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Home My WebLink AboutBuilding Permit # 9/4/2015 %&ORrII 1 BUILDING IT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION e Permit NO: Date Received ...« �> � COCq�[w x.4d Top Date Issued: LL711L S CH 1VIPORT'AN T: Applicant must complete all items on this 2age LOCATION L" __ �'. Print PROPERTY OWNER 1 A 010- _ Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes Pno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N(One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other o Septic ❑Well ❑ Floodplain ❑ Wetlands F Watershed District ❑Water/Sewer ,-r Identification Please'Type or Print Clearly) OWNER: Name: ]1 () AS Lei tC%A ARCO Phone: (h 6 8 0 - 9)P,3 Address: Z C)& W A\/ERLY HA CONTRACTOR Name Phone: Address; Supervisor's Construction License: Exp. Date: Hoene Improvement license: Exp: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. {SEE SCHEDULE:BULL ING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIAMAT COST EASEL)ON$125.00 PER S.F. Total Project oat: $ z ,./ � _ FEE: Check No.: Receipt o.: NOTE: Versa cantrcrc _-m- contr°actor°s do not have access to the guaranty fund . lt#r.Lnra" ' �l°ed SiHato `�, of A ent/O g g e u i mature of contractor tkORTH Town ofAndover ty ® .:�... 0 No. ' a oc� _ 14 Z � o LAK6 h h very Mass, .Q COCHIC"tWOCK R ® 0 RATED U BOARD OF HEALTH Food/Kitchen Septic System PEIAMMT T LD THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect .......................... buildings on .........040.ft -jollllr-ft......406... Foundation... • Rough to be occupied as ... 4 ........... .........................®.................. ......................................................... Chimney . provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final IT EXPIRES IN ONT ELECTRICAL INSPECTOR ® UNLESS CONSTRUCT S Rough Service ............. .. ........... ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. N°RTN TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT �o ^* 1600 Osgood Sheet,Building 20, Suite 2035 North Andover, Massachusetts 01845 9SSACHusE� Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: 1 15 JOB LOCATION: Z®(e WAVF_R1 X Number Street Address Map/Lot HOMEOWNER_�_k� Name Home Phone Work Phone PRESENT MAILING ADDRESS-2-0(o U AuEkLY Ris, No A�,i bc,)Ex MA 00� City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that-he/she will comply with said procedures and requirements. ` HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 JacksonProSales r r Baler of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 F- 09/16/2015 Billing Fax:978-687-5841Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UM Pricefunit Extension 1 SOSCHROCK 1 SCHROCK,MAPLE,FLETCHER DOOR EA 94.12 94.12 COCONUT FINISH APC PERIMETER WEP1236F1.5WD 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 2 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 202.64 202.64 CONTI) W3018 1 SOSCHROCK Due on PO#456809DB 912f 12015E timated 3 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 226.02 226.02 CONTI) W1636R FB 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 4 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 21.18 21.18 CONTI) F336 1 SOSCHROCK Due on PO#456809DB 9/21,:12015 E timated 5 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 266.93 266.93 CONTI) W361824 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 6 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 364.06 364.06 CONTI) W3636 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated Amount: 10,989.24 Tax: 0.00* Special order and manufactured merchandise is non-returnable. U Total: 10,989.24* Customer agrees that any amount not paid within 30 days of U Paid: 10,989.24 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, Due: 0.000 Page 1 of 7 9/4/2015 8:57:34AM JacksonroSales eater®f the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description uml Price/Unit Extension 7 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 365.06 365.06 CONTD WMC1236L 1 SOSCHROCK Due on PO#456809DB 9121/2015 Etimated 8 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 23.40 23.40 CONTI) OL336 1 SOSCHROCK Due on PO#456809DB 9/2,112015 E timated 9 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 364.06 364.06 CONTI) W3636 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 10 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 387.79 387.79 CONTD W3636 FB 1 SOSCHROCK Due on PO#456809DB 9/2,112015 E timated 11 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 414.92 414.92 CONTD DW362424SR FB 1 SOSCHROCK Due on PO#456809DB 9/21/2015 E timated 12 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 241.73 241.73 CONTD TEP2490F1.5FPE 1 SOSCHROCK Due on PO#456809DB 9/2,112015 Etimated Amount: 10,989:24 Tax: 0.00* Special order and manufactured merchandise is non-returnable. U Customer agrees that any amount not paid within 30 days of V Total: 10,989.24* Paid: 10,989.24 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, Due: 0.000 Page 2 of 7 9/4/2015 8:57:34AM Jackson ProSales Order Baler of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UM Price/Unit Extension 13 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 1,074.09 1074.09 CONTD U249012 AUTHLffKP/RECTKL 1 SOSCHROCK Due on PO#456809DB 912,112015 Etimated 14 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 1,074.09 1074.09 CONTD U249012 AUTHRffKP/RECTKR 1 SOSCHROCK Due on PO#456809DB 9/2,112015 E timated 15 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 414.63 414.63 CONTD B36 RD12 1 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E timated 16 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 750.89 750.89 CONTI) SLS33R 1 SOSCHROCK Due on PO#456809DB 9/2,112015 E timated 17 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 450.47 450.47 CONTID 3DB21 1 SOSCHROCK Due on PO#456809DB 912,1/2016 E timated 18 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 286.37 286.37 CONTD TD15R 1 SOSCHROCK Due on PO#456809DB 9/21,:12015 E timated Amount: 10,989.24 Tax: 0.00* special order and manufactured merchandise is non-returnable. U Total: 10,989.24* Customer agrees that any amount not paid within 30 days of U Paid: 10,989.24 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, Due: 0.000 Page 3 of 7 9/4/2015 8:57:34AM JacksonPro:ales r r Baler the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UM Price/Unit Extension 19 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 542.70 542.70 CONTD B27 AUTHL 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 20 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 501.04 501.04 CONTD BWB18 1 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E;timated 21 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 372.78 372.78 CONTI) SB30ST 1 SOSCHROCK Due on PO#456809DB 912,1/2015 Etimated 22 SOSCHROCK 6 SCHROCK FLETCHER COCONUT EA 67.33 403.98 CONTD TF396FH 6 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 23 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 35.22 35.22 CONTI) PAINTQUART 1 SOSCHROCK Due on PO#456809DB 9/2,1/2016 E timated 24 SOSCHROCK 3 SCHROCK FLETCHER COCONUT FA 17.64 52.92 CONTD SSM8 3 SOSCHROCK Due on PO#466809DB 9/2,112015 E timated Amount: 10,989.24 Tax: 0.00* Special order and manufactured merchandise is non-returnable. U Total: 10,989.24* Customer agrees that any amount not paid within 30 days of V Paid: 10,989.24 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, DUB: 0.000 Page 4 of 7 9/4/2015 8:57:34AM JacksonPr4:ales r r Baler the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A. MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description 21 Prlce/Unit Extension 25 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 9.62 9.62 CONTD TKC 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 26 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 24.05 24.05 TUK 1 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E timated 27 SOSCHROCK 4 SCHROCK FLETCHER COCONUT EA 34.31 137.24 CONTD VFR8 4 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 28 SOSCHROCK 3 SCHROCK FLETCHER COCONUT EA 35.28 105.84 CONTD TB8WD14 3 SOSCHROCK Due on PO#456809DB 9/2E 12015 E timated 29 SOSCHROCK 2 SCHROCK FLETCHER CHERRY EA 71.29 142.58 TUNDRA FINISH ISLAND APC BBM8 2 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E timated 30 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 545.17 545.17 CONTD VB333418 AUTHL 1 SOSCHROCK Due on PO#456809DB 9/2 2015E timated Amount: 10,989,24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* U Total: 10,989.24* Customer agrees that any amount not paid within 30 days of U 24 invoice date will carry interest at the rate of 1.5% per month Paid: 10,989. and further agrees to pay all costs incurred in collection, Due: 0.000 Page 5 of 7 9/4/2015 8:57:34AM JacksonPro: 'er Balethe Year Oder LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description U!LL Price/Unit Extension 31 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 185.79 185.79 CONTD BP9634.5CSGR 1 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E itimated 32 SOSCHROCK 4 SCHROCK FLETCHER TUNDRA EA 72.72 290.88 CONTI) W1530"DOOR ONLY" 4 SOSCHROCK Due on PO#456809DB 9/21f 12015 E timated 33 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 545.17 545.17 CONTI) VB333418 AUTHR 1 SOSCHROCK Due on PO#456809DB 9/2,1/2016 Etimated 34 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 19.76 19.76 CONTI) OCM8 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 35 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 24.05 24.05 CONTI) TUK 1 SOSCHROCK Due on PO#456809DB 912 /2015 E timated 36 SOWILSONART 16 WILSONART HARDWARE EA 1.75 28,00 BP53019-GlO PULLS 16 SOWILSONART Due on PO#456809DB 9 25/201 Estimated 37 SOWILSONART 34 WILSONART HARDWARE EA 0.00 0.00 AK-BP 53005-G10 KNOBS INCLUDED IN PRICING Amount: 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* U Total. 10,989.24* Customer agrees that any amount not paid within 30 days of U Paid: 10,989.24 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, Due: 0.00 Page 6 of 7 9/4/2015 8:57:34AM Jackson ProSales Order Baler of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A. MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description Uml Price/Unit Extension 34 SOWILSONART Due on PO#456809DB 9 25/201 Estimated Amount: 10 989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* V Total' 10,989.24* Customer agrees that any amount not paid within 30 days of U 24 invoice date will carry interest at the rate of 1.5% per month Paid: 10,989. and further agrees to pay all costs incurred in collection, Due: 0.000 Page 7 of 7 9/4/2015 8:57:34AM a' Baler®f the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203844 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 10/09/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A. MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# I Order# Order Date Oper Purchase Order Terms Ship Via 1810 1 203844 08/15/2015 139 EMPLOYEE DIR SHIP LN# Item Number Ordered Description U!LL Price/Unit Extension 1 SOGRANITE 1 STONE CREATIONS CAMBRIA COLOR EA 2,450.00 2450.00 TBD EITHER SUTTON OR WINDEMERE NO BACKSPLASH PERIMETER,STAND ARD EDGE EITHER PENCIL OR BEVEL 1 SOGRANITE Due on PO#458817DB 10/16 2015 Eimated 2 SOGRANITE 1 STONE CREATIONS CAMBRIA COLOR EA 1,996.00 1996.00 TBD EITHER SUTTON OR WINDEMERE STD EDGE,ISLAND COUNTERTOP 1 SOGRANITE Due on PO#456817DB 10/16 2015 Es timated Amount: 4,446.00 Special order and manufactured merchandise is non-returnable. Tax: 0.00* U Customer agrees that any amount not paid within 30 days of U Total: 4,446.00* invoice date will carry interest at the rate of 1.5% per month Paid: 4,446.00 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 1 of 1 9/4/2015 8:56:31AM Y 39' 24B"—f--272" 7;" NWEP123f W3018 .1536 nip N W361824 TD15R N NN�GE1� 3DB 21 G�IQ 9H -- TEP2487F1.5FPE � �zl =gym o Schrock,All Plywood Construction `� m with Full Extension Soft Closing Drawers cn and Doors, Perimeter and Pantry wall is o Fletcher, Maple, Painted Coconut, Island is Fletcher, Cherry, Tundra Finish yip v O $10,655 to t0 N Fs � Co 0 �) 10 ' OD 10 m I O - 0 m O IX O Q W La (o x O r� f �r � y r I All dimensions_size designations DARLENE BENOIT This is an original design and must Designed:7/25/2015 given are subject to verification on JACKSON not be released or copied unless Printed:8/7/2015 job site and adjustment to fit job LUMBER applicable fee has been paid or job conditions. -MILLWORK order placed. J Marcotte,Patti_Tom Island Schrock All Drawing#: 1 No Scale. r e �l i t• i r rr. L 77 a c h t y 5 t rt ._. _ _ � `ice aeaf�lac4al?mrui�mu,vmn,.ohw.•t r' ` a ti The Commonwealth of Massqchusetts Department oflndlustWalAecidents .1 Congnegs Street,Suite 100 Boston,MA 021.1420X7 :vac www.mass.go-pldia s,. Wovkers'Compensation lnsuraxiceAffidavit:Buildexs/Contxacto:r$fElectricians/PXnmbexs. TO BE k'IGED WfTIC TER PERMI'TE G AUTRORI'TX, Ap-plicantInformation Please Print Le�ibiy a1TlB(Susiness/Ozganizationffn.dividual): ( A rJ+r As QTTE .Address: ZQ(, WAVt`f 1 City/8tate/Zip: ) )0 hot 0hri �lP� �J t 1�' Phone#: q 7d,- 6f Are you an employer?Cheektlie ap' opriate box: Type of project )Vequired): ]. X am a employer with employees(full and/or part time). ], New construction 2.Q X am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity,[No workers'comp.insurance required.] 3.0 lam a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10 F1 Building addition 4.L_--1 X am a homeowner audwill be hiring contractors to conduct all work on my property. X will ensure that all contractors either have workers'compensation insurance or are solo 11.Q Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.❑X am a general contractor and X have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors hate employees andhave,workers'comp.insurance# 6.Q We area corporation and its officers have exercised their right of exemption perMGL c. 14.❑Other 152,§1(4),and we have na,employees.[No workers'comp,insurance required.] yAuy applicant that checks box#1 must also filll out the section below showing theirworkers'compensation policy information. i Homeowners who submit'this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. sContractors tbat checkthis box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Tf the sub-coniract'ors have employees,they must provide their workers'comp.policy numbez. .damanemployerthat ispr•ovidingworkr's'coMperasationinsur°anceformyemployees.' Belowist/iepolieyandjobsite information, Insurance Company Name: Policy#or S elf-ins,Lic.#: Expiration Date: 1 Job Site Address: City/State/Zip: Attach.a copy of the wor leers'eoanpeusation•policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under MGL o.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 Snvestigations of the DIA.for insurance coverage verification. ature: ' trueand correct. fdo hereby eertifunderthepains an pena erofpe�jury Hat the infoNmaionprovidedabo Y : Date*sign —-- Phone#: Official use only. D0 notIprzte in this area,to be completed by city or•town offtelal. City or Town: Pernilt/License# Issuing Authority(circle one): i 1.Board of Health 2.JBuildingDepartment 3.CityJTown Clerk 4.Electrical Inspector 5.Numbing Inspector 6,Other Contact Person: Picone 4: