The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #952-2016 - 71 MAYFLOWER DRIVE 3/8/2016Alt"4 a- BUILDING PERMIT , TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION PermitNo#: Date Issued: IMPORTANT: A LOCATION Date Received cant must complete all items on this r-1 11 IL PROPERTYOWNER.- "e� Print 100 Year Structure Yes MAP AOMPARCEL: 17 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resiontial Non- Residential .1, Aew Building ?"O'ne family D Addition El Two or more family El Industrial 0 Alteration No. of units: El Commercial El Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition El Other El Septic 0 Well --- 0 Floodplain El Wetlands El Watershed District 0 Water/Sewer 5;71: DESCRIPTION OF WORK TO BE PERFORMED' 3 6eg ev&&i. a S�0� �eOw�710�,WA'r, Identification - Please Type or Print Clearly OWNER: Name: Phone: ?V�696-31t*3 Address: A9 ,?. )W# '01-pf!5r Contractor Name: keW),,i_,Nr, C-57 a6-600 Address:_/0 e, Supervisor's Construction License: C!�� e,7!�30 I- Exp. Date:- IA. Home Improvement License: Date: ARCH ITECT/ENGI NEER 2),e#Pr1,'-y Phone: cc.,p e4 r, Lr W,4 Address: Wo Reg. No. FEE SCHEDULE: BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F_ �_T FEE: $ Total Project Cost: $ Check No.: Receipt No.: .1!0 -.- - guara��_fund NOTE: Persaus contpaqjm# withligiregistered contractors do not have access to^ -_ '36'� i I nature of Wn Plans Sub(nitted [I Plans Waived 11 Certified Plot Plan 11 Stamped PlansEl T ypF-,6F SEWERAGE Dl1P0— �A ji I ic Sel 'er w - 1"t, lk( Tanning/Massage/Body Art F] Swimming Pools -13 El Tobacco Sales Food Packaging/Sales El LWell Priv Private (septic tank, etc. Permanent Dumpster on Site F1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature—_ COMMENTS CONSERVATION Reviewed on - COMMENTS -r3S� HEALTH COMMENTS Reviewed on Si_qnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes IV Planning Board Decision: Conservatio n Decision: Water & Sewer Connection/sic In t! DPW Town Engineer: Signature: r Comments COMM95 Located 384 IVA- P7-&/ Dimension Number of Stories: Total square feet of floor area, based on Extd-hor-, dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requiie�.approvall of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine NU FF -5 and UA I A — (For department use) .4 El Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. 11 Roofing, Siding, Interior Rehabilitation Permits ci Building Permit Application • Workers Comp Affidavit • Photo Copy Of H.I.C. And/Or C.S.L. Licenses • Copy of Contract • Floor Plan Or Proposed Interior Work • Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) • Mass check Energy Compliance Report (if Applicable) • Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application Li Certified Proposed Plot Plan • Photo of H.I.C. And C.S.L. Licenses • Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) Copy of Contract Mass check Energy Compliance Report Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit in all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must he submitted with the building application Doc: Building Permit Revised 2014 I Location /6, No. Date Check# TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector *ORTN Al CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 952-2016 on 3/8/2016 Date: August 15, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 71 Mayflower Drive — Lot 17 MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Key Lime, Inc. 71 Mayflower Drive North Andover, MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 30099 Check: 7595 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION C""Ic .11 Arlo BUILDING PERMIT # Fw_ - 2 e) /to ADDRESSILOCATION OF PROPERTY: Map_______yarce1 LotNumber /2 C-71 &*4Fj,9Lve SUBDIVISION: ad.-C4910*7 Ala',fleaa DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY:. FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE PennitIssuedto: k&VO4.""wdelf Address: /0 ko,& ROUTING TOWN ENGINEER,- SITE PLAN — DRIVE -WAY REVIEW I �01 11911 CONSERVATION PLANNING 4�" t,4� aq0 DPW-WATERNIETER (P SEWER CONNECTION Fv( DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW SIGNATURE File: Application for OC form revised Jan 2007/2011 LO JL "a C-6 %0 kr2o 6 4 T 4c 4!,2 0 Go ki\ CA N ui L.L 0 0 LLA 0. Ln lift "1 Mll-i ui CL Ln %, z < Ru co E LU LO JL "a C-6 %0 kr2o 6 4 T 4c 4!,2 0 Go ki\ CA a m LLI am LU C-) U) 0 U) :2 W 0 .2 W U) E CL U) cc 0 0 Z cu 6.2 IA t; E0 L CD U) 0 0 E tm r- cc 0 0 0-0 =CG 0 z CL =n 4- 0 T 0 CL w w 0 0 cc 0 cn m 0 r r— cc CL a) cn m a) .2 0 0 U) a :E .2 r 0 a) U) .0 o%- r - o L- r- 0 .I-. CL 0 (.) E U) U) :2 0 U) c .2 0 0 0 z 0 F. CO 3: I -- z 0 m cc :z Cl) LU w CL x ui LU 0- �vl 0 LLI CL Cl) Cl) C0 LU —i .Z 9 0 E 0 :z 0 cn .E CD 0 CD 0 cc CL 0 CL cn r. 0 C CL (n lw I.: 0 CD 0 0 00 L- L- 0 CL CL 0) cc 0 CD z CL U) a ui L.L 0 0 LLA 0. Ln lift "1 Mll-i ui CL Ln %, z < Ru co E LU 0 co u co LU -j ui (,qA cr L.L 0 CL 0 a) V) D D 0 0 L.L CC U L� tw 0 cc LL cu u � M�Z� M.0 a m LLI am LU C-) U) 0 U) :2 W 0 .2 W U) E CL U) cc 0 0 Z cu 6.2 IA t; E0 L CD U) 0 0 E tm r- cc 0 0 0-0 =CG 0 z CL =n 4- 0 T 0 CL w w 0 0 cc 0 cn m 0 r r— cc CL a) cn m a) .2 0 0 U) a :E .2 r 0 a) U) .0 o%- r - o L- r- 0 .I-. CL 0 (.) E U) U) :2 0 U) c .2 0 0 0 z 0 F. CO 3: I -- z 0 m cc :z Cl) LU w CL x ui LU 0- �vl 0 LLI CL Cl) Cl) C0 LU —i .Z 9 0 E 0 :z 0 cn .E CD 0 CD 0 cc CL 0 CL cn r. 0 C CL (n lw I.: 0 CD 0 0 00 L- L- 0 CL CL 0) cc 0 CD z CL U) a CN rA =)�m mcm;OP cl MI, w am LU cr w cc 0 LU L.L 0 Q\ �% LA z 0 u LU Ln LAJ C� cc u LLI w cc < CL 0) Z u LU a E LU LU Q) uj Ln 0 CL 0 a) L L/) :3 0 LL. cc U LL- to :3 7v- 0 LL ai iu_> hi 0 W 0 U- 6 z E a) 0 E co Ln VI w am LU E I— F. Cl) z 0 m C.0 z U) LLI w CL x LLI LLI CL U) z 0 C-) U) W LLI I Iz. 0 E 0 z 0 CL 0 I -M-7 U: 0 0 no o r -J 0 z g - CL 0) E (D CL CD r r 0 0 z CL (A 0 0 CL 0 MCD CD (0-0 t 41 CL 0 .2 c m 0 .2 M cp a :2 .2 CL cn CO) cz r- a 0 0 4- CL 0 L) E I— F. Cl) z 0 m C.0 z U) LLI w CL x LLI LLI CL U) z 0 C-) U) W LLI I Iz. 0 E 0 z 0 CL 0 I -M-7 U: 0 0 no o r -J 0 z ;I -A n 0 M = (a @CL a 0 CD CD CD cn 00 :3 0 �; rr o cn :3 z 0 ca 0 cu :E 0 1 r_ R C2. w m m ." Z CL C) 0 0 — ET CD @ C:D' CL(B to < Cn o 0 0 CD < z 0 =3 EQ- < 0 > CD c) 0 OD -P, cyl 0) > M > cn 0 3 (D * CL < a: 0 C9 0 (D -0 m m ;a C) ? co Ln C) M cr 0 0 M = > r -j a) 0 =r CFY 0 =r 0 0 0 CD a) CA -11 C) 1� 0 c 0 ID -0 m -0 CL C:) > (n 3 r- ur < — > a) = :3 (a 2. 0 C) =3 lu S' CL — (D :E M ca X a CD F3 > -n 0 - 0 :r — 3 w C<D CD 0) 9 - CD 0 Z3 0 h CD X > m = (D - (D :3 — (D :3 -0 '0 C :3 < < CD a) co ,n Ly :3 C, X, �< a- ;z 0 =1 0 3 .. -N CD c) M CL G) C) C) cL G) a 0 ca CD ET cc CD m CD cc 0 c, M C) Er 02 0) CD @ 0 a) CD CL CL CD CD m = w =r cD 0 :3 m co CD a M 0 0 0 -U E :3 =r CD o M (Q - -, M (D m C) — CD U) r- Cn CL 0 ;u 11 m a < =3 (D > CD cn M - Q- 0 0 — M CD -0 CD 0 -n LD. 0- > m 0 0 r a 0 a M M M M m 0 a — - > (n ---u2 cn 0 0 CD CD 9 a ET — a — 5. m a- 0 E 3 3 =r 8) cn CD 3 0 ;T zr a c M 0 > x 3 cD to cc co CD 0 9 c En CD r = 0 - ID E 0 m '< :z g w (n m CL cr :3 m m 0 m co I r) C) -4 — -C� N) x z ;D 0 . M M > -n 4' w w w (<D L X, w x C, ba (D 8 ca (o 6 w co > -L cn -4 (D X :r N) 6 =;- o r- — 0 0) CO o — :3 =i co m CD CD m N) cn -4 -4 0 C) CD M CL CD CD Co cn C� =w t :3 a) c C) 0 :3 CD @ 5 0 3 OD 0) C) ;u m N) CO p p p ET 0 co ET C) -n m c 0 0 :r C� C) C) C) C) C� C) N 0 Z' 0 :3 0 CL m c) -u -69 N) 0 0 co CD CD< (a CD — CD CD -0 A - 0 to C.) W 4W -4 C 4N. C� 0 (n 0 0 0) CD =r CD CL (D ca tj C) co 0) co co (n 0 3 4 m C) N) CZ) (a cn 3 3 F o 9 0 0 3 o CD 0 0 0 0) CL CD 0 :3 CD Z -< 0 CD m C) CD cn N) 6 cw" cD w COD (n CO M x 'D M M ;U c) jo --4 w :3 ai� 9 0 -n a) 0 EP ::r CD z) CD @ CL 0 (A M :n CD -n 0 0 CA :1 CD (n U) 0 0 :3 CD CL C) En 0 < CD CD 5 ;o :0 -n c CL CD C) T , -n 0 a w 70 6 m 0 o m n .. .. .. :3 CD -n CD CD ca a: 0 cn Cl) --J (D W m -V a- (a - . a< 1 6 00 6 C, 9 C� 0 cD (D m 00 CY) ID C) ct cL -9� , , CL co 0 , U2 0 CD 9 p 2 La CD m 3 %< a (a 0 C) CL cy, OD cn m (a C) CL CD co m E; G) 3 CD o :T C-) n :3 CD CL -4 cn o c) cn C) (D (A U) -U - (n E z 0 =3 EQ- < 0 > CD c) 0 OD -P, cyl 0) > M > 0 3 (D * CL < (D -0 0 CD Ln C) M cr 0 0 M = > r -j w =r CFY 0 =r 0 0 0 CD a) CL < a) N) c 0 ID En C:) ur < — > a) = :3 (a at :3 to =3 (D CL Z) 0 (D :E M ca CD 0) :r — 2. -a E; �o 9 - CD (a m CD > CA 0 3 0 M C) m C) — co a) - 0 0 a ;u :3 (D Q- C:) CL > C) C) 0 ca (n m CD U3 Z CD (D m CD (n 0 ID a 0- to CL :3 U) zy 0 (D U) CL 0 ;u CA) > CD 0 (D M ;u - Q- 0 0 — M CD -0 () 3 CD -n a) cr * cn 0 0 CD CD =r 0) 0 CD 3 0 a c M 0 > x 00 cn > -4 CD 0 z c En CD r = 0 - E 0 m '< :z g w (n CL cr :3 a) 0 m co I r) C) -4 — -C� N) -,j Cn ca D = 0 . < > CD CD Go (<D L X, w x C, ba (D 8 ca w r—Z 3 -4 ::r — 0 (D ::L 0 :3 =i co m CD CD m CD M CL CD CD Co cn C� CD @ 5 0 3 M a ;u m 9 CL (a ET 0 co ET a) c o :3 0 :r to %< N 'a :3 0 m 40 -69 N) 0 0 co CD (a CD — :3 CD -0 A - CD 3 to C.) W 4W -4 1.9 LT1 , C) 4N. C� 0 (n 0 0 CD E. > (D ca tj C) co 0) co co (n 0 3 .0 C: C) (a cn 3 0 0 3 CD 0 CL CD CD Z CD m N) 6 cw" cD w COD P ai� BUILDER'S AFFIDAVIT Property/Builder: Owner's Name: Key Lime, Inc - Ben Osgood Property Address: 71 Mayflower Dr city,st,zip: North Andover, MA 01845 Phone No.: 508-328-4630 Builder's Name: Key Lime, Inc - Ben Osgood Model: Development: Old Salem Village Phone No.: 978-683-3163 Rating Date: 8/15/2016 Rating No.: ABA6328 IMPORTANT NOTICE TO BUILDER Builder affirms in this affidavit that all components listed in the Building File Report are accurate and incorporated into this New Home. Builder agrees to permit home energy rating system (HERS) Provider and/or Rater, to randomly verify components solely for the benefit of the HERS Provider's and/or Rater's interest. The HERS Provider and Rater do not create or imply any duty or obligations to Builder or any subsequent owner. Builder is responsible for making any inspections to protect Builder's interest. There is no GUARANTEE or WARRANTY expressed or implied, from the HERS Provider or Rater as to this New Home. Builder's Signature: Date: S7_/ HERS Index: 52 Raters Signature. - Rating Reason: Confirmed Date: 1 6/' REM/Rate -Residential Energy Analysis and Rating Software v14.6.3 This information does not constitute any warranty of energy cost or savings. @ 1985-2016 Noresco, Boulder, Colorado. RESNET HOME ENERGY RATING Standard Disclosure For home located at: 71MayflowerDr City: North Andover State: MA I - The Rater or the Raters employer is receiving a fee for providing the rating on this home. 2. E In addition to the rating, the Rater or Raters employer has also provided the following consulting services for this home. - A. Mechanical system design B. Moisture control or indoor air quality consulting 0] C. Performance testing and/or commissioning other than required for the rating itself ElD. Training for sales or construction personnel 0 E. Other (specify below) 3. 0 The Rater or Raters employer is: A. The seller of this home or their agent B. The mortgagor for some portion of the financed payments on this home C. An employee, contractor or consultant of the electric and/or natural gas utility serving this home 4. J_] The Rater or Raters employer is a supplier or installer of products, which may include: HVAC systems Thermal insulation systems Air sealing of envelope or duct systems Windows or window shading systems Energy efficient appliances Construction (builder, developer, construction contractor, etc.) Other (specify below): Installed in this home by: Rater Employer Rater Employer Rater Employer Rater Employer Rater Employer Rater Fj Employer Rater 1-1 Employer OR Is in the business of: Rater F1 Employer Rater Employer F1 Rater Employer Rater Employer Rater Employer Rater Employer 1-1 Rater E Employer I attest that the above information is true and correct to the best of my knowledge. As a Rater or Rating Provider I abide by the rating quality control provisions of the Mortgage Industry National Home Energy Rating Standard as set forth by the Residential Energy Services Network (RESNET). The national rating quality control provisions of the rating standard are contained in Chapter One 4.C.8. of the standard and are posted at http,//resnet.us/Standards/RESNET–MortgagE�_lndustry_Nab( The Home Energy Rating Standard Disclosure for this home is availabile from the rating provider. Steve Weglarz 1225336 Rater's Printed Name Certification # August 16, 2016 Rater ign ure mate RESNET Form 0300-2 AC CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 952-2016 on 3/8/2016 Date: August 15, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 71 Mayflower Drive — Lot 17 MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Key Lime, Inc. 71 Mayflower Drive North Andover, MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 30099 Check: 7595 7 -A rr =r =1 U, @0. Q —0 (D CD co co cyl o rr 0 = =i (D 70 - = 0 0 0 w CL @ CD =3 00 0 — CD CL,Q U2 9,< co) o 0 0 CA S =3 P6 to > -n cy 0 C, > 0 0 CD -0 c < < v :3 CD 0) = CL G) c (D A = 0 0 a) CD M CD U) 0 CL a 0) ::r (D :3 CD — cl) co 0 CD Ej' m -n LD. Cl- - > -n 6, a-3, :y =r Z ��: ca 0) C) 0 0: 0 0 0 CD C) 0 -n 0 tr =3 < 3 (D -n -,n m c c -n (D CD 0 W m T 0 m CY) > > 0 = a C4 mg < m 0 0 CL 0 U < CUL COD a) :E CL ZI co o :� 9 = M CD > CD CL cr CL 5' CA) > U2 a) 0 0 0 � > (YI 0 0 m x CL 0 0 U) CD :E CL :� 21 (n 0 0 -0 0 w CL 6 m R cy co = C: ;D m q <' & 6 a) co c Ln m CL 0 CD CL 0 0 to o - m C.) C) 0 cn C) > 0 0 :E .- CL Ln C) 0 0 0 0 3 'a CD 0 (D =r CD CL CD w =r — (D 0 3 co IV v w CD -V r- - (3' cl 0 0 m (D olm 0 m > Co c 0 0 ::r 6 Ri- m M a) a M Al . 9 T. < �; 2. 'a 9� (D :3 co C 0) cc) M a- m 0 5; -0 m CD 3 0 m 0 —0, U) S a CA 7 3 > 0 0 ca 0 CL m (B Z CD CD a) M< a) PIC, 0 CD co (A 0 o cc a 0 -n CD S CL ;u 3 Q 0 =3 CL ID C) m ju 0 CD CD C/) !t CD = CD ;:w E5, K ;u S CL > c =F (D :3 z o CL :3 0 2) CC) " CD g cn 0 0 0 (7) r�) 6 m = C:) CD 0) 0 0 C Ut a 0 9� 0 TD oo E CL > C) o m ---to a 5' 5 5" w 3 3 @ W K) ca n m cc) 2� 3 m ca cc ca 4A ca cD a) 9 Ln Go 0 m to (o — 40 -4, m �w N) 0 0) 0 0 CD cn W in -14 N) . 00 o " 0 o) i3 ED 0 CF) U) 0 m CD m X > =;' to 0 w Cl) 0) CA 0 a 5 =r C) 0 0 0 CD 00 OD — C� cn M (D CD :3 0) m C) CLn om 0 CL to 6 ka) 0 -n 0, a) CL c) (D< (n 0 l< PQ cn Cyl cn ZT CD CL 0 m CD 0 0 3 0 9 0 2. -- 0 cn ca 3 1p iD cn cn m - cm 9 CL m M 0 jo a) (n 0 -1i -u cn M CC) -n M E (n :n 0 0 CD iD > CL CD G) n C) 9 C/) M rn :3 (D co U, -n 0 co cn CL 9 0. m 0 co = 0 at 0 :3 CD 3. co cn CL — CT l< m a) (n CL CD T -4 Q 0) CD 3 o ID CD =r CD CL X C:) cn CD o CD (n ca CL :3 CL 0 o K :E > (D o 0 OD 4� cn I OR 6a v w CD -V r- - (3' m 0 0 0 m (D 0 m > Co 0 ::r 6 Ri- M a) a N) C:) < �; 2. 'a 9� (D :3 co C 0) cc) M a- m 0 5; -0 m CD 0 m —0, U) a 5 CD U2 M CL > 0 0 ca m CD (B Z CD (D U) 0 CD (A cc a 0 CL ;u 3 Q M CL (D ID 0 7! CD C/) 0 CD a S CL > > z o CD j�i < > CC) M ID F (7) r�) -4 CML r r- C:) CD 0) to 3 C4 N) m =h C) o m m m m M -ft = SD — CD 00 co 0 =3 CL M n m cc) D 0 :3 = 0 m 4A fA to 0 Go 0 m to (o — 40 -4, 4A -N �w N) 0 0) 0 0 CD W in -14 N) . 00 o " 0 o) i3 ED 0 CF) 0 to 0 m a 0 CL 3 M (D m CLn om 0 to 6 ka) Lo cn Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 3439750.00 m $ - $ 4,125.00 -Plumbing Fee $ 515.63 -Gas Fee 100 comm. $ 100.00 -Electrical Fee $ 515.63 Total fees collected $ 5,256.25 71 Mayflower 952-2016 on 3/8/2016 Single Family Home 0 r .r U) Af� CD CD CL 0 CD 10 CD C.) m 0 CL C) rb. q. r U) z o = =-o —4 0 su -- 75 h -I. CD 0 - 0 0 CL m -ft M 0) 00 -- CD -*� CO) m CD 0 U) 0 N (D"a 0 =- CD CD CL 2) @ a > o 0 q co CL U) '*� 0 0 SU (D CD _COD 0 CD CD 0 <(a CL r- M Cl) CD 0 U' Cl) -h cno Z CD > Cl) r 0 C) M 0 CD Cn 0 z > C-) cl) W< Ck 0 0 CD 0 0 CL C<D o ;z cn I U) �P%. M m < CL a Cl) CD CL Q 0 =r w Z CID --i CD Z5 U) CD C, 01 CD 0 z U) CD C.) cn 0 _0 CD Z CD 0 r CD Cl) CD CD x C=n U) CD CD Erp > CD fu CD En CD 0 < 0 CD --I 0 CL CA LA Ln 03 -n Ln PO -n -n -n 3 — c 5. 0 0 ;o 0 :;0 0 0 Ln (D 0 0 c C '0 0 77 M 2L OrQ :3 CL rD I fD zr :3 =r a- 0 Z rD ID 0 0 m (D r- r- w (D m c C 3 J w 0 m > 2 m z M z C) > (A 0 m z z z -M L'I LA LA M "a V m m 0 m m m > z 0 0 0 0 "M r, 7�4 A � Z I� II i � �I I ! I � 7 1 I _ __ L � f i i E s �z w -Z .9 -.OZ Ora LF7% Q0 - - - - - - - - - - - - - - r NOTICE EMPLOYEES ff-XI The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS I Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this vAll give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ACE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6S62US-OG23626-9-15) POLICY NUMBER M P ROBERTS INS AGENCY 1060 OSGOOD STREET 08-15-15 TO oa-is-16 EFFECTIVE DATES NORTH ANDOVER MA 01845 NAME OF INSURANCE AGENT ADDRESS PHONE # OLD SALEM VILLAGE OF NORTH HEPATICA DRIVE & ANDOVER CONDOMINIUM TRUST; MAYFLOWER DRIVE NORTH ANDOVER KA 01845 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions or the Workers' Compensation Act. A copy or the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will he paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the Massachusetts - Department of Public Safety Board of Building Regulations and Standards k,R)UNti ULLIU11 X11JUX I INVI License: CS -075302 IV BENJAMIN C OSOOOO 69 Old ViHage Uxfe North Andover MA- 0 Expiration Commissioner 121041201C N 8u 71.2462800 ILD ZONE - 1.246 75-96 yeseng.com ?r M, 2015 17 2004, F t44 t�, c B. NE rn 546)9,, 3 J , 2 ) ( S' 11 / 17 I ov'jo 16 0 YA pliff 69 RR