HomeMy WebLinkAboutMiscellaneous - 9 SARGENT STREET 4/30/2018N
i
This certifi (e/s 'thaf
l,�r r�
has permissi�in to
Date lG.:�..3%.........
t
TOWN OFNORTH ANDOVER
U
PERMIT FOR PLUMBING
plumbing in the buildings of..... L
at ..�nd....� ...... ...� .
Fee Lic. No. /247()
Check #
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ,n� MA DATE la- �f F,.LPERMIT # ,
JOBSITE ADDRESS % �� OWNER'S NAME
OWNER ADDRESS TELL 11FAXI_---___
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0j
NEW:I RENOVATION: 0 REPLACEMENT:
1 FIXTURES 7 FLOOR- BSM 1
j BATHTUB
CROSS CONNECTION DEVICE L:: -]
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER(
FLOOR I AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK I --..--
LAVATORY
ROOF DRAIN ^_.I
SHOWER STALL I
SERVICE / MOP SINK
TOILET I -_-.-
URINAL
WASHING MACHINE CONNECTION �I
WATER HEATER ALL TYPES 6 _! _
WATER PIPING L=+D
OTHER
2 1 3 1 4 1 5 1 6 1 7 1 8
PLANS SUBMITTED: YES EI NOD
9 1 10 1 11 1 12 1 13 1 14
INSURANCE COVERAGE:
have a current liability 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 i OTHER TYPE OF INDEMNITY Q BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F AGENT 10
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are
and that all plumbing work and installations performed under the permit issued for this application will be in coi
(Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \
PLUMBER'S NAME �. tio_�' , a,j!I( LICENSE #
MP [j Jp Q CORPORATION! # PARTNERSHIPO#
COMPANY NAME _ / _11ADDRESSI '7eEr o �
CITY
STATE: '--� ZIP Q%,�' __►
FAX J1 CELL"V%j MAIL
and accurate to best of my knowledge
pa with all Pea- 1t prgvision of the
SIGNATURE
LLC a�-�- -i
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Busines.
Address:' ria,
City/State/Zip:
Are you an employer? Check the appropriate box:
3
Phone #:�IQ -
1.❑ I am a employer with employees (full and/or part-time).*
2W1 am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.#
6.0 We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and we have no, employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 ❑ Building addition
1 LE] Electrical repairs or additions
12: 0 Plumbing repairs or additions
13.0 Roof repairs
14. n Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who subriiif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
Iain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company N
Policy # or Self -ins. Lie.
Expiration Date:.
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u or thepains an1pYnqJfies ofperjury that 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 #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth, for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensatioii'policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Date .... .//..I . ...............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
e--7�—
This certifies that ............. 140
.rnz4l
..... .. . . . ......
.� ! ..... i ..................................................................
has permission for gas installation
in the buildings of ...................................... 0 .........
"Ae el,
....................................................................
atY7�d .. .. . ........ rt—**,*,,***,* ... *,*,, s North Andove Mass.
f, as
L IC -L
Fee ..... No../ :70 .. ....... .......... kA -I-
................................
GAS INSPECTOR
Check #
I U : 05
Ir
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE oL PERMIT
'-JOBSITE ADDRESS , •-I I OWNER'S NAME I
GFAXE
OWNER ADDRESS TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL El
PRINT
CLEARLY
NEW: El RENOVATION: El REPLACEMENT:';A PLANS SUBMITTED: YES F1 NO®
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 22a Z, = (Pa T
BOOSTER
CONVERSION BURNER
COOK STOVE .... I _ ._ . .__._ _ C....I .-_ __.. - 1 _
DIRECT VENT HEATER
DRYER T � � _ _. _ ._ -._ .. - - L-_-
FIREPLACE`-)-
FRYOLATOR
FURNACE
GENERATOR
GRILLEINFRARED
HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
R30L HEATER
ROOM/ SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER �.
- - - - -- - - - - - -
---- - -
1.niij1 L
-- - - - _ _=3 I - - -=-1 - �_-- - - -
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YESJ�]1 NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Xl OTHER TYPE INDEMNITY E] 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 EI 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 be f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertine vi of the
Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. 11,
PLUMBER-GASFITTER NAME LICENSE # SIGN TURE
MP N MGF �� JP JGF LPGI CORPORATION ®# E:= PARTNERSHIP D#= LLC [J#
COMPANY NAMEL _ ADDRESS
CITY STATE ZIP TEL -
FAX CELLM EMAIL
VJ ❑
F_-
W
a
Iii
W
LL
The Commonwealth of Massachusetts
Department of IndustrialAceldents
1 Congress Street, Suite 100
d
Boston, MA 02114-2017
aM SV'VO
www.mass.gov/dia
•
Workers, Compensation Insurance Affidavit: Builders/Conixactors/Electricians/Plum ers.
TO BE FILED WITH TEE FF'P2&TT1NG AUTHORITX'. -m _ ^ ^ ^ iD__+
Name (Business/Orgal&ation/Individual):
Address:
City/State/Zip:_
Are you an employer?
the appropriate box:
Phone #:
I-01 am a employer with employees (full and/or part-time).*
2.❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp, insurance required.]
3.E] I am a homeowner doing all work myselZ [No workers' comp. insurance zequired.] t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.FJ I am a general contractpr and I have hired the sub -contractors listed on the attached sheet.
These sub-contctors have employees and have workers' comp. insurance
ra
6.FJ We are a corporation and its. officers have exercised their right of exemption per MGL c.
152 i(4) and We have no employees: [No workers' comp. insurance required.]
Type of project (required):
7. ❑ Nevi `construction
S. [] Remodeling
9. ❑ Demolition
10 [] Building addition
1l.[] Electrical repaixs or additions
l2�[].Pl`wnbing repairs or additions
13•. [] Rb6f repairs
14.0 Other
,§
*Any applicant that checks box #1 const also fill out the section below showing their workers' compensation policy information
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
�;�•
#Contractors that check this box must attache additional sheet showing the name of the sub -contractors and state whether or not (hose entities, ave
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
X am an employer that is providingworkers' compensation insurance for my employees. below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lie.
Expiration Date,
City/State/Zip-
fob Site Address:
compensation policy declaration page (showing the policy cumber and expiration date)-
Attach a copy of the workers''
violationa criminal
Failure to secure coverage as required under MGL
c. 152,es in §25 form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well Pen
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do hereby certify under thepains andpenalties ofperjury tht.
at the information provided above is true and correct
Date:
Simature:
Official use only. Do trot write in this area, to he completed by city or town official
permit/License #
City or Town:
Issuing Authority (circle one):
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
1. Board of Health 2. Building Department
6. Other
Phone
Contact Person:
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
receivbf bt 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 b6 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 op6rate a business or to construct buildings in the commonwealth for any
applicant -who has not produced acceptable evidence of compliance with the insurance coverage xequiired."
Additionally, MGL chapter 152, §25C(1) 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. B e advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
IndustrialAccidents. Should you have any questions regarding the law or if you are requured 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
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASS.AFE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
d16Cj2
Date... ( G
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
.E
This certifies that.....J` C.��!- C G�
..........................................:...........................................
has permission to perform ...... W ...... .................................
plumbing in the buildings of ...6L.4".,4 ........ .a 4A .............
at ...... ..q ....
r.......!...k.......S.S� ........... -.................. North Andover, Mass.
Fee... .:.t....... Lic. No. I4847
PLUMBING INSPECTOR
Check* Z
M
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY RW�1u1�" MA. DATE t `06-�6 PERMIT#
JOBSITE ADDRESS _ �� iSr � W OWNER'S NAME I, IZ,Ut, So Vb i etv
POWNER
ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY
NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES 1 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 • 13 14
BATHTUB I ..
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY 1
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
Inv
INSURANCE COVERAGE:
I have a current liabiliv 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 d OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the
best of -my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME 5-rEW1513 C- Gpi.IPSKie SIGNATURE
LIC # 103q S MP [e' JP ❑ CORPORATION X# i9 b PARTNERSHIP ❑ # LLC ❑ #
COMPANYNAME 6A14#.)SKY PLUM01A9b *- RVAT0(D ADDRESS: P•O• GGX 1701
CITY il4AyCRBiw- STATE MA- ZIP 0I131 EMAIL WvvW. t'v►rp1yrAbeg93sOI , C.om
TEL CELL •50t- 50g - 5q0i1 FAX q7$- 5,21- g13i
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Date .....
I.. ... ..... ....
.�..............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... 4 l,n S �................`..��...............................................
has permission for gas installation .........4 ............!'..t'tGC,
in the buildings of ........ t �.-�.�..........�� c{rf e itJ
.......................................................................
at . ..'.. �Gr � Lt�t;.......: 1 North Andover, Mass.
Fee...{,n.'` Lic. No. h!`F.........
GASINSPECTOR
Check # 7'952-
2"
'952..-
—� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
W) CITY: 140% -os' A7WAC MA. DATE: -2Z 46 �r.� �p'PERMIT f#� ,
JOBSITE ADDRESS: ' C� �. � OWNER'S NAME YI ►GVI.ec t-
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW ❑ RENOVATION: [� REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES -1 FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER'
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
f
INSURANCE COVERAGE
I have a current liabilq insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES g NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 9 OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 fiance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1m
PLUM BER/GASFITTER NAME: Si EPhEN C. GALTN5KY LICENSE# 10314t3 S1411GNA U E
COMPANYNAME: GAi.W5Kq PL0AAl0C -r 14pAl-1t & ADDRESS: P.G• WX 1701
CITY: 14AVE-I-HILL, STATE: 1'1-A ZIP: 01231 FAX: q79- aal -jil
TEL: 979-3714- 17143 CELL: 5,0f - sig- 59oq EMAIL: W*VV W, ml•`plUMbieffyt. c,av►^ V
MASTER [d JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION [d# 3190 PARTNERSHIP 0 # LLC ❑ #
I' - "
Date ....11.-..Z., 5 ...
......... ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that �6 0 V"h h 4? I't
..................................................... ................ 7 ..................................................
has permission to perform tC4 e i,,
....... I .... �?,el V l ',,,C
KA . ..... ................... f .... b 1 ....................................
wiring in the building of......./
at 16 19. 14 � .57— ,North Andover, Mass.
............9.....51 ... .. ... . ...........................................................
j
Fee .. .... 5 .. . ........ Lic. No .................. ..........
1
1 ..............................
ELECTRICAL INSPECTOR
Check # 111k
12.0122-/
1
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (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 WINK OR TYPE ALL INFORMATION)
City or Town of: NORTH ANDOVER
By this application the undersigned gives notice of his over inti
Location (Street & Number)_ / �J
Owner or Tenant
Owner's Address
Date:
_ To the Inspector of Wires:
to perform the electrical work described below.
Is this permit in conjunction with a building permit? Yes ►� No ❑
Telephone No.
(Check Appropriate Box)
Purpose of Building /QQ p t//�p_ Utility Authorization No.
Exis
' Service_Z01) Amps U/ ,%U Volts Overhead Undgrd ❑
w Service( Amps ` 0 / 2 0 Volts
Nu f Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead Undgrd ❑
No. of Meters Z
No. of Meters_
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires 0
No. of Cell: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outletsy
No. of Hot Tubs
Generators ISA
No. of Luminaires /L
Above In-
Swimming Pool rnd. ❑ rnd. ❑
o. o mergency Lighting
Battery Units
No. of Receptacle Outlets 5,No.
of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burgers
No. of Detection and
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
p
Heat Pump
Totals:
Number
"
Tons
' "
J.KW
' ' "" "
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ElMunicipal El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Ecialvalent
OTHER:
Attach additional detail if desired, or as regtdred by the Inspector of Wires.
Estimated Value of Electrical Work:/,2 DUG (When required by municipal policy.)
Work to Start: %) S/f /P Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, tat tl information on this application is true and complete.
FIRM NAME:. . LIC. NO.:
Licensee: Signature LTC. NO.:
(If applicable, enter "exempt" in the license number line)us. Tel. No.:
Address: Y �'%/9 DQ5 It. Tel. No.:,
*Per M.G.L c. 147, s. 57- , security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed •
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass r?]
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE SPECTION:
Pass 0 V
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH IN ECTION:
Pass M V
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:'12,,Z6
FINAL INSP TION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
�-V
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA. 02114-2017
www mass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORYi` '
Name (Business/Orga/riization/Individual):_
Address:
Citylstate/Zip: ? c
Are you an employer? Checlt ttie appropriate box:
Phone
1.0 laftiaempl,oyer with employees (fall and/or part time).*
2. a sole proprietor or partnership and have no employees Working for me in
any capacity. [No workers' comp. insurance required.]
3.01 am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ 1 am a general contractpr and I have hired the sub -contractors listed on the attached sheet.
and have workers' comp. insurance.t
These sub -contractors have employees
6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 §1(4) and v✓e have no employees: [No workers' comp. insurance required.]
-//,7 7 --
Type of project (required)
7. ❑ Nevii'constriictlon
8. F1 kemodellhg
9. ❑ Demolition
10 ❑ Building addition
11.[] Electrical repairs or additions
12Q Plumbing repairs or additions
11 [] Ro6f repairs
14.n other�_,_
*Any applicant that check's 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 ane theneme of the sub -contractors and state whire outside contractors must hether or not (hose entitit a now affidavit es have h
,,
tcontractors that check this box must attached an additional sheet showing
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
X am an employer that is providing workers' compensation insurance for my employees. ,below is the policy and job site
information.
Insurance Company Name: (_' e
Expiration Date:
Policy # or Self ins. Lie. #: G
r, u City/State/Zip:
Job Site Address: the olio number and expiration date).
Attach a copy of the workers' co ensation policy declaration page (showing policy
on punishable by a fifib up to
0-00
and/or
to secure coverage as t, as well ased civer il penalties enaltieszinthe form of criminal25A is a TOPrWO1RK ORDER and a fine o£ p to $250.00 a
and/or one-year imprisonment, as P
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance
coverage verification.
X do hereby cert' undei�X�epcis andpenalties ofperjury that the information provided above is true and, correct.
Of nese only. Do not write in this area, to be completed by city or town offeciaL
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
Phone #:
Contact Person:
V
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniploy,'ees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hize,
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 enferprlse, 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 Iicensing 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 r`eq'W`red."
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
Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificate's) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. B e 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
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
il
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License'No.
Expiration bate.
Serial
} Location
��-
No. `-� ��' C Date �� �" vv
NORTH
TOWN OF NORTH ANDOVER
F 9
Certificate Occupancy
$
of
s,KMU
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # y� G 7
7779 C `L
rte• Building Inspector ii
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
►�il'L'f10AC! i s
BUILDING PERMIT NUMBER: DATE ISSUED:
21 —vim "4
SIGNATURE:
Building Commissioneffl for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
I� Acr
1.2 Assessors Map and Parcel Number:
6118 DOa
Map Number Parcel Number
/ ?
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
RvLWred Provide Regifired. Provided Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT "� �' �"r t%'i`.-triCt: YeS
2.1 Owner of Record
%�� 1�i9--�D1n l
Nurse (Pnnt) Address for Service
1
7
Signa Telephone
2.2 Owner of Record:
Name Print Address for Service:
{
*ignature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
• j" _�\ � \\ ` �
Address
Signa �/- �, t/�/� /}, Tele hone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
a
Expiration Date
Signature Telephone
00
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SECTION 4 - WORKERS COMPENSATION (MG.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes .......0 No ....... ❑
SECTION 5 Description of Proposed Work check as applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
I SECTION 6 - ESTIMATED CnNRTui rTMN rncmc .
Item(0/
Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY '
1. Building(a)
Budding Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
.,a...aa..�. .o v.. 1.rrAV L11V1liLt111V1\ 1V 6Ll,V1gYL1.1L'L Wt1L5P1
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
q
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T VIBERS i ST 2 ND 3
RD
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
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PATRIOT ROOFING CORP.
PO Box 305 • Billerica, MA 01862
NEWTON (61.7) 965-1.558 • BILLERICA (978) 670-7353
Fax (978) 670-4781.
"Serving the Greater Boston Area"
SUBMITTED TO
PHONE
ESAL
DATE
JOB NAME 1
ii
CITY, STATE AND ZIP CODE
JOB LOCATION
... r1L;i;C'ti
ARCHITECT
DATE OF PLANS
B PHONE
P-4—, ru, luaus, rrwrenets eno tenor necessary tor the completion of:
. , ;: 1.' . c' ._ ,, .1 .. i� 1 . _ L C: �; � V ?. O.1. (4 L'� <,) (:i .i: i I i .{ ,;1 •.it 't, �s i 1. ;a 1 ,
!i1... 3f a. (: !_.1,1....y.. )Tl ca .1.!. ida uitC] 1c:i; a ,._/:J_:LC: (•i;(_.. j
�_ ..... .,_ _l .. � (_ 1. '_: �.' ,.. •J _. 1. (. C t: I 1 iJ :'i :.{ L l:._ .'! 1 1 �. �, �.. (_! .) is i `J L. ,.. ,i A:1 V i I.` ,' V .
Lc.: 3;_:x111:1 ti: (4;1.'.
r1' CIw ldl t~il 111bJ .%:iii l 'i.
t y "::.'
,. s,;,.J .., � {.�cx 1j. l?.✓:'.Ll.si"'La 1'1l.�'tF�,f,', U�
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is ;li[1.j.L_' 3.3Xi1 f 'C LaI!Ite %t rra(1?j".0 t , jC! �v�Iz" .fill.l 1 .. :tfi Y'.)Ll
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1:'VU�^_XGC3ti l.a I," .
1, _. .i1V V'L' ,1 EIV 11: fit 1::3 1.11. .:i i„�,.1`/ iN l: ..1:� 1iV i_
i.J._ ''It . 1C.
- 1
i i t� wi.
WE PROPOSE hereby to furnish materials and labor – complete in accordance with above specifications, for the sum of:
dollars ($
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a substantial
workmanlike manner according to specifications submitted per standard practices. Any
alteration or deviation from above specifications involving extra costs will be executed
only upon written orders and will beocme an extra charge over and above the estimate.
All agreements contingent upon strikes, accidents or delays beyond our control. Owner
to carry fire, tornado and necessary insurance. Our workers are fully covered by
Workmen's Compensation Insurance.
Authorized
Signature
Note: This proposal may be
withdrawn by us if not accepted within
ACCEPTANCE OF PROPOSAL. The above prices, specifications and conditions are
satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature
Payment will be made as outlined above.
Date of Acceptance //� O/�) Y Signature
days.
{,
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:
(Location of Facili )
gnature o F
Da
0
kffL----
it Applicant
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Workers'
.<ttC t-uAirriuriweut[n uimassacnuserrs
Department ofbidustrial Accidents
MCO of1171/estigati0n9
600 Washington Street, 2h Floor
Boston, Mass. 02111
ltion Insurance Affidavit: Buildine/Plumbino/Eli
Contractors
uV 1IAUrr GUU1GS57.
❑ 1 am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel
(� l am a sole proprietor and have no one workin M any capactrt Building Addition
.'S.Fy,: w" ,''r>.;ymer: 5Ty.7 �.q,;., i.r, 0 .,s ��.�;: r:yis lw'E"�•. r�"• .,.: _ O
3.. :'tau+: kfaa n..�.�T, .Ix.�,t'••:'I::: B'�• aii.. ".I: „ft. et' Sx.,. ^�. a'ra*�.a':'x�i' 7.;, t;Y>t:c•. - may, t'..rc....
..s-dtR,...:tC..'0t%(...t ..� 's,: �::�la.t.;:r.'v4° *:... ,51.�1it r1 "L': ...Fik"r .. .i'•g'.�...
•• ;'' .wk 'ii':u:7��
❑ I am an employer providing workers' compensation for my employees working on this job.
company name `` ( C
TIM , , .
e ,... r ••'i7'45��1?!ii[iC,ia�, sf�`a`'�:rtZ%i3'1''i;i?h;r'114:ik�N"�st�CFG�134tF.�iruu�rra�•sz;ac,�••uxsr xa..?�•.'.rrr.•i..,�.rxranrr,,...,��Fr��«�,.��,---....,..,,....--_�__
yceuava �i�Ju:5u:3:181VF7�FLT3Ylf7344)4d$:'YUl"Y'?:8
I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
commanv name:
address.
city ;
uho�e•#: � r'
insu�rance.co. otic. #
''7.4!3_»:.,..' .' e1.�in.."�€. e S Gb'',; "i1i'�K+''c ::rt
Failure to secure coverage as required under Section 25A of 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 5100.00 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.
7 do herehy certify tinder thepains and p ,nia/l es ofperjrtty that the information
Signature_ �[/" IJV" "
is trite and correct.
IMA,
,f
Print name F�P11/ 1'Vdt lq Phone #
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
❑Licensing Board
❑ check if immediate response is required ❑Selectmen's Office
contact person phone # ❑Health Department
❑Other
(revised Sepe 2003)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
.the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 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, 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.
yC,1 � •',,' 1 w
:sit�9: 4U
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 retained 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.
or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
f yut'2K •Y :i+'bs^• 0"'N'
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;'.�: .�'u-:. �.. 'ri'•:�� �'' y�11& s^' .ri "ti<'�r';�1% r.' .'��•�'(:;E b�:..p�.{�,}!�± i}yk Cc .>: �,��jf�>•4 rfw '.'L,�• ^p
r�'4p: ': `5' ' • d�kt�7iym � ° t9�".+ � -� � a4' '(rc�,u G'� �1F ' �: •'i' a.,�-n�A1'r�h�,Y;k�:IS��KirY,�.�Fi!3. h� ,A.d:2C•Y.
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,7`h Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
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North Andover Fee Calculation
Construction Cost
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m
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$
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9-11 Sargent Street
608-2016 on 11/17/15
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CONSULTING STRUCTURAL ENGINEER, INC.
53 Knox Trail, Suite 201
Acton, MA 01720
October 5, 2015
Michael Suffoletto Jr.
46 Hidden Rd.
Andover, MA 01810
978-461-6100
www.cse-ma.com
RE: Structural Inspection & Professional Opinion Regarding Existing Condition
and Structural Damage to Girders at 9-11 Sargent St., North Andover, MA
Dear Mr. Suffoletto:
In response to your request, this report summarizes our findings, professional
opinion and recommendations resulting from the inspection on August 19, 2015
of structural damage to timber girders at 9-11 Sargent St., North Andover, MA.
FINDINGS
The 2'/2 -story, two-family residence was constructed before 1900 according to
the Town of North Andover, MA assessor's records (see sketch & photo below).
ifi
fm 3
laze Sq.R r13
3.
During our inspection on August 19, 2015, we noted the following findings:
1. First floor supported by 2x8 full-faced joists at 16" o/c spanning 13 feet.
2. 8x8 center girder deteriorated over five steel posts (see photos 1-4).
3. 6x8 first floor girder rotted and sagging at right side extension.
4. First floor sagging and door frame misaligned (see photo 5).
5. First floor sagging and hardwood floor splintered at right side (see photo 6).
CONSULTING STRUCTURAL ENGINEER, INC.
53 Knox Trail, Suite 201 978-461-6100
Acton, MA 01720 www.cse-ma.com
PROFESSIONAL OPINION
We offer the following professional opinion regarding the observed damages.
The first floor 6x8 timber center girder and right side extension girder failed as a
result of dry -rot, deterioration and compression failure at four of the five columns
in the middle of the building and is sagging significantly at the right side extension.
RECOMMENDATIONS
We offer the following recommendation for repairs related to the timber girders:
1. Install temporary shoring beneath the first and second floors adjacent to
the center girder and right side extension and remove rotted sections.
2. Install a (4) LVL 13/"x9%" center girder on 3" Lally columns up to 6'9" o/c.
3. Install four Lally columns on existing footings with Springfield slates at top.
4. Connect 2x8 floor joists to center girder with Simpson U26R joist hangers
and 2xX hardwood shims to accommodate the notched ends.
5. Connect 6x8 floor girder to center with Simpson U668 face mount hanger.
6. Install a (3) LVL 13/"x9'/" right side girder spanning 12 feet to foundation.
We reserve the right to amend these findings, professional opinion and structural
recommendations should additional information become available. If you wish to
discuss this report, please contact us directly at 978-461-6100.
Yours truly,
NO � L
IST
Michael J. Berry, P.E., SECB NAL
Consulting Structural Engineer, Inc.
Attachment: Photographs 1-6 Taken August 19, 2015
CONSULTING STRUCTURAL ENGINEER, INC.
53 Knox Trail, Suite 201 978-461-6100
Acton, MA 01720 www.cse-ma.com
1) Center girder deteriorated in basement 2) Girder failure at column (close up)
3) Column compressed and girder splintered 4) Girder compressed over column below
5) First floor sag and door frame misaligned 6) First floor sag at right side extension
BCG
Benjamin Construction Group
BUILD • DESIGN • REMODEL
Date: 11/09/2015
Name: Michael Suffoletto Jr.
Address: 46 Hidden Rd.
City: Andover
Phone: Cell:
Email:
This Proposal includes the following:
108 Wilson Rd
Framingham, MA 01702
Phone: (617) 395-5658
service@beniaminconstructiongroup.com
Customer Information:
State: MA Zip Code: 01810
Project Information
• All surface preparation necessary to complete the project
• All necessary material to complete the project
• All necessary labor to complete the project
• Company is full insured
• Complete clean-up of the job site on daily basis.
Labor and Materials
2 %2 -story Two Family house
• Install new beam in the basement
• Remodel kitchen on the first and second floor
o Install cabinets
o Install counter tops
o Paint wall and ceiling
• Remodel bathroom on the first and second floor
o Replace all tiles
o Install durock on the walls
o Install new vanities
o Paint wall and ceiling
Licenses
11... r+w, m+ ^f niihlir Cofn+%i /Rnnrri of Riiilriina Rcoidntinnc and Ctnnr1nrr40
Insurances
• Liability Insurance
o Farm Family Casualty Ins. Co
• Worker's Compensation
o Farm Family Casualty Ins. Co
❖ A certificate will be provide from our insurance company under the customer's name.
Estimate Cost and Acceptance
I agree to have Benjamin Construction Group to perform the work described above. Our services are
backed with three years guarantee quality on all completed work and for which payment has been made.
All of the above work is to be complete in a professional manner.
Total cost:
$60,000.00
Customer Signature:
&CLZ XA.4 AL /6&-
Thank You for choosing Benjamin Construction Group
OV/17/2015/TUE
03:16 PM
FAX No,
P. 001/001
OP ID: PS
ACORN° CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYM
ACORl7
�...��
1111'&12015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Foster Sullivan InsurancePHONE
163 Maln St,
North Andover, MA 01845
Stephen
NfrA -T—P&67 U van
IC 878-ti8(i-2266 FAx No 978-8886410
Ao
Sullivan ss: sulllvan fostersulllvan roup-com
CUTOM PROOUGBR
,D r: CALLA -1
INSURI:R(e) AFFORDING COVERAGE NAIC*
INSURED Callahan A Q and Ing
Services, Inc.
Kate Callahan
91 Belmont Street
North Andover, MA 01845
INSURERA:LIBERTY MUTUAL INS CO 23043
INSURERB:GUARD INSURANCE COMPANY
INSURERC:
INSURER D :
INSUR ERE:
INBURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 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,
LTlR
TYPE OF INSURANCE
INaR
WVD
POLICYNUMBER
MIDD=
Q!MJDDrYYnj
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,00
A
X COMMERCIAL GENERAL LIABILOY
X
CBP4016154
09/25/2015
09125!2016
SES Ea DaourrenCe $ 100100
CLAIMS -MADE ® OCCUR
MED EXP (Any one person) $ 5,000
PERSONAL & ACV INJURY $ 1,000,00
CONTRACTUAL LIAB
GENERAL AGGREGATE $ 2,000,0011
GENLAGGREGATE LIMIT APPLIES PER:
PROAUCrS-COMP/OPAGG $ 2,000,0011
POLICY X P Ll LOC
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
x
13A4544005
09/25/2015
09/2512016
COMBINED SINGLE LIMFr
(Eaa06dent) $ 1,000,00
BODILY INJIURY(Perperson) $
X
—
ALL OWNED AUTOS
BODILY INJURY (Peracadent) $
X
SCHEOULEOAUTOS
HIREDAUTOS
PROPERTY DAMAGE $
(PERACCCENT)
$
X
NON -OWNED AUTOS
X
UMBRE_LLALIA13
X
OCCUR
EACH OCCURRENCE $ 5,000,00
$ 5,000,00
A
EXCESS LIAR
CLAIMS -MADE
XAGGREGATE
CU8809394
09/25/2015
09!25!2018
DEDUCTIBLE
$
$
RETENTION $
WORKERS COMPENSATION
WC STATU- X DTH-
B
ANQ r;MPLOYER8' I.IAI%LITY
ANY PROPRETORIPARTNERIE)ECUTIvE Y I N
OPFICER/MEMBEREXCLUDED? FN
(Mandatory In NHj
NIA
CAWC804073
09/25/2015
09/25/2016
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA fiMPLOYEE $ 500,000
DESCdesorlbe RIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $ 500,00
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Addleonal Remarks Schedule, tr more apace IB required)
" EVIDENCE'
fax # 978 688-9542
1111'"Pillu91MIll1:M:Ltl1111111 a. W-IRLataIII A_\ILai ►
TOWN OF NORTH ANDOVER
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DE:LIVERIED IN
ACCORDANCE WITH THE POLICY PROVIGIONG.
AUTHO RIZED RgPws =NTAT1VB
(% 199E 2009
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
rinhIR reRerveA
The Commonwealth of Massachusetts
x Department of IndustrialAccidents
f d I Congress Street, Suite 100
Boston, MA 02114-2017
=` www mass.gov/dia
yJ•V Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Orgar&ationdadividual): 15,0,0e
Address: 160'11,112 _5R-X4�7 45q4-g'e,
p ��
City/State/Zip:�,�f,9yy�i �� G f f.�r 1017Phone #:.
Are you an employer? Check the appropriate box:
l.[Y1 am a employer with employees (full and/or part-time).*
2. I am'a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
i
Type of project (required):
7. n. New construction
8. Fj Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. [] Plumbing repairs or additions
13.0 Roof repairs
14. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who subfi if this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or a
not, those entities have
employees. If the sub -contractors have employ ees,tliey must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:.
Expiration Date: /� A6
Job Site Address: /177 City/State/Zip: /w7A ,��CYO��P.t'
Attach a copy of the workers' co. ensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written." '
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required. "
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-'contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
ot/j�twac�cc e%11
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
registration: 175261 Type:
�—
� Expiration ;_5/1/20'17� Individual
WAGNER.M BRAGA,`
WAGNER BRAGA
108 WILSON DR
FRAMINGHAM, MA 017021 Undersecretary
Massachusetts
- De
Board s Q,.; 5 Re aliment of
Of �...�idin gulati
Public Safety
ons and Standa'ds
%OritPiiCtiiiii j11lJC'"1-i�fi�
License: CS
-106815
k I rI N �
WAGNER RRA
108 WILSON DR-`
Framingham MA7017
r
I
Commissioner
Expiration
09/23/2016
(92. �pon�n�ao�zusecr o�C�/�a�curel�d
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
UVExpiratiot
egistration: 175261 Type:
=w01=7- Individual
WAGNER M BRAGAI'II t�
WAGNER BRAGA
108 WILSON DR.
FRAMINGHAM, MA 01
Undersecretary
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Massachusetts -'Department of Public Safety
Standards
Board of Building Regulations ant!
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License: CS-106815��!
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108 WILSON DR%FraminghamMA,017
Expiration
0912312016
Commissioner _ -
Not valid without signature