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Miscellaneous - 85 HILLSIDE ROAD 4/30/2018
*b/2016 �sl Date: July 19, 2016 OF 1 " • This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20889 140R7y qti OTOWN OF NORTH ff=. Op ANDOVER +� PLUMBING 5 ❑ . �9SSACHUS�� ~ This certifies that has permission to perform plumbing in the buildings of SCHAALMAN FAMILY TRUST at 85 HILLSIDE ROAD , North Andover, Mass. Lic. No. 1/1 This document was sent to the printer Y x �-' Document Printed from permits - - - Printer. COMDEV_RICOH on sneezy Time 12,4837 PM 7/122016 . Total pag-1 712/1 Tuesday, Jul 12, 2016 12:47 PM r :; , J'Ir https:/)norhandoverma.virapointdoud.comltF)users)atith015.Q � C rillPaul-YewPoint Cloud - Town of North Andover, MA Q search... T� M� This document was sent to the printer Y x �-' Document Printed from permits - - - Printer. COMDEV_RICOH on sneezy Time 12,4837 PM 7/122016 . Total pag-1 712/1 Tuesday, Jul 12, 2016 12:47 PM r :; , J'Ir https:/)norhandoverma.virapointdoud.comltF)users)atith015.Q � C rillPaul-YewPoint Cloud - Town of North Andover, MA Q search... INBOX Paul Elder No action required... 1, 508-509-0380 ® elderplbhtgehotmail.com Action that requires your attention will appear here QA 173 Hayden Rowe Hopkinton, Ma 01748 - ... ..... - . -.....—_.. .... .... ... ......., Infomation Message from PrintKey 2000. Profile AE 1 Pictue Sera to%1.ne,rylCOMDV�.Rl00H ESC i k Type Location Date Created 20889'®' *Plumbing Permit 85 HILLSIDE ROAD Jul. 12 2016 This document was sent to the printer Y x �-' Document Printed from permits - - - Printer. COMDEV_RICOH on sneezy Time 12,4837 PM 7/122016 . Total pag-1 712/1 Tuesday, Jul 12, 2016 12:47 PM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CIN �✓- /IC®i MA DATE% 1 ( PERMIT # JOBSITE ADDRESS �S �T l �S�C A OWNER'S NAME P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW. ❑ RENOVATIONS REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR asm 1 2 3 4 5 6 7 8 9 10 1112 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 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 ❑ 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY. OWNER ❑ AGENT 0 1 hereby certify that all of the details and information l have submitted or entered regarding this applicatiiz%17!7 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will t provision of theMassachusetts State Plumbing Code and Chapter 142 of the General Lays.PLUMBER'S NAME f� J%', LICENSE#C�RE MPC JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC 0 # COMPANY NAME Pw %L ADDRESS _ /r'>Q CITY STATE Zip _ dC 7Y$,-- _ TELS7>kS�✓9 1() 3� FAX CELL EMAIL The Commonwealth of Massa chusetts zF Department of lndustrlal Accidents 1 Congress Street, Suite 100 =u ' Boston, M9.02114-2 017 www mass.gov/dia SJ• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE ]FILED WITH THE PEPMTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):,d��IL�U6`iG3'6d�C� Address: Q City/State/Zip:. Prchvrvo IIA 0/7 `%P Phone #: -Of- 0 7 0 3�?d Are you an employer? Check the apliropriaie box: '7 Type of project (required): 1'PI am a employer with • i employees Gid/or part-time).* 7. ❑ New construction 2.n I am a sole proprietor. or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp -insurance required.] 10 ❑ Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or.additions proprietors with no employees. 12: ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ These sub -contractors have employees and have workers' comp. insurance.# 13.' Roof repairs ❑ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy intormation. i Homeowners who sulimif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, &y must provide their workers' comp. policy number. • I am an employer Mat is providing workers' compensation insura information. Insurance Company Policy # or Self -ins. Lie. #: /tca oc r - J,0L-s CP my employees ' Below is thepolicy and job site Ak©SoN i 1-46 /-t oKP14"y 4 � �-. Expiration Date: Job Site Address: City/State/Zip:—k ALINVi/t 14 p 1 c?/ S Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification,. - Ido hereby certif nd r the ai a dpenalties ofperjury that the information provided above,is true and correct. Signature: Date: Phone #: 5-0— r S 3,�-o 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector. 6. Other Contact Person: Phone #: v, 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, ox any two or more of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the receiver or trustee of ati 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 -'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 Depaftment of - Industrial Accidents foi• 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 N O N C D "7 ai cu ❑ o -a 0 N W O 0� E 0 Z o Z w a 0 o w .o iL > F. E 0 LL 0 N Z �-- o Cn cu LL 0 Z W ° a Q L 0 mo z a > F- N c � -a (h Q c U) O N U o o -0 E CO,Z E L .- _ c C ❑ a a m c c O 0 cu LLI ko ^ O Q ❑ d �`� a �c- m a•� (n N 00M Co m 0 N O c • i coU N ~co—CU T. - CD N O M .ii C- 10328 " ,� �- Date .................. -7, .�,............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... .... 17- < . ................ ....... ... .... .. .......... .... ...... haspermission to perform ..... ............ ....... wiring in the building of Z/Z . .............................................. at . ...... ........ �//j Oe ...... . North And6veff, Mmlss." Fee ... ��'3 .......... Lic. ..... . ..... .... . ELECTRICAL INS' CTOR Check # —file 9 °cider 5amiaCi M 40.N O \ *J3 N� y0•a 0.j y d o a p R w 4 LL Eq Rs o 8 t— 40, G. oIN°' aai o 82'0 .0v�0 ..0 'O L' O. N LL .d N ro- w 2 �o o P q N C c°d' b ° w otio� a. •� .on a. � � U O oo r.ca A W •� b i"O-• N 0 o.O "vii Cl) ca 0 0 y LLT O a> N Cq N � 'd ••'. c-,� ❑ � w�, cv o � •PSK. C �, � o � �°j ,� >;u �3 � � ' w 0 U •U y w p ycq I(� CO i� ° O O b M � O y0.� • 0 ti C N Mal \ 0 8 y ro o. a a x o ani b 'C O •U N b G^' .U. O V W° N N N LL o . p. ti d a bo >, y ani � O td yN .G .O U i. U N fd p N O ^� d cC p •-• N y0 �" a•CJ .k N ° 3 w ^ w ni @ rail '� f-. 7•� .. �y O i.. m m U y +°+ 3 6 W .5 w b�da�a��00 0 0 1 U > o a,(�.H 0 o ,0 w w 0- 'e o O LL W W p 40. ca -- y` o a> q v o o y o wclb ti y y GL ti LL p .O y W •�'^. w0 .fl k° �N N LY � •� mca .� O a7.i wit a� O y ., 04 LL o 75 0 P i 0 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. %i ill� Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5p,? Ze�"/ 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) ?5— f�flGS"tri Owner or Tenant SCjtka_(F-J Telephone No. Owner's Address <,A u-9, Is this permit in conjunction with a building permit? 01 Yes 2-" No ❑ Purpose of Building t� Y (Check Appropriate Box) Utility Authorization No. Existing Service ZXCj Amps / 241,,0 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: &"F- Completion "F- Com letion of the following table may be waived by the Inspector o Wires. No. of Recessed Luminaires IZ No. of Ceil: 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 rnd. ❑ rnd. E]Batter o. o mergency ig ting 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/_ 0/A5 No. of Air Cond. TonaTotal No. of Alerting Devices No. of Waste Disposers ( Heat Pump Totals: I 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 �JTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3��� (When required by municipal policy.) Work to Start: G,� �7 �2pt 1 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 R" BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: -?64 j —1 &,,Pce x / LIC. NO.: Licensee: Signatu LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.. Address: 0!gZgqg 15j- gJS1t1 e:!? j Alt. Tel. No.: - *Per M.G.L c. 147, s. 57-61, security work recfuires 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 Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of Massachusetts' a 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 P Name (Business/Organization/Individual): Address: e �-7, V OW e- 56w -t City/State/Zip: _ fie 4 &W -t Phone #: _5DFWt-9WY Are you an employer? Check the appropriate box: 1. Ell am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑?Electrical Ming addition 10. repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they 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: ZC�I Job Site Address: -51 12& City/State/Zip: Aemmrr�,�� 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 cert o under the pa' sg0penalties of perjury that the information provided above is true and correct. Phone #: 509"& S'27�{�=1, M -L Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date. j. 9102 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING _rt +r. This certifies that .. �.l.�f!L!... 10. 4. .................... has permission to perform ... K-"1,:, ......... plumbing in the buildings of .Alu'oh - -'Ca/2 w"`.......... . at .. ��" .. i /� t oo ................ North Andover, Mass. f Fee. iJJaLic. No..YD�............� 3. PLUMBING INSPECTOR Check # w 1 MASSACHUSETTSUNIFORM APPLICATION FOR PER TO DO PLUMBING City/Town:ii:::MA-Dat�e:.� / C �Peerml�t#�'_ Building Location: Owners Name: c Type of Occupancy: Commercial[] Educational ❑ Industrial ❑ institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Ix LU DEDICATED z z SYSTEMS w in W Z 0 y H Cn Q y 0 z H Y ¢ J U in Lau: ,y, O Q w X Lnz cr 2 Q Q w C7 a ❑ O p Q w o F- y a ¢ N Y y 0 _a }{_�- N y x w a C7 X Q d U p a w ❑ ❑ w Z w Z u ° u Z — Q ¢ 00 1- cmi j Q OLL a z x w w .6 O w a m m o❑ LL i�� s���°1 tn SUB BSMT. `" "' �" ❑ 3 O Q 3 BASEMENT 1STFLOOR 2ND FLOOR BIRD FLOOR 4' FLOOR 5TH FLOOR 6T" FLOOR 7T" FLOOR $T" FLOOR _ Instco1irig C0JJ-1iP&nV Nam_� : P flilAr Address: /" O k/Qx % City/Town: /— State. G Business Tel:. Name of Licensed Plumber: Fax: CC'' 6w!t Cher— On lr:�ly GFri:iiiCvat� �r EJ Corporation ❑ Partnership Firm/Company INSURANCE COVERAGE: I have a current liabilit1r Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes If you have checked Yes, please indicate the -type of coverage by checkingtheaNo ❑ A liability insurance policy• ❑ type of indemnity Other t ppropriate box below. ity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does h_aee the Insurance coverage Massachusetts General Laws, and that my signature on this permre application waives this requirement. required by Chapter 142 of the i nature of Owner or Owner's A ent Check One Only > Owner ❑ Agent ❑ 1 hereby cerci fy that all of plum details and information I have submitted (or entered) regarding this application are Prue and accurate Knowledge and that a!1 pf��mbing t: ork and i nstailations performed under the permit i Pertinent provision of the Massachusetts state Plumbing Code and Chapter 742 0; Gen ral Laws ate to the bas` o, my p forthis application will he in compliance with all i Type of License: t le Plumber Signature of Licensed Plumber Y/Town Master / 'PROVED (OFFICE USE ONLY) ❑Journeyman License Number: w ---------- 7:07 r- M.Z zm 't- F5Z Z x L - 51firr_ ." z o;: X -4 0 P- m uirn POE Z Ul r -w C:U)cnc U1 u m m m m M ON/) z in Ul r- Cl on z m om M Waw Zzo Ul > cn,, 0 < MEZ -n XN > 00 MU)6 zm cn m S16 w ---------- 7: tv 't- F5Z ." z o;: X . t- M;6,: Fnzr-,' C:U)cnc m m z in Ul r- Cl zm m M Waw Ul 0 < MEZ C) > MU)6 w The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02I11 UV www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6bly Name (Business/Organization/Individual): t�J Mi✓UJ�ClcF/ V� Address: City/State/Zip: A6940&lP /0 4/70 Phone #: 308 �D? 43YO r you an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. FJ Plumbing_ repairs or additions 12. ❑ Roof repairs 13.❑ Other *any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. -lain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: 0761 , Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: & �QD(/L 4 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify der e of perjury that the information provided above is tru /and correct. Si ature: Date: G l Phone #: TQC'' S-7)? 0 3Sv 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. EIectricaI Inspector 5. Plumbing Inspector 6. Other ContactPersona: Phone #: 7C a Date. . ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. .................... has permission for gas installation ... ..�f ........ . in the buildings of A ILNA pp...Co17 v at .. 6 S /s fff?'¢'........... , No Andover, Mass. Fee AS ':� ... Lic. No........... /�/� `..... ih✓ ........ GAS INSPECTOR Check # /05 FIYTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: %V- MA. Date: Permit# Building Location:_ de Owners Name: _ A* cQ/C/cS� Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No (❑ ra FIYTI IRFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ u 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title City/Town ae of License: Plumber Gas Fitter Master LP Installer Sighattr're of Licekised Plumber/Gas Fitter License Number: W W Z co U 2 ra Q m 2 0 W Co W UO 0 H O = W W Z H Z 0 Of W M w O � D W U) LU to U W W fA m 0 U' . ~ F- W w IL 0 W W a W O W F- a> UJ = li Z W W Z O J I- H O Z J 0 W Lll Fes- L=u W W W W tr U D Cal == aaa O a H>>> O u�. C�7 i SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 Ku FLOOR -Z'FLOOR 5 I H FLOOR 6 THFLOOR 7 FLOOR 8 FLOOR Installing Company NValne:&ALL�[�_ ,/),,���Check G/, One Only Certificate # Address: �� �Qr /� ,A City/Town: /"f� ��`'�//� State:%% El Corporation Business Tel: c-� :�2l` d� Fax: El Partnership 'OFirm/Company Name of Licensed Plumber/Gas Fitter: Aj INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ u 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title City/Town ae of License: Plumber Gas Fitter Master LP Installer Sighattr're of Licekised Plumber/Gas Fitter License Number: 9926 Date ....... 0 ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ e,� & ..... S . . ....................... has permission to perform .......... ...................................................... wiring in the building of ............. .......................................... -5 aq t at .................................................... ...... ...... ,North Andover, Mass. Fee3S_moo Lic. N942t.� I ............ e ELECTRICAL INSPECTOR Check Check# AN— comomo wean o/ /l/amac`uc ,& Official Use Only Permit No. q,� 2- Ea eU lira Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev_ 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 5 7 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL RVFORMATYM Date: �� City or Town of: /�/d� f �,�,���^ To the I ect r 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 %�G, fUy �P /,)O,= /c3� �' � G. Telephone No. Owner's Address Is this, permit in conjunction with a building permit? 'Yes 21 No ❑ (Check Appropriate Bog) Purpose of Budding Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps * / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity _ Lotion and Nature of Proposed Electrical Work: No. of Meters No. of Meters No. of Recessed Luminaires Na of Cel[.-Susp. (Paddle) Fans o- of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tabs Generators KVA No. of Luminaireso7 Swimming Pool Aboe ❑ d. ®Butte Um�tsan� g g No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Tom No. of Alerting Devices No. of Waste Disposers eat Pump Totals- I Number I Tons I KW No. of Self-contained Detection/Alerting Devices F I No. of Dishwashers Space/Area Heating KW Local ❑ Municipal❑ OWer Connection No. of Dryers No. of Water KW Heaters Heating Appliances KW o. of Na. of Signs Ballasts SecuritySystems:* No. No. of Devices or Equivalent Whin Na of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Whingg. No. of Devices or E uivalent OTHER naacn aaamonat aerate tI desired or as required by the Inspector of Wires. Estimated Value of electric Work:f jam, QC� (When required by municipal policy.) Work to Start: a� o? — 234,1 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance inchuling "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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the airs and penalties ofperjury, that the information on this application is true and conrktp- FIItM NAME: /&e , LIG NO. Licensee: Signator LIC. NO. fir: (If applicable/ enter `exempt" in a 1' bei )J Address: ;� _ % i�7r_uOre �%f� tj2/S/ Bus. TeL No.•?�d/-���/ �1281a Alt TeLNo.: R/-J?YY-3D& *Per M.G.L. c. 147, s. 57-61, security work requires Department ofpublic 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 Signature Telephone No. PERMIT FEE: $ 5 The Commonwealth of Massachusetts ----_ - - Depar#m w of Intim vial Accidents OffCe of "estkaffons . 600 Washington Street r Boston, Maw 02111 www mass:gov/dia Workers' Compensation hmrance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print x4gft ,.1. Addrew. I iZaAlzml t Are you an employer? Check the appropriate bog: 1. if I am an employer with 6— 4.0 I am a general contractor and I employees (fall and/or parttime).* have hired the sub -contractors 2. D I am a sole proprietor or partmx ship and have no employees working for om in any opacity. [No workers' comp. insurance 3.0 I am a homeowner doingall work myself [No workers' comp - insurance required] t listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance. t 5.0 We are a corporation and its officers have exercised their right of exemption perm MQ. c. 15% § 1(4), and we have no employees. [no workers' comp. insurance required.] Type of proms (required): 6.0 New construction 7.0 Remodeling 8.0 Demolition 9 0 Building addition 10. W Elettriol repairs or additions 11.0 Plumbing repairs or additions 12.0 Roofrepairs 13.0 Other *Any apprkant that ebeehs box #r mast also IM out the seefma blow showing theirworkes' eompen"in policy information tHomeownamwboeabmitthhaWdwitindieafttheyaredo%g0vwksadtheatdreoatddetoo&"'M Imastsabantanewaffidavit indkating suck tContadm tient the& this box mast stWb so addtCond sheetshowiq the name of the sub -contractors and state whetbw or not those enfides have employee. V the sub-conh=Wn bave gpm$gpm they' mostyrovide tbur workers' comp, z2gu smuber: I aea an employer&W isprodOgworkersbaa hrsiasanceformy anWloyem Below is Arepoffey and job site infomsakon — , 1 A r insuranceCompany Policy # or self -ins. I.ic. #: f o �J/� _ D/ 3/t*J/ Expiration Date: 3 �® kJob Site Address: 8�'` Attacb a copy of the workers' compensation policy declaration page (sbowing the policy number and expiration (date). Failure to secure coverage as required under Section 25a of MGI: -152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one year imprisonmeml as well as civil penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of tins statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and, ofpe*" that the nafommidon provided above is true and correct 0.01dd use only Do not write in this area to be complefed by city or town ofj`tcitd (Sty or Town: _ PerzaWlicense #.- Issuing : Issuing Authority (circle ow): Board of Heath 2. Building Department 3.4cuy/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #.- 9. : 8870 Date. . 'AORTh 0 -1 TOWN OF NORTH"'ANDOVER 0 PERMIT FOUR PLUMBING This certifies that ...1i' 4. FT. (�/ ..... has permission to perform .... ............... plumbing in the buildings of . 4./ .................... at. J -S.—. /-/z. . ....... North Andover, Mass. Fee . ./-/?. --)-��Lic. No.. 9. <D, . ....... .. ....... PLUMBING INSPECTOR ZG Check ff FIYTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: 40�d / C , MA. Date:9,2111-/ Permit# r— F Building Location: O �%/GCS/%%C� J2d Owners Name: DEDICATED Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIYTI IRFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 •••�. ya a„ Num IIU wul ft anu mswuauons perrormeo unaer the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbina Code and Chanter 1d2 of tho r:nncr�l i - By Type of License: e C Title ber Signature of Licensed Plumber City/Town [aster APPROVED OFFICE USE ONLY []journeyman License Number: G DEDICATED Z SYSTEMS H O W f• W Y Z O W Z cm Ln %• V1 S W _Z Z Q J � Q Z V1 W cQ Z ? Q Q W Z 3 H X H Q y� H Q m H 5 5 P � y ce 0 Q Lu Q Z d: W H H Q Y C7 CC W Z H W to Q a - (7 W X Z U d U. Q I.- = J ? Q 3 LL F 3 C♦ 3 W Q Y X X a = Z LLJQ VI Q LL 3 a W Y Q S W W N I- W 0� Ln > 1 Q 7. U W r- m m O O = Y ' > O O O Z IQ- _Z Q Q Q F, H W Q a < = � Q 3 SUB BSMT. BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4' FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR / Check One Only Certificate # Installing Company Name: ��-f�C����t-�-y�F �-(<<�LL�%/�`-/G/ �tp Corporation ^ Address: -7 2/(% City/Town: !TL �� State:L�/�1- ❑ Partnership q �y �e Business Tel: ! B'�/7� 71-(2y Fax: 'M327 J /6 I ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 •••�. ya a„ Num IIU wul ft anu mswuauons perrormeo unaer the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbina Code and Chanter 1d2 of tho r:nncr�l i - By Type of License: e C Title ber Signature of Licensed Plumber City/Town [aster APPROVED OFFICE USE ONLY []journeyman License Number: G ' as ,Y. ..'C...'. . a ♦_ s...iM1r e.. y CONTROL # F 6 6 4 6 5 0 a IMPORTANT, If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 239 Causeway St., 5th Floor, Boston, MA 02114. + If your name or address shown is changed, notify your board 1 of correct name or address to ipsure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required'by law. wAhr,,MG TI?iIS DOCUMENT 1IAS E.NNAru-Tp SECURITY FEATURES-_.-_-- .,...,�-r...� _r,�...�_-,..,-y.. _ _ 1 CONTROL # T 6 4 4 $ ;--- If this license is lost or'MPORTANr , Division of Professio' destro j y 5th Ffoor, Boston naf 'Licens"re 2 your Board at the: MA 02114. , 23,9 Causewa If Your Y St{; of correca name ovaddress sho ` Rene name or address toninsuhe aged, notify your bo wal APPlication. At rioti . This license is subject to ays refer to Proper mailing of and I as amended. next It is the provisions nse number. or assigned to Isany other :Personal pripilege and f the •General Laws person or posted as required by9,, eep th s license ust n Of a loaned . Rtrra�M1,.on youW. rl .✓k.,. �taii�ll$�7 C�MMOf�VUEALTH (9F.MAS$ACHUSETTS; 6 Date.... 'k0RTk TOWN OF NORTH ANDOVER 000 PERMIT FOR GAS INSTALLATION This certifies that .................. has permission for gas installation I ��r in the buildings of..................... at ... ........ North Andover, Mass. Fee5k57.ten Lic. No................ GAS CTOR Check # 5242 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FI'T'TING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations i L L' �^ f Permit # �� v Amount $ Owner's Name L /,VA 17/ New El Renovation Replacement Plans Submitted (Print or type)Chec one: Certificate Installing Company Name -� �` Corp. Address 2 �" D /�y /7 03 D Partner. Eusiness feleptione y 2 iM Firm/Co. Name of Licensed Plumber or Gas Fitter - 7—/W n %')i,y 4 1 /�>G INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy r Other type of indemnity Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa chu State Gas ode and C pter-!P of the General Laws. OVER (OFFICE USE ONLY) Signature of Licensed Plumber.Or Gas Fitter ® Plumber VS 2'2- 0 Gas Fitter License Number ®Master Journeyman w w a oG H x x) a 0 - U a > A 96 H O SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type)Chec one: Certificate Installing Company Name -� �` Corp. Address 2 �" D /�y /7 03 D Partner. Eusiness feleptione y 2 iM Firm/Co. Name of Licensed Plumber or Gas Fitter - 7—/W n %')i,y 4 1 /�>G INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy r Other type of indemnity Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa chu State Gas ode and C pter-!P of the General Laws. OVER (OFFICE USE ONLY) Signature of Licensed Plumber.Or Gas Fitter ® Plumber VS 2'2- 0 Gas Fitter License Number ®Master Journeyman .1 A ,ORTN 01p 9 ......_. _.... lDate.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SACMUS� f This certifies that . �..._, ................ . has permission to perform ... C)... ................ plumpbing in the buildings of ; r.ta-c° ........ ,at ....... > .' �':..... , North Andover, Mass. Fee . r` .. Lic. No.......... I . ,%f PLUM NSPECTOR Check # " R 7 t/ ,6614 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New 10 Renovation 11 Z) 11 Owners Name Date C-)4 4(� � MA�nit #_ Amount Type of Occupancy Replacement 11 FIXTURES Plans Submitted YesNo ❑ (Print or type) f Check one: Certificate Installing Company Name 7:VL S PL L- "Al 9 1 ✓Y i A ❑ Corp. Address 2- OL 0 RL., J?,9 LA 0 Partner. Business a ep one Firm/Co. Name of Licensed Plumber. —7--)4--'7 OT jgY Z) 1�9& —n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner Agent I hereby certify. that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac u State Plu ng Code Cha er 142 of the General Laws. By: Signature of Licensedr1up5er Type of Plumbing License Title rz Z City/Town 1�icense lNumoer Master pM Journeyman ❑ APPROVED (oFFtCE USE ONLY 1�T '26 0.4" Date ... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ................... has permission to perform .... e!� ................. I wiring in the building of .... .................................. at North Andover, Mass. ........... ELECTRICAL INS Fee..t? ..... ........ Check # DERUMWE YfOFP[IBIx9*= Peit No. BQDOFEmyI0RDaA65Qaywkepaey < Fee bChecked n APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALLwORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECMXAL CODE, 527 CMR 12:00 (PLEASE PRI" IN INK OR TYPE ALL INFORMATION) Town of North Andover To the Ins for of Wires: The undersigned applies for a permit to perforin the electrical work described below. Location (Street a Number) Owner or Tenant JC c' Owner's Address yy� Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building C "dc:LaLUtility Authorization No. Existing Service !w imps ./EOverhead M Underground No. of Meters New Service 2,=4�) Amps/ Volts Overhead ® Underp wid Q No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work bo t yvi ; , "/ i"- ie,,2g C - vi.c7 Na of Ughting Outlet Na of Hot Tub• No. of Tran.Eonmee Taw Na of Ughting FiMM Swimming PodAbove around ri BelowKVA round OaAmtats KVA Na of Receptacle Outlet 1G No. at Oil Burnes No. of Emerencr Ughting Battery Unit No. of Switch Outlet No. of Gas Bamers FIRE ALARMS No. of ?.ares No. of Rugae Na of Air Cond. Total Tana No. of Deacdoa and Na of Disposab Na of Hat Total Total Pumps Ton KW Initialing Dei No. of Devlca No. of Dishwashers apace AHeating KW nsaouKe" N a Detacdod3omWing Devka - - a No. of Dryers Heeling Device KW C7 0 F,N•ta o. or WsNeaten KW Na d _ Na or Siam Baiw6 No. Hydro Maosge Tabs No. of Motors Total HP Ihmeah ilbdv&poafgf=wlD rets M ® I dnddi8f 'D- 24 )RANCEE f El BMC:] am, WotkioStat Npmun crw tsPaJ� BOMMDNe Rai, 9%rte //O`C Vaklecfl3e2WWCar$ Milli (` UmnleND. 1'x'//77 D — Linum &WMlBTdNa 7'-132- a+teq, '`� viii d 4 J CY9 � �, vim_. �(•Y�b'�%?G6Z 3 0W?I WSII�IS JRANMWAIV 1anaweredletdreLrtased�,g�hg�lheia��ae AL Td Na a�thetrrrys�ondisperritapplc�tut�iwaliisregoilmrert �`�o�s��e�����eidbYae�GmaalLawa (Please check one) Owner Age Telephone No.pgg _ L 51111111111 of Owner WAVW� FEE DEPAMENTMENCSOM Permit Na BaAiu)OFFiREPREVEWWREGULA77M527( MUlV I Occupancy & Fees Checked 6 P&qO N F I �P (PLEASE MALL C X Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. 1;10 Number) Location (Street Owner or Tenant Owner's Address is this permit in conjunction with a budding permit: purpose of Building ; Existing Service 10t Amps/�--r Volts New Lqnda AmW - f -Yl Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Yes No Overhead E Overhead r (Check Appropriate Box) C/ 0 Utility Authorization No. Underground M No. of Meters Unde%mund C:1 No. of Meters No. of Lighting Ontlets r7 Na of Hot Tubs NO. Of Thmsfixfoers Kota) KVA No. of uskiins Fiatores Swimming Pod' Above 1:1 Belowund Oaterstots KVA yound yo NO. Of jwceptscls Outlets No. of Oil Burners NO. of Emergency LISINIng Battery Units No. of Switch Outlets No. of am Owners FIRE ALARMS NO. of zMW No. of Ranges No. of Air Cold. Tots! Tons No. of Deaction and No. of DisposalsNo. of Ham Total Total I Pangs Tom KW Initiating Devices No. of Soandins Devices No. of Dishwasher Space Arm Heating KW No. of Self CAaWned Detictionr3oundiRs Devices Locs' mun"d Other 00. of Dryer Heating Devices KW Connections 1:3 0. of WSW Heaters KW N& of No. of S logs Beilssis Hydro Massage T -to No. of Maim Total HP '&brdIkdvaIdpWofs=I0#Z0ft YM r"T" LLJ LAME BM am ism mitis 'ANZ 0rlfflmlm 801dianne dEbc"Whk$ Ra* LiMaNa 41177 e,) 7-7-7 Yi &w*==TdNa 7177 7 -77 J 0WtWSMJRANMWAM-l=mm#WftLia=d=mt AXIIINd ,-0ftmy!gvWcnft' ' " o " 116ma6mus 00WbyMwdnftGffnWLm (Please check one) Owns Apo Telephone No, ailgrialum or Owner or XpE ----JWWT FEE I pa& q /20`D /'Z_ nom' ppg�-, 60�� A� .�.:.. {.. �•...,,.�s✓.��,,:..:.��..+..�.- _�.-w-/.�'^N�`rarY�^.�J. .�.rF"Yr.. ., ....T.r-«1.... Location No. 1107 Date NORTq TOWN OF NORTH ANDOVER - O F s 9 • : Certificate of Occupancy $ NUs <� ✓Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # W 18569 Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING may,}- , f : fix- .; r...,aa s; -R stti^Eaa•x€ BUILDING PERMIT NUMBER:/ / DATE ISSUED• 0//74s— SIGNATURE: 0 SIGNATURE: �(�-�-- Building Commissioner/for of Buildings Date 11V1\ 1-ul1L' 11\a`V1�1�1L111V1� 1.1 Property Address: 1.2 Assessors Map Number Map and Parcel Number: Parcel Number AA Ono jer, 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided R ' 'red Provided 1 1.7 Water Supply M.C1L.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 PSC !S PIC @Sp 2.1 Owner of Record Do"\ -t MoL(y LO L) 2C) Name(Print) S c lAqA I r%Qn Address for Service: C"K ,8- C,? '7 f?Z Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Kr ypTo, Cons [tvc�la„ PAUL, ()rte Licensed Construction Supervisor: (� Cid%CC r Sr �q�" `t 41'l� O til � O Add 978'-53Z-�'go8 Signature Telephone Not Applicable ❑ - S2 Cf C 5 09?S2 10 License Number / 2l rz��avg �r Expiration Date EIV �J 3.2 Registered Home Improvement Contractor jKr7PTo,n ' Coat STs - meq ov-\ Not Applicable ❑ I g 1 3 6 3 BUILDING w Company Name ) / Vo 61 d °I co �'� ST qi3ov` y Mat 0(13 60 Registration Number tll iyl 2 Ad es Expiration Date Si natu a Telephone Wo M �o SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit ust be completed and submitted with this in the denial of the issuance of the build rmit. Signed affidavit Attached Yes ....... V No ....... 0 SECTION 5 Descri tion of Proposed Work check all applicable) Failure to provide this affidavit will result " New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) Q,` Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: DyT govYV\ cr L lecTtl: c- 5Fi v; c e, Cover- Raa r �6clz I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant t 1. Building/ '/ b -1 IS 3, 3 (a) Building Permit Fee Multiplier 2 Electrical (� ( 00,00 (b) Estimated Total Cost of Construction 3 Plumbing 6- $. 15� Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Agent of subject property Hereby athtrbrize Kf Y P To '^ C• 0 /1 s 1 (y C -(i V'1 C Pit t L Ave) to act on My, be ' in all tters re ive Pwork authorized by this building permit application. g,ks Si¢natur of er Date SECTI(W7b OWNER/AUTHORIZED AGENT DECLARATION 1, Yea v L Ptfa Co `" 1 (u e'T' ° 11 ,ash/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief PAIL ate C KryAlu^ cans rrvc i,vn Prin mL - 8 / 36/6 Sian tore ofcaner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I 2 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE THICKNESS X s G Recessed Lights 21'-6" Elecrtic outlets to code & spec 5'-2" 121-4" 4'-0" Cable & Phone jacks to spec p Starron Counter Tops Closet Light Solid core masonite doors with ball pin closer Z UP 1CD co CLOSET e 2 New Adjustable skylights (D tp O (Di CO ao � 1 N i N U ��. S Shelves under counts // CD t� r Panasonic Fan Light Combo, 6-3" 10'_4" 1 1/ 4'-111/2" 21'-6" CONSTRUCTION CONTRACT This Agreement (the "Agreement"), dated as of August 27th, 2005, is made by and. between Krypton Construction Services, LLC, with offices at 40 Endicott Street Peabody, Massachusetts (the "Contractor") and Don & Marylou Schaalman, (the "Owner") with a principal residence of 85 Hillside Rd, North Andover, Massachusetts 01.845 (the "Property") WHEREAS, the Owner desires to make certain renovations to the Property; and WHEREAS, the Contractor is in the business of providing such services. NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: SECTION ONE SCOPE OF WORT. The Contractor shall furnish all labor listed on EXHIBIT A necessary to make certain renovations to the Property. The specific work to be undertaken by the Contractor shall be as set forth on EXHIBIT A, attached hereto (the "Project"). The Contractor is not responsible for furnishing any improvements other than those as specifically set forth on Exhibit A. The Contractor agrees that all. workk on the Project will be conducted in a workmanlike manner. In the event that the Owner elects to make changes to the original specifications set forth on Exhibit A, or if unforeseen additional work becomes necessary to complete the Project properly, the Contractor and the Owner shall Execute a Change Order. For purposes of this Agreement, a "Change Order" means a written amendment that becomes part of and is in conformance with this Agreement. Change Orders must be contain the revised contract price. Once the Contractor commences the Project, there may be additional repairs or other matters that come to his attention that may have to be addressed in order to complete the project properly. If this is the case, the Agreement price may have to be increased to conduct such additional work. The Contractor will make every effort to avoid additional costs. Before the Contractor undertakes any additional costs, he will obtain the Owner's prior written approval through a Change Order. Nonetheless, the Owner expressly agrees that they will be responsible for any such costs. If the Owner does not elect to make such necessary repairs, the Owner agrees to pay the Agreement price to that date in full, and all obligations of the Contractor to the Owner will cease. SECTION TWO PAYMENT The Owner shall pay the Contractor (for all labor associate with the Project the suin of SEVENTY SIX THOUSAND SEVENTY TWO DOLLARS AN SEVENTY TWO CENTS ($76,072.12) in the following installments: 1. $27,330,59, paid this day; and 2. Three additional payments as follows: $23,152.21, upon completion of Rough Electric & Plumbing Inspection. $23,152.21 upon completion of the Final Inspections. And $2437.1.1 Final Customer Satisfaction Payment shall be made by check made payable to Krypton Construction Services, LLC. In the event that any installment is not paid when due, the Contractor may stop work until payment is made. In the event any installment is not paid within ten (10) days after it is due, the Contractor may take such action as may be necessary, including legal proceedings, to enforce his rights hereunder. SECTION THREE RESPONSIBILITY The Contractor shall not be responsible for damages to persons or property occasioned by the Owner or his agents, third parties, acts of God or other causes beyond the Contractor's control. The Owner shall hold the Contractor completely harmless from, and shall indemnify the Contractor for, all costs, damages, losses, and expenses, including judgments and attorney's fees, resulting from claims arising from causes enumerated in this paragraph. The Contractor shall be responsible for all costs, damages, losses, and expenses, including judgments and attorney's fees, resulting from claims arising from causes enumerated in this paragraph occasioned by the Contractor or and of his agents, SECTION FOUR NON®CONFORMING/UNSATISFACTORY WORT{ In the event that the Owner maintains that any of the Contractor's work on the Project is not in conformance with the work set out on Exhibit A, they will notify him immediately, in writing. The writing shall state with specificity the nature of the dispute. The Contractor and the Owner will work together in good faith to resolve any disputes and arrive at a written agreement to address the matter. In the event that the nature of the dispute is not a material deviation from the specified work, the payment obligations of the Owner shall continue. In the event that the nature of the dispute is material, the payment obligations of the Owner will be suspended until the repairs are undertaken. SECTION FIVE WARRANTY The Contractor warrants that the work will be free from faulty materials; constructed according to the standards of building code applicable for this location; constructed in. a skillful manner and fit for habitation or appropriate use. All workmanship is guaranteed for a period of one year from the date of completion. SECTION SIX ADDITIONAL PROVISIONS The Contractor maintains liability insurance in the amount of $1,000,000.00 per occurrence and will continue to maintain such insurance during the term of this Agreement. The Contractor may retain fully licensed sub contractors for the Project. Said sub contractors will also maintain sufficient liability insurance on file with Krypton Construction Services, LLC and its principal is licensed to perform the work referred to herein. In addition, the Contractor will .retain. such other licensed and insured tradesmen necessary to perform the work described herein. This Agreement will be considered completed upon approval of the Owner, provided that approval cannot be unreasonably withheld. At the end of the Project, the Contractor will leave the Property in a broom swept condition; however, personal cleaning (i.e., maid service quality) is not provided. The Contractor anticipates that the Project will take approximately six (6 weeks to complete. The following situations will effect completion without fault to the Contractor: (1) if materials arrive late, or are damaged or defective; (2) failure of the Owner to make any payment when due; and (3) in the event that the Contractor encounters unanticipated additional work, or the Owner elects to have additional work undertaken, the completion date will be extended for an amount of time necessary to complete such work. SECTION SEVEN MISCELLANEOUS There are no understandings or agreements between the Contractor and the Owner, other than those set forth in this Agreement. No other statement, representation or promise has been made to induce either party to enter into this Agreement. This Agreement may not be modified or amended except by written agreement of the parties. If any term or provision in this Agreement is deemed unenforceable, it shall not affect the validity of any other term or provision hereof This Agreement is a legal and binding contract under the laws of The Commonwealth. of Massachusetts. Any disputes arising hereunder will be heard in the courts sitting in said Commonwealth. IN WITNESS WHEREOF, the parties have executed this Agreement as of the day and year first written above. CONTRACTOR: Krypton Co i ervices, LLC. Y Paul Pare,1 Representative, Krypton Construction Services, LLC 8/0710< 4 EXHIBIT A TO HOME DESIGN CONTRACT All Work Described in Invoice #309 and #310 Dated August -17,2005 i New windows Anderson per spec Solid core masonite doors All .Electric Outlets.& switches to Code & spec Sky Lights (3) Building New Paint Grade book shelving in specified areas Matching -the pitch of the deck cog -RO' I'' Mohaha.ny decking Trek stairs & railing for deck area All Color choice per home work sheets provided �?L-,,j 0(0 /imp _\ C� U C11- 0 oS fI �'C ()4 i�l 0 5 C s �0, Tr Ddu' �()(< co""-60 CSG p� J �c,y a IWC a NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with provision of MGL c 40 S 54, a condition of Building Permit at:�r is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: f 0, L W 0 -S -Fe -(D r Ac, 1) OCII (Location of Fac' 'ty) Signature of Permit Applicant Fire Department Sign off: 6uw� Dumpster Permit ate Department of Indaustr d Accidents Oft of Investigations kv 600 Washington Street Boston, MA 02111 www.massgovIdle Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers ApyUcant Information Please Print Legibly Name(Business/orvidual): C o ^ <1/- y eT i on Address: VO ` co .T 5 T City/State/Zip: ()2A 1?0c -f M q o t`9 60 Phone #: q'72- 6-32- S�909' Are y an employer? Check the appropriate box: 1, 04 am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub-contracion 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. insurance workers' comp. insurance. 5. ❑ Weare a corporation its [No workers' comp. and required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, 41(41 and we have no insurance required.] t employees. [No worken' comp. insurance required.] Type of project (required): 6. ❑ construction 7. [remodeling S. ❑ Demolition . 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repass or additions 12.❑ Roof repairs 13.❑ OQier .Any appnomm mm coven oox a l must alio mr eau my lemon oelow showing their women' Pommy infarrrrtion t Homeowners who submit Pots diidevit iodwadzu they we doing tit work end then hue outride coh6actas mast summit a neer e66vit indica a such tConvacoon Poet check tris box must et"ed sn additions! sheet showing the none of tete sub-connactm and Poeir wo&=, coag,• policy infornudim I ani an employer that is providing workers' com, pensadon bourenee for my empfi*W . Below is des poiby mdjob slate Information. Insurance Company Name: j� rj U d r4n e e CO, Policy # or Self -ins. Lic. #: Q W C (11 ® O '% S 4 a 0 1,2 O 05' Expiration Date: Job Site Address: S ll S �� city/State/Zip: (Vo, d k AAJOyXt ✓letg Uc8't's Attach a copy of the workers' compensation policy declaration page (showing the policy number and eVirstlon date). Failure lo secure coverage as requiref under Section 25A of MGL c. 152 can lead tD the imposition of criminal penalties of a fine up to S 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 v4rification. I do hereby c/ 7" flff� the pains and penaMa of perjury Phar the inforMM*X pmvlkd above Is arae and comeet Phone* 9?q-- T-72- 15-90e Offlcial use only. Do not wrke in this area, to be completed by clay or town ohkiaL City or Town: Perms ucense 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cky/Town Clerk 6. Other X3012 , r 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone 0: inns im—L tnt a Axiom iii►7%i %ara/avaa.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 at 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 wbo 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 darned 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 is the commonwealth for any applicant who bas 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 I enter into any contract for the performance of public work until acceptable evidence of cotnpliance with the insurance requirements of this chapter have been presented to the contracting authority." , Applicants y 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(a) 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 i 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 at3ldavlt. 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 Accideuis. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Deparount at the number listed below. Self-insured companies sboum enter their self-insurance license number on the appropriate line. City or Town OHiciala 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`inf m ation (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy -of the affidavit �g has been officially stamped or marked by the city or gown may be provided too the applicant as proof that a valid a j� is on file for future permits or licenses. A new affidavit mast be filled out each year. Where a Lome 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 yon have any questions, please do not hesitate to give us a cal 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.mm.gov/dia 08/04,,2005 THLI 10:03 FA.X 978 405 6204 Chase & Lunt Insurance It 002� 002 A CERTIFICATE OF LIABILITY INSURANCE 0 DATE (MM1001YYYY) -CORD C 'rw KR I 080q CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chase & Lunt In$, Aq.611cy Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P .0 Box 590 HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 47 State Street ALTER THE COVERAGE AFFORDED 13Y THE POLICIES SELOW. 14OWbUrYP*rt VAA 01950 Phone.978-462-4434 Fax.978-465-6204 INSURERS AFFORDING COVERAGE NAIC 4 INSURED A' AIN Mutual Ina Co. Lon Cqnstruction ServicersK94"Ingtallations, os-urim a: Et'. L11-SUREPCI PO Box 503 Essex M 01940 INSURi�k I): INSURER I-: COVERAGES I HE POLICIES OF INSURA,1ICE LISTED LIELOW HAVE BEEN ISSUFO TO 11ir INSURED NAMED ABOVE FOR THE POLICY P15RIODINOICATGO. NOTIVVITHSTANDINCt ANY REWREMENT, TERM OR CONDITION Or ANY CONTRACT OR OTHER QCCUMENT WITH RESPECT' TO WHICH'Tmls CER 1'11-14,A IE MAY BE ISSUED OR MAY PERTAIN. AIN. THE INSURANCE AFrORDEP BY THE POLICIES DESCRIL49D HFRPIN IS 6tJSJr:CT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF �UCI I POLICIES, AGORF(' AT-;: L!fAITS $HOIAW MAY HAVE BEEN REDUCED BY PAID Cmma LTR)NII T I ROFFINSURANCE POUOY NUMUER WDRn LIMITS GENERAL LIABILITY CQMfllEli(,fALGENF-RALLIABit.t'rY NPP950681 I MCH OCCURRENCE 1000000 02/05/05 02/05/06 00 0 -FREMISESS-5 1) 2 rIAW3 MADE OCCUR MED EXP (Any Enc' pemo _n 8 5000 PERSONAL & AOV INJURY iS1000000 -1. 1GENi La GREWE t2000000 GEN AGGRFGAI I; LIMI f'APPLIES PER: PRODUCTS -COIAPWAGG I s2000000 AUTOMOBILE LIABuTy ANS' COM31NEO SINGLE LIMIT ALL OWNED AUTO$ I GORILY INJURY SCMEDLILED AUT i (Ppr person) $ I HIRr()AVT0J3 I NON -OWNED A01-5 nDiLY INJURY (per awd"I' GARAGE LIABILITY ANYAQ IL) PYCESSIUMBIRELLA IJA9(U'Yy CLAIWIS MADE RETENTION VMRVEP3 COMPENSATION AN13 EMPLOYERS' LIABILITY ANY PliOPRISTORIPARTNE�XE,:CU7,.VFj 3rFIcFR/WCf0fIPR F;XCLUDErJ7 cotqfimuation of coverage$, TE HOLDER ITORYLIdgITE VWC6007840012005 03/09/051 03/09/06' L, CACH ACCIDENT i> :L00000 E.L_ E)IqWE - EA EMPLOYEE' $ 100000 191, DISEASE - POLICY LIMIT I S 500000 N KryPtOft COnst�ructxon Services PO Box 503 Essex MA 01940 (2001/08) CANCELLATION KRYPTON SHOULD ANY OF vir AfWW9 DrSCRIM POLICIES RE CANCELLED BEFORP THE EXPIRATO DATE THEREOF, THE ISSUING INSURER WILL 5NDEAVOr< To ,,jAfL 10 DAYS WRITTEN NOTICE TO THE, CF11TIMCATC HOLDER NAMED TO I'kr-. LrFT, BUT FAILURE T'UD0 SO SHALL IMPOSE NO OBLIOATION OR LIABILITY OF ANY KIND UPON IttE INSURER. ITS AGENTS OR REPRPiSFNTAnVPS, All 11: 1 )4: 1 1-14: l�i R E ENTATIVr 80%"'e- Its. AUG 04,2005 10:53 CHASE,&LUNT INC 978 465 6204 Page 2 PROPERTY DAMAGE - (PC, AUTO ONLY, FA ACCIDENT OTHER THAN EAL ACC AUTO ONLY: — S aACM OCCURRENCE AGGREGATS ITORYLIdgITE VWC6007840012005 03/09/051 03/09/06' L, CACH ACCIDENT i> :L00000 E.L_ E)IqWE - EA EMPLOYEE' $ 100000 191, DISEASE - POLICY LIMIT I S 500000 N KryPtOft COnst�ructxon Services PO Box 503 Essex MA 01940 (2001/08) CANCELLATION KRYPTON SHOULD ANY OF vir AfWW9 DrSCRIM POLICIES RE CANCELLED BEFORP THE EXPIRATO DATE THEREOF, THE ISSUING INSURER WILL 5NDEAVOr< To ,,jAfL 10 DAYS WRITTEN NOTICE TO THE, CF11TIMCATC HOLDER NAMED TO I'kr-. LrFT, BUT FAILURE T'UD0 SO SHALL IMPOSE NO OBLIOATION OR LIABILITY OF ANY KIND UPON IttE INSURER. ITS AGENTS OR REPRPiSFNTAnVPS, All 11: 1 )4: 1 1-14: l�i R E ENTATIVr 80%"'e- Its. 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