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Miscellaneous - 89 BLUEBERRY HILL LANE 4/30/2018
3 t ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING k - This certifies that � �Y �. Q ............................................. has permission to perform ... 4-.�\, wiring in the building of........1(- ......................... at....... ....... rD00 ` 7 . ........4 .................................. Fee.. �q... ......... Lic. No � 0% Z .. Check # 140+3 \,) e- V"\� . \Z�Ao� Date.---[ TOWN OF NORTH ANDOVER PERMIT FOR WIRING ...0 ............... .......... .................... ... ...... . .......... This certifies tha"',-t J. has permission to perform ... ..vv\c, co v .................................................................................................... wiring in the building of ........... ...... .. . .......................................................... at ....................... ^rth Andover, Mass. ............. .IA ......... Lic. No.t �)O% Z- .................... Fee.JPL ........ ................. .......... 11� ......... . .......... ELEIRICAZ I&S�PE�C�TO�R Check # .4 -7 'm r 7 � U�. iZ 141`# FlAr I „p' commonuiealth o� �a�achu�e� BOARD OF FIRE PREVENTION REGULATIONS Print Form> Official Use Only Permit No. 1"7710 —1 Occupancy and Fee Checked ,[Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All ,work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:l6 City or Town of: X22/ AIZAP 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) � f ,�4tc",/-&/- L,'4 Owner or Tenant -tyf Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity 44 - Location and Nature of Proposed Electrical Work: 1 /jam, Completion ofthe folhnvine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators ISA No. of Luminaires Swimming Pool Above❑ In- ❑ grud. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers j Heat Pump Totals: Number - Tons - ---- KW ` No. of Self -Contained Detection/Alerting Devices No. of Dishwashers / Space/Area Heating KW Local Municipal [I El 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 E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties ofperjury, that the information ontrue and complete th' ap icaV FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC. NO.: Licensee: DAVID HAGGAR Signature LIC. NO.: 14963 (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.; 978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA 01845 Alt. Tel. No.• 978-375-5734 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � � d A R� •� The Commonwealth of Massachusetts Department of Industrial. Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address: X87 BELMONT ST City/State/Zip: NORTH ANDOVER MA. 01845 Phone #: 978-682-6262 Are you an employer? Check the appropriate box: 1. I am a employer with 8 4. E] 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. 13 We are a corporation and its required.] officers have exercised their 3.111 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. E3 Building addition 10. a@ Electrical repairs or additions I LEJ Plumbing repairs or additions 12. [[] Roof repairs 13.0 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. Nbntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: FEDERATED INSURANCE Policy # or Self -ins. Lic. #: 9353694 Expiration Date: I� Job Site Address:' City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Imlestigations of the DIA for insure coverage verification. I alo hereby certify under the ain ebink es of perjury that the information provided above is true and correct Signature: Date: 6 S— Phone #: 978-682-6262 or 978 375- 734 Official use only. Do not write in this area, to be completed by city or town offkiaL 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 4: - COMMONWEALTH OF MASSACHUSETmumm TS . 11040 Date ..��o . . ................ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... 6A.A-p-ri .............................UCt ........v...�......-j ................................................... has permission to perform .............. Artp-.�'........c--' Ju............................ plumbingin the buildings of ........... ; ............................................................................. at ....5....1... ... Lrl.,, North Andover, Mass. ........... .. *-*-----*---1 ...................... ......... Fee3l)': . ..... Lic. N031<m....... M(.� . . ........................................................ PLUMBING INSPECTOR Check # WATER HEATER ALL TYPES WATER PIPING OTHER r_____ j ._.._.. IL INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES f NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY tof OTHER TYPE OF INDEMNITY © BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT IQ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliano� w' II Perti ent rovision of the (Massachusetts State Plumbing reode and Chapter 142 of the General Laws. /� PLUMBER'S NAME c �'I�c.�'►� / �I LICENSE # %S`7.3 ( v SIGNATURE (VIP 0I JPt CORPORATION RJ PARTNERSHIPO#1 iJLLC a© COMPANY NAME ADDRESS CITY — _ r9✓ .. - -I STATE I_lvt I €I ZIP ? FAX CELL _. EMAIL TEL I q 77' ?'a K_ V7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # JOBSITE ADDRESSq OWNER'S NAME POWNER ADDRESS S Y,c _ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:U REPLACEMENT: © PLANS SUBMITTED: YES NOF -I FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM V DEDICATED GAS/OILISAND SYSTEM 1 ,__,_ I ___ t - __j I _ --J, DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _I ..._.__.S ___-- I i t (____.J _-_-._I _____.. ,___._J ..._____1 -------f ._....._ I __ ___t _! FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) I _._ f _ _[ _._i _..__._i I _ I J I .._..__I I= KITCHEN SINK LAVATORY ROOF DRAIN. I _._-.J _._ _I k € J J J ..__J SHO ER STALL._1 AL—] SFRVICE / MOP SINK _ _ -I _- _� I _ I _ _J 116 _T URI AL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER r_____ j ._.._.. IL INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES f NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY tof OTHER TYPE OF INDEMNITY © BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT IQ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliano� w' II Perti ent rovision of the (Massachusetts State Plumbing reode and Chapter 142 of the General Laws. /� PLUMBER'S NAME c �'I�c.�'►� / �I LICENSE # %S`7.3 ( v SIGNATURE (VIP 0I JPt CORPORATION RJ PARTNERSHIPO#1 iJLLC a© COMPANY NAME ADDRESS CITY — _ r9✓ .. - -I STATE I_lvt I €I ZIP ? FAX CELL _. EMAIL TEL I q 77' ?'a K_ V7 RON N ❑ W a ui LU ki 0 I Date..... ..................... I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ',This certifies that ... OO ..... ... M ............................................... ... .... ... ... ........ has permission for gas installati n ... in the buildings of ...... :e. ............... - C., ...... a.�.J-tz .. 'AnUdoVer, Mass. at ........ 3. Q.. r, - � ...... Lic. No. -0-15 . . ................................................. GASINSPECTOR Check# U : 4 > MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ify 'A'-Q MA DATE —R= PERMIT # JOBSITE ADDRESS _ - ve �{T. OWNER'S NAME GOWNER ADDRESS� Gam- Nt TELT FAX TYPE OR OCCUPANCY TYPE COMMERCIAL R EDUCATIONAL ® RESIDENTIALij PPJNT CLEARLY NEW: RENOVATION:I] REPLACEMENT: ® PLANS SUBMITTED: YES Q NOD APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER_ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER :'- FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATERLABORATORY COCKS .L C�_ _ MAKEUP AIR UNIT OVEN _ _ I- _ _.. l An. _ ... _ POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER,-- OT ER INSURANCE COVERAGE have liability insurance its the MGL. h. 142 YES f NO [�] a current policy or substantial equivalent which meets requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY, OTHER TYPE INDEMNITY [j 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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 ith all Pertinent provision of the Massachusetts State Plumbing Code and C yapter 142 of the General Laws. PLUMBER-GASFITTER NAME ILICENSE #� SIGNA URE MP ED MGF Ell JP JGF j LPGI CORPORATION ©# PARTNERSHIP ©# � LLC �E#= / COMPANY NAME: / c,•le„s� ADDRESS �/q_ 11 CITYy✓ _ _ _ STATE& dl �`Z�TEL FAX CELL EMAIL _ H U \W a� d � . zFl O ElN W F- W O w O LU W � � w Q � a W Ow w w c a o a a J a a Cf) w x w F- LL f/] H °z 0 H U W M C7 C�7 `,, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ` f www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are 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. # 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.] i employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site P information. Insurance Company N Policy # or Self: -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL o. 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 certo under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person Phone #• Information and Instructi®ns 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 employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom 1 of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant ' that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial ,Accidents Office ofIavestigatiions 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 oyt 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass,gov/dia -0 Fold, Then Detach Along All Perforations ..COMMONWEALTH OF BOARD -OF P L UMB ER..*'-::A'RD GAS F I TT ERVi;.<i% ISSUES THE FOLLOW SE L I GT" Xs MAN R -U B ER::-'*.-* A JOURNEY. all ,.'-,:,SH:AWNq.'P SEVOIAN z W�::::x 2, Z 5 M E A D Ow..:. S T LU Ud JIA 01354-97 3 15,73:208320 ::�05/0.1./ lkl N2 9698 Dates#z?..i.1-? . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACHUS� This certifies that P J Cls. ' ... . has permission to perform f ........`.^k plumbing sin, the buildings of h°�.h� !'`'— ...................... at .... . ! ...bklr� A N** ?'�:�11�, , North Andover, Mass. Fee.OV �i�P� ..... Lic. No.�..° ....................... . PLUMBING INSPECTOR Check #�� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer p� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY oil _. �m[Et . _ _ Y MA DATE fZ �Z_ 1 PERMIT# JOBSITE ADDRESS LZ[..L.yEt•e�+.a _„/1�_I� OWNER'S NAME�g POWNER ADDRESS - /l o . _ TET _ _�Y 3 _ , FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW:�]' RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES Eq NO FIXTURES -1 FLOOR --r BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEMI DEDICATED GAS/OIL/SAND SYSTEM ._i ......___ .. I _.�i ._, ._..._._._.-1 ! �!.-...__._ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i _... ! _ i f ---.----_...-{ �- - I __- _-.-! _---_ } . .....I A=-JIL, I DEDICATED WATER RECYCLE SYSTEM �6 ._...._._...) ..__..-_..i DISHWASHER __._( _...,._f ..___._l . -.` ..__ _I ( ...__..! .._-_.._I .._. _._(- ._..,.1 ... ! ..-...._ (_.._ DRINKING FOUNTAIN FOOD DISPOSER ----- ----- _.-I FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY-----.-( ROOF DRAIN_...___! __.,__I SHOWER STALL SERVICE 1 MOP SINK __.._! URINAL_ I ..... ._.-_I ___.i _ . _.._. ASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING f _. -_i _. _ ...-_ . ! _ __. _ OTHER c f t t f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ( NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q 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 IEJ SIGNATURE OF OWNER OR AGENT R hereby certify that all of the details and information I have submitted or entered regarding this application are true and a r 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 it all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME�� LICENSE # -..f3G 4 _ GNATURE Mpg[ JPS,.( CORPORATION [:]# =PARTNERSHIP _ _ PARTNERSHIP D# _______ - LLC E� COMPANY NAME ,SPC /vti��,�� �l „z,7,,� ADDRESS CITY �, [�y�,��--__.____....-..... _ _ _.._ STATE � ZIP � TEL �y_1 _�� FAX __ CELL 9731/s-7MAIL H ` O z � z � o � F T W W o❑ z u) El W w O W a z w � w w a w O IL LU L LU U) p o a w� as a U J a a Cf) w s w F u. rA W F z 0 F U a a ' O A. .40 p a w V, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual):5,;oC Address: 12 / <-- City/State/Zip: �e, ���,/ f/7A phone #: - 3s 3 G Are you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t 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.] ❑ I am a homeowner doing all work officers have exercised their 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 reouired_1 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they 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. nsurance Company Name: ?olicy # or Self -ins. Lic. #: ob Site Address: Expiration Date: City/State/Zip: attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 ,f up to $250.00 a day aga' st the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the D or insurance coverage verification. do hereby certify the pains and penalties ofperjury that the information provided aboveis tryle and correct. �r op/>` - 3 S3 Official use only. Do not write in this area, to be completerl by city or town official. / Z_ City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an •employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia � . ` � ICA CL Wo ow 20 Ln Wen w li3w .r NORTH 0 9 • o •" Z SSACMUS� q Date.� - -3 y i TOWN OFZRTHNDOVER PERMIT FOR PLUMBING This certifies that ..Ac.lg4/ P`�. 14 has permission to perform .... c4r .. ................ plumbing in the buildings of ................. at ...FY ..13A ,�-. br. µ !' % h c .(..� .... -... , North Andover, Mass. Fee.//? Lic. No.. i.�1'�.Z. �. ...... ......-. ........... ' PLUMBING INSPECTOR Check # %Cil 7769 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 11 Building Location yJ�V{ I CV✓ Lu. c,� .LwW 4uL. -r Date �' 3 0/ C, Y Owners Name Permit_ 7 6 9, Type of Occupancy Amount New Renovation Replacement ' `d Plans Submitted YesElNo Ii YVrVY TD tacr (rent or type) Installing Company Name �� e� E N Check one: Certificate Corp. Address Zai �eJ ✓1 W �° (f�-VAC F1Partner. Business elephone t Z LA 0 Fimi/Co. Name of Licensed Plumber: 1?0 to (k C,o�Vso Insurance Covera e• 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 Massachuse State Plum ' Code and Chapter 142 of the General Laws. By. �gna ure 01 L.J,ujjbUUrjUTnDeT X_ Title Type of Plumbing License City/'Town I "I ( Z 5 icense um er Master r-1Journeyman APPROVED (OFFICE USE ONLY LJ Ir -V Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ............................. has permission to perform ..... .................................. wiring in the building of .................. I ................. ; % ......................................... a, ....... ................ :1..9� ............................. /Iqbrth Andover, Mass. Lic. No..J..Y.'61 ..3164 ......... /Check # ELLfcrRICAL INSPECTOR 10742 'b (fommonwo-A of Mamac"th 1JaParimant o��iro �awica� BOARD OF FIRE PREVENTION REGULATIONS Official Use Only ff Permit No. 1 of Occupancy and Fee Checked Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -5 26 11-2-- City 2City or Town of: Nbp-,ra 4,,.,,,2 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) [lJ,i, �� �-tLU LN, Owner or Tenant A OArm S}(�gL13 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps ! Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r Com letion o the ollowin table m %;-4 b h No. of Recessed Luminaires 12- No. of Cell.-Susp. (Paddle) Fans smllectorgLWires. No. of otal Transformers KVA No. of Luminaire Outlets No. -of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd, rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 1 No. of Oil Burners FIRE ALARMS. No. of Zones No. of Switches No. of Gas Burners o. of Detecflo'n an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers eat ump.- Totals: um er_ ons o, oSelf-Contained Detection/Alerting Devices �..... No. of Dishwashers Space/Area Heating KW Local ❑ un cipal ElOther Connection No. of Dryers 10. o ti aterKW Heaters Heating Appliances KW o. o o. of Signs Ballasts echo oy f Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: nrracn aaaumnai detail ydesired, or as required by the Inspector of Wires. '/Estimated Value of Electrical Work: (When required by municipal policy.) Work to Stan: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify: I certify, under the pairs and penalties ofperjury, that the informal o this pplication Is true and complete. FIRM NAME: DAVtO CLEC,-rR J CA L CON-i"({/dU C LIC. NO.: Licensee: tD 14A66AA Signature LIC. NO.: j 9 k2 3 A (If applicable enter "exempt "in the license number line) Bus. Tel. No.`ci78• to -(014a Address: 91 BEILM Dt%i �" ST=' i.j(?�T ,�{tlDfji( J,6&15- Alt. Tel. No. "7tsJ• 37 ate- 'Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER. I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ I—"",u.�. Edi �—1 l � l'Z ✓� r yr _ T ' The Commonwealth of Massachusetts Print Form Department of Industrial Accidents kv Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST NORTH ANDOVER, MA. 01845 Phone #: 978-682-6262 Are you an employer? Check the appropriate box: 1.2 I am a employer with 7 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. employees and have workers' [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' Y comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.2] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: THE HARTFORD Policy # or Self -ins. Lic. #: 08 WEC C18293 Expiration Date: MARCH 1, 2013 Job Site Address: F47 A44bfZGG City/State/Zip: /--/ /¢,,c. P>&t9e 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 lnvestgations of the DIA for insurance coverage verification. 1 do hereb certify under t eallies of e ury that theinformation provided above is true and correct - _ SiQnahire — — — LJ 3A.. /Z 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 #: -5-2 7 Clqg / 7-, eco ..' 2 co 9 Date ..... ............................. f HORT►1 �r;•';�`` ,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING _ . .FThis certifies that ................��o...................... 7 C ................. has permission to perform .n. Qe� LE /Z .......................................................................... wiring in the building of .......... SC. �. � z �....................................... at ..... ........ �EF�C%I?l�Y...���LC , North Andover, Mass. ............................ ...................... Fee..2,0 7�. p...�.. Lic. No. �. � L 3 ......... Q. h ..... F LECTRICALINSPECTOR Check # 7899 l,ommonwea& of //laasachudetb NEW .()epartmenf ol5ire Jervice9 UV BOARD OF FIRE PREVENTION REGULATIONS Official Use Only —� Permit No. 1 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 (PLE.gSE PRINT IN INK OR TYP/E�ALL l FORMA770N) Date: City or Town of: N .,�d pU e r- To the Inspector of Wires.' By this application the undersigned gives notice of his or her intention to perform �thf electrical work described below Location (Street & Number) �It/L�e/`r y ti�� L. / Owner or Tenant A L�a --i SCrh ci II Telephone No, qac %Ctrl i Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r C I ®t 1 — ✓G Comoletion of the fnl/nwino ruble ennv he wcfived h, No. of Recessed Luminaires No. of Ccil.-Susp. (f addle) fans T 'TNo, of otal ransformers KVA No. of Luminaire Outlets No. of Hot "hubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- E]o. of Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners , FIRE ALARIvtS No. of `tones No. of Switches No. of Gas Burners o. o etection an InitiatingDevices No. of Ranges No. of Air Cond, o Tonnss No. of Alerting Devices N'o. of Waste Disposers eat Pump Number„ Tons '� No, oSelf-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating Kw Local ❑ Municipal ❑ Other - Connection No. of Dryers Heating Appliances KW Security ystems:* No. of bevices or E ui\ alent No. of 11 aterK\, No. o No. of Signs Ballasts Data Wiring: No, of Des ices or Et uivalc-nt \u. Hydromassage Bathtubs No. of \Motors Total lit, I eleconununicatiuns \\ iring: No. of Devices or Ee uivalent OTHER: Attach adchriunal deluil rt desired, or os reyurre,i hr the L"perker IT it 1r,-, Estimated Value of Electrical Work: (When required by municipal policy.) Work to Stan: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE,BOND ❑ OTHER ❑ (Specify:) I certify, under the� sins and penalties of perjury, that the information on this application is true and complete, , FIR.N1 N':+n1E: `/./ l / �.&-71t'iC�t� �'� Ti' cr' LIC. No.: / c16 Licensee: L�4L l //-> 17j4 /j(y;.f; Signature LIC. NO.: (/f applicable, e r "ex mpt" in the license number line.) n Bus. Tel. No,:97'6�L !�^?( •1 . address: %=LlI�[W'T si /�%Gk'7i% �9N/>v1 IN Alt. Tel. N'o `�7,P 'Per M.G.L. c. 147, s. 57-61, security work requires Depanment of Public Safety "S" License: Lic. No OWNER'S INSUR-ANCE 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) Elowner Elowner's aeent. Owner/Agent —�--� Signature Telephone No. PERIb11T FEE; S .. 's R Q Location? No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ CH t�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �w 18475 Building lector It TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING ^ m. BUILDING PERMIT NUMBER: r7 DATE ISSUED:-�. .J f €. SIGNATURE. Building Commissioner/InELwor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ` 1/.2 Assessors Map and Parcel Number: i SECTION 4 - WORKERS COMPENSATION (AI.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 ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify ,1 Brief Description of Proposed Work t�-? aC '�-.Q – I SECTION 6 - F.STIMATFlT C0NfiTR1TfTTnN f'ncTc I Item Estimated Cost (Dollar) to beOFFICIAti'USE Completed by permit applicant ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee te) X (b) �. 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 00 , Check Number az4-IlV1\ is VVVI'4Err F►V I"Vi(1L.A11VA 1V BE UUMME IED WHEN OWNERS AGENT OR CILD CONTRACTOR APPLIES FOR BUILDING PERMIT I, q4) c [A r—a as Owner/Authorized Agent of subject property Hereby autlkorize )( /al. 1A1A % �� f to act on My,b� f, in ll matters relative to work application. Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Duval Roofing Hereby declare that the statements and inforrrpt'p�>63lregoing application are true and accurate, to the best of my knowledge and belief North Reading, MA 01864 Print Siature of Owner/A ent Date ". --" MIMMIN-MIM 11111111111M.1111111 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND SPAN DMENSIONS OF SILLS DMIENSIONS OF POSTS DMIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 3 E a f r Cris y; 6/uv� Page No. of Pages Builders License # 58443 Home Construction Reg. # 109288 O �0 e� 00 o 0 (759) 944-9994 (995) 654-2559 "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 PROPOS ATE STREET JOB NAME CITY, STAT ��%%D ZIP CODE 1 - �F B LOCATION .� We hereby submit specifications and estimates for:Recommended Optional 4:" .. (Included in price) (Not included in price) ✓ Rip & Remove all shingle debris from roof & job site: :!"1 layer ❑ 2 layers ❑ 3 layers or more *� Repair/or Replace any roof decking; not to exceed 50sq_ft. + Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill, white or brown tYInstall ICE & WATER underlayment along horizontal eaves, valleys, sidewalls and sky -lights & chimneys t/ Install premium base sheet underlayment between roof deck and roofing shingles • Install 25yr CertainTeed/GAF/TE mko or Owens & Corning traditional 3 -tab roof shingles ❑ 30 year Install 30yr CertainTeed/GAF/Tamko or Owens & Corning architectural roof shingles ❑ 40 year ❑ 50 year ! ❑ Lifetime See manufacturer warranty policy for more details •r Install new aluminum vent -pipe flange (s) f Chimney (s) -counter-flash and re -step existing flashing ❑ Cut & Install new lead flashing +' Ridge-vent/exhaust vent with low profile design, hidden by shingle caps - .•. - /� ❑ Soffit -ventilation ❑ Roof louver -vents • Seamless style aluminum gutters - custom fabricated at job site ❑ downspouts +r Other -I "Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off Price includes all items above that are checked only / others may be priced separately upon request. We JJrapase hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: Total price not including options. dollars ($ Payment to be made as follows: 30% deposit required- before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of $50 per week for all outstanding bills due upon day of Authorized completion. Signature - Accepting proposal means agreeing to the terms of the enclosed binder Note: This proposal may be contract. Please sign contract & return top copy (white) with deposit. withdrawn by us if not accented within 31 b ria�l� 1i 1 x w U)w oUWx o o lu. x U w a o G x a W W o C N O G o G E z. z `.1 5 CDF. y O y CDa C O V _cc a. h O V .y c 0 0 C _ca d C* Ck U) W W W U) m� C N O C vV CL c Cc o Ea C ms �m o c y E� :gym o cj mS _CD hW mm O �3COD cm O •O m W '= OAP W 16 - y O ID La=CD O C C yC :mss � yz $ w c � o a � W CO �=...-OZ C ++ C CC= Go CL=O "' LU m a woc°ti� o•mp C COD m Go.0 =tea=m 5 CDF. y O y CDa C O V _cc a. h O V .y c 0 0 C _ca d C* Ck U) W W W U) The Commonwealth vfMassachusetts Department oflndustrial Accidents Office ofInw-stigadons 600 Washington Street Boston, MA 01111 UT www-massigovfdia Workers' Compensation Insurance Affidavit: BuiidersiContractorstEledricianslPluxnbers Duval Roofing Name (9usiawjorganizationft ividuaD:P.O. BnY F►37 North Reading, MA Address: CitylState/Zip: Phone #:7�l � �� �� C/ Are,y an employer? Check thcapproprlate box: Type of project (required): I am a employer with 4. ❑ 1 am a genal oontractor and i 6. 0 New constriction employees (fall and/or part time).* bavc hind tttc sub-c=uactors meted on [lie attacbeii slicer. t 7. Remodeling ❑ 2. ❑ 1 am a sole proprietor or paler- ship and have no employees These sub -contractors have S. Q Demolition working for me in any capacity. Workerss' comp, insurance. 9. ❑ Building addition (No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical =pairs or additions rapire(L1 3- ❑ 1 am a bomcowuer doing all work officers crave ctemised their tight of exemption per MGL §1(4), wehave uo 1 t -� Phimbing pans or additions i2.P-<fnp@is•-- myself [No workers' comp. c.152, and insurance required -j t �loy�- U40 13.E] Other ! comp. imttrance requirod.j ' um Any aWit tlut t w4m box M must also fill oat the 5COil n beton *owiaa *cir wea•itt W aotttptatsatian palmy infastrtntion: t ltor000watcrs who submit chis affidavit in&c ng they tut: doing all avant tmd then hire aWiAe *mM8'*n trust sobirdt * tt w offidayii ID&cadng sttcb. I Convuloss that check this box mad enacted in additional sheet shawias the Bane of Ste tmb.ctmtt u mt: mad Char workers' txatla< policy infb--tiba I am an employer that is providing naorkers' corrrpattstttian hawarrt a for troy etr:playera Below Is Nu palfry and, jab site inforrmarion, ---- A insurance Company Name: Policy # or Self -iris. Lie:. #:. � ��� -77AAO-5Expiration Date:. Job Site Address C City/Statrop: 4 16 Attach a copy of the workers' compen policy declaration page (showing the policy number and eapiratton date). Failure to secure ooverage as tequired under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 arxilor one-year imprisanment, as well as civil penalties in the form of a STOP WORK ORDER and a rine of up to $250.00 a day against the violator. Be advised that a copy of this sntcnmt tray be forawded to the OfBcc Of Investigations of the DIA for insurance coverage verifcation- I do hereby cervti y under thte pains and penalties of perjury that the informaiian provided ahove it true and correct Sienature: C Date: Phone #• ?0J '7YC/ / ygLK Official use only. Do not write in this area, to be completed by city or town afield City or Town: PermlilUcense # Issuing Authority (circle one): 1. Board of Reapb I. Building Department 3. Cityrrowu Clerk 4. Etectried inspector S. Plumbing Inspector 6. Other Contact Person. Phone N: 1 y � N O e �y 9 00 Cl 00 o W rn IA! W m O_ ce p (n CD 00 = Z F- p Z j Y. C%l Z �m I�����Illllllll�llllltu Ilul�illllllllilllllllllll ,�,�' co 0 a U- 0 CO 0 o 0 2 Z i C Z D Y. r Z l 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 at: 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: &J670-�- //V6 (Location of Facility) Fire Department Sign off: Dumpster Permit Signature of Permit Applicant Date Location,y No. �%� �/ Date A) 21' TOWN OF NORTH ANDOVER o Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 143, 3 Building Ins a or I - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �;� � �, �tiq � e < ,+�z� .>��` �S� � �8'�t►T Ol�i��.��� �>��-`� °, � ���� �� `•, �'a<.��� ice" � �x:' �s� BUILDING PERMIT NUMBER: ' DATE ISSUED: O a SIGNATURE: Buildi ommissioner or of Buildings Date 1h. Q. SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: � I �; Map Numberr`P�oeI NurAI3&1" 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide LeT±ed Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record are (Print) Address for Service . Signature Telephone 2.2 Owner of R cord: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licel.sed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone L�� L SECTION 4 - WORKERS COMPENSATION (n 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 buildinE permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check alta Ucabte New Construction 4... .. Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ . Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: / � 9 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant (i`ICIAIC, USE ONLY p: 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZA ON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT T A ! ' ( - h ACUk, , ) a j as Owner/Authorized Agent of subject property Hereby authorize to act on My,bzhz ' i al matters relative to ork a orized by this building pen -nit application. Signa ire of O ler Date SECTION 71b OWNER/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 Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE -..AAI Q®® STOVE I S•TALLAFION CHECKLIST F_.!)1'� IIU: . Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stave installation and not to the stove construction. Stove A. New Used ;�"'%4- No -252• A S. Type/radiant a Circulating ' 5� C. Manufacturer ! ab. No. Name/ Model No. Collar size DlmensionsiHeight 10� /d t� tvri� ?_?� ��. ' Width it Chimney A New E.cistin 9 B. Size (flue area) C. Other appliances attached to flue (Number and flue size) D. Prefab (Manufacturer—name and type) E. Masonry/Lined Flue liner typo 6 manulacturerl Unlined F. Height (refer to diagrams) cap aVEZ IC' WK S MIK a 1� CHIMNEY HEIGHT Hearth (non-combustible) eSub-floor construction C. Minimum dimensions (refer to diagram) Clearances and Wall Protection isee s:cve in:.;allat:cn c!e=_rances chart) A. Type of wall protection provided B. Clearances (refer to diagrams) FIREPLACE IZ:r (rtlt{. ! 2•' MIN. I$ IN. h !=A H 1 1` 1 WALL'CENTER. 13 io Oo obo w° `f'cox cn � U w° U a w OF ►a c to a�' w O W U w W °�° cG° v J� w � C7 w W rz �' 147 z cn v Q o R,1 0� 0 7 —C4 �j ER -L* 0 z o m c o C2 C H O C "r O v C2 p. C cc O CO = O 0 m Ea coco C ' � V r..� 0 Q co dw O CD c CDcm O c m o �' ( 3 . co G cm m . _ m O Ca N CC CA C, coco C2 CL C.3 I y CD m CA :m0'C :��oZ c c a co N O C m CL r��+ O +D m�0"~ C �_ G m CA CO CCf CO) d= C = 0. -CU. E U-0 0 cm m O .0 C O. CA '� O eyv a 0 m'= L d_.. 1c E a H N O ca C O R m O) m o. C �C N CU t O Z O O 1 6 0 Co O c L 0 V Z y0 p c C CO) co cm0 c Ag co �E m m co Q co CL _~ CO co O cc O a' a- oma ca C O }0 C cc C JCO2 Z -o C CD C-3 CO) R C .0 C _m CA 0 IIIZ7I1ZI .clam& Maria Paz Schaller 1 > Lit T77' MA 01.8<5 Town Andover Department To Whom it May Concern; Unfortunately, halfway through our basement remodeling project we had to change plumbers from Hoffman and Kelly Plumbing to SPC Plumbing. We are asking you to transfer the permit (#496 dated 12/20/11) to SPC Plumbing. The rough inspection was completed and all remaining plumbing work has been completed and we are waiting now for a final plumbing inspection. Thank you for your time and consideration. Regards, dam& Maria Paz Schaller Date. q44 . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -j 0Hv-n(,-j I �?-R --1-,-Q L This certifies that ....... 9F has permission to perform ......... ...... ...... ........ plumbing in the buildings of at. . ....... 0'... North,Andovei, Mass. Fee ......... ILic. No.... `. 2... ... 0.y?. . 249'7 PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PIERMIt TO PERFORM PLUMBING WORK jr TYPE -bit PRINT CLEARLY -CITY MA DATE 1PERMIT 9 JOBSITEADDRESS OWNER'S NAME OWNERADDRESS IFAXI OCCUPANCY TYPE COMMERCIAL F EDUCATIONAL I RESIDENTIALT.;4% NEW: 1A RENOVATION:1 REPLACEMENT -1 I PLANS SUBMITTED: YES I NOI I rKrU. . T. FLOOR-' Bsm 1 2 3 4 .5 6 1 7 8 9 11 12 73 14 BATHITU11 008SOONNECTIONDEVIC5 DEDICATED 8PECIALWASTE-6Y4TEM DEDICATED GASIOIUSAND SYSTEM ----------- DEDICATED GREASE SYSTEM i A DEDICATED CRAY WATER SYSTEM ............. DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR !AREA DRAIN Y INTERCEPTOR (INTERIOR) KITCHEN SINK HA� 5 LAVATORY ROOF DRAIN SHOWER STALL $EMAOEIMOP SINK TOILET URINAL WASHING MACHINE CONNECTION J- WATER HEATER ALL TYPES. WATER PIPING -OTHER INSURANCE COVERAGE: I have a ctirront.liabiiit ihs0rai1ce pol1q.or its sul0anflaI.CqUiValellt Which meets the treqa.ireniefits of MGL Ch. 142. YE8 VNO, IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE 13Y C14ECKING THE APPIZOPRIATE43OX BELOW LIABILITY INSURANCE POLICY 0THERTYPEOF. INDEMNITY I BOND OWNER'S INSURANCE WAIVER: kim aware iliat the 11censee.does nol have ihelnsurance coverage requited by CfiapI6142 of the Massachusetts General Laws, and that ally signature olithis permit epplicatiollwalves thisrequim(heNt. CHECK-ONEOftY: OWNER I AGENT -1.1 SIGNATURE bFOWO-Ok AGENT I hereby certify that all of [lie details and information I liave-liblimilled of entered rbgardinqIbls application ate true and accurate to the best of d q.0 and that all plumbing work and ln§tallations performed under the permit Issued for this application will be in cornp�l�ianv VbeW M Massachusoffs ate'I'lumbing Code anddiap!qr 142 of Hie General Laves. g. PLUMBER'S NAME LICEN SE it IGNATURE7 MPI I JP) I (:�-C)6&C0.RPORATI0Nk'1W1,! JPARTNERSHIPI' 111f ILLCI' ifil COMPANY NAME tt464&67 lty ADDRESS I I�IL,-IV� W CITYJ STATE 11"OV� ZIP !ELI FAX 1'7?rl CELLI EMAIL j'Z5%WLA 311 o� ® cn 0 ��v u co a a Q J � LI F- is F R=� The Commonwealth ofMassachusetts Department of Industrigl Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organ'rzation/Individual):—_��'�" Address: City/State/Zip; Phone #: Are ,yyoou an employer? Check the appropriate box: 1. I� .I am a employer with � 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.) 3111 am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions I LgKurabing repairs or additions 12.❑ Roofrepairs Mr! Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached anadditional 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 ihepolicy and job site information. Insurance Company Name:.CJO/ Policy # or Self -ins. Lic. #: jExpiration Date: Job Site Address: 'I ,/S_16 CL I X V CZ � lLLC. State/Zip: /W Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration Failure to secure coverage as requiredunder 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. X do hereby certiry under flie pates an 'ApenaJkes ofyerhrR,4at the information provided above is true and correct. - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 permithicense 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance. for your cooperation and shpuld you have any questions, please, do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of M-assachv..setts Department ofzndustrial Accidents Office of Intvostigatitons 600 Washington Street Boston, MA021.11, Tel.. # 61.7-727-4900 eyt 406 or 1.-877,:MA SSAFE Revised 5-26-05 Fax # 617"727'7749 www.xnass.gov/dza