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Home My WebLink AboutMiscellaneous - 563 Chickering Road Cf7ic�r�i`v �� - �G� �' L CC/✓T�� LaMarche Associates P.O. Box 179 Natick, MA 01760 508-650-9777 Fax: 508-650-9870 June 16, 2010 RECEIVED Building Commissioner/Inspector of Buildings uUL_ 1 2 2010 , NORTH ANDOVER, MA 01845 TOWN OF NORTH ANDOVER Board of Health/Board of Selectmen HEALTH DEPARTMENT NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chanter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: CHICKERING CONDOMINIUM ASSOCIATION Loss Location: 563 CHICKERING ROAD NORTH ANDOVER, MA 01845 Policy Number: 1120D17099 Date of Loss: 6/10/2010 Cause of Loss: Water LA File Number: MA-2-18237 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Thomas Bratkon Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 i NORTH ED 1 619 p T O W N O F * __ N O R T H A N D O V E R T Q _ �= LAKE T COCHICHE WICK DATE: /D-A ! - yoZ �•9S R'4TED PP .4_C NORTH ANDOVER, MASS. ,/ SAC HUS PERMIT # 2541- S S I G N P E R M I T THIS CERTIFIES THAT. . . y. . . . . . . . . . . . . . . . . . . . . . _ has permission to erect . G llJ. . . . . . . . . . . . . . . . . . . on. . . . . . . (� . . . ..... . ... /�D _nr.ovided that the person accepting this permit shall in every respect conform �j file in this office , and to the provisions Location - ' �i , ,� No. f o the Sign Regulations in the Town of Date _, e NORTF, , TOWN OF NORTH ANDOVER {ulations , Section #6 , Voids this Permit . Certificate of Occupancy $ qW ,•�; Building/Frame Permit Fee $ C°.�t� Foundation Permit Fee $ J /GSL O�t r Permit Fee $ -? ' . . . . . . . . . . . .,:/,.!4�1 �Z. . l. . -G?� . . . . . . . . . . " w - -- Building Inspector O�'l"' Sewer Qo vection Fee $ �'�&r Connection Fee -- ,OTAL $ Building Inspector + Div. Public Works SIGN PERMIT APPLICATION NORTH ANDOVER BUILDING DEPARTMENT Division of Planning & Community Development Date Filed: fe)' r 1. Site Address 2 . Owner 3. Applicant 4 . Number of Signs_ Size of Sign(s) Q6jti, 5 . Site of Proposed Sign(s) /lEt� _ ,�,• �� 6 . Materials : 7 . How attached: (a) Against the wall (r� (b) Roof ( ) (c) Ground (d) Other ( ) 8 . Illumination: (a) Not illuminated ( ) (b) Internally illuminated (�X" (c) Illuminated from separate service ( ) 9 . Proposed Colors : Background Lettering E Border. 10 . Will sign overhang any public road or walkway: Yes ( ) No (� 11 . If Yes , Name of Agency who will provide liability insurance : 12 . Attachments : ( ) ',Photographs of building ( ) Material sample ( ) Color samples ( ) Site or Plot Plan .(Required for all free-standing signs ) ( �) *Drawings of proposed sign ( ) Other, specify 13 . Is Board of Appeals decision required? Yes ( ) No ( ) �1- &,6t4 fi . Signature ok Appl ' cant 1988 �; .JNA� Y'; , ••�,----- Ot ! , r . • Ii 1 r r'! I I ' 1) j �� t '' _ ' �' „'� • i z ' 4 ` �Y ��' � �s �s+. / in / �I , � �� u; � �� '�� y , �f � � LaMarche Associates P.O. Box 179 Natick, MA 01760 508-650-9777 Fax: 508-650-9870 November 14, 2011 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chanter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: CHICKERING CONDOMINIUM ASSOCIATION Loss Location: 563 CHICKERING RD NORTH ANDOVER, MA 01845 Rete Policy Number: 1120D17099 Date of Loss: 11/10/2011 JAN IQ Cause of Loss: Water TOWN OF NORTH RTMENTER LA File Number: MA-2-20924 HEALTH pEPA On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Thomas Bratkon Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 f NORT#I q BUILDING PERMIT �� b°'�`eD °' TOWN OF NORTH ANDOVER 1 r o APPLICATION FOR PLAN EXAMINATION . b Permit NO: Date Received °9 �! °Awreu Date Issued:' I� ' CHU WFPORTANT:Applicant must complete all items on this page LOCATION K3 A Ch Jer Print PROPERTY OWNER !i?� E, 1-ai,+ai/i e- Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesnn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑One family 0 Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: Commercial epair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑Other 0 Septic 0 Well ❑Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer ac4 f I A4 �ei�j�H o c fes Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: 663-afi'�-7507 _ I"ey 4or" Address: /7(,c, 1 erny Al H,, e)3o 3 Supervisor's Construction License: Exp. Date: 00/9 b/ Home Improvement License: Exp. Date: 5. 3i I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �� FEE: $ 7�, Check No.: 14-13 Receipt No.: o? 13 5--? - NOTE: Persons contracting with unregistered contractors do not have access to a guaran and Signature of Agent/Ow Signature of contractor i L TOWN OF NORTH ANDOVER } APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print. PROPERTY OWNER � Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no j Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family j ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ElWell ElFloodplain ElWetlands El Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: I Address: CONTRACTOR Name: Phone: Address: i Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si filature of contractor �Siature�. f gnA_gent/Owner ,___ ._9..___ _ - Plans Submitted E _ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - r J Plans Submitted ❑ PlansWaived-0 .Certified Plot Plan ❑ Stamped Plans ❑ -_ I - -TWE_ORSEWERAGEDPSPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ i Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc._ - =Permanent Dempster ori-Site ❑ =THE.FOLLOWING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS 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 Water & Sewer Connectionlsi nature Date Driveway Permit DPW Tow;2 Engineer: Signature: - Located 384 Osgood Street EIRE DEPARTM,rINT: -Temp Dumpster on site yes no Located-at'l24Mair Street- - re Departme►"it�sigiiata'r'e/date= " - Y _T Dti ensicyn 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 ONE LITERATURE: Yes No MGL-Chapter 166 Section 21A.=F and G min.$100-$1000.fine NOTES and DATA— (For department use I � i El Notified for pickup - Date s Doc.Building Permit Revised 2010 Building Department The fol;0wing is a list of the retluired.forms to be filled out for the appropriate.permit to be obtained. Roofipg, Siding, Interior Rehabilitation Permits o 7 Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Gr C.S.L :Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to Issuance of Bldg Permit Addition Or Decks Li Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o 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) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report Li 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 ors special permit was required the Town Clerks office must stamp the decision from the Board of Appeals P P 9 P � that the apn•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 3/17/2014 2:14 PM FROM: Fax TO: 978-688-9542 PAGE: 002 OF 002 LIRERA1 OP ID:CD CERTIFICATE OF LIABILITY INSURANCE D031171201ATE Y10 03/17/2014 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(les) 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 ACT NAMME: Linda Gallant Gallant Insurance Inc 694 Route 3A AIC,No Ext):603-224-0993 FAX, No) : 603-224-7710 Bow, NH 03304 Linda T Gallant ADDRESS:linda@gailant-insurance.com INSURER(S)AFFORDING COVERAGE NAIC S INSURERA:MMG Insurance 15997 INSURED Ray Lirette Custom INSURERS: Design Carpentry 176 FOrdway Extention INSURERC: ^^'�e INSURER D: -Tf --� - _ -• - —� ,INSURERE: COVERAC Location LJ� ,NUMBER: THIS IS 1 0�G ABOVE FOR THE POLICY PERIOD INDICATENO r/ ' WITH RESPECT TO WHICH THIS CERTIFIC cccwvvv / IS SUBJECT TO ALL THE TERMS, EXCLUSgI Date /7 INSR LTR LIMITS GENE t JRRENCE $ 1,000,00 J RENTED A X d • TOWN Ea occurrence $ 250,000 • b'r 1IY OF NORTH ANDOVER Any one person) $ 5,000 _&ADV INJURY $ 1,000,00 AGGREGATE $ 2,000,00 IGEN Certificate of OccupancyS-COMPIOPAGG $ 2,000,00 $� $ Building/Frame Permit Fee �('(7 DtSINGLE LIMIT $ AUT`' _ Q ee Foundation Permit Fee `P NJURY(Per person) $ Other Permit Fee -- INJURY(Per accident) $ TY DAMCIDENT)AGE $ TOTAL f � $ t - I CCURRENCE $ Check# JI ' 3ATE $ $ W� /C STATU- OTH- Ar )RY LIMITS ER A< < ��+_J � �A�Uilding BCH ACCIDENT $ OISEASE-EA EMPLOYEE $ (" Inspector I fn D ISEASE-POLICY LIMIT Is PERTY 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Liability Limits Apply at Inception of Policy CERTIFICATE HOLDER CANCELLATION TOWNOFA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Andover ACCORDANCE WITH THE POLICY PROVISIONS. 36 Bartlett Street Andover, MA 01810 AUTHORIZED REPRESENTATIVE O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NORTH own of ndover G A- .No. ( * _ z � oh ver, Mass, coc NIC Ml WICK S U BOARD OF HEALTH Food/Kitchen PER T T � LD Septic System woo �+Of%1114 cm BUILDING INSPECTOR THIS CERTIFIES THAT ....rm..�M................................................... .. � Foundation has-permission to erect ...... ................... buildings on TP�. .. .... .....�.�r..... !�1... .........p............ ` � Rough tobe occupied as .... ... ��.................................................................................. 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ..........'. .,..... Service ................ ... .� . .:Y.-rte.......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,17 Or- Address: C City/State/Zip: 36360 Phone #: Ko0 3 —cW 5 - Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub=contractors 6. F]New construction 2.X 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I afn an employer that is providing-workers'compensation insurance for irfy employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: _ _ _ City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern oder the pains and penalties o that the information provided above is e and correct. — — Si ature: - - Date 3"_ �-7 Phone#: 7-5 0 7 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Isgnina.Autherity-(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact P&i6h`., Photic#: 3/17/2014 2:14 PM FROM: Fax TO: 978-688-9592 PAGE: 002 OF 002 LIRERA1 OP ID: CD CERTIFICATE OF LIABILITY INSURANCE PATE1201YYY)1 03/11774 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. y IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policytiesl.---- ,)GATION IS WAIVED, subject to the terms and conditions of the policy, certain policies ma.r.- -"'"` ite does not confer rights to the certificate holder in lieu of such.endn- - PRODUCER Gallant Ins (`//,)!Y/tA/`.(_�J`� /< , 694 Route i / (alc,No): 603-224-7710 Bow, NH 0: Linda T Gal Location Date 1GE NAIC S INSURED NO. 15997 TOWN OF NORTH ANDOVER COVERAGE!, Certificate of Occupancy THIS IS TO i, �� 1MBER: INDICATED. • /Frame Permit Fee WE FOR THE POLICY PERIOD CERTIFICATE Building TH RESPECT TO WHICH THIS �... EXCLUSIONS Foundation Permit Fee -- UBJECT TO ALL THE TERMS, LTRI LIMITS GENERAL LI/� Other Permit Fee $-� ,E $ 1,000,00 A X COMMEP� TOTAL irrrence $ 250,000 CLA person) $ 5,000 ! wJURY $ 1,000,00 TE $ 2,000,00 GEN'L AGGREGk / )P AGG $ 2,000,00 X I POLICY Check# AUTOMOBILE LI}, Building Inspector MIT $ ANY AUTO! C]r� -rerson) $ ALL OVVNECF /�„ AUTOS BODILY INJURY(Per accident) $ 1l PROPERTY DAMAGE HIRED AUTO PER ACCIDENT) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROPERTY 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Liability Limits Apply at Inception of Policy CERTIFICATE HOLDER CANCELLATION TOWNOFA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Andover ACCORDANCE WITH THE POLICY PROVISIONS. 36 Bartlett Street AUTHORIZED REPRESENTATIVE Andover, MA 01810 O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NORTH Town of . s E :. 1, ndover i No. ,� zy oh ver, Mass, COC "ICH&WICK A�RwrEo ►`Pa`,��(5 S V BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .... PERMIT ....................�`................................................. BUILDING INSPECTOR ............................................ � • has-permission to erect ............ buildings on . .. .... . ...�. r..... !R!1... .........�........... Foundation m% Rough tobe occupied as .... ... M�.................................................................................. 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service .................... ................. ... .� .......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Offue of Investigations } 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): —&. 652641 1-17 Address: City/State/Zip: bercv 3035 Phone#: 663 c�S5 - 7-TO 7 Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or pari-time). have hired the sub=contractors 6. ❑New construction 2.JQ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance. 1 required.] 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I-am an employer that is providing workers'compensation insurance for my employees .below is the poliey and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: _ _ = City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder the pains and penalties of that the information provided above is true and correct Si ature: Date C-5 ;d Phone#: f�3 — �& — Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Iscyina_A41tlherity(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Pe so" is Phone M Custom Design Carpentry 176 Fordway Ext, Derry,NH. 03038 Tel. 603-289-7507 Elizabeth Fontaine 3/14/2014 Century Hair Salon 563A Chicering rd. N. Andover, Ma. 01845 1, Install Drywall to cover old Barn board,mud and sand seams. 2, Install baseboard along floor of drywall. 3, Install crown along ceiling. 4, Trim four door, one front and three in rear. 5,Trim one window in front of unit. 6,Box out pipe in between stations. 7, Cut back overhang over stations. 8, Remove two partitions in between stations. 9, Replace 2x4 ceiling tiles. Total cost: $ 5850.00 Plus Permit Fees Rand Lirette Cus om Design Carpentry Date Elizabeth Fontaine 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super N icor License: CS-092527 RAYMOND C UOTTE 176 FORDWAY EXT.')ur''� Derry NH 03038 Expiration Commissioner 08/20/2015 �'%�r.`�nrn�zza�ztt�ent�l�t�ff�'7 fttJSrxc�«1c� Office of Consumer Affairs&Busidess Regnlition lea ME IMPROVEMENT CONTRACTOR __ egistration: 172177 Type; xpiration: 5131f2014 DBA RAY LIRETTE CUSTOM DESIGN CARPENTRY RAYMOND LIRETTE . 176 FORDWAY EXT. DERRY,NH 03038 Undersecretary ; s� �