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HomeMy WebLinkAboutMiscellaneous - 864 CHICKERING ROAD 4/30/2018 (2)N � m O �, I p I� Z Q a T O A b � o j0 00 0 0 v C � U) 0 -0 O CD CD CL r - S O CL D cc. cn O vCD CL — Cr CD CD O Im ou CD CD v . _, N CL CC C ' � v 0 z CD O X z CD 3 O CD O r D 0 z O -h rr N O ca O S. c� (D (O O 2. cn cn -0 CD o=�- _ <• (Dr (DD U' MO Mn CD (D 0 - n 0 � = C) � m o � �-a N 0 Fri h=saFD Ln ri :3 2) o (D 2 F � 0 O ca rt n .rS( S (DD (D•a� � O �' 2 O� O O W �. U) -a : O �, S f i S (SD N Q C O=r- CL0o• CL Co. o o (n < N O �, �CD CL W(D r D as � C .At O C'1 O rt rt (D (T �CD -0� r ciN O h DCD rt � O _rt 03 O C O �q 0 LW O wommo. N N O� p-41# (n O m Ln mj OZ co C o rn M D m z T A r G1 H N O T N (n O G :;o r_ r- m A M m -� -n RL ]j r C m T N () j N .Z7 T C v O 0 O WN C G z V m 0 N "a N N 3 T Q � P 3 N ' Go z O m = 4-64 Major Window & Contracting 21 Lexington Ave. Methuen, MA 01844 MA CS. # 86282 MA HIC. # 134277 Phone # 978-807-3416 Majorwindowandcontracting@yaho... rax # 978-688-0644 'Mark & Maureen Hentz 1864 Chickering Rd. No. Andover, MA. 01845-1912 ;'978-886-0109 Job Address I Same ---- .... .. 'Furnish and install 24 Harvey Classic white vinyl replacement units. (21 double hung and 3 picture window units). All units to have Energy Star efficient glazing, half screens on double hung, grids between the glass to match existing windows ( kitchen area to conform to the rest of the house), white exterior capping of window sills and casings. Repair 4 exterior sills and casings. Haul away all debris and clean work area. No painting is included. If lead paint exists an additional $ 30 per unit will apply. Building permit included. CA1?4i Invoice 6/29/2016 14,200.00 14,200.00 Total $N=NMX 08-03-'16 13:14 FROM 9785572130 T-091 P0001/0002 F-081 cG�RD� v CERTIFICATE OF LIABILITY INSURANCE DATE(MM/) 08/03/20182016 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS .ERTIFICATE 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, subjact 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: Michaud Rowe and Ruscak Insurance AssocBONN PO Box 188 North Andover, MA 01845 FAX No): 978-557-2130 E-MAIL ADDRESS: FKQDUqLR CUSTOMER IP 9, 09/06/2016 INSURER(S) AFFORDING COVERAGE NAIL# INSURED INSURER A: Hanover Insurance CO INSURER 0: GENERALAGGREGATE $ 2000000 Major Window Installations Brian Major 21 Lexington Avenue Methuen, MA 01844 INSURER C INSURER o AUTOMOBILE INSURER E: INSURER F: J COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TME POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R TYPE Of INSURANCE ADL USR NUMBER POLICYPOLICY M/DD EFF MMIDD EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR i —' ` -= OHN-5719575 09/06/2015 09/06/2016 EACH OCCURRENCE $ 100000 PREMI E pr�yner7pe $ MED FXP (Any one person) $ 5000 PERSONAL &AOVINJURY $ 1000000 GENERALAGGREGATE $ 2000000 GEN -L AGGREGATE LIMIT APPLIES PER: POLICY , PRO- LOC PRODUCTS - COMP/OP AGG $ 2000000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS J I I ED SINGLE LIMIT CO Bd (Eae$ BODILY INJURY (Per person) $ BODILY INJURY (Per accdent) $ (ROPERTY) AMAGE $ Per accident $ I $ UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S '""—' DEDUCTIBLE RETENTION $ S 13 WORKERS COMPENSATION AND EMPLOYERS' LIABILRY Y / N ANY PROPRIETO"ARTNERIUCCUTIVEN/A OFFICERIMEMBER EXCLUDED9 (Mandatory in NH) if under Syea, AI P be �J I J To Be Issued by Carrier WC STATU- OTH- I TORY LIMITS ER E,I-. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A-,.,,., •.i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Scheat ie¢ K more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 1600 Osgood Street POLICY PROVISIONS. North Andover MA 01845 AUTHORIZED REP NTA ACORD 25 (2009/09) ®195'$- 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 08-03-'16 13:14 FROM- 9785572130 T-091 P0002/0002 F-081 Ae"Ra CERTIFICATE OF LIABILITY INSURANCE I DATE(MMnArn100"" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 nCi ME T Jason Michaud MICHAUD, ROWE AND RUSCAK INSURANCE ASSOCIATES, INC. PHONE E (978) 688-8829 FAx No E-MAIL ADDRESS: michaud mrrinsulance.com INSURERS AFFORDING COVERAGE NAIG0 PO BOX 188 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 NORTH ANDOVER MA 01845 INSURED INSURER B MAJOR BRIAN DBA MAJOR WINDOW INSTALLATION INSURER C: INSURER 0: INSURER E: 21 LEXINGTON AVENUE INSURER F: METHUEN MA 01844 CDVFI2AGFR CFRTIFICATF NI IMRFR• 7d7R7 DC\fieInki ur IMRCO. 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. 1NSR I TYPE OF INSURANCE ADL a OLICY NUMBER P LI EFF !DD/YYYY) POLICY EXP IMMIDDffYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1:1 OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ MED EXP (Ant one on) $ PERSONAL & ADV INJURY $ N/A P -L AGGREGATE LIMIT APPLIES PER: POLICY � jECT LOO GENERAL AGGREGATE s PRODUCTS-COMP/OPAGG $ $ OTHER AUTOMOBILELIABILnY =SINGLE LIMIT $ ANY AUTO I BODILY INJURY (Per paraen) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOSAUTOS P I PROPERTYDAMIAGS P r ccident1 $ I $ I UMBRELL,ALIAO OCCUR — EACH OCCURRENCE s EXCESS LIAR CLAIMS -MADE NIA AGGREGATE $ OEd RETENTION S $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILrTY YIN A�ICERIM ETOR/PARTNERIDCECUTIVE OFRCERlMEMBEREXCLUDED? N!A (Mandatory In NH) If yea, describe under N/A N/A 7PJUB0236M05015 09/11/2015 09/11/2016 V I PER ERH- /� E,L. EACH ACCIDENT $ 100,000 6,L DISEASE - EA EMPLOYEE s 100,000 E.LDISEASE - POLICY LIMrr $ 500,000 DESCRIPTION OF OPERATIONS below I NIA DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Iy 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.govllwdtworkers-compensafionAnvestigations/. Sole proprietor has not elected coverage. Town of North Andover 1600 Osgood Street North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4;y,MA 01845Daniel M. CPCU, Vice President — Residual Market —WCRIBMA 4.) 1988.2074 ACORD CORPORATION_ All rinhfs rowarvael ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth o f Massachusetts Department o f /Industrial Accidents F 1 Congress Street, Suite 100 ' d Boston, MA 02114-2017 www mass.gov/dia Svc 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE JE'ILED WITH THE PERMITTING AUTHORITI'. Name (Business/organization/individual): U Address: City/State/ZiD: tki-A 0,9, VA �U t S4 �i Phone #:. Are you an employer? Checktiie apprropriate box: I 1. ❑Tama employer with • ! employees (full and/or pari time).* 2. 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3_ Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. [-]1 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 proprietors with no employees. 5. ❑ 1 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. insirance.t 6. Q we are a corporation and ip officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no.,employees. [No workers' comp. insurance required.] 0 £7 Lem 1-.t ) 760'8073`1 Type of project (required): 7.. R New coristruction 8. [] Remodeling 9. ❑ Demolition 10 L] Building addition ILL] Electrical repairs or.additions 12: (] Plumbing repairs or additions 13.-[(Roofiepairs 14. ® Otherj,,,j,.& D1,J 5 *Any applicantthat checks box -RI must also Id out the sectton nerow snowing uGu wuince ux� amu.. il policy information i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must s4bmit anew affidavit indicating such. tContractors that check this box mvst•attaghed an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the subcontractors ave' employees, �liey must provide their workers' comp. policy number. fain an employer that is pioviding workers' compensation insurance for my employees.' Belo* is the policy widjab site information. Insurance Company Policy # or Self -ins. lir,. #; Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compepsation 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 DIET for insurance coverage verification. I do herebycern under thepains andpenaides ofperjury that the information provided above is true and correct T - - - n " „"f,..- S/ ? // 4 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. PIumbing Inspector 6. Other Contact Person: Phone -eIp�Ao2'ss-em-m. 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METHUEN, MA 01844 SCA 1 0 2CM-05111 - �e �ponrmranaretcl��- o���6srrc/rtael�6 ffice of Consumer Affairs & Business Regulation WOME IMPROVEMENT CONTRACTOR egistration: ` 134277 Type: - Expiration: 10/19/2017 DBA MAJOR WINDOW INSTALLATION— - BRAIN MAJOR 21 LEXINGTON AVE. METHUEN, MA 01844 Undersecretary Type: DBA Expiration: 10/19/2017 Tr# 271678 Update Address and return card. Mark reason for change. Address D Renewal F] Employment E] 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 Location U tk` No. �`� — - Check # `2 301503 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ _ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector',.--' v V)' 0 70 O CD n Z N (DO e� �• N 0 O vCD CD O C�= Cr as s CD O W W CD 'v�'� CL = N CC C � v O Z CD 0 n �"♦ 0 71 cfl CD n e� W c 2 Z c 0 rn Z CA �rn cn VI O Z tr�l cn O O z O CD N O CQ O W Q. csz CD to 0 0 E cn cn CD p = � :3 y; < .r CA c (D• CD 0 CD r.L C o � � $ v, = Cn rt FD - 0 D O. O O •� Q. O W -tea N o m CD Q. 13) @: CD O Q. O c7 to (/) o n D) �I O ,F SC � CDD CD O < CC O OO ., U) �"— z CD 0. 0 Cr �- CD Cn D D N 0 = O co Q. _ N CDN': CD �CD CL C��CD do G CD N rt CSD 0 O U3�. �� - O CD .N CD ..•.CD r. C.) N =to T DC Z CD @� O p1 O CL r N 0 m Fn 2 N N W T �oT V1 x T 7O T r) ]O T N T O � (D r -r 3 T m -1 O Oc S N W N m [7 -� 3 N O < NS O =E m m n Z H V '4 0 3 O S r C cl Z N m m � 0 O' N _S 7 O =rCL O 3 p :3 3 C p z V) O O c Cl m O 0 CL \ n s (D D O v p S n x r RISE ENGINEERING 60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: (Property Address) Al vee-, 1114 c� o (Property Address) hereby authorize �bY1, (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. C � L� �- 40wer5stign�ature s -I.-> — e31U /to Date C Federal ID S 05.0405629 RISE Engineering RI Contractor Registration No 8166 VA Contractor Registration No 120979 E%� A division of Thitlsch Engineering RISECompany /�1, Address, City NLA 00000 ENGINEER��* .� ARA �� 401-123-1234 FAX401-123-1234 Page 1 PROGRAM C ►'t�-111:5 E QREEERRMD�ANND ISS W cCUSMARED ER FOR%GMEVUMAS DESCRIBED OEM CUSI ER PNDNE DAM CLIM4 vfm DICER Maureen Hentz (978)88Cr0109 05/12/2016 A134592 SERVICE SWIFF etat7ND SIREE1 864 Chickering Road 864 Chickering Road SERMCE cnY.SS%1 zP DMLRD CN. aP r..% 3 of North 845 North Andover, MA 01845 moi G:116 JOB DESCRIPTION U U1 PHASE ONE -Proposal for this calendar yexr. - Y 50.00 AIR SEALIN n r and materials to seal areas of your home against %wstcftl. excess air leakage. Thi%twrk %till bL performed in concert %lith the use of special tools and diagnostic tests to assure that your home %oll be left %lith a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary areas for scaling include air Icakage to attics. basements, at Cached garaws and other tnhcatctl areas (windows are not generally addressed.) This %%ill require (12) working hours. A reduction in cultic feet per minute (cfm) ofair infiltration %+ill occur. but the actual nu rnber of cfm Is not gwranteed. At the completion of the %wot herizat ion work, and at no additional east to the homeowner, a final blower doorand'or combustion safety analysis %till be conducted tn• the subcontractor to ensure the safety of the indoor air quality. $1,020.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unlaced fiberglass baits to 140) square feet for damming Purposes. $82.00 STORAGE BARRIER liomcoancr is responsible for the removal of the stored items blocking the installation of ncathcriration %wrk in the attic. Removal must occur prior to the scheduled %%ork start. S0.00 SLOPES Provide labor and materials to install a 6" layer of R-21 Class I Cellulose. added to (80) square feet of slope arca. Wherever possible baffles %%ill be installed to the entire length of each hay to maintain ventilation space. S148.80 KNEEWALLS: Provide labor and materials to install R-13 faced fiberglass to (262) square feet of knecmill. Then install 2' rigid board insulation. Scat all scams %%ith FSK tape. HOMEOWNER TO REMOVE ALLUMiNUM FOIL. 595630 STORAGE BARRIER: Homcoaner is responsible for the mmoval of the stored items blocking the installation of %wnthcriraion work in the kncchwll areas. Removal raw occur prior to the scheduled Work start. Su.00 KNEEWALL FLOOR: Provide labor and materials to install a 12" layer of R-42 Class I Cellulose adkkkd to (64) square feet of open knee wil floor. $93.44 KNEEWALL FLOOR: Provide labor and materials to install a 9" layer of dense packed 11-33 Class I Cellulose added to (224) square feet of knce%wll Moor. 5405.44 A'T'TIC ACCESS Provide tapir and materials to insudate the tick of the attic door %%iih 2" rigid Thcrmas board and seal the door's edge: with weatherstripping to restrict air leakage. 5144A4 Federal In 9 OS -06115629 RISC Engineering RI Contractor Registration No 8186 k1AContractor Registration No 120979 vi!tr ► division or7hiciscbFAgincerinp RISE ENGINEERING' Company ;Wdrcss,City,Ai►00000 CONTRACT 401.123-1234 FAX401-123-1234 Page 2 PROGRAM CNIA-1111B EENaHE RANDINEanIO FONtWOORKAEA S OEscPjKD BEIM•! cus=ER PHONE DArCUENTS W= ORDER Maureen Hentz (978)886.0109 05/1212016 434592 00003 SERVICE avtEET anuNc STREET 864 Chickerine Road W Chicketina Road SERVICE giY. sWTE. DP OWNG crN.SATc. DP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION VENTILATION: provide labor and materials to install ventilation chides in (36) rafter hays to maintain air flow. $72.00 VENTILATION: provide labor and materials to install ( 4) 4" X 16' rectangular alwnimmm soffit vents to increase ventilation in attic areas, Specify color: White or Cray. 5100.00 VENTILATION: Provide laborand materials to install (4) 6" X 16' rectangular aluminum soffit vents to increase ventilation in atticarels. Specify color: White or Gray. $100.00 COMMON WALLS: Provide labor and materials to install 2' f :SK fatal semi-rigid fiberglass board insulat ion to (32) Uwe feet of common wall area. $112.00 CRA►VLSPACE: Provide labor and materials to insaall (400) square feet of 6 ml polyethylene over open ground in designated cmvdspaccleanhen basement areas. 5308.00 RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible muasures, Columbia Gas offers 75% incentive. not to exceed $2,000 per calendar year. and an incentive of 100% for the Air Sealing measures up to the first S6S0 and an additional $340 it savings are justified fel• the auditor. For the safety and health of your home's indoor air quality, we will be conducting a blower door diagnostic of the available air now in your home both before the wort is beam, and after the weatheriration wort: is complete. We will also conduct a full assessment of the combustion safety of }roux heat ingsystem and wetter heater. This tins a value of S90 and is at no cost to you. Tota( allowable wtatherimtion incentive isS3.1 10. S90.00 BE D 1 !0I6 L 1 �' Federal 10 0 05-0405629 RISE Engineering RI Contractor Registration No 8166 MA Contractor Registration No 120979 A di�sien DEThiclseh Fn�inceri0g RISE IF ENGINEERING' Company Address, City, L-1011000 CONTRACT 401-123-1234 FAX 401-123-1234 Page 3 PROGRAM US CCUMCTM REDOASCMA-11FS IMMRMA07MCtSMMR K DESCRIBED BELOW CUSIMER PHONE DATE CUENTB WORK ORDER Maureen Hentz (978W x0109 05/17/2016 434592 00003 SERVICE SWEET BILLING SWEET 864 Chickering Road S64 Chickering Road SERVICE CNN. SAI., aP BKLING CIN. SAE, ILP North Andover, MA 01845 North Andover, MA 01345 JOB DESCRIP170N Total: $3,632.42 Program Incentive: $3,001.82 Customer Total: $630.61 WE AGREE HEREBY TO FURNISH SERVICES- COMMATE W ACCORDANCE WITH ABOVE SPECIFICATIONS FOR THE SUTA OF *'"Six Hundred Thirty & 611100 Dollars $630.61 UPONFINALDNSPE APPROVALBYRISE£NGNEEItlNO.=OERACREESIDREWAkJMTDUEDIiRLVMFtESTGF1% I'MISECNMOEDLOMYONANY UNPMD RAIANCE AqM 30,60S. SEE REYERSEFCR LON CH CUARANEES.81MMOFRECStOKSC1EDU1DI0, AND CONRAMA REGISIUIIM O I SIGN THIS CONTRACT IF E 4 ANY BLANK SPACES A D S .RISES . NDE: LOS CCNRACTLSSY DE VaIMRAWN/ tF NDIEaECtrED WILKN DAEDFACCEPANCE ACCEPANCE OFCONRACT.9E ABOVE PRICES, SPECIRCATONS AND CONDn IGHS ARE 30 DAYS. SATSFACIDRY A US AND ARE HEREBY ACCEPEQ YOU ARE AU11CRUM ADO IIS WORK AS 3PECMED. PAYLL•NTWILLBE RW E AS ODUMED ABOVE AY 1 3 2616 The Commonwealth of Massachusetts 1w,-\ 4Z. Department of Industrial Accidents Officeof Investigations kv .1 Congress Street. Suite 100 ZY Boiton, M -A 02114-2017 4-1 wicle,mass.gaildin NVorkem' Compensation Insurance Affidavit: Builders/ContractorsiElect riciansliflumbers applicant Information Please Print Legibly Name , B-jmm,, inji i iduLl C Address: 00 130)t 314 C Phone- t: 9 "T V -!) I Lo - 34 .5 Are you an employee! Check the appropriate box: Type (of' project (, required), am a eTal {,,nmacvn and, I I emplovc-cs I f;ja Lnd or -pari-tin-te 0 ha,. c hired ehesub -coo; adors 0 -n 11sted'on the allachuE i0leel. ship. and have no crnpiovcz-, haw %Vorlorig 1,or me ;n anv wpacil�, ernplo�c%�s and �vorkers* 9, Building addizi Non [,�o W-orkims, rcquirc-J-1 5. COMM M�iluralzlck��, We zirc a corvQratioa and its I L- fecu-ical mpair, or 'Widitiorl's I -ndho r doing H �Xofk- M—�vvn oing al a. Mc 11,4% e t�xer,�,,Wd the"r I I 1,C) Plumving rcPairs or MV_ LV vvorker�- �.�omp, j right jo, exemplion pee MGL I 12.0 Root repairs insurance rcquir�dj » c. 152. }t -t). and I u t . , i Other ewpltryeo- tNo kvotkels, 1 -11) ctylllp. m5urallce !CILY'Aired'] 3,4w 1'11 +,qjl 1, tvku lvr; 4 3 Himwowrwn -Asi, I I <, vAl.tv - , .six ,a I ,T; o-r.!rac.'4ra m Mwil Pnividc L�67 WuTkcn,! :o:q, ;mInbc, Aelowt, is the jmficj, andjob site ififiormafion. 11'suralicc lm —ft-(ILLOL I Expi.rawin Date: Policy =t or Self ins, Lic. Jol> Site:add{-, : City state zip,tj—, ri 4- o� e LW Aaach a copy of the workers' comprnsatitin ficy declaration page Ishowing the policy number and expiration date). I pcna - f 14jilure,60-'ecure cw orage as required ander SLim, -1 �tii5A ol,-MOL t:.2'c � 15jr, leadw, tfw impusition ofc6rc&ial it�e, oa file up S 1 7 MKI(A) and onc--viw Tnp-a'+(;Tuwn;, L4S tk-01 a,s cl6 I ptruhics sit flit', ffmnolr a 51 OP WORK ORDER and a fits: ol,41"7 to S2,sof n, 'clay gailmT Thevi,olat(w- He adv iwd thw;t cony of tis stat;nnen( may b.- for%virded tO the 00,11ce of Pf the DIA fiv in;amnz, covcrago kerifiijfiorl.. I do hereby rcrrify ander the pains and penalties of ' that the ittfitrmation provided above 4 feria and carreel. U -,Y. PhoTT 1� IN - 34 Official uvc only, Do not x=rin, in this areii, to be comphewd by cin, or lown a Ilial. City or Town: Permiti'Mcenw # Issuing Authority icircle one): I.board afHealth 2.Building.Department 3.Ci1YT7'o%wn(.'lerk 4J'lvctricallwq*ct.or 6. Other Contact Phone #: AC4R0® CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYM 7/7/2015 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 Martin J Clayton Insurance Agency, Inc. Northampton Street P. 0. BOX 989 Holyoke MA 01041-0989 CONTACT NAME: Nancy Usher PHONN Ext: (413)536-0804 FAX No (413)534-7874 (AIC1649 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Nationwide Mutual -Harleysville NATIO INSURED Gauthier Insulation 44 ESSEX ROAD IPSWICH MA 01938 INSURERB:Allied World Natl Assurance Co INSURERC: INSURER D: INSURER E : 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 REVISION NUMBER: 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 SUERPOLICY POLICY NUMBER EFF I POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE � OCCUR DAMAGE TO RENTED 50 000 PREMISES Ea occurrence $ � MED EXP (Any one person) $ 5,000 X GL43487F 7/6/2015 7/6/2016 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ JECTPRO ❑ LOC PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acc dent BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 B EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ BE020792125-194985 10/18/2014 10/18/2015 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If as, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED 1"3illliil41SAlL3i191A Uh110 Ly a A A1It I Lei � MASS SAVE PROGRAM CONSERVATION SERVICES GROUP, INC. 50 WASHINGTON STREET WESTBOROUGH, MA 01581 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sullivan/MEG ©1988 2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MPIU tbd with pi fFactory trial version www.pdffactory.com �....- .ACCIRV CERTIFICATE OF LIABILITY INSURANCE 3{Ifit70I5 THIS CERTIF:CA.TE 1S ISSUED ASA 44A:TTER OF INFORMAii'D:d ONLY AND CDNFERS NO RIG„'r'S unN T E CERTIFICATE HOLDER- THIS CERTIF-ICATE, DOES Wir AFF1fiKATWELY 09 tiFGAT4rE1.Y Ai"4END, 5 Er'D OR ALTER THE COVERAGE kM;DED BY TtiC POLICIES BELOW THIS CERTIFICATE Or INSURANCE DOES '.OT COKSTITUT: A CONTRAC, `9ETWEEN TME ISSVIN^ It, RER(S). AUT-i0FIZED REPPESENTA IVE OR PRODUCER, AND TME CER7I�ICATf Ht}LDZP- IM?ORTA.NT: Ef the certcrzte home- is an A-30 TIONA ER-SURED, the pohcYlf!s;1 mutt be eradersed. if SUBROGATION 1.5 WAIVED. sub? -d :0 :t* tmis and cciidttons of the pots^;^, certau. pOicies ” reggLe an e: Oorsrrnent. A staterr.ent on Ms certlkg a doCS no_ confer Nhu to the certr`rcate harder in Neu :of sw,;h eT+d9rsg�Ttiil$}. Martin t Inson 5t POBency Incox 989 1644 Northampton St P4 E1 Holyoke MA 03041 Serkley Asxlgned Risk Services .i. F� c 18M 8s4-+15es AS wn.s (855) 215.8I I E tics c5exsj3?tx�ek.klFiGkcA i"Su=�A_i : &'�ft�s+v ♦".{s'.iRM,aE 1 H4L� F t rwsAeEt+. h: k� C., 333 Gauthier Insulation Inc PO Box 344p. Ipswich, MA 01938 •dM+ry.'. a C. P, a+rx.+2cn = A.V vCr%AUtQ Ltlt I Ir ILA 1 t NUiMIStlt: FIFVi_Stom NL1FdF41-R- I ii -S 15 TO CER -t Y T►,k T 'a he POLICIES OF AV=- F LN iS'-5UED 7CT iE k SURED FW.'ED p$OV_ F£}F; i H=_ Pa #CY PT;5 CPO t—solcATE. WUTWTHSTAYDING ANY PE UOZEMVENT, TEPMOR CON017i(k,« or ANY CON o FACT OR C ThER DOC --WENT T Wrth RESPE'. T TO YMCA+ THZ CERTIRWE MAYBE ISSUED 00 MAY PEK7AI4, 11L' BY 7"E PWCIES DESMISED HEREN iS SWUSCT TO ALL +'"iE TEPIiS Y EXC UMONS AND Cow"' atas, € OF Sct41 ooctE5. LDAITS 5a+,ttVV\'� VAY KAVE BEEN REDUCED SY PAID �N�c A. f..k T+.'rE C`.cA$u'LfdiA:E IF.•m 7h;i FQ IGY h,a(°{r; _ •dM+ry.'. a a*k{ray4'Vwi LAC,$ 4E�LRAt UAl4R,Rt i - Er.[.�-t i7G�444fAEGi... % { CCL400CRC 4 v;€'.N.'ERA:! 4e,L^, C�ese.U-SES'Ea acswnE S j 0 QAVASKA:eF .7)c -*Lf �' --� ! �.. i w=y'.tt � S VERS[ Al AAJL'i..A1Qf S A3: p- 'E S aEi,'i!Lfi.1iaGA { LCN."i Ati�.B)a?. ax c. E _ T j_1 loc l i" {4R0lFOB" LIABLITY -M1 ALT✓ AL, O�wto D 5c—EX''LE A,TCS D !. •tlI? AWCn a^nta DUA E $ ;ter rrt]rn Vr-@AfLU :JD r OCi�.'R t f.rt EA::ti>�:GJRAfFs;.E .S EXrE*,$LV-6 C;.h*a-MAX xrz' L. s wopimn cowm AT -ch AND EINLCYF:R$ UAakAy Tit: G=YCI kLh^5. Mil to -S AFiM-taEnsd.eaecaxryas Ay'> ('riafET'4M�'�ARr<; t �raE -j. L7 htvZ.RP4032'r 1a,3C12015 10,rGt2016[ ot-i f.+r1C'EE SOt%- o►.� Awy.(7i a , c>.. ?farJ MscfP'Oh OF Of''`:RF r.04. btgx 7 i z5G r -1 l+'e'ft r x;ATAXVS .' ;T—M i'z6.4-,Z''v9 -6 * d*,lA`, t -?T iDa:d .3 '!p'a'E vx ' iICLIJ. �afQ'♦Cn' lriR>4<ji`p.'7, Ay -q,. F�S...,ACAmu�>wi: UER i IFrr.ra I e m LUrN ACORD 25 (2010/05) 8PAZ 3139 54+C)1.+tS: AarrCF Tt{f A* s;7i°E 'ISEE, F'D_ 9CAE£ &E r.A)4 £ 1 E-- WORE Clearesult THE EX• R,tTON NATE . Rs44'. *til I £ tS` SE SP-1%VUM LN Contractor Sacs ACCG.RZ-A s W..T°ETHE M C" DOw-s1041 tcv Ea,r _ 50 Washington Str*et,.� Westborough, KA 01583 -�fF-T`�fi �✓�' 'gnatufe: ACORD 25 (2010/05) 8PAZ 3139 ° t ca Ekw CL � .fIx�k��� : � '29§■ J z ci / �� � 7 00 m Of (3) W W T- C) < F- C,) (SOU < 0x Lr- YYaa- % CL 4� c u 0 U i5 cl,C,3 0 Ln _> 0 =o 2% C C ac L u zu- .2 OL .2 2-- cl> 040) ox, — li F -LC 12 D 0 c o ' a, x �j\ 'o t: tn 00) w 4- W 0 a CE 6 C> 0 Cd 00 m Of (3) W W T- C) < F- C,) (SOU < 0x Lr- YYaa- % CL 4� c u 0 U i5 cl,C,3 0 Ln _> 0 =o 2% C C ac L u zu- Of 2-- > 040) ox, 12 D c o > �j\ 'o t: tn 00 m Of (3) W W T- C) < F- C,) (SOU < 0x Lr- YYaa- % CL c GQ yE i5 0 O _> 0 =o 2% C C ac L c I% 73 zu- Of 2-- > 040) ox, 12 D c > lit 'o t: tn E &Z 0 a CE 6 00 m Of (3) W W T- C) < F- C,) (SOU < 0x Lr- YYaa- % CL i5 0 _> 0 =o C C ac L zu- Of 2-- 040) ox, O 'm- U, D < lit Date.... �.................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that................. .................................... has permission for gas installation C��r. .....*&pv,.. cid......... inthe buildings of ................................................................................................................... at .......... N ; h dover, Mass. FAO! J0..... Lic. No...... GA INSPECTOR Check #�a Fi G 018 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I ...... n10i'TH ._ .i? IIa2_- ....___-.._ --_ ._. __. MA DATE tP. _�o . j S _ PERMIT# JOBSITEADDRESSOWNER'S NAME a�lo ,G OWNER ADDRESS C.v.ic•.�.4�'-`.._ w•A TE FAX— _. . . TYPE OR PRINT OCCUPANCY TYPE COMMERCIALQ EDUCATIONALE) RESIDENTIALZ . CLEARLY NEW:[] RENOVATION:O REPLACEMENT:x PLANS SUBMITTED: YESQ NDE] APPLIANCES 7 FLOORS-* BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER -FIREPLACE - I__ ._ 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 _..- ._--- ____j -..._.. _..._.._. __ OTHER....__ . --- - __. _ .. _ .. _.._ . 1- ---- — ---- ------ ---- ----- -- : - -- - - -- --- ._ ___. _ INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO [71 I IF YOU 'CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R� OTHER TYPE INDEMNITY E] BOND Q 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 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit'issued for this application will be in compliance/ib P ' t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME $co'TT t-CfYE%� ._ _ LICENSE # �2oSZ_ SIGNATURE MP aMGF JP 0 JGF ® LPGI E] CORPORATION [A# 38- PARTNERSHIP 0# LLC E]#I COMPANY NAME:RRos sVeVN�-E s ADDRESS ©3 L4--,At-ca-,j y -r CITY STATE ZIP Lcit t z TELFAX CELL EMAIL MetLife Auto & Home® Homeowner Operations Field Claim Office Attention: Claims P.O. Box 6040 Scranton, PA 18505 (800)854-6011 February 11, 2015 North Andover Building Inspection 1600 Osgood St, Suite 2035 North Andover, MA 01845 Our Customer: Claim Number: Date of Loss: Maureen C. Hentz JDE88976 4X February 3, 2015 Dear North Andover Building Inspection: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 3B, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 864 Chickering Rd, North Andover, MA Sincerely, Larry Branco - FLD Metropolitan Property and Casualty Insurance Company Senior Claim Adjuster (800) 854-6011 Ext. 7177 Fax: (866) 958-0736 Email: lbranco@metlife.com MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI. MPL MA-REGDEPT Printed in USA 0698 Location .J No. �� Date A" �l TOWN OF NORTH ANDOVER p Certificate of Occupancy $ * _ Building/Frame Permit Fee $ ,ssA�MUSE� Foundation Permit Fee $ PAID 614r Permi(Re $ Sewer Connection Fee )OCLterr Connection Fee TOTAL Coljeftf Building Inspector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP KVO. LOT NO. I 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE ZONE SUB DIV. LOT NO.I LOC MON PURPOSE OF BUILDING /61.y OW R'S NAME t� NO. OF STORIES SIZE OWNER'S ADDR S fj V BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET "' POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL ?UT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR FEE PERMIT GRANTED l.L .J 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST 6040. EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR I 'NV-ld 101d S30V"Id3H SIH1 'a3S0dWlM3df1S '013 'S39VU 'V9 'S3HOHOd H11M 'SVNIa'linl3 d0 SNOISN3WIa 10VX3 aNV S3N11 101 W02dd 30NV1SIa aNV 101 A0SNOISN3Wla 10VX3 MOHS1Sf1W N01103S SIHl V Z I I AON Vd!1000 I OU033V 9NIa11n9 0NIIV3H ON _I PJC I +'t P"L 1.W.9 JI81J313 110 SWOON dO 'ON L SV9 S631V3H 11Nn EXLH 1NVIaVd ONINOI114NOJ MIV _ SM31dV6 QOOM dOdVA 80 M.1.M lOH 1. WV31S S10J '8 'SW9 1331S 'S10J 8 'SW9 839WIl NMnd MIV IOH 03J8Od 3JVNMnd SS313dId ISIOf 40OM ONIIV3H I1 I ONIWVNi 9 OOV4 3111 bOOld 3111 SRn1X11 NM300W ONHOOM 1108 _ M3MOHS 11V1S 13AV80 '8 MVI `)N19Wnld ON 31V1S ANIS N3HJ11A S30NIHS DOOM QOiVAV1 S319NIHS i1VHdSV 13SO1J 831VM 03HS 1V1d 1319WVJ 1'Xld LI 'WM 131101 08VSNVW 'Xld EI-H1V9 d1H 318V0 'JNI9I{.Wwf11d Old dOON 5 3MOIa3dns Mood I I ONINIM 9WV8d NO 3NO1S AMNOSVW NO 3NO1S A19 M34NIJ MO ':)NO:) _I MOON 8 'sd1S JI11V 3WVMd NO AJIM9 A8NOSVW NO AJI89 —� _E E k—, _ 8 3111 'HdSV NOWWOJ 3WV8d NO OJJn1S � AMNOSVW NO OJJn1S ONIOIS 183A ONI41S SOIS38SV 0 tA(JdVH °ONIOIS 1lVHdSV H18V3 S310NIHS QOOM 313MJNOJ OM; SO V09dNIGIS sdooll 6 �I S1lVM b N3HJ11A NM340W wood OV3H S3JVld 3dll 1.W.8 ON V36V.JIIIV NIA V38V .1.W.8 'Nid- llnd V38V 1N3W3SV9 E E � L t NIdNn 11VM AM M31SVld Q. MaMVH 3NId 8 VOIV31NI 8 SM3ld 3NO1S 80 A0189 'A.19 313MJNOJ 3138JIJOJ HSINId NOI1VONnoi Z N0u:)nZ:I1SN00 SIN3WIMVdV S3JIdd0 #-- A11WVd 'I1lnW S31N0!S A11WVd 310NIS Z I I AON Vd!1000 I OU033V 9NIa11n9 Z O cr N Q) T r a ?1 m s m 0 "h c _v V: • o c MM7 m o c 3 0 c oa C 0 �to z cc r � w m m c v � � O O �• eb 'C m? r' T O C a-• S c o0 wwo f1 < 0 M t eD ; P O z c Q. m N P► S o. -v eD ov 3 �v y• O m(A to '" C)p fl. cr N 0 E: l. 0 do H _a o O� CA fo y A (n Q) T r a ?1 m -t ii m 0 "h c S A o c N 0 m o c 3 0 c oa C 0 �to z rrrn E �a r � w m m c y Z �H 'm (^ o , y m m? r' T C m S 0 E: l. 0 do H _a o O� CA fo y A (n Q) T n (n m ?1 m -t ii m 3 c o c m o c 3 0 c y o c o � w m w< 5. m y CD m m m? r' T C m S c o0 f1 < ; c o m N m(A '" C)p z z tA M _ -i O m T n O 0 0 _ X !i T f ti Locations-�� No. Date %A --6-'Q3 NORTN TOWN OF NORTH ANDOVER O`t`•O .•,hO O O?• w F P Certificate Occupancy $ of �� s'•�°' E<�' �cMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ G TOTAL $ Check # 1-±- % iQ 6 16358 �' "'Suilding Inspect TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 10 a BUILDING PERMIT NUMBER: 01 DATE ISSUED: ,Z'., / O 3 SIGNATURE: oil A k ' Buildi sl n ldings Date 00 M X z 0 v n 0 z M go 0 D ic r v M r r z 0 ar -IlUil 1-011r, uIrUMMAJAUA 1.1 Property Address: Chu 11>h, f�� 1.2 Assessors Map and Parcel Number: 1/ a ✓'._ DOD Map Number Parcel Number Ale.A ,�) e V&--,,Z-la�1 // 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R red Provided 1.7 Wsjer Supply M.GLC.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside blood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �'iQATPlC//� A.�ItXVnV Name (Print) Address for Service ,/"��j/�7,f—- Z0/Z Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Lic4sed Construction Supervisor. Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M X z 0 v n 0 z M go 0 D ic r v M r r z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existin&Builc ❑ Repair(s) ❑ Alterations(s) D Ftion ❑ Accessory Bldg. ❑ Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: &/2 ms '�Nd I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be� * {IFFICIAL�tiEgOLY I , Completed by permit applicant �I �ft`'�.��� ;^�`"� •e�sv'#"m.^�iw�Kk'. i'"•�•'�"1,`.J.�.•t��bx �,�...hri �z f=C- �l. 1. Building (a) Building Permit Fee QQ(� Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection, 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Here a thorize A A to act on My 11 matte��to w rk authorized by this building permit application. �4k Si ture of Owner Date SE TION 7b OWN R/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2 NO3 SPAN DRVIENSIONS OF SILLS DIMENSIONS OF POSTS DEVIENSIONS OF GIRDERS I-IEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r 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,S-150A.. The debris will be disposed of in: (Location,,of Facility) Signatu�e of Permit Applicant SAld-3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 4 i� *' °N Q e Town of North Andover Building Department ' 27 Charles Street North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. J DATE 5 1 � JOB LOCATION CuznW Number Street Address Section of Town ,HOMEOWNER f'P 7 Ck4CktklM OLP(_ q 7 6 f� -Z�IZ. Number Home Phone Work Phone PRESENT MAILING ADDRESS r -(t q C d11 Gk et.rn�, d/ City Town The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) Zip Code DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, A The undersigned "homeowner" c, Building Department minimum in; comply with said procedures and HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIA that he/she understands the Town of No. Andover h procedures ap,d requjirements and that he/she will Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. C/) M m C/) D C CD o 0". . . y CD O O y C�• 0 CO) Om d C9 CD CD y CD CO) CD O CDD S z y O T � � w T m CWO) m -1 OIt R d z o til M M C• fA C C N C)0 z H CL 7d A co n do m CD ca C.) :p w n O D9 d �. y. O b n CD rf O a x n a' 0 d o x mCL=r o a O ti O o = C 0 > > H m �� O a fG O O N• n o o co C a N o0m• o to CD O y ' to ,off: CL y •O•►. O go y N d Q c• C — H O co '••► :E m : y ca H m O Zm 42 0 O O 0 �.: S z y O T � � w T m CWO) m -1 OIt R d z o til M M X W. 'Jd C)0 z H n7 y 7d A n "� n z � h J y rb G tz :p w n 7d G :7,m '17 G r z � c b n CD rf O a x n a' 0 d o x I 0=3 0 0 c CDol