::N1 G:1VA lON �. • -� - , � U w V-INO UdO'JNUSV19I 01OHd - W , { .7TV Ol0 I1S(lW �:, n L9 i� .,. .,t.IC,V a +� y - fi fi-9 LLQ +* SS SHOiVH9dO ONI1SV'19 s j C- V( ?+� t S cs Li •3SN30Il NO X09 s 3N0N 3-LVIHd01•JddVNIlNlHd R L 1 it -c 90 i/Ci/ � ; a '�,��,!� �" SNOI1�Ia1S3a evgnH11H018 ind `133H1 •ON -On 31da 3A1103333 � � -� 9 6 6 L/701/4D 1SNIVE)V NOIlO3108d 80-1 ? 31VC] NOUV81dX3 �� °A13dVs 80120 VW `NO1S08 30V'td NOlUOSHSV 3NO s113snHOVssVw d0 > ? 3nend d01N3WlaVd30 Hl7V3MN0WW0077 ,I I CD 0 ¢ r- o m ^ WC U V I— V S V7 O - O •--' � C N N CC � .� I i Z I Location No. c7S— Date 9 aa, av Mp^T� TOWN OF NORTH ANDOVER 9 a ; : Certificate of Occupancy $ '� s'•^° ;<�' Building/Frame Permit Fee $ ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # X�� 7652 f/ _wilding Insp�ebr r Plar_.Inv TOWN OF NORTH, ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING $ "I" for U - , ,Dee 00 :. ' . BUILDING PERMIT NUMBER: DATE ISSUED: / SIGNATURE: Building Commissioner/1for of Buildings Date ` } SECTION 1- SITE INFORMATION + + 1.1 Property Address: 1.2 Assessors Map and Parcel dumber: r4 51 -2-3 t /U Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Fronts 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Regifired ,ti , Provided 1.7 Water Supply M.G.L.C:40 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zona ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I - f r' 2.1 Owner of Record T044 77 a�>^� Name ( ht) Ad red ss for Service Signature Telephone 4 /% 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ 17 60r1 r { ,4 - Licensed Construct6n Supervisor: S C/ o7-5 31 Number ltloerhLioFnse Address Q G4 w JVG�PS�L�/ liv to Expiration Date Signatur � Telephone . ;7l 7 Z 1 S SS '/ 3.2 , gistered Home Improvement Contractor ) Not Applicable ❑ v ///?ll 0" Z % Company Name Registration Number Address Expiration Date • Si nature Telephone �' J •� r. SECTION 4 - WORKERS COMPENSATION (KG.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 it. -Si- gned affidavit Attached Yes ....... No ....... 0 SCTION 5 Descri tion of Proposed Work check all app&able New Construction ❑ Existing Building G. Repair(s) 0 Alterations(s) 0 Addition (- Accessory Bldg. ❑ Demolition ❑ Other 0 Specify -2- Al l'/':,• Brief Description of Proposed Work: {, /.c Roarer Fro/7i o hoc/se ci lid an/-ciAO�t a1<0 9rp7/ke tit t,AZ (Jw5 [Al 1NOS1• of l oyre Ap-OX+ 7a,"e4T1W CRCTION 6 - FSTIMATF.n CONSTRUCTION COSTS Item Print N - Sia ure o Owner/A ent J Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building t (vkAM a) Building Permit Fee Multiplier 2 ND 3 RD 2 Electrical(b) _ Estimated Total Cost ofQ/ Construction DIMENSIONS OF POSTS 3 Plumbing Building Permit fee (a) x (b) 3 40 D 4 Mechanical (HVAC). S Fire Protection . 'I 6 Total 1+2+3+4+5 4 Check Number IS BUILDING CONNECTED TO NATURAL GAS LINE SECTION 7a OWNER AUTHORIZA'LTLON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property I ' Hereby authorize ? My behalf, in all matters relative,to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION act on I d ,as Owner/Authorized Agent of subject property, Herebv declare that the statements and infmation on the foregoing application are true and accurate, to the best of my knowledge mid belief eu. — Print N - Sia ure o Owner/A ent J _ V -'X Y1 x' y Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T I1vMERS 1--, 1ST 2 ND 3 RD SPAN i DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION "- THICKNESS SIZE OF FOOTING } X MATERIAL OF CHI34NEY y` IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE b FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT 14AI h ga p /Z t/ �y e7 n / vA / LOCATION: Assessor's Map Number ,�/u / SUBDIVISION� STREET_ C.., 0 t/ /ZT PHONE -LCL_ �- 0 f 3&' PARCEL 03 LOT (S) ST. NUMBER % % **********OFFICIAL USE ONLY *********** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR o DATE Revised 9197 jm The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02191 Workers' Compensation Insurance Affidavit Name Please Print Name: All �l Osi w %/0 AT VAI/9 J tl �/, l 5 T1' city Po 9*Eh �Qy dovirr til .9, Phone # aI 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. :mmnaFn namp• n n 'T t,/nil % res P Pp All -1, L4 Address ? % ,/1/ 1;-6? 7C W ot 'J City: 64/ i^nPi �, ey7er Mit ® /,Po D Phone#: Insurance Co. r iJ t/I ^ 22 -e glc Policy # �� Q O s S 2 Q.� Company name: Address City: Phone #: Insurance Co. o ►cv 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 -as _well.as_civil.penatties in.the form -of a..STOP WORK_ORDFR..and_a fine nf.($100..DA)-aday 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 pains and -penalties of perjury that the information provided above is true and correct. Signature e/G �& Date 2-2 Qo Print Phone #7?1 721? —S,? C%S 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 F-1 Selectman's Office Contact person: Phone #. Health Department Other Fortunati Carpentry Home Improvement, New Construction 31 North Gateway Winchester, MA 01890 Phone 781-729-5895 Cell 781-820-0136 License # CS 069075 Proposal Submitted To: Tony Chong 77 Court Street North Andover, MA Comments or Special Instructions: Proposal is good for 90 days DATE 6/26/2004 Description AMOUNT Add two 4 ft dormers to front of house; will need to demo closets, reframe and plaster; allowance for new electrical outlets for lights and plugs ($750) $12,636.00 Replace front roof with new shingles $2,584.00 Replace all 3 tap shingles with new (shingles over garage and breezeway) $3,400.00 Replace all single windows with new Harvey replacement windows @ $350/window, or with new Andersen/Loewen windows S $640/window New slider or French door in kitchen; labor only $900.00 New cooper over front bay window $250.00 Replace clapboards in back of house $3,006.00 TOTAL 1 $ 22,776.00 If you have any questions concerning this proposal contact Anthony Fortunati, 781-820-0136 THANK YOU FOR YOUR BUSINESS! BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 069075 Birthdate: 11123/1966 Expires: 110/2004 Tr. no: 9957.0 Restricted: 1 G ANTHONY P FORTUNATI r 36 HARVARD STS WINCHESTER, MA 01890 Administrator . � GTS-P�►,��. a����� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR j Registration: 126897 Expiration: 8/412004 Type: Individual ANTHONY P. FORTUNATI ANTHONY FORTUNATI '20 UAM%IAMr% 0r 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: A&-, :y ,n 413IK3 Are I? 571Lp > > tic- /-'Y - 2 TG (Location of Facility) Signature of Permit Applicant /Z !I z a2 y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Roof Framing Plan PILLION GROUP, INC. Chong Residence �� SSharon, ENGINEERS - DESIGNERS PLANNERS i 71 East Street 77 court Street N. Andover, MA Massachusetts 04078 FILLION? Tel: (781) 7843110 ���� : Fax: (781) 784-9777 �i Aug. 10, 2004 t o FF I ---------------- -------------------------- N O li n A O CIA b 3 f�A O IL CL I t J IFF o �► A • i. ___..... � I ----- ....... ...... ------- ------ ------- �9 O s I � / I .......................... / I o i PIP Second Floor Plan FILLION GROUP, INC. Chong Residence �� SSha ENGINEERS •DESIGNERS •PLANNERS 71 East Street 77 Court Street N. Andover, MA 04078 pga Tel: (7 1) 784-c110 Tel: (761) 7843110 Fax: (781) 784-9777 Aug. 10, 2004 General Notes ----------------------- Chong Residence FILLION GROUP, INC. �� SSharon, ENGINEERS • DESIGNERS • PLANNERS 77 Court Street 71 East Street N. Andover, MA Massachusetts FILLION 04078 Tel: (781) 7843110 Fax: (781) 784-9777 Aug. 10, 2004 �����• s 0 J h Pd 0 50 a a o � O = i C V - Z .CL ccC A a > v Uw" a a°' w L � O • a o o 0 J CO) h L O C 0 as v ev a. CO2 CL y C O �C cc CO2 0 I� YI N W W W C4 h 0 50 o � O = i C V - Z .CL ccC O iy E;� L � Q • V:CD oao 1 E c �mccmnti =(k E L L m m� o .� .a r �► CA A� o o Amo C a� � m � �a cm C ga y�•o o mJZ ' V y O L O •� C, c = o �`.ono . • 3 N COD W O -'0" +- L F= .� 06= mC zc Z LU CM C.3 a m-�- g = A m ` N = O = a CL CO) h L O C 0 as v ev a. CO2 CL y C O �C cc CO2 0 I� YI N W W W C4 Date.. 0, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -I..-.,"-"! ..... .............................................. has permission to perform ...... .......... I ................................ wiring in the building of ...... 2.Z. ...... A ....... ........ .......... ...... ................... at .... ............... . North-Md4ver: Mass. ............................................ ................. Fee Lic. No . ................... 'ELEcmicAL INspEoroR Check # 5445 7BEC0AM0NWE'ALTH0F 1AS94CH %SE77S Office 'Use only DEPARTA10ff0FPUX1CSAFMY Permit No. BOARDOFFIREPREVEN17 INREGUTAT70NS CMRI2GI0 Occupancy &Fees Checked APPLICATTONFOR PERMIT TO PERF ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUS S ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 1,1130 D Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work descri led below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: No L J (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service � Amps 1.24 Volts Overhead ® Underground No. of Meters New Service I Amps olts Overhead r-1 Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ST I YS D P-0 obit S No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting FixturesSwimming Pool Above Below Generators KVA round gronrid No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal r --J Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of * Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- bSL1& eCovetage Rus<tanttpthetequmn 1sdWbmdu sGataalLaws IhaveaamaltLiab>7ityhmua=Pb yin b&gCorrViM Covetagzorg3mb9aiW gttivalat YES NO Ittva>brrdtedvabdploofofsametDdrOffioe YES EI Y3uuhawdrdxd YES, ple=inffic*therypeofcovmWby 11<,SURANCE box BOND err IJER (1'fmSpedfy) WbikoStatt kq)ecficnD01eReWesbd signeduncLe ept perjury. HRMNAME <,- s�yJ /�dl 7) &-,C, licertsee siglimm EsWnwd VahleofE1wncal Wcdc $ Rc ugh I Final tom' Lioens % Lic=,% / 7 3 -,5-`-f �f%//I I/I /lP 4-1V©3 �7/� YBus�TeLNo. Ad-. eIIA-f"�/ GP T Alt Tel. No. OWNER'S INSURANCEWAIVERIamawaethattheLxffwdoesnothawdieinsuta=covwqporitsabstaralogwmlaitaslagnWbyMass ducetlsGenerwLaws andthatmysgnahneon thispemvtapplication waives ttasIe4mmu t. (Please check one) Owner 0 Agent Telephone No. PERMIT FEE $� signature of Owner or Agent Alt3UILUINU PLKMI I TOWN OF NORTH ANDOVER o PLICATION FOR PLAN EXAMINAT N_ d �, / n e Permit N0: G� Date Received A0 4q MI(w V Date Issued: I S ACHUS IMPORTANT: Applicant must complete all items on this page LOCATION O li 12 q��N Print PROPERTY OWNER yE2 I_ Y t�1C Print MAP NO: PARCEL: ZONING DISTRICT: Historic District Machine Shop yes 1 no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 4 One family Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain 0 Wetlands [I Watershed District ❑ Water/Sewer Cc,Nnmyrmors of 12 x 12 :SEASON J�ot)h& (phi TOP EXIS-11MG DEU,LLS,0 CARRY -RQ0V MER -7X 12 SE("-rIC7y") OF XISTiN(:2 CK Atsh Abb SCKff-N5,_ IVo r I wG �R ��Zuy+V� �►�TuIR�iAU�E . Identification Please Type or Print Clearly) OWNER: Name: L_ -/m Phone: 9 idress: CONTRACTOR Name: Phone: g )8 439T 2 Address: Supervisor's Construction License: Exp. Date: C- a Lc'61 Home Improvement License: Exp. Date: �4��I 2 � X11, ARCH ITECUENGINEER KAF AM1-'Z Phone: 1-7 514 -7-30-1 Address: Wogur-y MfP Reg. No. F. 2 FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ '15"815-00 FEE: $ ,4TOf Check No.: 42�l IS Receipt No.: �-��� NOTE: Persons contracting with unregistered contractors do not have a ec ess to the guaranty fund of Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 4� TYPE OF SEWERAGE DISPOSAL Public Sewer 1), < Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORINT LANNING & DEVELOPMENT Reviewed On 12 �l'�p Signature ��� COMMENTS ONSERVATION Reviewed on �-i COMMENTSPs�-O n HEALTH Reviewed ori Siqnature COMMENTS � Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 11 Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/signature &Date Driveway Permit ]DPW Town ]Engineer: Signature: Locatea Jd4 usgooa Street =;SIRE DEQ MENT,T me p Dsfier on siteyes 12 Fire Departs ent �i,gnature/date Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) Date Time Contact Name 3 Doc.Building Pen -nit Revised 2014 r ❑ Notified for pickup Call Email Date Time Contact Name 3 Doc.Building Pen -nit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses � Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit .Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract ;ra Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location -7 No. /C) 76 —/--- Check # Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ r j� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost is 45,,91I53.00 m $ - $ 549.78 Plumbing Fee $ 68.72 Gas Fee 100 comm. $ 1100}.007 Electrical Fee $ 68.72 Total fees collected $ 787.23 77 Court Street 1076-2016 on 4/28/2016 12x12 Three Season Room m w mc �q v < C 'a p -� r0 U = < CD F to y 0 3•Q� ID '� m 0 z O ? =.O H S O O f/1 ,Of �D• N o 77 C M 7rD N O O ^' CL m 111 C y C 'O p CD NCD —• _ 0 3 = N Z F O CL n —DI CO)^ : S C to N OCD O _. O Ga O= n Z e� W CD CD N 10 AC ;t �. CD- M TO T Cl) CDCl) to, -0 S T z CD m m W m m �' 0m n��'`� o -% C Z U) (A: v c) �• :(� my Cl) co0CCD CD � o m i ��CD o CL��,< c cn Q C a 0 Z v > rrF CD 1..' y rx a ZM CD 0 z CD (q0 o CD D Z O rn v 0 ca3 O _QO c. �= •v z ��. z V / _ z .-t C O : �F n CD H. cn v � =r CD T O m 3 rt V� m U)`-° c O m CD CDD p 0 z n O 7U c)c CD y_ CD z. O cn . -a 00 m 0 = �• x CD - 0 O ;a. Q m w mc �q v 0 c S pr M 7rD N G 111 C y C 'O p CD 3 Z rD : S C T S T m m W m m C C 3 ' w my v > a ZM z D H rn v O •v z z _ z n T m m O m m z n 00 0 x 0 0 c rico. Building & Remodeling g . Adam Brien CSL 104428 417 Waverly Rd. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 3/31/16 adambricoCgmail CONTRACT Herb Lynch 77 Court St North Andover MA 01845 Job Description: Expansion of 3 season sunroom onto existing deck approx. 121x12' incorporating a 8x12" screen porch. All construction to follow architectural plans provided. • Existing deck to receive temporary protection during construction. All construction related debris to be removed from site. A dumpster will NOT be placed on site. All furniture located in existing room to be moved and stored by owner during construction. • All framing to plan. Underside of deck screening to be removed for structural framing. • Supply and install 2 Anderson patio doors, location per plan, 2 Anderson fixed panel units to plan, 1 "Velux", skylight to plan. Remove and reinstall 3, fixed window units located in wall area that is to be removed per plan. • Screen porch to be built on existing deck as well. The screen porch roof to be framed and incorporated into the existing house and sunroom extension per plan. Construction of screen unit with turn clips to remove screens for winter and cleaning. Existing deck rails to be removed and reinstalled per code at screen area. Supply and install full view screen door at top of existing stairs. • Rubber roof to be installed per plan matching existing look. Existing gutter to be modified for new roof line • Walls, ceiling and floor to receive insulation. Underside of deck to receive pressure treated plywood where insulation is exposed. Underside of screen porch area to receive screening only. • Exterior of sunroom walls to receive clad -board siding and pvc trim boards on all new work. On exterior wall of inside of screen porch to receive matching clad -board siding and trim • All interior walls to receive blue -board and plaster. 1 wall to have blended wainscoting. On either side of patio door. • Interior ceiling to receive matching tongue and groove knotty pine, material to be stained to match existing ceiling. • All windows, doors, skylight, base board areas to receive primed pine trim matching existing style. • Floor style to be 1x6 planks matching existing area, entire floor new and old to be sanded and stained alike. • Electrical outlets and light switch to be wired to code. Ceiling fan installed on the ceiling in Sunroom and screen porch. Fans supplied by owner. Electric baseboard heat installed with Thermostat in located in sunroom (exact location to be determined) • New exterior trim and siding to be painted. Interior walls and trim to be painted. Colors supplied by owner. • Permit Fees included. The Owner agrees to pay BriCo Building and Remodeling $45,815.00, for doing the work outlined above. The following payments will be paid to the contractor in the following manner: • Initial Payment of $3615.00 is due at contract signing. This is non refundable. It includes architects stamp plans fee and permit fee • First Payment is of $20,000.00 is due once permit is on site and construction is to begin. This payment will also coincide, with the window and door order. Doors and window generally take 3 to 4 weeks for manufacturing. 20 • Second Payment of 11,000.00 is due once structure is weather tight, glass is installed, roof is complete, electrical rough begins and exterior siding. • Third Payment $7,000 is due at completion of all interior finish except floor and punch list • Final payment is due after final inspection from the building department is complete and punch list is 100%. All subcontractors that are hired by BriCo or the homeowner must carry the appropriate license and insurance to perform work in the state of Massachusetts. The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall be subject to final approval by Owner. All work to be done incompliance with Massachusetts building code. BdCo takes on full responsibility of all necessary inspections. All craftsmanship is warrantied for one full year from completion of construction. Warranty is voided if repairs are necessary due to a natural disaster. All glass installed meets state energy code for performance and efficiency. Each glass unit will contain its own energy certificate. Any unforeseen work or necessary repairs found during this project to be brought to the owners attention as soon as possible. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. BriCo is a full service general contracting company. We take pride in our work look forward to the opportunity to work with you. Customer Signatur n w Date Contractor Signature Date The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ki p I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 417 WRyf rt cy BEiCD _aVILDIt G ND FM6Dk 1;M l►J 6 City/State/Zip: Kh2 o Phone #: 9 -1'9 51 6 Are you an employer? Check the appropriate box: Type of project (required): IX I am a employer with �Z 4. ❑ I am a general contractor and I 6. E] New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. W Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance required.] comp. insurance.t 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL ' 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp, insurance reauired.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:`r1ZAytlF 0_ Policy # or Self -ins. Lic. #:V y 61$ P 'C, OD 1, Expiration Date: 7— Job Site Address: -7-7 ('�(7l7rl S --T City/State/Zip:jJ0CD1 knDOA R l lc\ 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 Phone #: 91 g L119 1 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 #: ACORN® CERTIFICATE OF LIABILITY INSURANCE 64.� DATE(MM/DD/YYYY) 1 03/08/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Trudy Lawler MICHAUD INSURANCE AGENCY PHONNo,E . (978)685-2549 ac No): A DRESS: trudylawler@michaudinsurance.com INSURERS AFFORDING COVERAGE NAIC III 105 HAVERHILL ST. INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 METHUEN MA 01844 INSURED INSURERB: BRICO BUILDING & REMODELING LLC INSURER C: INSURER D: INSURER E: 417 WAVERLEY RD 1 INSURER F: N ANDOVER MA 01845 COVERAGES CERTIFICATE NUMBER.- 35ROR RFVIRIAN NIIMRFR- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLIC MM/DDY EFF POLICY EXP MM/DD LIMITS Daniel M. Cr y, CPCU, Vice President — Residual Market — WCRIBMA COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENT PREMISES Ea occurreED nce $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO JECT LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTYDAMAGE $ Per accident UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB N/A DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OE A AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVEN OFFICERIMEMBEREXCLUDED? /A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A NIA 7PJUB4618P50715 04/19/2015 04/19/2016 E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE [$ 100,000 E.L. DISEASE - POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER rANrFI I ATInN ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Herb Lynch ACCORDANCE WITH THE POLICY PROVISIONS. 77 Court St AUTHORIZED REPRESENTATIVE �«X North Andover MA 01845 Daniel M. Cr y, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM 3/ /)16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Michaud Insurance 105 Haverhill St Methuen, MA 01844 CONTACT NAMME:Konnie Phifer PHONE (978) 683-7676 1 WC No): (978) 794-5409 ADDRESS: Konnie hifer@michaudinsurance . coral INSURE S AFFORDING COVERAGE NAIC# INSURER A: Northland Insurance 4/13/16 INSURED BRICO Building 6 Remodeling LL Adam J Brien 417 Waverley Rd N Andover, MA 01845 INSURERS: INSURERC: INSURER D : INSURER E: INSURER F: GUVEKAGE5 CERTIFICATE NDMRER! RFVICInN NUMar-D• THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFINSURANCE AMLSUBR I= WVD POLICY NUMBER POLICY EFF MIDDY POLICY EXP MM/DO/YYYY LIMITS A GENERAL LIABILITY XCO MMERCIALGENERALLIABILITY CLAIMS -MADE OCCUR WS201172 4/13/15 4/13/16 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED $ 100,0 00 REM _ MED EXP (Anyone person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,006 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELUATAPPLIESPER POLICY PRO -LOC ,ECT 7AUTOMOBILE PRODUCTS-COMP/OPAGG $ 2,000.000 $ LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS Co%1NEDSINGLELIMIT $ BODILY INJURY (Per person) $ BODILY INJURY Per accident) $ PROPD$ DAMAGE Par. ccident UMBRELLA LIAR EXCESS LIAB E OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N"RYI. ANY PROPRIETOR/PARTNERIEXECUTNE OFFICE PJMEMBER EXCLUDED? (Mandatory in NH) Uyes, describe under DESCRIPTIO N OF OPERATIONS below N / A WC STATU- OTH- E.L. EACH ACq CE NT $ E.L. DISEASE - EA EMPLOYEE E.L. DISEASE -POLICY LIMB DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space isrequired) GtK I II-ICATE HOLDER CANCFI 1 ATIAN U 1995 2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The AC ORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 258-6953 E -Mail: konniephifer@michaudinsurance.com>. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Herb Lynch THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 77 Court St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Konnie Phifer U 1995 2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The AC ORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 258-6953 E -Mail: konniephifer@michaudinsurance.com>. �� c/� Office of Consumer Affairs and Business Regulation .10 Park Plaza -Suite 5170 . Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168512 Type: LLC Expiration: 3/1/2017 BRICO BUILDING AND REMODELING LLC ADAM BRIEN 417 WAVERLY RD NORTH ANDOVER, MA 01845 SCA 1 0 20M-05/11 &Xeam�iw.ncoe�c�� a�uac✓turel '\ Office of Consumer Affairs & Business Regulation W OME IMPROVEMENT CONTRACTOR egistration: ':.168512 Type: xpiration: 311/2017` LLC BRICO BUILDING AND. REMODELING LLC ADAM BRIEN 417 WAVERLY RD,___ NORTH ANDOVER, MA 01845 Undersecretary Massachusetts - Department of Public Safety LTJ Board of Building Regulations and Standards Construction Supervisor License: CS -104428 ADAM J BRIEN = ,.. 417 WAVERLY ROAD o,-=� North Andover MA 01845 ��• Expiration Commissioner 05/12/2016 Tr# 262883 Update Address and return card. Mark reason for change. ❑ Address F] Renewal F] Employment 0 Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer.Affairs and Business Regulation 10 Park Plaza - Suite 5170. Boston, MA 02116 Not valid without signature oil ATTY: 1 Z S t-r�k, - I CERTIFY THAT THIS LOT IS NOT IN THE F.I.A. FLOOD ZONE. THIS CERTIFICATION IS BASED ON THE SURVEY MARKERS OF OTHERS AND IS NOT A PROPERTY SURVEY, FOR MORTGAGE PURPOSES ONLY. <c ->z, f �-e e- I CERTIFY THAT THE BUILDINGS ARE LOCATED AS SHOWN AND, THAT THEY CONFO MEDJO �T)iE>>ZONING EV -LAWS OF THE CITY/TOWN OF /I ,ffd,6& 6tWHEN CONSTRUCTED. SCALE: 1' DEED BOOK "-7ctd e PAGE'79 ��OF ! AREA L% / SR ROBERT AIM PLAN'? "1 1� ASSESSOR MAP 5,b BLOCK LOT Z� MASYS No. 291%4 MORTGAGE PLOT PLAN OF LAND AT 7ti AS DRAWN FOR: R.A.M. ENGINEERING L i 16 is Havww 01830 TEL: (978) 373-0445 FAX: (978) 37VI183 6 L > U- :k8 Q3�O3W�:a1vO 101d m m ML 19 WOO'NDISMQIOAMO� 'MMM Im ,q N0183C1,80j891NI 38ninimuv 11 N- < (]J)4 :AG NMV2ICJ 91-22-2 :3.LV(] > z Liu J) utu :3-IV:)Scr 151sea Plo.1.1'1O�. w< L11 LL I IJ w F ko < 4�= U. 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