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Miscellaneous - 9 COBBLESTONE CIRCLE 4/30/2018
This certifies that Date .... // 7 ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION / - dc, 4, c Ie,,, Ile. has permission for gas installation..,. / installation � in the buildings of ........................................... at ..........% .......... (5� Fee.�O.-... Lic. No. ....... Check # ..................................................... ..................................................................... r-4—, North Andover, Mass. ..................................................................... GASINSPECTOR I�zr A� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a _ CITY it MA DATE t PERMIT # JOBSITE ADDRESS C�OWNEKS N ME GOWNER ADDRESS TEl FAX TYPE OR' OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:E] RENOVATION:, REPLACEMENT: ® PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-► BSM 1 1 2 1 3 4 1 5 6 1 7 8 9 10 11 12 13 14 - __- f BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER GENERATOR GRILLE' INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER (ROOM /SPACE HEATER OF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 01 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 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 andaccurate the b st of my knowl e and that all plumbing work and installations performed under the permit issued for this application will be in compliance erti i o Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �LC��.T LICENSE # aY ( SI GNA URE MP N MGF [j JP 0 JGF 0 LPGI 0 CORPORATION []# ��_ 'PARTNERSHIP ®#= LLC L1#�� COMPANY NAME: (/� G' ADDRESS CITY - �� - _� STATE �ZIP (TEL FAX CELL �fOEMAIL�Ur� -- I 11 .,1_ a .- k,. The Commonwealth of Massachusetts _ a Department of IndustrialAccidents M {^ I Congress Street, Suite 100 Boston, MA 02114-2017 q�< www mass.gov/dia . oRM SV.v Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plnmbers. TO BE FILED WITH THE PERMITTING AUTHORgy- -Please Print Legibly A13` � ant Information ,� Name (Business/Oigatiization/Individual): e52&zAi�% Address: .i► �) ���,o A.,4 A Phone Are you an employer? Checktlie appropriate box: Type of project (required): eto ees full and/or part-time)-*" 7. ElN6VG'onstriiction 1,Q I am a employer with mP y 2im I am a sole proprietor or partnership and have no employees vrorking for me in 8. E] Remo deliittg "any capacity. [Noworkers' comp. insurance required.] 9, ❑ Demolition 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 E] Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that. all contractors either have workers' compensation insurance or are sole 4 1 proprietors with no employees. 12�umbing repairs Or additions 5. ❑I am a general coniracf. Wand I have hired the sub -contractors listed on the attached sheet. ] 3•, E]Rb6f repair§ These sub -contractors live', employees and have workers' comp. msurance.t 14. Q Other 6. Q We are a'corporation and its. officers have exercised their right of exemption per MGL c. 152, §1(4), andWe have no employees: [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information such i Homeowners who submit. this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating 4u, . tContractors that check this box must attache d'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. f am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name - Policy # or Self -ins. Lie. #:. Expiration Date:. City/State/Zip: Job Site Address: comtpensation policy declaration page (showing the policy number and expiration date). Attach a copy of the �vvoxkers' Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a die up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK Oesgat ons of the DIA for insER and a fine of up to 2uran 0 a day against the' violator. A copy of this statement may be forwarded to the Office of Inv coverage verification. Y do hereby cert the information provided above is true and correct. 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 #: 11 North Andover MIMAP December 4, 2015 Q MVPC Bo i. Interstates 11 North Andover MIMAP December 4, 2015 Q MVPC Bo Interstates Horizontal Datum: MA Staleplane Coordinate System, Datum NAD83, — I - Meters Data Sources: The data for this map was produced by Merrimack — NORTH Valley Planning Commission (MVPC) using data provided by the Town of — Roads Of North Andover. Additional data provided by the Executive Office of 4, Easements j .6 6�O Environmental Affairs/MassGIS. The Information depicted on this map Is 3 G for planning purposes only. It may not be adequate for legal boundary ❑ Parcels • 9 definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER 16. MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING x K THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY f s •^ y OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 1"=56ft �° THIS INFORMATION SSA, Usk - c e a, 10 C. 10, 3 Date..,.IY26.1.A. ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �C, k4K.. k This certifies that .... ............................. ............................. . ....... eA.L ...... .... . ........ .... .. ........ ... ..... has permission to perform � ...... ........ ......................................................... .. plumbing 'nth buildings of ...... ,� CU "C- ............................................................ at ........ North Andover, Mass. ....................................................................... — . Fee ... . . ..... Lic. No. �+.i ..... .... H-0 PLUMBING INSPECTOR Check,4 FLOOR/ AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK URINAL I �f _._ _-_- � [ _..__ 1 __.._.._I ..___._ i '... __...1 . .._._I _ J V: ING MACHINE CONNECTION 1 I __.._ I _ _' .__.__. _._ I _� _._ _._I u... -__. E-7711 WATER HEATER ALL TYPES WATER PIPING __- I - I I _..._..__. I OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D 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 0 AGENT I© SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 c liance with all Pertinen vision of the Massachusetts state Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # J ( SIG URE IVIP d JP CORPORATION FjJ# PARTNERSHIP d#=LLC COMPANY NAME G— =�`�`'^'� - �_ J ADDRESS Z2 CITYSTATE � ZIP�n TEL 'Z 7AX CELL % .- MAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY /'1� MA DATE �-,—1 [ PERMIT # ' �� JOBSITE ADDRESS OWNER'S NAME—�(b;�Ly��� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES NO 01 FIXTURES'l FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTIONDEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I ._ _ (I _A __J11__ __A F DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I � . _ (. I i I _ _� 1 ___..._ I DRINKING FOUNTAIN[ J f _._._( _-.__.. I 1 � 1 .....__.. I -_____1 177J FOOD DISPOSER I ._._ _I __------____[ ( i _ ._....____.[ _..____I ._..._..._I - FLOOR/ AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK URINAL I �f _._ _-_- � [ _..__ 1 __.._.._I ..___._ i '... __...1 . .._._I _ J V: ING MACHINE CONNECTION 1 I __.._ I _ _' .__.__. _._ I _� _._ _._I u... -__. E-7711 WATER HEATER ALL TYPES WATER PIPING __- I - I I _..._..__. I OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D 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 0 AGENT I© SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 c liance with all Pertinen vision of the Massachusetts state Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # J ( SIG URE IVIP d JP CORPORATION FjJ# PARTNERSHIP d#=LLC COMPANY NAME G— =�`�`'^'� - �_ J ADDRESS Z2 CITYSTATE � ZIP�n TEL 'Z 7AX CELL % .- MAIL The Commonwealth of Massachusetts Department of IndustrlqlAccidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): in NO Phone #• 7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 7_ 4. El am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship andhave no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required:] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ ew construction 7. [� Remodeling 8. ❑ Demolition 'J 9. ❑ Building addition 10.❑ Electrical repairs or additions 1111 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit anew 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:- a-SCx_j 0J zJ F—V Policy # or Self -ins. Lic. #: LA) CGS Expiration Date: �L_ ZE5' t �3 Job Site Address: 3 C;nU")611.2 Ci Ir'�1 City/State/Zip: HC , C) J eY Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 tine 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 tlin pains annalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -122 f Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person Phone #: L-- im .......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..........� ........6.,q.��..4................................................... has permission to perform ............ A�............... ... wiring in the building of ................... .....(/1%u........................................................ at ........ 9!IQ6� .SZ/ &..............(- /. ............. orth Andover, Mass. ........................ Fee ... 4�-�-..v� Lic. No. Z/33/ ..................... .................................. EL CTRICAL INSPECTOR Check # �J _ Commonwealth of Massachusetts Official Use Only Permit No. 12,A qP Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: . City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)Y- Owner or Tenant .Jl/�A' 1�1 Telephone No. Owner's Addresses C�1 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps I& hNO Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Locationand Nature of Proposed Electrical Work:1dn,►m ,* Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets ' No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting BatterV Units No. of Receptacle Outlets Z. 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 No. Waste Disposers Heat Pump Number ..................................................... Tons KW No. of Self-Contained of I Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:'' No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts 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: 2G�--- (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: INSURA-NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the ns and penalties ofper ury, that the information on this application is true and complete. FIRM NArYtC,� LIC. NO.: Licensee: SignatureLTC: NO.: If Z i O aA ( applicable, ent "exempt" in the license number line.) � �. Bus. Tel. No. Address: Alt. TA No.•J9 I *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 Epk-RMITFEE.- $ Signaturl Telephone No. r ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the 1� permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible fort e notification,of completion of the work as required in M.G.L. c. 143, § 3L. • Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit,Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8— Permit/Date Closed: ) s,.ji',i'`i� =r*> Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: r _ Trench Inspection Pass 0 Failed 0 R Ins ection Required,($.) ❑ Inspectors Comments: f j Inspectors Signature + '�4-1 Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments. f A Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPE TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments 4' t-1 `r % Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-' IYtspectiotliRequiiedj. ') ❑ Inspectors Co�mmehts: '41,111141114 C / s-- , Inspectors Signature: V Date: '-,DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of ludustrigl Accidents Office offnvestigations 600 Washington. Sheet .Boston, MA 02111 www.mass gov1d1a '4 orkers' Compensation. Ynsnrance Affidavit: BuffdersfContrao Address: /t/W Phone #•. :7,YL" �- 3 Are you an employer? Check the appropriate box: Type of project (required): 1. [(I am a employer with 4• ❑ I am a general contractor and I 6. j] New contraction ` employees (full and/or pari time).* 2. BJ am. a sole proprietor or partner have ned the sub -contractors listed on the attached sheet t 7•Remodeling ship, and`have no.employees These sub -contractors have 8. ❑ Demolition wording forme in any capacity. workers' comp, insurance. 5. ❑ We area corporation. and its 9. ❑ Building addition. [Nb workers' comp. insurance required.] officers have exercised.their 10.❑ Electrical repairs or additions 3.E1 I am'a hoin.eowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions mysOW [No workers' comp. c.152, §1(4), and wehave no 12.QRoofrepairs insurancerequixed.] i employees. [No workers' IS.[] Other comp. insurance required.] !Any applicantthat checks box#1 must also fill out the section below showingtheir Workers' compensation policy information. . i -Homeowners who submit this affidavit indicatingthey ero d9ing alt work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheAthis box must attached m additional sheet showing the name of the sub -contractors and their workers' comp. policy infomuation. .Tam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. � Insurance Comrany Name:. Policy # or Self ias.Isic. (OZ ExpirationDate: Job Site Address, '7 �'a 4 C IV'' pity/State/Zip-/ `'' • 4,C�Ol1�r--• tet/ Attach a copy of the workers' compensation-polley declaration page (showing the policy number and expiration date). F&;Ure to secure coverage.as requiredunder 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 tine :' 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. 1 do Izereby (-e&& uri r tl aims an enalties o fperjuiy that the information provided above is true and correct. __1% Jr -1 Oficial use only. Do not write in this area, to be completed by city or town official. City, or Town: PermitMeense # Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions .0.. •%_ Massachusetts General Laws chapter 152 requires all employers to provide woxkers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person tri the service of another under any contract of hire, express orimplied, oral oxwxiiien" 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 enfzty,, employing employees. However the owner of a dwelling house having not more than three apartments and who;estdes thereiib or the occupant of the dwelling house of another who employs persons to (f iltenAnce, cons"truGiioii. or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucheniploymentbeeemedto be an enaplayer" MGL c1iapierFl32A25C(G) affi states that "every state or local licensing age6y shall withhold the issitance or renewal of a license or permit to operate a business or to construct buildings iu the cobinhoteaiflZ for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required:' Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic workuntil acceptable evidence of compliance with the insurance requirements of this chapter have b con presented to the contracting authority." K 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 numbers) along with their cexiificafe(s) of insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the members orpartners, arenotrequiredto canyworkers' compensation insurance. If an LLC orLLP doeshave employees,apolicyisxegiiired. Be advised fhatfhisaffidavit maybe submitted tothe, Department of Industrial Accidents fox connrmafion of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for thepermit or license is being requested, not the Department of 7ndusfrial 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 TOVM Officials Please be sore that the affidavit is complete and printed legibly. The Department has, provided a space of the bot%m of the affidavit,for you:to fill out in the event the Office of Tnvesiigationghas to contact you xegard #the applicant. Please be sure to fill in the lietmitg1cense number which will be used as a reference number. 7n. addition, an applicant thatx�°nitst s}xbm �mxiliiple ern�it - cense applications in any given year„need only subrrlii� n� af�d�'dUndicaiuig current P infbmtaiion'(if necessary) and under "Job Site Address” the applicant should write "alt locations in (city or town): ' A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided tote applicant as proof that a valid of idavit is on. file for fixture 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. ad og 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 a4dtess,te1g134one°an'c faxnumber: -All. -�'h.� CQ.oz���a�t� o��•as�a..�1?vS�tis .f' b-op'arimeut ofInclu a� .ae%da itsx i (afire offn�veslioa#ona 600 Wahtagon Ste, et o�onz,11 Q�l, Z x T01, 0 QM -2-7,4900 ,49Q0 ed 406 Qx 1-877MMSm_ Revised 5-26-05 Fax 0 617"727-7m WWW_Ma�s,gc�v clia 1. -10 K WA Location ��PS `��, j -,-- No. `"I 'I Date I TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 1 J� •� Foundation Permit Fee $ , Other Permit Fee $ TOTAL $ Check # S1 z'— `` `� `� Building Inspector . TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0:. '' 1� Date Received Date Issued: 1 I ORTANT: Applicant must complete all items on this page LOCATION q �,�1^�'P �� l f' - C.�-1 �--4 A�. X tA-JZ , MA Q lg q Print. PROPERTY O R — = P >✓ I t `Print 100 Year Old Structure yes r no MAP NO: 06 PARCEL: �`%� ZONING DISTRICT: _ Historic District yes <Tg;> Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial O(Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: G -M I F 6 KF= I?.DD F r=AJ'I- I gr k10 c J S F Identification Please Type or Print Clearly) 1973 � 851 - 1,,0 -7 0 06 ---)OWNER: Name: �E F -F kay P , bE86RAla IM, m"/u1 nIG Phone: '7$1-'1171- (0253- Je-6b M CONTRACTOR Name: bQVA L- RQ!DFI&)br L 0- Phone: C�1��o���j�S�� ,. Address: (�K) jo {03`."1 kb.t b Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ! %C) Li �1 ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BOLDIN PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $-t7:;7. o -D Check No.: Receipt No.:� O NOTE: Perso s contracting with unregistered contractors do not have access to the guarantyfund Sig_rature}ofyAgent/Owner r re of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ PlanslSubmitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OY-SEWERAGE DISPOSAL Public Sewer ElT I Tanning/Ma ❑ Swimming Pools El g Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ COMMEN CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments E Water Sewer Connection, /Signature & Date Driveway Permit DPW To,`v;z Engineer: Signature: - Located 384 Osgood Street' FIRE-DEPARTkENT - Temp Dumpster on site yes no C Located at:124tMair Strdet Fire Depar'tmeritsignature/date,' I COMMENTS W Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land' area; sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical' Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOTES and DATA — (For department use ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The folrsvOng is,-a.list of the required forms to be filled out for the appropriate permit to -be obtained. Roofiv6, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a.variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu.-al period,is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 ©m �xl 0 2 0 O O C O �o 0 c. m �a w = W 0 vs V E Q LU 2 LL. O 0 °0 uv+ Ll Y O LL E v -' i N Q Ln N Z Z m c O a+ N c LL t d' T N U t0 O LL (A Z Z a •� to : d' LL Z U U LN -CU OD 00 a. 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O ._ O N d t O z O a J _0 > doomw �v O w 0 v O LLI U) W W oC W H 11/07/2013 14:23 FAX 781 942 2226 GILBERT I 0001 COR ® CERTIFICATE OF LIABILITY INSURANCEOATE(MM/DD/YYYY) 9/10/2013 lr,fHIS 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 cera flcate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of .the policy, certain pollcles may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 51 2 " A Barbara McDonough ' I Gilbert Insurance Agency, Inc. PHONE (781) 942-2225 V,; I. (Tei) 942-2226 137 Main Street E:,M'viae.bmcdoncuah@trilbertinsurance.coal Reading MA 01667-3922 INSURER A-HARLEYSVILLE/WORCE INSURED INSURER V ;Travelers Ins. CC, Duval Roofing, LLC. INSURERC: P.O. Box 637 INSURERo North Reading MA 01864 1INSURER F: COVERAGES CERTIFICATE NUMBER:Cz1331300142 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 70 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. I11115R LTR TYPE OF INSURANCE AD SU POLICY NUMAFR POtJcY EFF POLICY EXP LIMITS A GENERAL LIABILITY COMMERGIALGENERALLIABILITY CLAIMS -MADE ❑'x OCCUR 641580 10/23/2013 10/23/2014 EACH OCCURRENCE $ . 1,000,000 PREMISES Faoccurrance S 100,000 MED EXP (Any one arson) I 5,000 PERSONAL a ADV INJURY s 1,000,000 GENERAL AGGREGATE1 $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER.' -xi POLICY PRO- LOC PRODUCTS-COMP/OPAGGI 5 21000,000 I S `a` AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCMEDULED AUTOS AUTOS X HIRED AUTOS X AUTOS MdED AUTOS 644560 0/z3/z013 10/23/2oia COMBINED SINGLE LIMIT I 11a accident) $ 500,000 BODILY INJURY (Per person) I $ BODILY INJURY (Per aceidenl) $ PROPERTY DAMAGE ; $ Par ac:dont Uninsured motorist BI split limitl $ 100,000 UMBRELLA U MOCCUR EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE $ AGGREGAYE S DED RETENTIONS I S $ WORKER$ COMPENSATION AND EMPLOYERS' LIABILITYTS ANY PROPRIETORIPARTNERIEXECUTIVE YEN MandaloryInNH) CERIMEMBER EXCLUDED? I it yes describe under DE88RIPTIONOrOPERATIONS 'be( NIA o be provided di"Otly la Travelers Insurance /11/2013 /11/2014 1 ILIMIU• OTMi I FR E.L EACH ACCIDENT S 100,000 E.LDISEASE-EAEMPLOYE� S 100,000 E,L,DISEASE-POLICYLIMITI I S 500,000 I DESCRIPTION OP 0152RATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more apace Is roqulrod) Evidence of Coverage , (978)688-9542 Town of North'Andover 1600 Osgood Street North Andover; MA SHOULD ANY OF THE AaOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRFUENTATIVE Gilbert, CIC/BAt2EAR ACORD 25 (2010105) ®1988-2010 ACORD CORPORATION. !All rights reserved. INS026 (2olo06).o1 The ACORD name and logo are registered marks of ACORD Page No. of Pages Builders License # 58443 Home Construction Reg. # 167338 D IAL u va RuofingLLC (781) 944-1994 (978) 664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvalroofing.com PROPOSAL SUBMITTED TO PHONE DATE STREET f I r r� CITY, STATE AND ZIP CODE Al We hereby submit specifications and estimates for: O'Rip & Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS 0 1 layer of existing roof shingles ❑ 2 layers of existing roof shingles ❑ 3 layers or more of existing roof shingles UReplace any damaged roof decking; not to exceed 32sq. ft. (additional at $1.70 per sq. ft.) 0 Install 8" Aluminum Drip-edge/Rake-edge along entire perimeter (Choice of Wh te, Brown or Mill) 0 Install ICE & WATER UNDERLAYMENT on all horizontal eaves, sidewalls, skylights and chimney flashing�- ® Install-a.prerniunbase.shget u� nderlayment.(felt)*that-is-in-cMMIIAllc6-with'the-a6phaat- hingle-manufarAurex chosen by the homeowner 0 Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles See individual manufacturer's warranty for specific details ® Replace all existing bathroom louver and/or exhaust pipe(s) with new aluminum flanges Chimney(s) -counter-flash and re -step existing flashing ❑ Cut & Install new lead flashing W Install a continuous low profile Ridge -Vent on all ridge lines ❑ Soffit -Vents ❑ Roof Louver -Vents ❑ Seamless Aluminum Gutters - Custom fabricated on site with our own gutter machine ❑ Downspouts at additional ❑ Leaf Guards Other ' I i S01117 'Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off Price includes all items above that are checked only / others may be priced separately upon request. We Vxtxpas$ 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 i Final Payment is due upon day of completion and is subject to the Authorized ,r supplemented Terms & Condition sheet when scheduling. Signature THIS PROPOSAL IS VALID FOR DAYS DUE TO \ rL.u%.1 uHI w110 1114 MMI r_n1ML_ a vIar%JQML. rn1%,r_a. NOTICE TO EMPLOYEES NOTICE EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-13) 03-11 -13 TO 03-11 -14 POLICY NUMBER EFFECTIVE DATES GILBERT INS AGCY 137 MAIN ST READING MA 01867 NAME OF INSURANCE AGENT ADDRESS PHONE # DUVAL ROOFING LLC 184 PARK STREET NORTH READING MA 01 864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance withthe provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the it NAME OF HOSPITAL ADDRESS b 001907 W20PiG02 TO BE POSTED BY EMPLOYER The Commonwealth ofMassachusetts Department oflndrustria[Accidents ©ffice of Investigations, 600 Washington Street z� Boston, MA 021-11 www.ma.ss.gov/dia Workers' Compensation Insurance Affidavit: Builders/ContlractO rs/Electricians/Piumbers Wlkant Information • -.. avuoai 1. 111L61/G lAl Name (Business/Oxganization/i'ndividual): rrl Rnorl LL . Address: PO BOX 637 -City/State/Zip: Phone #:_ % f�j„ /„ c./� SS -% Are o employers Check the appropriate box: a employer with 4. ❑ TYpe Of Project (required): oyees (full and/or parttime).* a sole proprietor havee hired the ub-ontrac o scontractor and f6. ❑ New onstruction or partner and have no employees listed on the attachedsheaet.1 7. ❑ Remodeling for me in any capacity. Ln These sub -contractors haveing workers' comp. insurance. Demblition orkers' comp, insurance 5. ❑ We are a corporation and its 9. ❑ Building addition ed.].officers homeowner doing all have exercised their I O•❑ Electrical repairs or additions work f• [No workers' comp. ' right of exemption per MGL c. 152, §1(4), andwehave no 11.❑ Plumbing repairs oradditions nce required,] r employees. [No workers' 12. @.Roof repairs comp insurancerequired.j *Any applicant that checks box #I must also fill out the section below showing their workers, compensation I Homeowners who submit this at Edavit indicating they are doing ail work and then hire #Contractors 13.❑ Other policy information outside contractors must submit a new affidavit indicating such. that check this box must attached an additional sheet showing the name of the sub contractors and their workers' lam an employer that is providing workers' information, comp, policy information. compensation insurance for my efnptoyees �e10W IS t11e otic p y and job site Insurance Company Name: 1A ro -4 v.. -e -/-Q� Policy # or Self --ins. Lic. #:n% F —TQY 9 d a: 0/3Expiration Date: Job Site Address. ` City/State/Zip: Attach a copy of the workers' compensatlon 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 cruninaI penalties of a civil penalties in the fomt of a STOP WORK ORDER and a fine fine up to $1,500.00 and/or one-year imprisonment, as well as 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. t do hereby cer MP under thepains andpenatties ofperjury that flee inforarration provided above is Official use only. Do not write in Mis area, to be Completed by city or town official City or Town: ___PermitlLieense# - bsuing Authority (circle one): -I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical -Inspector 5. Plumbing 6. Other - g Inspector `I and correct. Contact Person: ' Phone #: Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information conn: actor iniormauon Name PE601Z A M. ' N� (r Company Nae ---- L- -(!- Street Address (do not use a Post Office Box address) c©b blas ntractor/ Salesperson/ Owner Name V-\ Y� r City/Town State Zip Code / Business s (must include a street address) 377 o d (9 Daytime Phone lEvening Phone 3 8.85?— 66 0 Cityfro State Zip Code Mtn o 1 R6 y Mailing Address (It different from above) Business Plione Federal Employer ID or S.S. Number Home ]mpmvemeet contractorReg. Numbernxpim on date Law regmms that most home gmpmve tchave avalid regl,a ation ..mbmbaoaer )733K' (,O_ The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) S Clk ILL - /f__(_77—,77FVp. `JZ /j1L_/�Vr� l/p�� KOAu,A,�Cn.- J Required Permits -The following building permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the bomeownees agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of CDate when contractor will begin contracted rk MGL chapter 142A.)uy{Q.�a i a ac ti] ate when contracted work coil a substanti y completed. Total Contract Price and Payment Schedule The Contractor agrees to perforin the work, furnish the material and labor specified above for the total sum of: _ Payments will be made according to the following schedule: $� upon signing contract (not to exceed 1/3 of the total contract price gy the cost of special order items, whichever is greater) $ by or upon completion of $ by _/_/_ or upon completion of $-1-130 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both parry's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. / Express Warranty Is an express warranty beine Provided by the contractor? ❑ No IVYes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third patty/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sum the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important Information on the reverse side ofthis form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at aplace other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identical copies of the contract mut be completat and signed. One copy should go to the woeosi v. The other copy should be kept by the contractor. e� ' ,AAAZ____� omcowrier's Signature ntractor's 'gnature Date /f—' / Date a 25//3 Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to su it to such arbitration as provided In Massachusetts General Laws, cha ter 142A. o ieowner's Signature Contr (actor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home hnprovement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at hn://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hM2://db.state.ma.us/homeiMprovement/licenseelist.gsa For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1 - 11/22/2010 on ir`B"'inesati Office o Consumer A T CONTRACTOR ROVEMEN Type NOME IMP 167338 Registration: LLC - Expiration: 911012014 'AL ROOFING LLG OVAL, KENNETH D 72 NORTH STUndersecretary NO. READING, MA 01864:'T tiasw.tchusetts- Delmrtmcnt of Public Sakti 19 Board (If Building Rc-gulatio ns and Standards Construction Supervisor License License: CS 58443 KENNETH P DUVAL PO BOX 190172 NORTH ST N READING, MA 01864 f 'on�mix�T+Ener Expiration: 1 211 0/201 3 Tr#: 6884 9/10/2013 09:19 FAX 781 942 2226 GILBERT 10001 a� CERTIFICATE OF LIABILITY INSURRANIC�E ; 9ii 120 3 :HIS 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 endamoment(s). COeT PRODUCER MABarb3Y3 MCDono9ffh Gilbert Insurance Agency, Inc. P1,0P1,019%O(781) 942-2225 FAQ N,1[ (761) 942-2226 137 Main Street EMAIL,bmodonough@gilbartinalnranc6.com to 01867-3922 INSURED Duval Roofing, LLC. P.O. Box 637 Ina. 031 North Raadincj MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBERCL1331300142 REVISION NUMBFR, 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 NTH 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 SEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP LIM17S ILNT4R TYPEOFINSURANce POLICY NUMBER MMtoD GENERAL LIABILITY EACH OCCURRENCE B ] , 000, 000 TED rreDPJ$ _100,000 X COMMERCIAL GEN1 RAL LIABILITY PREMI ES (EQ.�Sda 64158G 10/23/2012 0/29I2013 MFJ] EXP (Apy one Or.on) 51000 A CLAIMS -MADE OCCUR 1,000,000 PERSONAL 8 ADV INJURY S OENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMB APPLIES PER: PRODUCTS • COMPIOP AGG S 2,000,000 9 X POLICY PRO- LOC --COMBINED SINGLE LIMIT 500 000 AUTOMOBILE UABIUTY BODILY INJURY (Per pe:svn) 3 ANY AUTO A gLLOWNED X SCHEDULED 6A456G 10/23/2012 0/23/2013 BODILY INJURY (Per sccfdent) 5 AUTOS AUTOS PROPERTY DAMAGE g X NON -OWNED Idanl HIREDAUTOS X AUTOS100 000 uninsured maarisl el s lit limn $ UMBRPI.LA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTION S WC 5TATU- OTN• B WORKIIRS COMPENSATION o be provided directly AND EMPLOYERS' L ABILITY YIN via Travelers insurance E.L EACH ACCIDENT S 100 000 ANY PROPRIETOWPARTNERIEXECUTIVE NIA /11/2013 /11/2014 OFFICE�EMBER EXCLUDED? E,L, DISEASE -EA EMPLOYE $ IQO OOO (Mandatory In NN) We,'a' ""nae E.L. DISEASE - POUCY LIMIT 500 000 DESCRIPTION OF OPERATIONS balgw DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddlUon41 Ramnrks Schedule, if more space Is roqulmd) Evi&ncs OP Coverage CERTIFICATE HOLDER CANCELLATION (978)688-95:42 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL I BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 0agood StreetAUTHORIZHD REPRESENTATIVE North Andover, MA Gilbert, CIC/BAP-MR ACORD 25 (2010105) ®1988.2010 ACORD CORPORATION.; All rights reserved. ,.,�,...r Tl,e annon norm anti Inne ara reaistered marks of ACORD Columbia Gas® of Massachusetts A NiSource Company 995 Belmont Street Brockton, MA 02301 February 19, 2013 Mr. Jeffrey Manning 9 Cobblestone Circle North Andover, MA 01845 Dear Mr. Manning: During a recent visit, our service technician detected a safety problem with your gas heating system at 9 Cobblestone Circle - North Andover, MA 01845 — generator needs to be serviced leaking gas. Accordingly, we have issued a Warning Tag because of this situation. Under the circumstances, we strongly urge you to correct the code violation. In addition, the Massachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737, Acts of 1960, requires that the condition be remedied. If you have any questions, please call our Service Department at 1-800-677-5052 and ask to speak with the Service Supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Customer Service Department Columbia Gas of Massachusetts Date. .. { TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. Vit. ��. Q I� has permission for gR 'stallation ..?:��! 0 ............. in the buildings of ...... at ...... � ...... .. .J..... ,No rth An er, Mass. Fee..%-�...Lic.No..9�a. mbi; .. ... GAS INSPECT Check # 8473 I` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE ["I C1� � PERMIT # „ . --- JOBSITEADDRESS _ ,5 OWNER'S NAME GOWNER ADDRESS - TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL_I EDUCATIONAL L]RESIDENTIAL - CLEARLY NEW: RENOVATION: �_) REPLACEMENT: (.;1 PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER =__J====== CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE . -._ _f . l I - — — _._J FRYOLATOR �(� _ I . l . _ �� L=I FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT (- l J _I OVEN POOL HEATER R OM /SPACE HEATER ROOF TOP UNIT TEST YI I __ UNIT HEATER UNVENTED ROOM HEATER L-A ,. i _ _ i, _ _. L _ WATER HEATER OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES e§ NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ®4 OTHER TYPE INDEMNITY ( BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER (] AGENT �I 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 com li c . it all P rt- e t p on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f PLUMBER-GASFITTER NAME'I LICENSE # -(I SIGNATU MP 0 MGF [--]I JP JGF [] LPGI CORPORATION _� # PARTNERSHIP ©#= LLC # COMPANY NAME: L7 /oLU��_� . LGA) ADDRESS 'SIt �__.1�.~-_- CITY STATE ^/1 ZIPSTEL FAX CELL CELLY9a7i EMAIL (kI'�a�ry 1w��k rZk—C-1- VV' -RI i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 www mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnlioant Y_r ..__4-t.._ Name (Business/Organization/Individual):_ L // l-/ � J �1�,/1 e .—, Address: City/State/Zip: 6 Phone #: ?'�Y7 U ze� Are you an employer? Check the appropriate box: 1. I - am a employer with 1_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I 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. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] I 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] f 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 I l jgPlumbing repairs or additions 12.0 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. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site %reformation. Insurance Company Name; ?olicy # or Self -ins. Lic. #: ��L � �� �p Expiration Date:_/� �ob Site Address: 4 City/State/Zip: kttach 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 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under tl ins an Halt es jury that the information provided above is true and correct. ignature: i� L%% / — /% n - 2 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 r —�TH MAS A.:..�_ WEAL OF SA ND ,CSA�SFITTaERS 1 LICENSED ASAMASTER PLUMBER j ISSUES zHE ABOVE LIL ENSE TO r,> r r ti R D Zd i RD jEn 0AN U 18.1 DJ= Z 9 x 1 `83:14;x''-' j:...: ...r 05/01/1+ i � ' ✓ .-,•mow+'_ eu�..-1 rt` CONTROL # H 3 917 31 IMPORTANT oti our Board at the: ro ed, n fY Y 1' onal Licensure, 1000 Washington St, If this license is lost. or dest y . Diwsior► of Profess Suite 710, Boston, MA 02118'610®: our board ed, notify Y If y proper mailing of next �1 our name or address shown is Chang our license number. of correct name or address toinsurey p Renewal Application. Alway row to of the General Laws This license is subject to the p „and must not be loaned as amended. It is a personal privileg, , this license on your or assigned to any other person. peep , person or posted as required bylaw- ; j j r t' f . f .t WEAL.TH OF MASS...,,, ` DU MR -K --ANDBA�SFITTi RS s t VAS -AN PLUMBER - 4 6 ISSUES THEAf30gE'LICENSE To. f .t .WAR ti_g 1 tKEtLE'Y`• IjL'Y.N � 7' ;M RD AR_ . MA '0181D'-293 ; ANDUVER .• � :,•, Z 05/O1/14 183146 . • 'ir ' I OONTROt.# H391731 IMPORTANT y your Bo rd at the: 1000 Washington St., 1# this license is lost or destroyed, notify Division of Professiona02118-6100: Suite 710, Boston, MA - ` � notify your board ed tY ' • changed, - If your name or address shown !s r)per mailing of next refer to your license number. ` of correct name or address to insure p Renewal Application. Always Mtti This license is subject to the provisions of the Genera! Laws personal privilege, and must not be loan ed± other person. t{eep this license on your as amended. It is a or assigned to any required by, law person or posted as it: • 1,l , t I , ,j i t� i i GENERATOR APPLICATION DATE: I I )�b a'.- LOCATION: / LOCATION: OWNERS NAME: 0 M GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR:E U e%� vlkar PHONE NUMBER: ELECTRICAL RE'SIDENTI GA COMMERCIAL LOCATION OF GENERATOR: *ZONING DISTRICT: TEMPORARY *CONSERVATION APPROVAL rtol' (Q-01 tA ul I DateJo! TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1*4 This certifies that ........ has permission for gas i t flation........... in the buildings of �-k P3.t'� yn. . . ........................ at ... .......... . .................. I N An v r, s Fee'Z05b. Lic. No. GAS INSPECTOR Check # 8177 ` AL\ GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY r! U, vj0 MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME r ly W ADDRESS OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL ®' NEW: D RENOVATION: D REPLACEMENT: 02" PLANS SUBMITTED: YESF-- NOD APPLIANCES' FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER[ E:_ 1 .. E:: [ l L _ [ I I - [ BOOSTER CONVERSION BURNER COOK STOVE( DIRECT VENT HEATER DRYER 1 _ 1 —j . FIREPLACE FRYOLATOR I 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 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES W0 El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY [j BOND FJj 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 E-11 AGENT El 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 an ac rate to he b of y knowledge. and that all plumbing work and installations performed under the permit issued for this application will be in compl' ce all P ine ro ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ��-- 44 .e_ _ LICENSE # 3 SIGNATURE MP MGF 0 JP] JGF D LPGI CORPORATION Q#.=i (PARTNERSHIP E-1# i LLC ®#� COMPANY NAME:DRESS,�Y_ CITY u . _iO'er _ ( STATE t -i ZIPTEL S.0 �r.._. -D._ - Ell FAX CEI , � F/5�7 _ EMAIL ?'he Commonwealth of Massachusetts Department of Iradustrial Accidents Office offsavestigations ullf ..600 Washington Street Boston, AM 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Clectricians/Plumbers Name (Business/organization&dividud):_ ,J ��4 /.G�i �,j„_ L f :• _ ' - - Address: :__ ;7 ----- Ci State/Zi tY/P' h U . ✓¢'�✓� ce,, ✓tti iF. Phone #: 7 ,r (o E - �0 - o X zZ) .Are you an employer? Check the appropriate box: 1 • LJ 1 am a employer with 1/ 4. ❑ I am a general contractor and I employees (full and/or part time).V 2.01 am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet t ship and have no employees These sub -'contractors have working for me in any capacity, [No workers' comp. ipsurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. E1.1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' COMP. insurance required.] *Any applicant th.-t checks box 41 ninst also BE out the section bel(�:- Type of project (required):' 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition ME Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other T Homeowners who submit this affidavit indicating they are doing 01 work and then hire ir outside contractors must submit 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' comp informadon.l ensation insurance for my employees Below is the policy and job site Insurance Company Name: j4, TZ -4- S (0 D Policy # or Self -ins. Lic. Expiration Date: Job Site Address:__ 5 e�b-�`�Q City/State/Zip:_ 013 y, 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 ofMGL 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 np to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations I of the DIA. for insurance coverage verification. I do hereby rd er the pains a71desnd peperjulY that the information provided above ' true and correct Sitmature: � 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. Electrical Inspector 5. PIumbing Inspector 6, Other Contact Person: Phone #: 9430 'LOW This certifies that ... !''� has permission to perform DateTw tQ, 4 ,2b ) 2 -,; TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .......... . It lie, r, .. ........ Ar plumbing in the buildings of 1f�.11J.i 1 ..................... at ... ........ N h An Mass. Fee3TSU. . Lic. No7��.:�O. . Hll PLUMBING I PECTO*R* Check # � 2-40 �5 4PLUMN;?' The Commonwealth ofMassachusetis • - Department oflndustriglAccidents Office of Investigations 600 Washington Street .Boston, MA. 0211 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers Applicant Information Please Print Le0biy r Q -, Name (Business/Organizationgn(Rvidual):_ /� J 1 Address• /_110 419-Y Ct/ City/State/Zip'�i �'.�d _1 , _ _ Gt2 Phone M 7 (� D 2� Are you an employer? Check the appropriate box: Type of project (required): 1.01 am a employer withy 4. ❑ 1 am a general contractor and 1 6. ❑ New construction ' employees (fall and/orpart-time).* 2. [] 1 am a sole proprietor or partner- have, bired the sub -contractors listed on the attached sheet. t 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their ME] Electrical repairs or additions 3.E1 X am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing, repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13J:1 Other �61G P 6tt comp, insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. "yt d /�—�!/��.•c--�. Policy# or Self -ins. Lic. #: ExpirationDate: Job Site Address: City/State/Zip: � 6), Attach a copy of the workers' compensation policy Ileclaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 wellas civilpenalties in the form of a STOP -WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby ce fy ander the pains andpenaltiesgXfperjury that the information provided above is true and correct. 20 Official use only. Do not write in this area, to he completed by city or town official. City or, Town:. PermitUcense # Issuing Authority (circle one): 1. Board of Realth 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. 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 grouttds 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.aceeptable 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 ibis chapterhave beenpresentedto 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 notrequired 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 fox 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits orlicenses. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license o permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT xequired 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: Tho Conuaaozwoalth ofM-assaohimetts - Depaftent of%dustzyal Acoldo:ats Of n o lu-festigati.om 00 Wasbingtoa Street Bostw, MA 021 It TO, # 617 -7.2? -•4900 oxt 406 Qx 1-87WA.SS.AFF, Revised 5-26-05 Fax # 617;,727-7749 www.Mass,gevfc 'a 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY `YL(, c% v MA DATE L PERMIT # JOBSITE ADDRESS fV%-� e-. <=OWNER'S NAME 01 14 W n/7 ti POWNER ADDRESS TEL 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: ( PLANS SUBMITTED: YES ® NO® FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM E-11 _ J- - - - - - - - - - - - - I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER LL FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK I TOILET I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I mill INSURANCE COVERAGE: have a current liabillij insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ©- NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2' OTHER TYPE OF INDEMNITY ® BOND ®I 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 El AGENT 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 ' ance with :117Pe#en!3Sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME wi. LICENSE # ��3 r SIGNATURE MPR JP CORPORATION[# S PARTNERSHIP 01 LLC®# COMPANY NAME ;J . S' 'x L ADDRESS 13 DOL CITY 6, u n1-C_r2 I STATE 1 ZIP0 / �( j' TEL S 7 (9 d S FAX CEI EMAIL O z 0 w PLO w � ^� O of z r a �❑ Z �- o w O W a z 5 O a w N a O I z w d p z a w � as a U J IL CL Q � w x w LL W H zz z 0 H v w a z as a a C�7 O O a .1% Date .... �7 / 3-/ 7, . ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perform ... scg6 is---/ wiring in he building of. ........ .. ............................................ .................. at .............. .......... .. . 'North Andover, Mass. Fee..................... Lic. No. 4� ................ .... .. J�sp c� c; INSPWTG� PLECTRIC Check # ,% 10777 Commonwealth of Massachusetts a Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. t0 7 7 7 Occupancy and Pee Checked [Rev.1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECT ICAL WORK All work to be performed in accordance with the Massachusetts Electrica41nsptor 527 CMR 12.00 (PLEASE PRINTINXNKORTYPEA L INFORMATION) Date:City or Town of NORTH ANDOVER To theo Wires: By this application the undersigned gives -notice ofhis or her in �o^to perform the electric- work pies ribed below. Location (Street &Number) 9 � 3 j�ypp Pel L XP Owner or Tenant Owner's, Address n !�,_ Telephone No. Is this permit in conjunction ith a bui ding per ' Yes!" No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts OiVrheadEj Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No, of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No, of Switches No, of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers table INo. of Ceil.-Susp. (Paddle) Fans 1140 Th No. of Hot Tubs Ge; Swimming Pool And e ❑ In- [i [iLyrBat No. of Oil Burners FH No. of Gas Burners N0• No. of Air Cond. Total m.._,. IN,. Space/Area Heating KW Beating Appliances KW No. of No. of Siunc Ballasts No. of Meters No. of Meters 21vedpE thi Inspector o Wires. Total s KVA KVA Z ALARMS INo. of Zones of Detection and Initiating Devices of Alerting Devices of Self -Contained action/Alerting Devices 11❑ Municipal C.'nnnPrtinn ❑ Other No, of INo. Hydromassage Bathtubs INo. of Motors Total HP Telecommunications Wiringg. _. ,. No. of Devices orEauivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lec ical Work: (When required by municipal policy.) Work to Start: V11311,7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c verage ism force, and has exhibited proof of same th peOue 'ssuing offe . CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �f �� Xcertify, under the pains and enald ofper'� ,that the i rtna ' n th'i a licafion and cd �;At to--T-�� PPp FIRM NAME: `/U MCI LTC. NO.; Licensee: 57Mw eh i &AP Signature LIC. NO.e__ (Ifapplicable, enter" x mpt" ' t e licens mimberline. Bus. Tel. No. / Address: S v - Alt. Tel. No Per M.G.L c. 147, s. 57-61, security work requir Department ofPublic Safety "S" License: Lie. 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: $ l f • , 1 .- • •a%/./.JJU VJ Y ,����(�{(�(,, /V�+K/■.Jryi' .Ai X0. Q�('T •�Q'.',�[ ./.1, `IJif. J.:(VJ•..SVi.7 JLv��V/�.`tiJ4� / — jJJ1.-1./.�i .L ��1. � V 1a'. ®.11.0. � • .. � ; �' � _ . P�ssetT--� +'ailed-•[ � �e-zuspecizon xec�wixe�!($�0.00) � [ ) �ns,�ectQrs' comme�afs: L ld Z' (nspecta 7 izgn e - uoziiaTs) Pate 2. Y'WAL )W8PPCtTOX,- �'asse�.�-- ' �'azTec�--[ � � �.t�-3�us�ectioxtxe�uixe� (50.00)-• [ � . 7Yts�ectaxs' c mm�ents: • A r (61sX Bdors' Pz atare no Wfials) Slate r2ed RODND I N'�PECTXON. , omments: ' (inspectors' ijignatzzre -no inifialsj Date A. WSPECITON—S Y ICE: Y-1'& E,f r Iii U NATIONAL OKI 1 : Passed--[ x laspectors' coramegfs: railed - PSP ectors',5iguature •• io r te-5�aspectionx� 'assed--•[ II+ailed�[_ Xte�nspecti aspectors' coxrtxnerifs: Date (w—sl►ecfors' i9zgnature no znitiais) Date D 0 O TAGIUM TO 1319 MMED QlJT AND IEET ON 91TE IF M .APMA, TO M WSTE CUD 10 NOT ACCEMELF, AND .A RWNSPECTION OF $59.0 0 M TO BY CMRGED. 9386 Date. TOWN OF NORTH ANDOVER < o PERMIT FOR PLUMBING This certifies that .� �Ph�C ........................ w" has permission to perform . r4A- ./w,06V'..................... plumbing in the b", Id 'ngs ildings of .. /�%5'n/�/.hl................... . at ... y'...�o,� ��� ivt......... .... , Nottth dove,, ss. �.���. Fee 3ZOV... Lic. No..RA . // / 491PL.UM8ING INS CTOR Check # / �3� ✓�a — ,,L•—_• erg P TYPrl-Ok. PRINT CLEARLY MASSACHUSET'T S UNIFORM APP1,I0AT1011 FOR A PFERMIt TO PERIFORM PLU"IIING WORK . / aTi(� ` , v • /r��l �-v--�t_ MA DATE (-! (/ 7/1 PERMITt� JODSITEADDRESS i -( C� �'�<E/ S:1�r��-�-� `OWNER'S. NAME 4 /1/14 I✓ /t/ OWNERA.DDRESS ( 5 q--- TELT IFAXI I OCCUPANCYTYPE COMMERCIALI ! EDUCATIONAL ( I RESIDENTIAL NEWS � • 1 RENOVATION:( I REPLACEMENT: f V PLANS SUBMITTED: YES( j NO.t [ WOO 7 FLOOR-* 13SM 1 2 3 4 5 S 7 a 9 10' 11 12 13 14 BATHTUB I '. • , CE�OSS C6NNECTION DEVIGL :. :. _ . _... ,.:..:._ .. .. .. .... ". DEDICATEDPI=C IALWASTESYSTEtii [ DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM I I .... .......... ....._. ......., .. _.__ DEDICATED GRAY WATER SYSTEM !. DEDICATED WATER RECYCLE SYSTEM i DISHWASHER I DRINKING FOUNTAIN ! FOOD DISPOSERI .. i ....:. :. I • ... ' FLOOR IAREA DRAIN .- . _ INTERCEPTOR (INTERIOR) : _ I -. — --`._: ; .... , .. , . _. ! -- .: i, 4. •...i . . KITCHEN SINK ..... i LAVATORY _. .... ROOF DRAIN SHOWER STALL- SER=EIMOP SINK TOILET URINAL- tNASIiING MACHINE CONNECTION WATER. HEATERiALL TYPES. _ WATER PIPING �4/ -1</�L .OTHER _ t _ .. ....'.• INSURANCE COVERAGE: -- — I have a ctirrentitsilralice policy.or its stllistalltial equivalent wliicli meets the requirements of MGL Ch.142. YE8vl NO ( [ IF YOU CHECKED YES, PLEASE INDICATE THE TY.eE OF COVERAGE BY CHECKING THE APPROPRIATE 8OX BELOW LIABILITY INSURANCE POYCY' ,j OTHER TYPE OF INDEMNITY [ ( BOND [• j OWNER'S INSURANCE WAIVER: f ani aware that the licensee sloes not have themsurance coverage required by Cfiaptei-•942 of the Massachusetts GeneralLaws, and that.Iny signature on lids perttiit applicatioti v,j fives this regtlim(iient. CHLCK-OWLONLY: OWNER AGENT- [ - SIONATURE OF OWNE110It AGENT I hereby eerlify that all of the details and irifonnaVan I have 6ubmIlted of entered regarding;ols applicaliorf ate , nd acc rate to a hes r m knoerled�e and that all plumbing work and lnstallations performed under the permit issued for this application will be in mpl' nce •' all Pe neat ovisof the Massachusetls Stale Plumbing Code and Chapter 142 of the General Lags. PLUMBER'S NAME[ AME S't,GCtom; -� LICENSE ff 1 [ GNATURE MP[ [ JP[ I CORPORATION[ [fi 'PARTNERSHIPI' jfi� ILLCI jfi) COMPANY NAME. �� r S J `�.i44 t,► e (9t-14 ADDRESS I PJ 1-70 % t-1 C1TYl Vo �l Get ...•. !STATE I AIA j ZIP 1 U 1 J"t TEL 7 �t?"� -?,o FAX CELL I EMAIL a ra F p❑ F� v J a F u: 9 The Commonwealth ofMassachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Orgai 'mation/Individual): i Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a' em to er with 4. ❑ I am a general contractor and I ' p Y 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions . 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself., [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] i employees. [No workers' comp. insurance required.] 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that 1s providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self --ins. Lic. #: Expiration Date: Job Site Address: Pity/State/Zip- Attach a copy;of.the workers' compensation policy declaration page (showing the policy number and expiration date). 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 forth 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 cert under the pains and penalties ofperjuty that tlte.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. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact 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 ofhire,. 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Con onweal& of Mossarhvsetts Department ofZndustriai Accidents Office of Investigations 600 Washington Stxoet Boston, MA, 021. It Tei, # 617-727,4.900 est 406 or 1.-877,MASS.A.k'B Revised 5-26-05 Fax # 617"727=7749 www..tnass,gov/dia Date. l ... ` 06 ......... TOWN OF NORTH ANDOV p PERMIT FOR GAS INS T LATION This certifies that ..:.4.... has permission for gas installation in the buildings of ....:� ::'-�' .. -�= �;'.........!........ . �/` s' at .,�!... 1-.. ........ .. . , North Andover, Mass. Fee`.5 .... Lic. No. 7�-�...t �; - z._:........ . GAS IN ,ECT R Check # /_. 5 81; 8 G 6'AaQAM -MU*t d t o UNlthtJ}' M APPLICATION FOR PERMIT TO DG ;ASF1T�r1NG Z-1!�- fPHnt or Tyr e) Mass. Date. ZO 20 d PermlC Building Location Owners dame _.._ 'type of occupancy � fte-.,e ke«novaltion c. Replaeenmnt flans Subltdtted: 'des No � i 4 rest�tdan� tbtarr�any Miami ��.(-_ __-- �,00r�ss t U"-stne*b Telephone iry o LlCemeCl plursfber or pas Fitter Check one: Certificate Partners hl o L) Firnuto. Sfi5�2Ri'IJV'Ci �@tfER'pCE: i. pave a current 113blllty InXW6ace poliCy or Its substantial equivalent, wtalCtf rnestrt flee raQultrernents of MGL Ch. 142. Yes No u sf you have r4heckeCd Xes, ole#s e Indicate the type of coverage by ctteekino the appropriate box. i A ( 00Wry InSUr2nCS policy �j Other type of Indemnity o Bonet L 1 i ,;4ftaltls IMURNLri, wsuvit ii am aware that the 11censee f ORS not stave the dssssurance coverage required by Chalpcer r t2 of that l assn venerflal ana mat my signature on ti fserrn at$"ptlCed9ott Walvet Elsa requirement. i , n!retrV tertf fy Mat atl isf the rny k.,10wtr09e and Etat all ;Ku all Pert mt:rrt vrivwons of Me ( zFi'}i1,�C) tIUF'Fli;d�tiSir GP.C.Y"t' Check ore: O%vnerr o Agent p and Ir4errrr3130n t nave subtl9ltt0Ck tors n a e tees snd wcc►crats tr9 "Yrr P�exS a,� vmrt anz imi2flations perfortnac9 Eris perfefltIssouerd for 300n wltl bs an Cornoitan6E with ,hose= 5 Mte Cas Code and W►ufp 162 of th Gan t>swst. TV LMen$a. -W • s$na ants i'"na�ar:Rr a it r. W-O tet Liters* Number_ � -I _.._ �>,urneyman ay �� � � � � � � z �g SEMEN t - --7 2ND- FLOOR D FL 41'M FLOOR C jF 1 5TH 16TH FLOOR. ,;7—HF L70i i;,fiFLOO'p , I - 4 rest�tdan� tbtarr�any Miami ��.(-_ __-- �,00r�ss t U"-stne*b Telephone iry o LlCemeCl plursfber or pas Fitter Check one: Certificate Partners hl o L) Firnuto. Sfi5�2Ri'IJV'Ci �@tfER'pCE: i. pave a current 113blllty InXW6ace poliCy or Its substantial equivalent, wtalCtf rnestrt flee raQultrernents of MGL Ch. 142. Yes No u sf you have r4heckeCd Xes, ole#s e Indicate the type of coverage by ctteekino the appropriate box. i A ( 00Wry InSUr2nCS policy �j Other type of Indemnity o Bonet L 1 i ,;4ftaltls IMURNLri, wsuvit ii am aware that the 11censee f ORS not stave the dssssurance coverage required by Chalpcer r t2 of that l assn venerflal ana mat my signature on ti fserrn at$"ptlCed9ott Walvet Elsa requirement. i , n!retrV tertf fy Mat atl isf the rny k.,10wtr09e and Etat all ;Ku all Pert mt:rrt vrivwons of Me ( zFi'}i1,�C) tIUF'Fli;d�tiSir GP.C.Y"t' Check ore: O%vnerr o Agent p and Ir4errrr3130n t nave subtl9ltt0Ck tors n a e tees snd wcc►crats tr9 "Yrr P�exS a,� vmrt anz imi2flations perfortnac9 Eris perfefltIssouerd for 300n wltl bs an Cornoitan6E with ,hose= 5 Mte Cas Code and W►ufp 162 of th Gan t>swst. TV LMen$a. -W • s$na ants i'"na�ar:Rr a it r. W-O tet Liters* Number_ � -I _.._ �>,urneyman Location�- No. �� Date NORM TOWN OF NORTH ANDOVER O: •o ,� 1{r00 • L 9 Certificate of Occupancy $ E Building/Frame Permit Fee $ sAC Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ( 6 3 ` Bwlding Inspector Permit NO: 7 4 Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1� A � Date Received Z6� 4 IMPORTANT: Applicant must complete all items on this page I LOCATION Print PROPERTY OWNER)e� F - 4 5796f90Y � Print MAP NO.: PARCEL: TYPE AND USE ,OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration XOne family ❑ Two or more family No. of units: ❑ Industrial ?'Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving relocation ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Ar�2� roF X ��P-rD T2/�1, exAPA�42D5, MiD `1 Identification Please Type or Print Clearly) OWNER: Name: D�&W *1A0k11 11V6- Phone: P25.691-0015— - a Address: 2 CO a6d-,;rveWr- G# F CONTRACTOR Name: Phone: 9X -Z/75f wQ3 C Address: Supervisor's Construction License: 0 ,Q 21? f Exp. Date:�f h> //1� Home Improvement License: ZYO f" � Z/ Exp. Date: l /Z�6If If ARCHITECT/ENGINEER Name: Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $10.0ER $1000.00 OF THE TOTAL ESTIMATED COST BASE8NN $125.00 PER S.F. Total Project Cost:$ 51000-1w— x10.00=FEE:$ Check No.: I V' 1 Receipt No.: Page lof4 TYPE OF SEWARGE DISPOSAL Art ❑ Swimming Pools ❑ g Public Sewer F1Tanning/Massage/Body Well Tobacco Sales ❑ Food Packaging/Sales El❑ ❑ Permanent Dumpster on Site ElPrivate (septic tank, etc. Electric Meter location to project ri v i r,: rersons contracting with unregistered contractors do not have access to the uaranty fund Signature of Agent/Owner Signature of contra Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ tamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS I DATE REJECTED ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED 11 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments X DATE APPROVED Water & Sewer connection/Signature & Date Drivewav Permit Temp Dumpster on site yes_n0K Fire Department signature/date Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required IProvides Required Provided DIMENSION Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. NOTES and DATA — For department use Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC. Jan.2006 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 i _� z w o O O 00 C14 2 f= �Q ; > ` 1 U'' a °c o an H I (� aaGz m a Z 0 O 0 is G,U o rn o v S p L o N U. O Z M (3O U O o Q y ai of Zf Y m 0 a v W U) chi Z r W o m w o J m J 2 jZO !� m t- w El 0 NOTICE OF ASSIGNMENT EMPLOYER: COMBO I.D. BRIAN D HOLLENBECK 000117698 9 iTHOMAS RD METHUEN, MA 01844 COVERAGE GROUP 0117698 The Waiver of Our Right. to Recover from Others Endorsement is available on Pool policies. Contact your agent for details. AGENT HOWE INS AGCY INC OR 4 PUNCHARD AVE PRODUCER: ANDOVER, MA 01810 AGENCY FEIN: 042 5 3 8 84 9 CLASSIFICATION OF OPERATION -------------------------------------- CARPENTRY -DETACHED PRIVATE RESIDENCES CARPENTRY -DWELLINGS -3 STORIES OR LESS CARPENTRY -NUC EMPLOYERS LIABILITY 100/100/500 STATUS OF EMPLOYER Individual Coverage under this assignment applies to Massachusetts operations only. For coverage outside of Massachusetts, contact the appropriate Pool or Plan for that state. INSURANCE COMPANY: GRANITE STATE INS CO RESIDUAL MARKET OPERATIONS P 0 BOX 409 PARSIPPANY, NJ 07054-0409 (800) 645-2259 CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION ----- -------------- ---------- ---------- 5645 $20,000 9.03 $1,806 5651 $0 9.03 $0 5403 $0 16,48 SO 9845 STANDARD PREMIUM $1,806 EXPENSE CONSTANT 0900 $284 TERRORISM CHARGE 9740 $6 ESTIMATED ANNUAL PREMIUM $2,096 DIA ASSESS. 4.4% OF STANDARD PREM. $79 EST. ANNUAL PREM. PLUS ASSESSMENT $2,175 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $2,175 1 THIS IS NOT A BILL COMMENTS Coverage effective 12:01 AM on 09/09/05 DATE OF NOTICE: 09/09/05 PREPARED BY: Joanne Shea EXT 530 * * VOLUNTARY DIRECT ASSIGNMENT * * LETTER ID: 805879 COPY: EMPLOYER The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439-9030 • FAX (617)439-6055 - www.wcribma.org M3 IVM3N38 90/91/£0 (0016) OLbs-tg All A8 :pau6isaaiunoZ) Z 6 1 ` 1 S S398VHO (INV Wn IW38d IViOi 4201 ` 1 S :wniwaad lenuud paiew!is3 so g 4Jed 86euan00 autueW puelul 1etoJawwo0 sallddV 1!pnV lenuud :1!pne wn!wa.id of inafgns sapllod aoj waoj ,algeo!idde j! alnpagoS eabe6uolN pue Aoilod s!yi of 6uiAldde siu9wasaopu3 pue swaoj 'sa6eaano0 leuolidp '96eJ9AoO Apadoad 'saslwaad Jo uoiid!aasaa aoi salnpayas payaeiie ayi aaS Aoilod s!yi ui paieis se aoueansui ayi ap!Aoid of nog( yi!M aaa6e am 'Aoilod s!yi jo sw.iai ayi lie of inafgns pue wn!wa.id ayi jo ivawAed ayi joj uaniaa ul (anoge paieis pa.insul paweN 941 JO L0/90/s0 :uoi;ejidx3 ssaippe ayi ie awil p.iepuelS -vy-V iO:ZI) 90/90/50 :ani130113 ' Z1 :w-191 A3110d ivnaIAIQNI :A W3 IVIlN3aIS321 AHIN3dM :ssouisn8 spainsul paweN i 10 Z 0 0 Z :opo0 uaonpoJd ZhZtp8S0V0 :jagwnN ;unoaaV ZtiZh8SdW :jagwnN AOilod NOIlVW2IOdN1 H30I0HAOII0d OOhO 5L12 SL6 : 3NOHd 1N39V ONI A0N39V 30N"nSNI 3MOH 3H1:;ua6V htPOTO VW `N3nHl3W aB SVWOHl 6 N339 N3110H a NVIIIS ssaippV 6uil!eY11 pue painsul paweN SNOIldM"33(l A3I"10d SMO13d211NO3 9£LL-9b9-999- 6 :auoUd anal l£b£0 HN 'auaa)l `13aa1S 1saM SS ANVdWOD HDNVHnSNj a3snSNI -ldninW HONt-Io IVNOIIVN 96ea9no' A1!l!ge!l s.ieuMosseu!sn8 ayi jo -b•Q uo!ioas of aaiaa aseald •po!aad lenuue algeo!ldde ayi 6u!anp ap!Aoid am aoueansui jo iunowe ayi saonpa.i sa6e -aanoa anoge ayi aoj wield pled yoea 'Ai!l!ge!l le6al ai! j aoj ida:x3 :asuadx3 leoipa" pue A1!i!ge!l ssauisng 000,01 S uos.iad aad - 1!wil asuadx3 lea!paIN 0 0 0 ` 0 0 s $ uolsoldxa ao aiij auo Aue .- Ai!l!ge!l le6al aa! j 0 0 0 0 0 0` Z $ 1!wil ale6aa66V leaauaE) 0 0 0` 0 0 0` Z $ )!w!l aie6aa66d suolieaadp paialdwo0-sianpoad 060,000, 1 S i!w!l )Unful 6UISIIJanpV pue leuosaad 000,00011 S aauaaan000 yaea - sasuadx3 Ien!paIN R Ai!l!geil 30NvunSNI d0 SllWll 39Vkl3A00 A11IISVIl SIONMOSSMisn8 ,algeo!idde j! alnpagoS eabe6uolN pue Aoilod s!yi of 6uiAldde siu9wasaopu3 pue swaoj 'sa6eaano0 leuolidp '96eJ9AoO Apadoad 'saslwaad Jo uoiid!aasaa aoi salnpayas payaeiie ayi aaS Aoilod s!yi ui paieis se aoueansui ayi ap!Aoid of nog( yi!M aaa6e am 'Aoilod s!yi jo sw.iai ayi lie of inafgns pue wn!wa.id ayi jo ivawAed ayi joj uaniaa ul (anoge paieis pa.insul paweN 941 JO L0/90/s0 :uoi;ejidx3 ssaippe ayi ie awil p.iepuelS -vy-V iO:ZI) 90/90/50 :ani130113 ' Z1 :w-191 A3110d ivnaIAIQNI :A W3 IVIlN3aIS321 AHIN3dM :ssouisn8 spainsul paweN i 10 Z 0 0 Z :opo0 uaonpoJd ZhZtp8S0V0 :jagwnN ;unoaaV ZtiZh8SdW :jagwnN AOilod NOIlVW2IOdN1 H30I0HAOII0d OOhO 5L12 SL6 : 3NOHd 1N39V ONI A0N39V 30N"nSNI 3MOH 3H1:;ua6V htPOTO VW `N3nHl3W aB SVWOHl 6 N339 N3110H a NVIIIS ssaippV 6uil!eY11 pue painsul paweN SNOIldM"33(l A3I"10d SMO13d211NO3 9£LL-9b9-999- 6 :auoUd anal l£b£0 HN 'auaa)l `13aa1S 1saM SS ANVdWOD HDNVHnSNj a3snSNI -ldninW HONt-Io IVNOIIVN r 1 P 0,5 i Page of ` 'G'f> 0602SP AW oily/ Proposal Submitted To: Job Name Job # Address Job Location 9 <o8 7o v,� S4140— Date Date of Plans lY _ �N �vGR �9r4- d b o6 We propose hereby to furnish nd labor — complete in accordance with the above specifications for the. sum of: $ /p l&lwaw COC:' %r �O s9 "Wol!/4 Tc.s T3F A 7Z-YZ41AJF— Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be withdrawn by us if not accepted within 21cceptance of Pr000gaI The above prices, specifications and conditions are satisfactory and are Signature / be.LL NIM 11A - �- hereby accepted. You are authorized to do the work as specified. Payments will be made as outli d above. / Date of AcceptanceSignature s>s NC3819 MADE IN USA A w° GL cin U z w° p.0 w Uw" G w a o°' G w" O w U Ucz w w°' w" F W0 G w" A a rA V-) 0 cn `\ C� 0 <i �t J ji 1 o Q o W0 U w ol • O Iz o ' m c w Mom c H O_ r-. O •: � V V d� a C OC Z C �om y t: ECF a 0 • y • �.: ' Gi +O+ is CQ! c N W O � y CO m� ccl N co E0 C o O.V � Z v, pip c �cya acz C.S z •�~ Cc H o c a m m c S o ' %i = 0 CLO- W c �.Z.-Z LL O N.Oa.. c~ � •tA •a Z W c r W •E U o, C* 2 A .OptA� f- t .0.. CL CO E if M 0 y 75 cm CD S CD c m 0 cm c •c N 0 t w O Z O 8 0 M I R, 0 ai • O � v Z aL O. O CO) Q C I Ctm O•— y Coo •i m m CD = O� 3.0 O Q i Cc o a K:. c a ca C O 0 C CD 0 CL V h O C ■ C � Q cc CLCA Q LU N U) W W ce W U) C� 0 0 Cf) Z W0 U Cn M I R, 0 ai • O � v Z aL O. O CO) Q C I Ctm O•— y Coo •i m m CD = O� 3.0 O Q i Cc o a K:. c a ca C O 0 C CD 0 CL V h O C ■ C � Q cc CLCA Q LU N U) W W ce W U) Location % 62 � IFS�N"� U/A- No. 31-5— Date I a - -)-0 Check # f? 0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ aff (rte 15 198 Building Inspector TOWN OF NOR', HANDOVER BUILDING DEPARTMENT APPLICATION TO CONST RUCT.REPAIR, RENOVATE, OR DEMOLISH . A ONE OR TWO FAMILY .DWELLING - 3UILDING PERMIT NUMBER: f DATE ISSUED: l / iIGNATURE: �( Building Commissioner/Insoea r of Buildings Date :1Pr•T1rnnr t- CTTF. INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /OD d9 Map Number Parcel Number < lir L �/y O D v (IL n i< i 1.3 Zoning Information: 1.4 Property Dimen$iohs: . rQuin District. Lot Area; s Front R 1.6 BUILDING SETBACKS ft Front Yard Side YardRear Yard { Required Provide Required Provi&a R red Provided L7 Water Supply M.Cr.LC.40. Sq) 1.5. Hood Zane Information: ' Zone outside Flood Lone 0 1.8 Municipal Smcrago Disposal System: 0 on siteDisposil System. Q .. ?ublic 0 Private D 5E.CTION 2 - PROPERTY OWNERMIP/AUT-HORM—D A GENT 2.1 Owner of Record rley �`-e121 eG Le,91ZIZii72_ Name (Print) Address for Service: Si re Telephone 2.2 Owner of Record: Name Print Address for Service: } SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: License Number AVIV Address pp. 7�,'' t�v �g- O p JExpiration Date nate Telephone f 3.2 Registered Home Improvement Contractor kemle J eiyl i e zz Company Name H Not Applicable 0 /OD d9 Registration Number Expiration Date i i i -~ SECTION 4 - WORKERS COMPENSATION (lVf G L C 152 § 5c(6) Workers Compensation Insurance affidavit must be completed and submitted with this, appliedtion, Failure to provide this affidavit will result in the denial of the issuance of the building rmit. Si ned affidavit Attached Yes ...., No.......0„ . . SIECTION.S''Desct tiohofW6 tisedWork'cheekalia Zl�cable New Construction 0 Existing Building Repairs) pAlteration s(s) Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description. of Proposed Work: v t E SECTION 6 - ESTEgATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Com leted.b rrrut a licant 1. Building a :13 (> Building Permit )+ee 2Electrical Mtilt� ier T (b) Estsmai. ted Tota} Cost of t m190. Constructton 3 Plutnbxn Building Permit fee.(,).x (b) 4 ; Mechanical.; HVAC. — 5 Fire Pxotestion 6 Total 1+2+3+4+5 / ©O, ^ %� b oo Check Niizgtber SECTION ?a OWNER AUTHORIZATION TO BE COMPLETED WHEN j OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Of as-Owner/Authorized Agent of subject property Hereby authorize T©SP�// /( /}J�j' My behalf; i a natters r ahv to work authorized b this building to act on Y g permit application. i nature er � 1' Date SECTIO b OWNER/AUTHORIZED AGENT DECLARATION To�e�� property as Owner/Authorized Agent of subject Hereby declare that the statements and information on the foregoing.application are ttrue and belief and accurate, to the best of my knowledge Print SIDE OF FLOOR TIMBERS 1 sr j SPAN DIMENSIONS .OF SILLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS . HEIGHT OF FOUNDATION i SIZE OF FOOTING MATERIAL OF 7 rNEY IS BUILDING ON SOLID OR FILLED LAND iIS BUILDING CONNECTED TO NATURAL GAS LINE THICKNESS X 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,S150A. The debris will be disposed of in: Signature 6f Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Name: Location: 10/� 01921, Phone / N—,2 9 am a homeowner performing all work myself. F—II am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name iqd: Address�� City ��yy�/Ut� �i �%� D��y,� Phone* / " 0 Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify ugqer the pains and pqriq_lties of perjury that the inflation provided above is true and correct. Signature Date AA ow Print nameaS6i°h� /°/�e� S Phone # / % _604?e Official use only do not write in this area to be completed by city or town official' Building Dept ❑Check if immediate response is required Building Dept p Licensing Board ❑ Selectman's Office Contact person: __Phone #: Health Department 0 Other FORM WORKMAN'S COMPENSATION BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 015ON Birthdate: 08/27/1958 Expires: 08127/2003 Tr. no: 3960 Restr!qted: 60 JOSEPH R RATT-E 340 MT VERNON ST LAWRENCE, MA 01843 Administrator HONE IflPROVEMENT CONTRACTOR Reqktralion: 100754 Expiration: 6/14101 Type: Private Corporatio ROGER J. RATTE, INC. Joseph Ratte &Tr -,fl'/ 342 Mt. Vernon St AnMINISTRATOn Lawrence HA 01843 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 015ON Birthdate: 08/27/1958 Expires: 08127/2003 Tr. no: 3960 Restr!qted: 60 JOSEPH R RATT-E 340 MT VERNON ST LAWRENCE, MA 01843 Administrator Hesidential & Commercial building ahu�ss`/ a� Remodeling - Additions CONTRACTORS COPY Roger J. Rath, Inc Est. 1954 General Building contractors RESIDENTIAL CONTRACTING AGREEMENT. . Read this agreement and make sure .you understand it before signing it. This Agreement has legal force and effect birtds those who sign it. Notice: All home improvement /general contractors and subcontractors engaged in home improvement contracting, unless.specifically exempt from registration by provisions of Chapter 142a..ofthe general, laws, mutt be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registtration, One Ashburton, Place, Room 1301, Boston, MA 42108- . Designated Registrant's Name: Roger J. Ratte', Inc. Salesperson's Name: Joseph R Ratte' Registration Number: 100294 License Number: 015004 This agreement is made on December 3, 2001 between Roger. J. Ratte', Inc. of 340 Mt. Vernon St. Lawrence, MA 01843. Ph. (978)-688-8839 hereinafter called "Contractor" and Jeffrey & Angel Leonard of .9Cobblestone Way North Andover, MA 01845 Ph. (978)-258-5878 hereinafter called "Owner".. I. DETAILED DESCRIPTION OF WORD TO 13E PERFORMED Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following: Renovate Screen porch. as per attached plans specifications. DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above. descnbed work consist.of,the following: As per attached plans and specifications: H. PRICE Contractor agrees to do all work described in Section I for the. total price of : $18,500.00 Eighteen thousand five hundred dollars. HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK: Hidden conditions or additional work may require adjustment in the overall price for the necessary work related.to this contract In such case the Contractor shall inform the Homeowner of such conditions forthwith and where necessary a written amendment of this Contract will be negotiated and executed by the Parties. Additional work beyond the scope of this contract. will be billed at an hourly rate of $48.50 per man hour. Additional material and subcontract work will be billed at direct cost plus a 20% General contracting fee. (Excludes light fixtures.) 342 Mt. Vernon Street - Lawrence, MA 01843 - (508):688-8839 III. PAYMENT Payment will be made as follows: $3,000.00 deposit with signed contract $3,000.00 At start of job. $5,000.00 Completion of rough electrical. $5,000.00 Completion of plastering $2, 500.00 Completion of job as per specifications. Payments as. provided above shall be made when due.- Any payments that are. delayed shall.be subject to a finance. charge of 1% per month: Notice: No agreement for home improvement contracting work shall -require a down payment . (advance deposit) of more than one-third of the total contract price or the total amount :of all deposits or payments which the contractor. must "make, in advance, to order and/or otherwise .. . obtain delivery of special order materials and equipment, whichever amount is greater, IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the. signing, of this. Agreement, unless specified here in writing. Contractor will begin the .. work on or about December 10; 2001. Barring delay caused by circumstances beyond Contractor's control, the work will be completed on or about January 18, 2002:. The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made. in advance. of the time specified in Section III (Payment) above for the reason that he deems himself or the . payments to be insecure:... . If, however, he deems himself to be. insecure, he may require, as a prerequisite. to continuing the work described herein, that the balance of the. payments under, this contract that are. in the control .. . of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner -&r withdrawal - V1. INSURANCE. Contractor will, be responsible_to Owner or any third party for aW property damage or bodily. . injury caused by himself, his employees or his subcontractors in the.perfoTmance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to cover. such or injury. Jury. VII SUBCONTRACTING :.. Contractor agrees that, notwithstanding any agreement for materials and/or labor between . . Contractor and a third party; Contractor is responsible to Owner for completion of all work described in a timely and. workmanlike. manner. VIII CONSTRUCTION -RELATED PERMITS: The following construction related permits will be necessary in order to complete the scope of work included in this contract and are the responsibility of the Contractor: (mark X where applicable) Building X Demolition Plumbing Electrical X The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction related permits. Home improvement work (i.e... additions, garages, porches, etc.) may require other permits including but not limited to Variances and Special Permits under Zoning by-laws through the. Board of Appeals,. Board of Health Permits. for expansion of sewage disposal systems, Conservation Commission for an Order of Conditions, etc. Such permits which may require non -construction related, engineering, technical or legal representation of the Homeowner, shall be the responsibility of the Homeowner. Notice:_ If the homeowner obtains his own construction -related permits for.the work described under this agreement, the homeowner is hereby advised that in the event of a dispute, judgment and, nonpayment of the Contractor, the homeowner will. not be entitled to make a claim to or collect from the guarantee fund established by Chapter 142A, M.G:L: fX. MODIFICATION This Agreement, including the provisions relating to price and payment schedule cannot be changed except by a written statement signed by both Contractor and Owner. However; cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed). X. WARRANTIES The Contractor warrants that the work.furnished hereunder shall be free from defects in. materials and.workmanship for a period of one year following completion and shall comply with the requirements of this Agreement. In the event any defect -in workmanship or materials, or damage caused by Contractor, his subcontractors, -employees or agents, is discovererd within one year after Completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, .repair, Correct, replace, or cause to be remedied; repaired, or replaced, such damage or such defect in materials or. workmanship. The foregoing_ warranties shall survive any inspection performed in connection with.the agreed-upon work. All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties, the Owner may be required to register or mailin a warranty card or other, evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such equipment: Xi. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and-until all blank sections have been filled in or marked as void,. deleted or not applicable, and until all exhibits and .related or referenced documents that are incorporated herein are attached hereto. XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the.Laws of Massachusetts. It must be executed in duplicate, and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner of a copy thereof. RIGHTS TO CANCEL The owner may cancel this agreement if it has been signed by.the owner at. a place otherthan an address of the contractor which may be his main office or branch thereof, provided that the owner notifies.the contractor in writing.at his. main office or branch by ordinary mail posted { by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner's Signature Date Signed Co tractors:Signature Date Signed . t y,. Roger J. Ratti, Int Est. 1964 Genual Binding contractors Dr. Jeffrey Leonard 9 Cobblestone Rd North Andover, MA 01845 Hesidential & Commercial Building '- Remodeling - Additions December 3, 2001 Specifications 4nd allowances for renovation of existing screen porch. PRELIMINARY: Submit specifications and obtain all required permits. INTERIOR DEMOLITION: Remove existing screens and door, siding, and ceiling in porch Support second floor and remove wall between family room and porch. Dispose of all debris: FRAI PING: frame in new front and side walls in porch to accommodate proposed windows and door. Frame new floor over .existing to match height of family room floor, Frame down new. ceiling to match existing. Install structural beam to carry second floor load as per plans WINDOWS/DOORS: Install new windows and entrance door unit as. selectedby owner. Allowance for windows and door unit: $2,400;00 SIDING: Wrap new walls with.Tyvek.air barrier and install .clear #1 Cedar clapboards to match existing. EXTERIOR PAINTING: By owner. ELECTRICAL: Install wiring for new room as per code and as directed by owner. Allowance for electrical: $1,000.00 PLUMBING: None. HEATING: Extend forced hot air duct eff existing kitchen area into new room. INSULATION: Insulate ceiling with R-30 fiberglass insulation and exterior walls with R-13 fiberglass insulation. SKIM COAT PLASTER: Install 1/2" blueboard on ceiling and wall areas, and apply 1/8" skim coat plaster troweled to a smooth finish on walls and match texture on ceiling,.. 342 Mt. Vernon Street - Lawrence, MA 01843 - (508) 688-8839 . INTERIOR TRIM: Install new 2 1/2" colonial casings around windows and doors. Install new baseboard trim to match existing. INTERIOR PAINTING: By owner. FLOOR COVERING: Install'/," Maple hardwood flooring in new area and blend into existing floor. Allowance for Hardwood flooring, installation, and finishing: $1,200.00 Complete clean up and removal of all debris. We are licensed, registered, and fully insured. License #01500 Registration #100294 . Total cost as described above: $18,500.00 of ok11*7d D Omer jZ/3l ntractor CD m DO C m m 0 m • rF � yCD C7 C Z NA QO C. r c � � c d� CO) o v CD CD Q CD CD 'O CD Wma C CD y C.� y to C=D C c m .� CO) CD n m n CA= m„ c' c.0 3 Z =r- H -4 d wCL 0 VJ T m a � os > tmi� O O m H O -� o ? m ilr) a O_ m �.0 :♦ O zs cc) O.O:(r O N O r� a rto 0 �m o C!) �o m m H rf m n h� O iff cn s y � co m �Q cn ? yQ :� O H N O n n m d N n :� O .n 3_ O g0 o mo` cn y e a CD c* ^_. ? CD VJ 0 y 0 � om � o s �o tori c o CD d R C2 � y 9 d C � rF � yCD C7 C Z NA QO C. r c � � c d� CO) o v CD CD Q CD CD 'O CD Wma C CD y C.� y to C=D C c m .� CO) CD n m n CA= m„ c' c.0 3 Z =r- H -4 d wCL 0 VJ T m a � os > tmi� O O m H O -� o ? m ilr) a O_ m �.0 :♦ O zs cc) O.O:(r O N O r� a rto 0 �m o C!) �o m m H rf m n h� O iff cn s y � co m �Q cn ? yQ :� O H N O n n m d N n :� O .n 3_ O g0 o mo` cn y e a CD c* ^_. ? CD VJ 0 y 0 � om � o s �o tori c o CD d R °C., � � 9 o o rrD to 0 � � n o o d 0 z (/)cd o O 0 y Ct 1 r O O , A �N 36 6 Of Date * /* TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... . . r. f .A..(�/ ........... z ..... ........... has permission to perform ....... 6(��e ................................................ wiring in the building of ............ 4.JCM!.f�&el ............................................ at ...../................... Nort/hd Fee. .5:. r,,A)... Lic. ......... . ..... ELECTRICAL I Check # THBCOM110AWE4UHOFARY MMUSE77S Office Use only _ DEPARTMENTOFPUBUMFM Permit No. t!pd BOARD OFMEPREVEM ONREGULAT OAS 52709120 Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date, % � O I Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform thr�eepelectrical work described below. . Location (Street & Number) C� O JiG g/ V%V C3 YZ, Owner or Tenant ^4,,V,C o lyi f ����,� Owner's Address 4f., Is this permit in conjunction with a buildML� Yes No (Check Appropriate Box) 0 Utility Authorization No. Purpose of Building -G tY Existing Service �_ Amps/ Vog Overhead Underground Q No. of Meters New Service Amps Volts Overhead Underground Q No. of Meters Number of Feeders andAmpacity Lcication and Nature of Proposed Electrical Work .No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground around No. of Receptacle Outlets �..-+ No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Toffs KW Initiating Devices No. of Sounding Devices _ No. of Dishwashers Space Area Heating KW No. of Self Contained �v Detection/Sounding Devices Local Municipal Connections Other No. of Dryers Heating Devices KW r No. of Water Heaters KW No. of No. of Si Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER Irstriarrc�:Co� Pit�itatt�lhetegimatta,�afMCt�taallaws a o Iha%eaaaatliabtlitykurmePb yetdudngCa►qI*Opmf*°mCamaWcriissizt dde*ataiatt YES NO I.tmea i,miMdvatidpmofofsarelotheOffm YES U NO r7 WymbmeduiWYES piea9em&*thetAxcf=rWbydmckirigto alprcpWh.x INSURANCE E'BOND WakmStxt , Sigtted tndA FIRM NAME � hpeceonD&RequcWd ftfflespoffy) ExpiabortD& Eshmakd ValuedEectical Wak $ BtsirmsTdNid Addrms1 �LL��{i' ��Lr: Zr . /�/ i AICTeINa OWNQt'SINSURANtEWAIVER; lam awatethattheLi=wdo Ckneral Lam and thatmysigmtuteonthispamitappkE6onwailthisreguasnat (Please check one) Owner1:3 Agent Telephone No. PERMIT FEE UU Location No. Z— Date TOWN OF NORTH ANDOVER a n • � ; , Certificate of Occupancy $ �' b''•°''t�' cBuilding/Frame /Frame Permit Fee $ �ss►Musa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # �� 55 17 % Building Inspecto TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/InEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 9 CoWnsfane Ccezk.000,% J Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: i p, S?3 R-9. (p6 Zoning District Proposed Use Lot. Areas Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Requireda Provided rig. a1.9? gg 1 SV - 1.7 Water Sipply M.6.L.C.40. § 54) 1.5. Flood Zone Information: 11.8 Zone Outside Flood ❑ Sewerage Disposal System: *)!5 Public Y, Private ❑ Zone Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: 25�--�f Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ -�A,YI&l(?C/N� Licensed Construction Supervisor: d� Number fil,llck�4,Dafcl McCkAr'CT�.License Address �J S J Expiration Date Signature Telephone 3.2 itered Home Improvement Contractor Not Applicable ❑ TCAP67kMCN -Rd Company Name Registration Number // 'LC•'/n �?� �'' p�'_ / /nn� /j� (/�� Addr:L"� 0/ Expiration Date Si nature Telephone Ma M X Z O G SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 S 25r(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 .......JF No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ci, -- G!� r' G1 N 10 & SECTION 6 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bypermit applicant OFFICIAL 7 1. Building ' -?d. J (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 Q Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN _F_ OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Own Authorized Agent f subject property Hereby authorizeto act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUT IORIZED AGENT DECLARATION 1, 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 Y12 s/Z Si a e of Owner/ADate NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD 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 00 FORM U .-LOT RELEASE FORM c (C. INSTRUCTIONS: This form is used to verify that all necessary approvals er ��vBoards and Departments having p mets from , �wr p ng jurisdiction have been obtained. This does not relieve I� y G��� the applicant and/or landowner from compliance with any applicable or requirements. � n s�c ******" """APPLICANT FILLS OUT THIS SECTION CAPPLICANT_�� 'r PHONErC4 ('4'sk"43 j,le_ LOCATION: Assessor's Map Number s I PARCEL_ viker�U,.c�S SUBDIVISION Q LOT (S) STREET '/ ST. NUMBER CIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: oir CONSERVATION ADMINIST ATOR DATE APPROVED S' DATE REJECTED COMMENTS J fI&JS trti ^ 6 �-- e,. S A 12 -foa— T^IAIKB ME w COMM FOOD INSPECTOR -HEALTH r, SEPTIC INSPECTOR -HEALTH , COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED t PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT — I RECEIVED BY BUILDING INSPECTO Revised 9197 jm TE 0 ■ �.'ur�`. Fc v. D +rN✓ �aGwT/a✓ i i'Oi.i .r%v Iv�T.Q�n^�;V r SC/,evc) r Apt/v 1722 TNE�d Nit' T qTT N� O rcrLL.44if /J GPc'.IU� /`'f p6,55 Cq v"'Oelyl �N lf�iT.S! >,VE" Yaw, O�,ct� .�uooYF,e 2avivc .�E6v�,ar,<zvs i 6� f0/ crG JET�AC.�S /-Zaw r f(/ClyCC GEST/F✓ T�S44T TA/J P,v'E(L/iy6 /1 LVOT i LOl�77"CA /N iNE FE�.q FL�O ,wv2.0.e-p i4:PEA, O.PAH'/V �D,P . NiTy,.INGL lot Y��-r1"� ,5;� � ;h�Y� 2',SO 4�%GT (�00,$' B `Y~G'.`�, �� BdG E•J TO,v6' C,M S J,w� ISE vEC o P.niti T (o p�TIO ✓v.�/E /S, /9Y3 (.i JEFFREY •�� "�—�. CP J F ��; .�/OF,N%O V• P, L . S. PATE .�.. �.�•,vv��� �VOTFO<P Bovvv,Ps� �'TE.P�risivrrov_ Bo�.vo.reY/.c%�o.�.rt- �E•P.P/itf.9G�' E'.VG.�crEE.P�.(/6 AT/O.(/ T; a.c'E-�/ front EX/STit/C ,PLrL�OS. SE,Pi�/lEs 6 ( �q,F�� ��.EEJ- • ,I r4.VO0YE.f; �AS.�oGvvS�TTS o/Bi0 r IBOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 066851 Birthdate: 08/21/1946 Expires: 08/21/2003 Tr. no: 1004 Restricted: 00 JAMES R FINLAY i 2 WATERTOWN ST LEXINGTON, MA 02421 Administrator I Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 111975 ' Expiration: 01/28/2003 Type: DBA METRO WEST RES.CONT.INC/AR JAMES FINLAY 48 MECHANIC ST,,,.,,, NEWTON, MA 02464 Administrator COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING CERTIFICATE OF LIABILITY INSURANCE OATEIMM/DDIYYI 01/03/2002 PRODUCER Lockton PO BOX Kansas Risk Services, Inc. 410679 Cit,., MO 64141-0679 POUCY NUMBER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED Archadeck of Metro West 48 Mechanic Street Ne ton MA 02464 A INSURERA: Legion Insurance Company INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POUCY NUMBER POLICY EFFECTIVE DATE IMMIDDNYI POLICY EXPIRATION DATE IMMIDDNYI LIMITS A GENERALUABIUTY CP11933420 1/01/2002 1/01/2003 EACH OCCURRENCE a 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR FIRE DAMAGE )Any one fire) i 300,000 MED EXP (Any one person) t 10,000 PERSONAL 6 ADV INJURY 4 1,000,000 GENERAL AGGREGATE t 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG 1 2,000,000 X POLICY PRO- El LOC 1 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT � (Ea accident) BODILY INJURY (Per person) ALL OWNED i AUTOS SCHEDULED AUTOS BODILY INJURY III (Per accident) HIRED AUTOS NON•OWNEb AUTOS PROPERTY DAMAGE (Per accident) R I GARAGE LIABILITY AUTO ONLY - EA ACCIDENT t EA ACC i OTHER THAN ANY AUTO AUTO ONLY: AGG $ A EXCESS LIABILITY. X OCCUR is CLAIMS MADE UM11943139 1/01/2002 01/01/2003 EACH OCCURRENCE t 1,000,000 AGGREGATE $ 1,000,000 i DEDUCTIBLE, X RETENTION $10,000 > A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC11933421 3/23/2002 03/23/2003 X ORYLIMU• OTR- "— E.L. EACH ACCIDENT i 500,000 E.L. DISEASE - EA EMPLOYEE { 500,000 E.L. DISEASE - POLICY LIMIT t 500,000 OTHER i DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Proof of coverage %,cn r iri%,m r c nvLvcn I I ADDITIONAL INSURED; INSURER LETTER: L A111L.tLLA I PUN Archadek of Metro West "M ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAT EREOF, THE ISSUI SURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Q �I�iCt►ER NAMED TO THE tEFT, BUT FAILURE TO DO SO SHALL NO C THE CERTIFIC E KIND UPON THE INSURER. ITS AGENTS OR AUTHORIZED REPRESENT AGUMJ ZD -5 l//U/I, aACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Print I? a-66 t a/LCcC, am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity YPam an employer providing workers' compensation for my employees working on this job. comRaarnr name: L-0 C�'T21� f2tS k S-1rl.Vl [c? 4/ City: KA -US -47 . C c 7�-j j'�j 0 Phone Insttrar_tce Ca. L,£Lolary Ti�.S✓i'4tice' Cd Farcy # ('�') C Company name: Address City:.. Phone # lnsurante Co. Policy # Failure to secure coverage as required under Section 25A or WIL 152 can lead to the imtposition of criminal penalties.of a tine up to $1.500.00 and/or one years' imprisonment as'wefl as civilin the form a STOP WORK ORDER and a fine of ($100.00) a day against me. t understand that a copy of this statement may feof ed to the Oifice of investigations of the DLA for coverage verification. I do herby certj6nd f the pains and per#las pf perjury that the information provided above is true and correct r --- signature ► Date_ V2,9 Print name._ Phone # Official use only do not write in this area to be completed by city or town official' ©Check if immediate response is required Building Dept Contact person: Phone VORKMAN'S COMPENSATION 0 Building Dept p Licensing Board p Selectman's Office 0 Health Department Ofher i North Andover BuildingDepartment Tel: 978-688-954 DEBRIS DISPOSAL FORM . l . In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid. waste disposal facility as defined by MGL c11,S150A. i The debris will be disposed of in: I �- (C �" • l�ki�-C�7�rr (Locatio o Facility) �; Signature of Permit Applicant t' Date I NOTE: Demolition permit from tide Town of North Andover must be obtained for this project through the Office of the Building Inspector ■ i a � x c � 3 w LL Z Z �1$ OQ ■ i � O � OQ ' N C^V cu E O n x-, � X U N E O Q (L 12L U— Q U LQ —5 `- LL Cn 1 9 N I t i I I N ■ i m r 0- x x r• t ogc � Y ' c N t (7 Z O m — cD �O O x W y ° o F....� CD m mal 1 N y . ° _ O o O th .v o -o d v N C 1 36, c � i v '7 N X m , `n 0 x J6 X r 0- x x r• t M p XLMp � Y ' c t (7 Z O m — cD �O O x W y ° o 3 c m •'^ m 0 1 N y O O th o a. m _ d v 1 36, i '7 N X m , `n 0 x J6 X �— ^� —1 -0- 2. 3 I I cD 3 o ' X _ a v o CO x w x x x .o X ^' 0 x o N a x N 0, a (-w c7t n x rn^ m �c o o �, _ —� 0 ac c- 0',.<= 3 1 m _ n 0- x x r• t M p XLMp � ' c O m — cD �O O x W y ° o 3 c m •"f .�+ 01 1 N y O O th _ d v 1 . m 0 A O W �0 w E cn p cn o z A ,.a a ro O0 w a u U w O [r O ow C c�G O U W to x z d O 0 G z w A w Wto 114 z cn D cn c c 1 m c :cam V c ` ci C.) v n C O O ra a �m� 3�2 is 0 CLm ~Q E C m Q� t co &E L m am ` ca Q: C ! ■ :C C m N ev O N .0 wino cm co y m m :Lz p cm It. c c oQ W ; m p m 1i; v•� O Q CDOO O .■ - Cf : caCL C O 3CD N t W p C ry= LUF- N gat c Z O p '.• ui E m •N O V V C.m p m !E C y a 0:6 _ 0 cm O d_, m 0 I LU 0 U) uj w W CcW Location No. .3 33 Date C� 3 �ORTM TOWN OF NORTH ANDOVER • ° OL p Certificate of Occupancy $ p l-5 53 Building/Frame Permit Fee $ j sscHus ACH E�� Foundation Permit Fee $ - I G�1 Other Permit Fee, $ �7 Seva# Connection',�ee $ S3 WateF43onnection�gia�. $ TOTAL<S �op . $ I I D2, �� 'Q Z ��� ""`Building Inspector '14 tj33? Div. Public Works e.o rid ,location ..%hc� &,c� No. 313 -3 Date 2 1) NpRT" TOWN OF NORTH ANDOVER A Certificate of Occupancy $ .2 J " Building/Frame Permit Fee $ SS "" �� ACNUSE ; �•oundation Permit Fee $ / _. � r , ,,.t Other Permit Fee $ Sewer Connection Fee $ .� j9*ter Connection Fee $ a „TOTAL �y C17 Building Inspector li �ln r G c3 _` `i Div. Public Works Location �51e C�t�`P t— �D'L 1Q aNm S Date 7-2Y— 93 MORTiy TOWN OF NORTH ANDOVER Ott�o ,.�ti0 „ Certificate of Occupancy $ ` Building/Frame Permit Fee $ 'Ss�ToocMusEsA Foundation Permit Fee $ rpr Otl�e�, Parrnkfee $ ••I&iwer Connection Fee $ Water Connection Fee $ 1t ,�9 TOTAL �g9yj $ ��, J eh ` t uilding �1,,ector, fr 6M Div.,F'uplic Works APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 4133 V/1 - PAGE 1 iVIAP 4-40. I LOT NO.— l/ 2 RECORD OF OWNERSHIP DATE —I BOOK 'PAGE ZONE -:5 SUB DIV. LOT NO. d /�ee LOCATION ► I Ca PURPOSE OF BUILDING �� l OWNER'S NAME Ce)l� /t 5 �� !��� NO. OF STORIES SIZE % OWNER'S ADDRESS d J "L4 ! BASEMENT OR SLAB 2 J G✓Z-l- /JkfJ ARCHITECT'S NAME ,N� �14-�O R "� ( b SIZE OF FLOOR TIMBERS IST 7v Iz 2 DO ! 3RD L1l BUILDER'S NAME SPAN s� DISTANCE TO NEAREST BUILDING i/v • DIMENSIONS OF SILLS x DISTANCE FROM STREET / POSTS DISTANCE FROM LOT LINES - SIDES r�/LJ REAR / Q I (J GIRDERS ( f/� y�iI Z. ICD AREA OF LOT / 7 S FRONTAGE /a HEIGHT OF FOUNDATION THICKNESS /O IS BUILDINGIS BUILDING NEVA/mss 1 SIZE OF FOOTING/0 .� p X IS BUILDING ADDITION /1 /O MATERIAL OF CHIMNEY[ 13,,dC� TES I� IS BUILDING ALTERATION IS BUILDING ON S21:lp OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE I/{ s / IS BUILDING CONNECTED TO TOWN WATER f BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER - IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS -- SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ` 0 Lm m"I'l 90/, v A D-lE FRAME PERMIT ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR f{ DAT FILED - Z! / a �^ 6". "SIGNATURE OF OWNER OR AUTHOR ZED AG NT i F E E -n_/1 OZ .J' -O A -b, lD O v PERMIT GRANTED oge 19 �. I . dioz� 0/7 7/i " (085' 1 Z'�- OWNER TEL. #Jl1?-7--1Z 4 CONTR. TEL. # X217-!/ Zg CONTR. LIC. Z 3 L9 ad-• 4,h. �602 3 PROPERTY INFORMATION LAND COST d EST. BLDG. COST Q� .ojlo rJ EST. BLDG. COST PER SQEST• BLDG. COST PER FTS' EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. A tl / 4 APPROVED BY s �F WARD OF HEALTH PLANNING WARD WARD OF SELECTMEN lyz zle L mu �l A BUILDING INSPECTOR 1 OCCUPANCY SINGLE FAMILY. SPFFIORIES- MULTI. FAMILY r OCES _ APARTMENTS CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETE }(� _ B t 2213 CONCRETE BL'K. PINE BRICK OR STONE HARDW'D _ PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ V. 1/2 '/, FIN. ATTIC AREA N_O B M -T FIRE PLACES HEAD ROOM MODERN KITCHEN " 4 WALLS I 9 FLOORS CLAPBOARDS x B 1 2 3 DROP SIDING CONCRETE I_ WOOD SHINGLES EARTH ASPHALT SIDING HARDt!✓'D ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BUILDING RECORD�� 12 THIS SECTION MUST SHOW EXACT DIMENSION$ OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 1 s r , WIRING 5 ROOF 10 PLUMBING GABLE I 1 HIP 1 II BATH 13 FIX.1 I Z SLATE 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FUF TIMBER BMS, 3 COLS. X STEAM STEEL BMS. 3 COLS. HOT W'T'R OR VAPO WOOD RAFTERS _ A AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS 011 B'M'T 2nd _ 1st 13rd I ELECTRIC NO HEATING .44 ` � I s a k r' FORM U - LOT RELEASE FORM ,INSTRUCTIONS: This form is used to verify that all necessary f ,approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, ` regulations or requirements. **********.******Applicant fills out this section***************** APPLICANT: CoWtS&ftot, Cvo t Phone 5_4-691-11Z6 LOCATION: Assessor's Map Number Parcel Subdivision Lot (s) Street St. Number_ ************************Official Use Only************************ RtCOMMENDATIONS OF TOWN AGENTS: cllcoollAbl Date Approved. Co ervati n -Administrator Date Rejected Comments Comments Date Approved Date Rejected Iz Date Approved Food Inspector -Health Date Rejected % Date Approved _ Septic Inspector -Health Date Rejected Comments r `te�f Public Works-- sewer/water connections l - driveway permit ZdEAI' -Z�- Y Fire 'Dg tmentG Received by Bui ding Inspectr -Date 291993 - w.. 4, t T. ice.'-•`^. �tT �-h -yah, r-f. ��_ e� VANE1 d ' of 020/97-4�► &MTE Els 'HEGW . t=ka la "6R MR. :6103," 170'M 14 CALMER; STEP EN e. 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STPESTS LOT 1 FG-,rT.s/E.c CE.!'T/FY T.SG9T 7WI-f OA✓ELL/N6 /S �t/OT / LOG9TE0 /� THE FE �„�q FLG�OO fi',9Z.4.P0 A.PE',4, O.P�i %l�iV fO,P syawn! o/v Fe■ jJl� SUN/TY /�.INGG 00 8 oao�oBB�E's ro,�`5' CEGSJi�vG UE✓ELOPMEciT G oGP, zsoa9 sa a tE C OATE'O c/vNE /S /98 /493. FD.P BO!/NO.PS/ G1ETE•Pi1!/.t%i4T/OrS! Bo�,vo�veY ��FO,P.ys- �ER��itl�9Gt' E.vGis/EE.P/,�/6 SE.PY/�'ES A7'/O.V T,4e�E.y F,e-any EX/ST/(/C .PECOPOS. 66 �q.�',� .ST,P�ET A/</ODYE,P, �1.4SS.4�l/SETTS O/8/O Location �61 o b L LETw No. e-333/17 Date } 3 �—pRTp, h0 TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ sAcmU Found tion Permit Fee $ � �.-Gi # Permit Fee $ �� w Sewer Connection Fee $ Water Connection Fee $ *40TAL G364 ;%) Building Inspector Div. Public Works lcaa OF: (.0 N S 1: 11 Vj\'j 'I N PLANNIM ATE. C- ) )CATION LINER'S NAM ]ILVERIS NAME: kSONIS NAME: Town of -it NORTH ANDOVE I 11VIN11 IN 111 .1'l,Y1NNING, & (A)AIAWNYYY 4 KAHWN 11.1'. NI :I 1 )11 11:(:"1()1( CHIMNEY APDL ICAION ANO I'Ll3l1f ),,3 t, IA", I A) PERN11'. # 4; 171 JOVs -17;-!; %SON'S ADDRESS: "114-- Za k)Q--, �.SON'S TELEPHONE: `�MJAL OF CHIMNEY: ITERIOR CHIMNEY:L Al E RIOIZ CHIMNLY:V1 ll�WER AND SIZE OF' FLUES: (ICKNESS OF HEARTH: ,XU chbiney al. (jilep.Cace con(joul tO Mlle, AC.(jU,iAClll(lllt16 V() .(.ILC CUdV- Mid 11(1ve "ttice.5 alld igutatiow been aecv-Zve(i: -- ,TE: .GNATURE OF MASON: 'WIT GRANTED: !BERT NIC-GITA 1ILDING'INSPECTOR 111 :'SPECTEO: SIARKS: SOLID BLOCK REQUIRED THIS PERMIT* MLISF GE VISPLAYLO 014 111E PIMUSES CERTIFICATE OF USE & OCCUPANCY Town o6 North Andover Building Permit Number 333 1993) THIS CERTIFIES THAT Date Tij.Ty 1, 1994 THE BUILDING LOCATED ON 9 COBBLESTONE CIRCLE (Lot #1A) - lype A MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR M IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO COBBLESTONE CROSSING R. T. 733 Turnpike S t . 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