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Home My WebLink AboutBuilding Permit #50 - 96 CAMPION ROAD 7/17/2009Permit. NO: Date Issued BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received p• St�ao �6�,ryp C o IMPORTANT: Applicant must complete all items on this page I LOCATION Print' . PROPERTY OWNERS WC Pt5cnu`SE'_ Print t MAP NO- PARC EL- ZONING DISTRICT r _ - .Historic District yes(.no n 'Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family v' -- Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic, INe[I • Floodplain . Wetlands Watershed District Water/Sewer _ (� DESCRIPTION RJ IPTIION OF WORK TO BE PREFORMED: �S/Lt f r e -1c /✓ law ('C7 41 A. 64/G4 Identification Please Type or Print Clearly) OWNER: Name: Phone: larir�racc• 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: $ 3e, Poe FEE: $�— Check No.: ^� Receipt No.: NOTE: Persons con acting hu e i tered contractors do not have access to the uarantyand Signature of Agent/Ovvn _ ignature_o scontractor _ :,.; _ Location pg No. Date 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ --` Building/Frame Permit Fee $ Foundation Permit Fee $: Other Permit Fee $ A TOTAL $ Check # i�� 22224 Building Inspector i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans y TYPE OF SEWERAGE DISPOSAL Swimming Pools. Public Sewer Tanning/Massage/Body Art. Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site E THE FOLLOWING. SECTIONS FOR OFFICE FORM E ONLY INTERDEPARTMENTAL SIGN DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS 10 -------------- Zoning Board of Appeals: Variance, Petition No: . Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments C Driveway Water & Sewer Connection/Si nature & Date Permit DPW Town Engineer: Signature: Locafe& 384 US900 Street w- :. _ no rr. FIRE DEPARTMENT :'T.emp.Dumpster on site yes Located at 1.24 Main -Street ca ner%ziv4 Pnt sianatureldate.. __ __ CA m X m m x y m N m v y C � W — � d CD � O a Z y C. r c � � c CL y o C -A C v CD CD o C .f CTC CD CCD O CSD C CD CO) C. CD Lv CO) r O CD I C2 CO) O 1 Z CD O CD O CCD C c_ ?� c I g = one? w odcm � y 7 ma m C) C cA r-�, = Z ' � =r CJ -4 s "dr m C "n ? m d?d o CO) O =' =rCDOCD > > O Om o ' ..► C) o o y 1--.�m =r -a 411hH A r a a o,'o co o ??: C/) ;9= C/)m nC o ap � y: C H r�•p' z y O. p' ro E A H C m ►9 �J COD C/)H o ? H �? Cc w O ao n s3 �z CMo sm • 5 rF . � a3 � N • d .�-■. �.CD �Z N-0 C c•'o col C � o o m d Omq 0 9 ti r v rb C/)� � z y m o w no wG n� °= o oCn ry M ��o w oGn z 0 �o �. 4 m 35i; _x18 In 3 � - - - - -- -- - - - - - - - - - - - -73-V 23 41- P, 9. 8,�31. T O CO 0 CO r-1 F-1 0 r 1_46L LWF6X36 LB213418RT-2-R L8213418RT-2-L 0 WF 7i_ _IMI T, 0 C) BWATD2 &VATD2 U) L836 416HI-2 z I.T.-VVI; __ Ey U p-CmEP-W12-27 LPW21L36 -RV12-27 LPVV2136-LLW2136JX36 112 1, 1 . I I'll, ,7�!, h 4 -2 151 9 20-L' 15 J9 26 38— 7 68. -2 21 21' LFP(H)4896Xl/4 All dimensions -size designations given are subject to verification on job site and adjustment to fit job > r- U) C Designed: 3/11/2009 6/15/2009 -Printed: 0 I order placed. lecourse,jisa All Drawing #: I CO WAINSCOT-SQ-CALC======,,-t- 45T-. v -4 U) 0 U) 0 701V' loo note 3" top and bottom rail C O on all 12" wainscoat panels r 0 Z W ��,S-COMO'824 --2-L] �C WAINSCOT-SO-CALC 3:LB21RT RMIISHAC":�� LXBC4, C) 0 I.T.-VVI; __ Ey U p-CmEP-W12-27 LPW21L36 -RV12-27 LPVV2136-LLW2136JX36 112 1, 1 . I I'll, ,7�!, h 4 -2 151 9 20-L' 15 J9 26 38— 7 68. -2 21 21' LFP(H)4896Xl/4 All dimensions -size designations given are subject to verification on job site and adjustment to fit job 20 7ECHNOLOG ES -A This is an original design and must not be released or copied unless applicable fee has been paid or job Designed: 3/11/2009 6/15/2009 -Printed: conditions. I order placed. lecourse,jisa All Drawing #: I - -- - - ----- - - - - - - -- , - ELBBXF34.5' i LBB:LBPS UT1884B-R' LDFSB48-4 I r O ; W O � CL J � o r WF6X36 LB213418RT-2-R LB213418RT-2-L O LWIF6:ILWFI B33FHD EL - cn O { -. (J BWATD2 BWATD2 � 1 . - - - - - - - -- 36 0 LB348RT-2 Z { r Q <f C �IA & 6) WAINSCOT-SQ-CALC v w JE Z , o ?I --r— n w . Ir O {, O -------------- ----------------- CO------ CD it-- Q- - ---- --- -- - -------- - - - n — D — -WAINSCOT SQ-CALC j 5 COMP B24 -2-L LXBC4.^ LB21 RT R_4.DISH ICS ! - �y - {t - ------ LPW2136-RV12-27 i'+�—�� —a i ,{�� PW21LW2136-L X36 f LFP(H)4896X1/4 All dimensions -size designations^nr�' given are subject to verification on job site and adjustment to fit job `v 4 'OG1E5 --A TECHNOl This is an original design and must not be released or copied unless p applicable fee has been paid or job Designed: 3/11/2009 Printed: 6/15/2009 conditions. order placed. lecourse, lisa All (no dims) Drawing #: 1 The 0071 MOMwealth of Massachusetts Depart"Wn.t of Industrial Accidents Office of.[ nivesti glebm . 606 TT"ashington Street Boston, MA 02111 c www massgov/dia . Workers' Compensation Insurance Affidavit: Builders/ContractorsMiectricians/Plumbers �PI1Cant rnformsitinn Neale (Business/oWi2ationAndividual): Address: City/State/Zip: �ei'✓I /'D !!< e �,e3a75-phone#-- 663 -57-V5-- 9e) 3 Are you an employer? Check.the appropriate box: E. ❑ I am a employer with 4. ❑ I am a genera] contractor and TFFJ f (required): employees (full and/or part-time).* 'I have hired the sub -contractors onstruction am .a.sole proprietor or partner- listed on the attached sheet i deling ship and have no employees . workingfor me at 'These soli -contractors have 8• Q Demolition . arry capacity. [No workers' comp. iasrrrance workers' comp. in 5. ❑ We are a corporation and its g• ❑ Building addition required.] I am s homeowner doing officers have exercised their I O.Q Electrical repairs or additions all work ' \myself. [No -workers' right of exemption per MGL I l .❑ Plumbing repairs or additions comp, insurance fired. t �N] . C. 152, § 1(4) and we have no .employees. [No woriCers' 12•❑ Roof repairs 'Any eppticatR tient checks boZ !# t must disc fill comp. insurance required..] Other out the section below showing their workers' compensation poriey information. t Homeowners who submit this affidavit indicating they ars doing ar) work and then hie outside contractors anist submit anew affidavit indica* �Coanactots that check this box must &ftched art additions) sheat show' cab such. ! ant ax empioyer that ispr? dutg:workers' mg t:he frame df the sub;-contraetms and the rkcm• cer �. their wo ,. pc)ic; r{om>etion. compensatirin insurance infonnadort f M.. ZMP10Ye=: Below is the Policy mtdjok site . Insurance Company Name:_ '/Vny 4 LIC _T. W,12 -et"r Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/StaieJZip: Attach a copy of the workers' compensation policy de*clar-atiion page (showing the policy number and expiratioa date} . Failure to semre coverage as required under Section 25A of MGL c. 152 can read to the imposition of crmtinal fine up to $1,500,00 and/or one-year imprisonment, penalties of a - of up to 5250.00 a day against the violator. advisedthata copy of this�statement may be forwarded es in the form of a STop Qto the Office of RK ORDER d a fine Investigations of thrDifBr*6.urance 4erage verification. I do he nder airs rid aloes o e .fP r*7 Mat the information Provided above is true and conacx Si tore: Date- ` Phone #: Qfj`icial use only. Do not write is this area, to he com hMedby �, or town official City or Tower; Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cle 6.Otbe'r rk 4. Electrical inspector S. Plumbing Inspector Contact Person: Phone #: Information a. nd Instructions Massachusetts General Laws chapter 152 requires all emp foyers 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." i 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 includit-ag the legal representatives of a &rased employer, or the receiver ortarstee•of an individual, partnership, associatioin 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 wdrk on such dwelling house or on the grounds or building appumtenant thereto shall not becaum of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shat! withhold the issuance or renewal of license or permit to operate a business or rto construct bnildings in the commonwealth for any appiicaut who has not produced acceptable evidenceair compliance with the insurance' coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public woric until -acceptable evidence of complia: with the insurance requirements of this chapter have been presented to the cazttracting authority," Applicants Please fill out tho workers' compensation. affidavit compiMtely, by checking the boxes that apply to your situation and, if necessary, supply sub-contmdor(s) name(s), addrms(es), aired 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 requiredlo cavy workers' cc>Tnpensation insurance. Van LLC or UP does have employees, a policy is required. Be advised first 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 du t the .application for the permit or license is being requested, notthe Department of Industrial Accidents. Should you have any questions regar-cling the law or if you are required to obtain a workers' compensation policy, please -call the Department attire nurnber.listed below, Self-insured companies should entertheir self-insraance,Iicanse numiier 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 mEference 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; "alt locations in (city or town)." A copy of -the affidavit that has been officiaily siarnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for furan permits or licenses. A new affidavit must be fined out each year. Where a home owner or citizen is obtaining a license or p-rmrit not related to any business or commercial vmtum (i.e, a dog license or permit to bum leaves etc.) said person is NOT.required to -complete this affidaviL The Office of Invesiiptions would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwea€ith of Massachusetts Department of Industrial Aacidemts Office of Luvesti stions 600 Wa&ington Sti:et Boston, MA 02111 TeL # 617-7274900 exit 406 or 1-977-MASSAFE Fax # 617-727-7748 Revised 5 -2b -t15 www-m2ss.gov/dia Gerald A. Brown Inspector of Buildings Please print TOWN Of NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION DATE: 7-1�_ o9 JOB LOCATION: 9& C*,v plov 0` / Number Street Address Telephone (978) 688-9545 Fax (978) 688-9542 Map/Lot HOMEOWNER Jl�ri^3t�ilSJ9�r'.�ct�U�SL q1 dl 83Y6 918 811 g000 Name Home Phone Work Phone PRESENT MAILING ADDRESS 9& 0,,`?VP)04 12,r) Alap-I-Y- %NQd JLC- M4_ 01M, City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the 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 require me an �e will c9rpply with said procedures and requirements. �� HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Dimension Number of Stories:. Total land area sq. ft.:_ Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2009 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o 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 P Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I:C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) -_ ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 r 10049 Date .-7�O/`.� . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING :.. This certifies that . . 4_ , . Z6L- .................................. has permission to perform .,Xev �"z . plumbin in the buildings of, !..l.�c� . !? L. . . . . .......... . at ..10 /�► ... ! 1�.. 1. . , North Andover, Mass. Fee . ..... Lie. NoZv<►.�?.. .. . .. �. ............... ... PLUMBING INSPECTOR Check c) 7- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK V-CITY 11 MA DATE % G /3 PERMIT # I JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS i TEL _ FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Ell RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES EQ NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ..._.-1 .__.-_._i __.__.__► ____ ._____j DISHWASHER. - DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN r ! I I _._! _ 1 SHQWERST'ALL _{ ._.___� ____.f ___ ' -.__ (_---._-_I .__.__ ► _._. _.� __..__I ..__._._l _._.__I __..___ � ___...� _r� _._._i SERVICE / I OP SINK TOILET FLiR—NAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING -.. _..► _, _ _....__3 i __I _ .I -- OTHER �___ _ _._ .__ ► _► _I __.._.__�—_._._I i (...__.__.( I —' -. _._ __.( .__ _I .... _; _i INSURANCE COVERAGE: , have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES -NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 52,E OTHER TYPE OF INDEMNITY E3 BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the R4assachuseis General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER D' AGENT _1 SIGNATURE OF OWNER OR AGENT E 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'S NAME _ - t . 'LICENSE # 6— SIGNATURE MP JP CORPORATION 0#=PARTNERSHIP _ l PARTNERSHIP _.I # ! LLC D COMPANY NAME L+js 1��+G3ADDRESS CITY ��-____-- _ `I STATE] ZIP TEL FAX CELL - - EMAIL-- 0 E z W CL iui LU LL rk I l The Commonwealth of Massachusetts - Department of Industriol Accidents Office of Investigations IN 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Print Legibly Applicant Information Name (Business/Organization/lndividual): /1 �- City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I �-, �e loyees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. 2, 1 am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. t c. 152, §1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they 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 their workers' comp. policy information. 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: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the 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 certify under the a' andpenalties ofperjury that the information provided above is true and correct. nate. �/��1 3 Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (cir`cle orie): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Co=_ onwealthofMassachusetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TO, # 617-727_4900 oxt 406 or 1-877:MASSAFF, Revised 5-26-05 Fax # 617"727;7749 wwtv.mass,govfdia FA L,L S, lop, ti Date. � 13 . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .& C? has permission for gas installation ... ��' ,,,,, , , ,,, , , , , , , , , in the buildings of...LP,ob-,(--s-,o....................... at ...... I. �f! .. .i�} v*�+-.' �,1.�� :. , , . , North Andover, Mass. Fee GASINSPECTOR Check # 8752 2 r Pr -k e3C).w LL # da3y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � CITY NORTH ANDOVER MA DATE JULY 15, 2013 PERMIT # JOBSITE ADDRESS 196 CAMPION RD. __ _ OWNER'S NAME JIM LACOURSE _ GOWNER ADDRESSJIM LACOURSE TE 978-808-9668 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALE] RESIDENTIAL E] PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES® NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ _ , 1 BOOSTER CONVERSION BURNER I. -� COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITYE3 BOND El 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 ® / SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 Pertine sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'AC4�e z PLUMBER-GASFITTER NAME I ROBERT WHITE LICENSE # —1G?3 SIGNATURE MP �& MGF ED JP Q JGF [j LPGI [] CORPORATION M# PARTNERSHIP []# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY I DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628 FAX CELL EMAIL Z? C. e- '& 1--; 01 VVNO- w F O z z 0 U W a z a Q z w a 0E z o �❑ �- w � ~ w O O w H aLLI ,� z N W O W Q W N r� V Z 0. d O G. I-- IL a IL a � � W x w W F � O z \ z 0 � F U W a z d c� x 0 x D ERC e ; *ll The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations .' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. massa ov/dia Workers' Compensation, Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): EASTERN PROPANE & OIL Address: 131 WATER STREET City/State/Zip: DANVERS, MA 01923 Phone #. 978-750-6500 Are you an employer? Check the. appropriate bob: 1. Q✓ I am a employer with 45 _ 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner= listed on the attached sheet. ship and have no employees These sub -contractors have working for mein any capacity. employees and have workers' [No workers' comp. insurance comp. insurance required.] S. Q We are a corporation and its 3. ❑ work all T .am a homeowner doing officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §l(4); and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. Q.Demolition 9:Building addition 10. Q Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.Q Roof repairs 13.Q✓ Other GAS FITTING *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 policy and job site information. Insurance Company Name: ENERGI Policy # or Self -ins. Lic. #: EWGCD000080613 Expiration Date: 03/15/2014 Job Site Address: 9& Cc--, 2,. uk- Ra. /V1%1 411 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 herebi, certify under the pains and penalties of perjury that the information provided above is true and correct. 4: 978-750-6500 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 4 _ Issuing Authority (circle one)_ I. Board of -Health 2. Building Department 3. City/Town Cler-k-- 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: N n w Date . bh..j TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies ., ,IS►' i.. I.! .... ` has permission for gas i stallation ..2— "P- , `j C 1 t � in the buildings of ....... C dlnr=se at ..... ,North Andover, Mass. Fee . t .... Lic. No. �.�. .. .................. .. . Check # 22eso 8743 GASINSPECTOR .4, 0d-(9 O.O d Ol V U' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - } CITY I NORTH ANDOVER MA DATE JUNE 14 2013 PERMIT # O q� 0-r- JOBSITE ADDRESS 96 CAMPION RD. OWNER'S NAME I JIM LACOURSE GOWNER ADDRESS I JIM LACOURSE TE 978-618-4026 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW: El RENOVATION: El REPLACEMENT: PLANSSUBMITTED: YES® NO® APPLIANCES -1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILERLLE— BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST - - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER FINSTALL 2 UNDERGROUND 2 GAS LINES GOING TO THE HOUSE AND POOL HOUSE INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 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 com lance with all in e ov' ' f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN MARSHALL I LICENSE # 778 SIGNATURE MP [:1 MGF ® JP ® JGF Q LPGI CORPORATION E]# PARTNERSHIP EI# LLC ®# COMPANY NAME:j EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY I DANVERS j STATE - MA ZIP 01923 _ TEL 1-800-322-6628 FAX CELL EMAIL Ike ) b1,m�1 �I IS11"3 The Commonwealth of Massachusetts 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 lE� N1nle (Business/Organization/Individual): EASTERN PROPANE & OIL Address: 131 WATER STREET City/State/Zip: DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the.appropriate box: 1. �✓ I am a employer with - 45 4. 0 I am a general contractor and I employees (full and/or part-time).` have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity., employees and have workers' [No workers' comp: insurance comp. insurance required.] 5.17 We are a corporation and its _,-El 7 .am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9.Building addition.. 10.7 Electrical repairs or' additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.7 Other GAS FI i PING *Any applicant that checks box 41 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 policy and job site information. Insurance Company Name: ENERGI Policy # or Self -ins. Lic. #: EWGCD000080613 Expiration Date: 03/15/2014 . Job Site Address: �1 to C.4w, t, l City/State/Zip: Ino, 191%d v,,t�, ,lMS . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date)p r4y5 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 certify under the pains and penalties of perjury that the information provided above is true and correct e #: 978-750-6500 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 ofHealth 2 -Building Department 3. City/Town eNer-k - 4. Elect—nea-1 Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: b . TA > < m CD 70 CIO I= > -n tr m > m V) m >> )> > ED ZZ m rn r- r— 0 < r—= m Z Ti > cn > cn U) cn m cp z > M LN .0 cn m o LN ti) M N-5-2012 07:33 FROM:RMS TOWN OF NORTH ANDOVER 6033357348 T0:9197868e9542 Building Department 1600 Osgood Street Building 2. Suite 2-36 Building Dept North Andover MA 01845 Tcl: (978).688-9545 . Fax (978) 688-9542 P.1 COPY p `�`+r /•• MO a p r r + ! -liiwr-r �,, �O�wrrs ✓r,�i4 COMPLAINT FOR IWFSTIGATION DATE: June 4, 2012 TEL#: &01 — [e70 - SS w 9 NAME OF COMPLAINTANT: Mark Lafond ADDRESS: 6 Capital Drive, Dover, NH COMPLAINT TYPE; Electrical: Plumbing: Gas: Building: Permits? Property Owner: unknown Address: 96 Campion Rd, N. Andover, MA Other: Were Permits pulled for this address's basement fit -up for Electrical, plumbing, and framing? Signed: Complaint Form . Rcvisod 61007 Xe ��-P Pr X67 Date......7.'..3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ....................... ....... ........... has permission to perform ... � .7?K�Y4/v ................................................ wiring in the building of ..........o. �r ...................................... at ........ ... ,,jorthAndover, Mass. . ............. A ........... vZZZ" Fee ='Ie . ..... Lic. No,? 3 Elyc-iRICAL INSPECTOR Check 4 rmc 0 0 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 9 10 Occupancy and Fee Checked Lev. 1/071 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 PRINTflV NK OR TYPE AU EVFORMAT10N) Date: City or Town of: NORTH ANDOVER _ 9 By this application the undersi ed To .the Inspector off Wipes: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9 eo c A /n o „- - , 0-) Owner or Tenant Owner's Address 415q «cou2s Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building l✓C t�� NO ❑ (Check Appropriate Box) e "' e'L' 3 L'aJ j Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: 4 121.1A, No. of Recessed Luminaires OW INo. of CeiL-Susp. (Paddle) Fans No. of Luminaire Outlets No. of Hot Tubs f Luminaires -------------- Swimming Pool Above ❑ In- FNo- d. f Receptacle Outlets No. of Oil Burners o.of Switches `� No. of Gas Burners No. of Ranges No. of Air Cond. Total No. of Waste Disposers ` . r Heat PumTons pFN--qP!ELTons ] _ Totals: _ No. of Dishwashers ENo. Space/Area Heating KW No. of Dryers Heating Appliances KW No. of Water Heaters of No -of Si s Ballasts Bal No. Hydromassage Bathtubs No. of Motors Total HP OTHER: table maybe waived b the Ins ector of Wires. No. of m,.4-..1 i ransiormers KVA Generators KVA o. o murgency juignung ❑ Rer+e.... rr_eL o. o. _ALA -RMS INo, of Zones Initiating Devices of Alerting Devices ElMunicipal Connerfinn ❑Other No. of Devices or to Wiring: No. of Devices or ecommunications No. of Devices or Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Q G'C3C�, Work to Start l (When required by municipal policy.) O`, ,0r,?- b 9 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 [r r BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: �l��rrU! /�C�<�2lc, IN< Licensee: �. LIC. NO.: ��le0�^, . Signature - (If applicable, enter "exempt " in the license tuber line.) LIC. NO.: Address: G FfL1 Sci4e-,j 1 /1/ 19UGUiL2 1 . /j/rBus. TeL No.:G+b3-�y i! 6 *Per M.G.L c. 147, s. 57-61, security work requires D Alt: Tel. No.:&d 3- epartment 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 Signature Telephone No. PERMIT FEE: $ .y k, r te t i 'ar The Commonwealth of Massachusetts Department of Industrial Accidents Qjf1ce of Investigations 600 Washington Street Boston, MA 02111 t j www.m=s gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plambers DDl iCBtnf nfAi-m.+;.. Name (Business/Organizaiion/individual): Address: City/,state/Zip Phone #:. Are you an employer? Check -the appropriate box: I . ❑ I am a employer with 4. 111 am a general contractor and I L(full and/or part-time).* 2. ❑ I am a:sole proprietor or have bred the sub -contractors listed partner- on the attached sheet = ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp. insurance. S. ❑ We are a corporation and its required.) 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No•workers' comp, C. 1.52, § 1(4), and we have no insurance required.].t .employees. [No workers' comp. insurance required_] wAnvannlironr#S..,...t._..t._�__e... _ Type of pr®ject (required): 6. ❑ New construction 7.Remodeling 8. Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1117 Plumbing repairs or additions 12.❑ Roof repairs 13.[] Other • • - -----..--••• ��^ R .....w mau uu out Rle secrloa below Showingtheir workers nom t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors sation must submit olicy o��ew affidavit indicating such. �Conmwtors that check this box must attached an additional sheet showing the name of the sub-contractons and their workers' camp, n ink r I am an employer that isprouding: workers' compensation insurance for m1' employees; Below is the policy and job site information. Insurance Company Name: ' Policy # or Self -ins. Lic. #: Expiration Date: Sob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration d04 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 of 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 certify under the pains and penalties of perjury that the information provided above is true and correct Si Lure: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town officio[ City or Town: Permit/License # Issuing Authority (circle one): I. 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, MOL chapter 152, §25C(7) states "Neither tlhe 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) acrd 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, notthe 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 insurane'e'license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 A -ill 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 bum leaves etc.) said parson is NOT required to complete this affidavit The Office of lnvestiptions would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Iu1A €12111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.gov/dia A Date. ? ? y!. G S TOWN OF NORTH ANDOV PERMIT FOR PLUMBI This certifies that ..' ?�. �.T ��....'�. �� . /............. has permission to perform .... t . rS ........................... plumbing in the buildings of c' ./I. ?.'` at ....%' 4< .. / o%? �... , North Andover, Mass. 39....C`Fee.��...... Lic. No. S .. ........,. -� ....... . PLUMBING INSPECTOR Check # 3 -) y 8,155 t V �a�tSt•1J A MAS5AL;KJLJSt I IS UNIFORM APPLiCAI IUN FUR -PERMIT TD DO PLUIIMBING �o (PAnt or Type) North Andoverm.rs. Date CY�I 20 ©9 P oermit # Building Location 6 ALV ��. Owner's Name fYsyr, 44 '1_'6 a type of Occupancy Resi dente al New ❑ Renovation ❑ Replacement 0" Plans Submitted: Yes ❑ No ❑ B.P. -# -SEWER # FIXTURES SEPTIC # tailing Company Name _- Andover P1 Umbi ng & Heati ng Co. , Inc. Check one: Certificate dress_ 20 Aegean Drive Un•i t *#10 Corporation 2122 Methuen, Ma. 01844 ;iness Telephone (978) 685-8383 ❑ Partnership ne of Licensed Plumber or Gas Fitter_ George, LaRose ❑ Firm/Co. - ISURANCE COVERAGE have a Curren liability insurance policy or Its Substantial equivalent, which meets the requirements of MGLCh. 142. Yes ! No ❑ you have checked Yes. please indicate the type of coverage by checking the appropriate box - liability insurance policy */ Other type of indemnity ❑ Bond D WNERS INSURNACE WAIVER- i am aware that the licensee does not have the insurance coverage required by Chapter l2 of the Mass. General Laws, and that my signature on this permit application waives this requirement- gnature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ •eby certify that all of the details and -information 1 have submitted (or entered) In above application are true and accurate to the best of mowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ertinent provisions of the Massachusetts State Plumbing Code and Chaptey142 of the General Laws. -.11 _1__% By Signature of used P umber �`— Title Ciry/Town Type of License:aster 13 Journeyman APPROVED (OFFICE USE OW -1n 9983 Z Yin z Nk N V_ < E1 ?�- Q O V Q I— N z i Qk W IX to in W o �--� ttu � !r = cn F— w c Z th z n M ` Z Ce a t- � LU in W ZN !L [A Z Z ~ O b .-a ul i O O crit O c°ii C3 ± F z N O O tQL �— to Q z Y z W O 11 U O_ tY g< m c=il O¢ cn 0 Q¢ < m o O SUB_%Mi" BASEMENT 1ST FLOOR I f { 2ND FLOOR 3RD FLOOR 4TH FLOOR - STH FLOOR 6TH FLOOR 7TH FLOOR " E 8TH FLOOR tailing Company Name _- Andover P1 Umbi ng & Heati ng Co. , Inc. Check one: Certificate dress_ 20 Aegean Drive Un•i t *#10 Corporation 2122 Methuen, Ma. 01844 ;iness Telephone (978) 685-8383 ❑ Partnership ne of Licensed Plumber or Gas Fitter_ George, LaRose ❑ Firm/Co. - ISURANCE COVERAGE have a Curren liability insurance policy or Its Substantial equivalent, which meets the requirements of MGLCh. 142. Yes ! No ❑ you have checked Yes. please indicate the type of coverage by checking the appropriate box - liability insurance policy */ Other type of indemnity ❑ Bond D WNERS INSURNACE WAIVER- i am aware that the licensee does not have the insurance coverage required by Chapter l2 of the Mass. General Laws, and that my signature on this permit application waives this requirement- gnature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ •eby certify that all of the details and -information 1 have submitted (or entered) In above application are true and accurate to the best of mowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ertinent provisions of the Massachusetts State Plumbing Code and Chaptey142 of the General Laws. -.11 _1__% By Signature of used P umber �`— Title Ciry/Town Type of License:aster 13 Journeyman APPROVED (OFFICE USE OW -1n 9983 Date ...... 0...-%/ TOWN OF NORTWIDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... ...."�... ........ . has permission for gads installation ..: . ...... in the buildings of ............... at .I ...... ... ............ , North Andover, Mass. Fee: . .. Lic. No.. jY/�1/.. ........... /f GAS IN .PE�' Check # 1,31l'o v 6003 M MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date 6/07 Building Location 96 CAMPION RD Owner Tel# 978 6818346 New 7 Renovation❑ 2007 Permit # Owner's Name JIM LACOURSE Type of Occupancy RESIDENTIAL Replacement Fl Plan Submitted: Ye[] No[] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Check one: Certificate ZCorporation Partnership INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes curO No 11If you have c ecked Yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑✓ Other type of indemnity ❑ Bond r] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner, , Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above a knowledge and that all plumbing work and installations performed under the permit issued for pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General L By Title City/Town APPROVED (OFFICE USE ONLY) are true$ d accurate to the best of my ,atiorvlm!ybe in compliance with all Type of License: Plumber Signature oficensed Plumber or Gas Fitter -Gas fitter Master License Number Viourneyman N OEM ISM MEMO ■■ WOMEN■N■■■■■■■■ Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Check one: Certificate ZCorporation Partnership INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes curO No 11If you have c ecked Yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑✓ Other type of indemnity ❑ Bond r] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner, , Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above a knowledge and that all plumbing work and installations performed under the permit issued for pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General L By Title City/Town APPROVED (OFFICE USE ONLY) are true$ d accurate to the best of my ,atiorvlm!ybe in compliance with all Type of License: Plumber Signature oficensed Plumber or Gas Fitter -Gas fitter Master License Number Viourneyman 10 N Location No. `43 � Date NORTH TOWN OF NORTH ANDOVER • OL 9 Certificate of Occupancy $ s'°t� Building/Frame /Frame Permit Fee $ s�CHusa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ c "40 Check # c�� 7 f ) �jt `Building InspecEor' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATIF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,, so" AW WOOL"— BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Comrnissi2Eef2R2qor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number. Map Number Parcel Nuniter 1.3 Zoning Information: 1.4 Property Dimensions: Zonin District Proposed Use Lot Area Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Regaired Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 34) 1.3. Food Zone Infamdim zow Oabide Flood Zane 0 1.8 Sewmp Dlspaal System Mmicgnl 0 On Site DkpoW System ❑ Public 0 Private ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service IL 97F -Ge/ -F3116 JN,e. lW o i J Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number �Ad Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ / Zg 7 % Company Name Registration Number Addres Expiration Date Signature_____ Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 Workers Compensation Insurance affidavit roust be completed and subn in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work chuck an appaubk New Construction ❑ 1 Existing Building ❑ 1 Repair(s) Accessory Bldg. 0 I Demolition 0 I Other Brief Description of/Proposed Work: with this application. Failure to provide this Alterations(s) 0 1 Addition ❑ ❑ Specify 1 SitCTTON 6 - ESTIMATF.D CONCTRTTVTinN rncTQ I G155 /'VZ> -D ►_3 _ r result Item Estimated Cost (Dollar) to be Completed bpermit applicant OffICIAL USE ONLY I. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) p� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 25 X -75 ' �70/-T7/11T -I- A11L?W 1M A WTTf7<Aff trs ♦ Check Number cava. av asr,' .. vlar LL' ar''Y VVr J'J I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT h 1• , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this buildnig permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ,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 Si tore of Owner/Agent Date —' NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 167 2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DRV ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Sold To: o�l, Address city: A Job site Address (If different): HIC Registration #129774 Federal ID #04-3277886 Pella Windows & Doors of Boston "Viewed to be the Best" WINDOW CONTRACT State: MgZip: ��/ y�- Pella Windows & Doors I 45 Fondi Road Haverhill, MA 01832 PH: (800) 866-9886 Service: Ext. 124 Fax: (978) 556-0394 Sales: (866) Pella06 Date: — 101-710 Phone (Home) 1cIV &Lo l - &351 -6 Phone (Work) Phone (Cell) PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATIONTO CHANGE ANY ITEMS OR MAKE PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHER THAN CONTAINED INTHIS AGREEMENT OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FORTHE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY REMOVAL OR INSTALLATION OFTHESETYPES OF ITEMS. FILLED IN DUPLICATE OF THIS AGREEMENT. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION WARRANTY PROBLEM. DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ONTHE REVERSE SIDE. This contract is a legal document. Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS BEEN SIGNED AND DEPOSIT PAID. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT THE ABOVE SPECIFICATIONS FOR THE PELLA PRODUCTS YOU ARE ORDERING ARE CORRECT. Pella Rep. Signatu Customer Signatur Date: Date: Customer Pink - Store Pella Boston Will Furnish -and Install: E-mail: 15. Clean up and vacuum nightly and remove all debris at completion of job site 16. ❑ Remove and Dispose of existing Windows and/or Storm Doors 17. Z. ❑ All workman's compensation and liability insurance maintained 18. 9 ❑ Warranty mailed to customer upon completion when full payment is received 19. lig, ❑ Total Project Amount $ 25675'-, `ii 20. ❑ er, Financed If Yes: Amount Financed $ (Reference # ) 21. ❑ Deposit Received $ 124 9=U-71 22. ❑ Balance on Substantial Completion $ /? r x%37- 7J (Payment is payable to installer at completion of job) 23. ❑ ❑ Additional Comments: 4119AI 27'n9�10 CD), -X PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATIONTO CHANGE ANY ITEMS OR MAKE PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHER THAN CONTAINED INTHIS AGREEMENT OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FORTHE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY REMOVAL OR INSTALLATION OFTHESETYPES OF ITEMS. FILLED IN DUPLICATE OF THIS AGREEMENT. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION WARRANTY PROBLEM. DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ONTHE REVERSE SIDE. This contract is a legal document. Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS BEEN SIGNED AND DEPOSIT PAID. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT THE ABOVE SPECIFICATIONS FOR THE PELLA PRODUCTS YOU ARE ORDERING ARE CORRECT. Pella Rep. Signatu Customer Signatur Date: Date: Customer Pink - Store 16 �J '�"� ✓tie �om�narause� a� j2�aaaacttuaeka BOARD OF BUILDING REGULATIONS r License: CONSTRUCTION SUPERVISOR Rj Number: CS 089839 j Birthdate: 06/19/1972 Expires: 06/19/2008 Tr. no: 89839 Restricted: 00 SCOTT P HOUSE 854 BROADWAY #1 HAVERHILL, MA 01832 Commissioner e✓tie ioom>rntam,--a o�✓�aaaciucaelita Board of Building Regulo:icns and Standards HOME IMPROVEMENT CONTRACTOR Registration: 129774 9 Expiration: 11/2/2005 Type: Supplement Card PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD., HAVERHILL, MA 01832 Administrator NUMBER DRIVER'S LICENSE `= 569694966 DATE OF BIRTH CLASS REST HEIGHT SEX w 06-19-1972 o r' ow MEXPIRES a 06-19-2006 HOUSE SCOTT P z, 854 BROADWAY APT #1 06-19.1972 HAVERHILL, MA 01832 —,e(„y I�ACaRD�, •111.I.6111�1.1. I:�4A'.1A.1:1ieY. PRODUCER Fred C. Church, Inc. 41 Wellman Street P.O. Box 1865 Lowell, MA 01853-1865 uiurcn, Inc. 8-2-2833 =ipa P. c of c VAR.. s 3"."J ENI Uferr OIREIW ODM 1 ' i $ .i.."`4.. a ,,.rr Y";at 08102/05 978-468-1885 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, MITEhD OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY INSURED A Hanover Insurance Company New England Window & Door, Inc COMPANY B Mess Bey Insurance Co dba Pella Windows & Doors, Inc 45 Fondi Road COMPANY C Hartford Insurance Company Haverhill MA 01830 COMPANY D , ii�I�.l THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED ABOVEFORTHE 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 DES EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN CRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR I TYPE OF INSURANCE I POU=T NUM®! POLICY EFFIECTIve POLICY EXPIRATIDII I DATE (W dDDMYI OATS I W MDNV I I uMRB GHIERAL UANLrrY COMMERCIAL GENERAL LIABILITY ZBN 8181407 0000 A X I I 7/01105 7/01 /08 GENERAL AGGREGATE • 200 CLAIMS MADE F-171 OCCUR i PRODUCTS -COMPIOPAGO 1 2000000 X I OWNERS i CONTRACTORS PAOr 1 PERSONAL 6 ADV INJURY I • 1000000 B L!!�T(316108I1ELLABIuTY ADNB162159 X I ANY AUTO 7/01106 710 1 /08 ALL OWNED AUTCS X I SCHEDIX AUTOS X I HIS AUTOS I X I NON -OWNED AUTOS I I GARAGE UABILfty I ANY AUTO I A LIXCESB UAmLrry UHN8187306 7/01 !05 � I ^ I UMBFiELIA FORM 7)01/0e .I I OTHER THAN UMBRELLA FMM I C WORKERSCOMPEIYSATIONAND OBWBNL6742 7/01!06 BAPLOYERS' UABLM 7/01 /08 THEPROPMETCRI ( INCL PARTNERSIEXECUTLVE OFFICERS ARE I EXCL I OTHER I DESCRPTLON OF OPERATiONSItDf.AT10NSNEHICLFS,SPECULI (rgf B Town of Needham is named Additional Insured as their interests may appear. 10 days notice of cancellation for non-payment of Dremium. EACH OCCURRENCE i 1000000 FIRE DAMAGE (Any am fire) • 500000 MED EXP Leah one P. • 10000 COMBINED SINGLE UMIT I f 100= BODILY INJURY i (Fer Pam BODILY INJURY • (Per eayawal PROPERTY DAMAGE I • AUTO ONLY • EA ACCIDENT 1 1 OTHER THAN AUTO ONLY: EACH ACCIDENT 1 1 AGGRMATE I 1 EACH OCCURRENCE If 9000000 AGGREGATE If 9000000 • X I WC STATU• I OTH•I TORT U. I ER .. .. EL EACH ACCIDENT I • :. 1600000 EL DISEASE - POLICY UNIT I • 600000 EL DISEASE EA EMPLOYEE 1 500000 !^n.cLtRf1011Ia � � ,>L, w��idlbAukr;z;rSarJ s �al.�:t:�c',s�SeJiau.l.ir... SNOLLD ANY OF THE ABOVE DESCRIBED POLIMN BE CJMCBiED BEFORE THE EIOBIATION DATE THEREOF. THE ISGUING COMPANY WILL ENDEAVOR TO MAL 3D DAYS "41"M NOTICE TO THE CERTIFICATE HOLDER MAMED TO THE LEFT, BUT PALURE TO MAL SUCH NOTICE BHALL IMPOSE NO OBLIGATION OR LIABILITY OF+AMY WD UPON THE CDLWAKV— ]ITS 1AG9YTa OR REPRESENTATIVES. .::-oAcoRlo:;coRPOI�JAnoN .� sss AUG -02-2005 05:38PM FAX:508 454 1865 ID:PELLA PAGE:002 R=92% m m X m m M m v m C) CM) y C � — d y C..) CD n Z y Q . O r �. c CO Co CL =' y a� 1CO 2� 0 c CD CD O cr� =r �C d CD cc C'�D C CD �. CD CLO y O = �C= CD v CA O cn cn n O cn C O z y cn 5PC%� Ir . C 0 C/) C/) :vg CW)Pd � m��.11 �In b 7 R 8 0 tz ro C Cl G� T� 0 O z H 0 9 O C 2313 Date..,.. .........n... TOWN OF NORTH ANDOVER PERMIT FOR WIRING r This certifies that ... S has permission to perform ................................................... .w wiring in the building of .................................................. �,t ...... ..... �,. ��.(./►'..!.......�j..................../. j� or/thh.A�ndover, Mass. (�/ i \ ..tom -f'( Fee . ................ Lic. No.6! . ...... ............. ELECTRICAL INSPECTOR Check # '� `� 8 A Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services ` BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), SMR 2.0 (PLEASE PRINT IN INK OR TYP ALI !�-F ATION) Date: City or Town of: To the Inspec r of fres: By this application the undersignedjg ves ng4e of his or hgr intentiAto/perform the electrical work described below. Location (Street & Number) Owner or Tenant 1(' / Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Telephone No. — _31 Yes ❑ No Eg"' (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system ComDletion of the following table may be waived by the Insnertnr of Wirev No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans - -- -- ------ - --. No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- rnd. rnd. ❑ o. omergencyiging Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number I Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equi valent No. o Water KW Heaters No. of No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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:) (Expiration Date) Estimated Value of Eltrical Work- (When required by municipal policy.) Work to Start: spections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under t e ains a d penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: 1 Licensee: John S. Bassett Signature Yd. LIC. NO.: 1533C (If applicable, enter "exempt" in the license number line) Bus. Tel. No.:603 594 5928 Address: U Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li*see see 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 a ent. Own turar/AgPERMIT FEE: FEE: $�r Signature Telephone No. Lodation / �p No. Date �d ?(- ,►ORTII TOWN OF NORTH ANDOVER p Certificate of Occupancy $ o •, Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Feed, %} $ (170 Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 2f Building Ins for nr 14/27/98 15:19 65.00 RA1p U V �) Div�VUDIIorks I Location No. r F 4 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector N-7 i 33 ,x:13 05.: : Div. Public Works a L J\ r \ VC > � Z _ z d° c ro Z \ v t0� o J \ z z z LnY ,I 1 W z Z z T. Z 7z D Li _ r, D rr V Z D D z m > z- N � m.. C z Z e-I - z I i ? a x m v _ z r I nil rO �J O 3 Z ZLn Z m Z m, Q > rf © n —LA n z z m _ i m iA m z Z z m V. -. w T f z M z�E- � X' i z Y i oX _3 N cn a z n 7 1 W A CORDE T1 '. PRODUCER' ::::............................................... CASSIDY ASSOCIATES 234 HUMPHREY ST SWAMPSCOTT MA 01907— ( INSURED QUINTILIANI CONSTRUCTION 583 MAIN ST HAVERHILL MA 01830— (978) 1374-9083 COMPANY A MARYLAND CASUALTY COMPANY B COMPANY C COMPANY D 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. CO OTYPE LTRDATE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS BODILY INJURY $ (Per person) GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE F] OCCUR OWNER'S & CONTRACTOR'S PROT SCP 313 515 3 0 05/13/98 05/13/99 GENERAL AGGREGATE $1000000 PRODUCTS - COMP/OP AGG $1000000 PERSONAL & ADV INJURY s 5 0 0 0 0 0 OTHER THAN AUTO ONLY. EACH OCCURRENCE $ 5 0 0 0 0 0 FIRE DAMAGE (Any one fire) $50000 MED EXP (Any one person) $10000 AUTOMOBILE LIABILITY ANY AUTO / / / / COMBINED SINGLE LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS CITY OF NORTH ANDOVER BUILDING INSPECTOR CITY HALL NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY A ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES. ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM / / / / EACH OCCURRENCE $ AGGREGATE $ $ WORKERS COMPENSATION ANDTORY EMPLOYERS'LIABILITY THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE p OFFICERS ARE: EXCL OTHER WC SUMITS ER OTH- EL EACH ACCIDENT $ EL DISEASE - POLICY LIMIT $ EL DISEASE - EA EMPLOYEE $ _��l DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS CITY OF NORTH ANDOVER BUILDING INSPECTOR CITY HALL NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY A ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES. HAVERHILL MA 01830- (978) 1374-9083 COMPANY D 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. POLICY EFFECTIVE LTR TYPE OF INSURANCE I POLICY NUMBER I DATE (MM/DD/YY) POLICY DATE ( MP/DD/YY)N I LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY / / / / PRODUCTS - COMP/OP AGG $ CLAIMS MADE FIOCCUR PERSONAL & ADV INJURY $ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTY DAMAGE 1 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CITY OF NORTH ANDOVER BUILDING INSPECTOR CITY HALL NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY On fINY KIND UPOk THE COMPANY, ITS AGENTS OR REPRESENTATIVES. GARAGE LIABILITY ANY AUTO / / / / AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM / / / / EACH OCCURRENCE $ AGGREGATE $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE OFFICERS ARE: EXCL WC 4 2 8 814 9 08/10/98 08/10/99 WC STATU-OTH- TORY LIMITS ER EL EACH ACCIDENT $100000 EL DISEASE - POLICY LIMIT $ 5 O O O O O EL DISEASE - EA EMPLOYEE $10 0 0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CITY OF NORTH ANDOVER BUILDING INSPECTOR CITY HALL NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY On fINY KIND UPOk THE COMPANY, ITS AGENTS OR REPRESENTATIVES. P -.K.�. (/%/ .�/ M9L1J7.ljflt[1J82'cI.2 • • �f [' Qd,1' Q�3(IQQ� : I' DEPART !ENT OF PUBLIC SAFETY ,,. CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: • CS 010696 99/10/200f 09/10/1964 ` Restricted To< PAULA_ QUTNTIHANI w� 583 MAINaST . NAVERHLIJ, NA 01838 T ^_ •✓he IJO�llnn4nuin.,•�;• o� %•�J9^.'ilUJr, /.I,. HOME IMPROVEMENT CnNj AC1 Registration ,124470 Type INOTVIOUaI �zpirat.ion 06/30/99 Paul Quintiliani G111t,cul G. Quintiliani ADMINISTRATOR 583 Main St Ha�whill MA 01830 t Fast, Efficient, Courteous Service ALLSTATE CARTING Complete Roll Off Service 10 to 42 Yard Containers Available 24hrs. - 7 Days a Week P.O. Box 253 Phone: (508) 363-8827 Groveland, MA 01834 Beeper: (508) 780-6212 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street WII.LIAM J. SCOTT North Andover, Massachusetts 01845 Director In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number 4w—_ is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c l 11, S 150A. The debris will be disposed of in: (Location oXacility) ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Once of the Building Inspector. BOARD OF APPEALS 689-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9333 to CO2 V! Cl) co n Z y CL n� O d �• CO) o p CD CL � O cr /�/�,, = CD CD o co C CD co CD O_ y I CC �p � v CACD O CD Z O CD O \Y A OT 80 r cn cn n O z cn C� O0mc Q N So Ro y =goo m Z =r -C h _1 CCIIL m a�of O y CD -4O m N p N O * m S > > m N m co = . 0 O N• m; C �y� CL noo m CL .. to o =r =r_ : - C CD N C Od m m W C� N O y N ' N O. d CL CL N m O V h N •� u 1 mo [r/VJ7 ca m 1 A � S m CN FWto `.� �C-): o o Er o z N � o . m � ^` m o 'CD m CO) O W d d O � CL O COD �1 • O .7 m z o 0=3 0 9 cn 3 p. cn - o a7 a 77 w 7J ° 1i �'_ `7� 7. ° 7' Cs9 ?7 ?' :� ° arc m �'- n T ° � c o ^, °° ° x � � z It 0 m r.L 0 c CD ` location No. x Y ES x`y � raa Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ._. Foundation Permit Fee $ ' Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL , $ Building Inspector mow, C'J '=AIS Div. Public Works w w c O m O ao` n �, ? O c cD .. C D o o Q a_ ci >> 3 :3" > > w o m m � g � 0-n m m O CD w m " m m 0 - 0 CD M m Z) ao m c (D a d9 EA EA fA 69 69 m � W CA r co o o CD COMmercial x > .: CONtracto W...FNMMftD Richard Leaver Fax (603) 890-9110 John LaRochelle (978) 970-4942 (603) 893-2002 X e" z D Z J rA r Q z LA n i. m v � v Y y ? z n n n p m r-. r c y a o z 0 m © _ _ V, V. V. x z _ _ 7 O kri r m Z r,= m Z z m y y z H Z Z Z z z y Z v Y Z Z .. Dg r T. \ — V. Y 7 Ln Z � W� yah m O � 1 _^� (�n N V 1 III .L ISN �J O I i 3 = A- z z Z Z Z C, ? n V m y r �i g z z_ Z k Q 4 N 1� y - T r �? r r > n th y Q z m N Z = z O w m m O < o Z rrm cn c, r m X - zI - o N Y w z U� O I� n V J c N � FORM U -LOT RELEASE FORM-�'�- � 4" INSTRUCTIONS: This form is used to verify that all necessary approv Is/permits from C,� Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION* APPLICANT 1��C� /�i�if PHONE -9-". k, =, LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) ST. NUMBER Q/ STREET �l •.�s1.©/�/l%� �T RECOMMENDATIONS OF TO ATION ADMINISTRATO COMMENTS J COMMENTS USE AGENTS: DATE APPROVED —1 • rX rY_ !. G� DATE REJECTED 11A. 0 I ( A- i vc) DATE F3EJECTEU FOOD INSP TOR -HEALTH DATE APPROVED DATE REJECTED J TI N PECTOR-H ALTH DATE APPROVED 7 -y `9� S DATE REJECTED COMMENTS ' PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWA PERMIT FIRE DEPARTMENT u RECEIVED BY BUILDING INSPECTOR DATE 1 fS N -r ►� 70 `a O r . Q=e W S .O. � N 1'•1 oNo � zav v '_� • 70 70 O e 70 T p N V O �"• fT 'C a a r" . V N � •~ OD �O 6 N w O tp jj A N �• • � • to - � d N ? fD N M O H O A tO O O O 1 O t0 t7 = F.• a 1 < N t0'1 � ""• �. O rt O 1 .°"-. r ~caI o 1 ` r. � tie � I Ca. a i I r C, c y O p. A �. ►�. F+• • A a 1 N O I I f0 �. I >P t A t co ' w c ' 1 'I O r 1 .. 1 10/0.2/98 FRI 14:30 FAY, 16tt.'_.€359627 PE -1111 nL^ , SUPPL Y OC I—b�-1`�yli 11 S S WUUU U l Kut- I UKtS 1 NkNk — 49( eta Z44.5 t'.Ue/L'.5lijp002 -1 0 7-6-7 14-9-0 21.11.9 t 29-6-00 30-" i -v^-0 7-u-7 T-21-9 -cw 7.64 1•-0 5xr 10.00112- 3 ,r 50% PREL!!�J+�ar �EgiSii /11 Z\; ONLY 6 lx4G� NOT FOR CO11STnv41!(JN d 4x4= 13 14 12 15 11 16 io 17 1a 4X4-- 3X4=— X4=3X4= 10- CXa= 9-12.5 l9 B -t'. 21-0 i nan1IJISl.,9f• 5PA�: .9.=�,0 I j r3€FL udefi (ire) tale Z2) rLdle.S Ii1P TOLL �S.b Pieta increase 1.15 TC 0.82 Vert(LL) 8.10 5890 l,A20 16s1123 TCDL 7.0 Lumber Increase 1.15 BC 0.88 ( Vert(TL) •0.55 8-10 >540 BCLL 0.0 Rep $!Ran I?W yr -6 M 0.68 %1:' -�L) 0-05 8 111 BCDL 10.0 S Code 80MANS195 � (Matrix) � Min Length i LL deft - 240 Weight 143 lb LUMBER TOP CHORD 2 X 4 SPF No.2 `Except* 1-4 2X4SYPM19,6,92X4SvpM19 BOT CHORD 2 X 4 SYP M 19 WEBS 2 X 4 SPF -S Stud — Except -5-12 2 X 4SPF 'Nol. a 13 2 X 4 Ser: N6.2 REACTIONS (lb/size) 2=1900/0-5-8, 8=190410-¢-8 Nlax Horz2=868{bad case 2) Max up! ft. s 'ttcs� r�:F a), 0=-W2�wad ;) BRACING TOP CHORD Sheathed or 3.1.4 on center purCm spacing. w %'"0R . ' chi' dirracti a 'at 7-11-14 an center bracing. 3 li fipmea g WEBS 1 ow at m dot li- 5.10 FORCES -t=est Load CaseOnly Tr�P rH0(tis BOT CHORD 2-13=1678,13.14=i678, 12-14=1678, 12-15=1120, 11 -15s1120,11 -16e1120, 10-16=1120,10-17=1678,17-18=1678. 8-ig=1678 VAESS 342=-5116,642=1021, 5-10=11021, 740-515 NOTES 1' This tr„oo has Wan ch2cke d for unbalanced loadhtg widillons. 2� This thus has been designed for the wind loads gener3ted by 100 mph winds &135 R suave around Ieve1, tmwg, 5.0 pad t -op a ±ord de=d I� end 6.0 psf bottom chord cc�yooad, 0 a from hultic ne oceanfine, on an occupancy category 1, condWah I enclosed building, of dimensions 45 R by 24 It with ar,--m!u w C At -r -E . -_3 W _OCA.P*!SI__ If end verticals- exist, Sit • am not - to wind. In cardikvem axis!, they are exposed to wind, if porches exist, they are not exposed to wind. The lumber DOL increase Is 1.60, and the plate grip increase Is 1,60 3' Aril plates are M20 plates uniass otherwise indicated. 4# This truss has been designed fora liVg load of 20,opsf On the battwa n card In al area -with a Msa ante grater than 3.8-0 between the bottom chord and arry other members. v) Pr.-.irsu,arti. r;i cofiiscii,un (6jf oiir��) imus to btradhg plate capable of% thsiandiing 882 lb upitp st Joint 2 and 682 Ib uplift at joint 8. 6) This truss has been designed wM ANSIRPi 1-1995 afterta. LOAD CASE(S) Standard PRELIMINARY GF.S1Gl; ONLY NOT FOR C41RS[R1!CT.1011 10/02/98 FRI 14:29 {}rAX 16036359627 PEr_.Irnu LLDC-,SUPPLY X1001 OCT-02-1y9ti 11:64 Wuuv W KUB A t%mC� INN. GkA I GVL C YGJ VJ. VJ T, -ATF -A-L, Bk kC DIAGRAM CUSTOMER: LNVOICEP: DEL:SIEg Y' P.O.# 170B: 1-0-0 7-64 7-2-9 7-2-e 7-6-7 1-0.0 6-3T� PI?F !"MRARy DESIGN ! � g ARY 3x4= 3x4= axis- bN Iy 0 r --lier ' WEB BRACING RFQT7Ht'_PD AS KARFiED. Sevv. :vi:S-X %r—EH MET. . BOTTOM CHORDS REQUIRE CONTIMUOUS L-ATIAL BRACT !G AT NO MtEI! TER THAN 10'0.0 AND NIA v - REQUIRE A LESSER MAXMUM SPACING W INDICATED ON THE ENG Mf ER TNG DRUA SSG. NOTE: Irl" iViiWLFr l TIRC100ESS DRYWALL APPLIED TIiROUGHOUT THE LENGTH OF THE BOTTOM CHORD, INIS Ta(ALLED ,IN ACCORDANCt Pr'iTH 'T= i. �,ANUr"AC'i'JRER'S RECOWm-ai DAT IONS ON 1 RUSSES 'VV tl! A L::.'Lf`.WJM 24" O.C. SPACING. V ILL Ae.SO PRL'N'I E A, ABC.)VE 2`+ ENTi^vWED I AMI RAL RES iRAW. Dufpj[NO EpXCTION, SET Cohov.9 7N BNIMS OF LIa T aUSSES ON ME SAME SIDE OF 9171LD NG, LOADING: 35,0+7,0 +0,0 +100 SPACING: 24.0" C.C. E4r1POB TA3`:Tf! SuE: "B�C'�*::i `::.^, If i`PiUaiEa: COI�Fc�viraFta wFv'i1r icrivlvt`MEIYFiAT'ivIvS" (G?tTt�`�'iV ;IfEE�) DELIVERED WTTFI TIBS OR -DEF -R, FOR. "COMI? ENDEL= MINIMUM -1 BRACING IREQiIllw. :Ts OF Top CHORD. BOTTOM CHORD, AND WEB PLANE& IN ADDITION TO THESE MINIMUM GUIDELINES, ALWAYS CONSULT THE PROJECT ARCHITECT OR ENGINEER FOR ADDITIONAL BRACING CONSIDERATIONS. TOTAL P.03 CDo .. .. d O CD _ y CD O O H 0 N! C7 CD O _ CD CD _a y, CD CO) O O CCD O C CD t`} 0 O I— �q cn C/) co aco a�:10 . H ;n CL m CA Z O' • • Er.S y . m O T r=.►� CL m � CO) a?d .'•r N O H m o o o -i fgm` m a ,v Amo: c c CA O G H n �o•m ay � to CL 0=r V m oCDto 1 CL CD 6000P > > _ CL t4O* O .W CL N � g C �m 0 O to o�� =r CD 1 O : N a o m ' o co y m �'p o C co Com. a 0 nom: � o CD I— �q cn C/) co ;n 7�:p 0 CA � ;n � C7 n ,v c CA tz O M rA Omi 0 0 c Ei L � c© �.i i2.. Ste-. • . CERTIFIED PLOT PLAN 0 o� LDR 6 I hereby certify that the premises shown on this plan is not located within a flood hazard area as shown on Department H.U.D. Federal Insurance Administration Maps. s� Community Number e5700<36 Registere4o6nd Surveyor RobERT M. Gill & ASSOCIATES, INC. LCIVIL ENGINEERS • SURVEYORS 418 bnidGE ST. • Iomll, MA 01850 • (978) 452-8510 IF W Setbacks shown I hereby certify, based on information provided, that the dwelling(s) on this on this plan are plan istare located approximately as sho hereon and that it complies with /�6 uVO I)E lZ 1A A for the determina- zoning set backs in the Town/City of tion of zoning when constructed. P�O ipC� 5 at) � 4 4 4 T t Q � requirements only. By This plan is an Registered Land Surveyor inspection plan only, not to be ountyor w�=== used as a Board Deed Reference of Appeals Plan. i ` IlIL scale: Book 3 Page US .�8 No. 2 dela: % `� • /C� Plane Reference s -iC Book 2M7 Plan 09/ ;_ 1 1 F5 1 e) I I I I I j, r N2 2 L - Date.................................. 0� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �K Al This certifies that /�.7� ...... ............. Z�4� ................................................................. his permission to perform :....... r... wiring in the building........ .................... at...,',/ . ..... ........................ . North Andover, Mass. Feel° ................. Lic. Nk� . . ............................................................ ELEcriucAL INSPECTOR 11/19/98 10:41 100.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ThE09M110NWE4LTH0FM4S"0WJSETI'4. office Use only DEPARTMONTOFPUBLICS4= Permit No. BOARD OFMEPREVEMONREGUI.A770AS527 12* 161v Occupancy & Fees Checked UVPPIKATTONFOR PERMIT TO PERFORM'ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant J-1-9 --XV ,t 21009 Cr C4 c r� Owner's Address 5P A- clef,, - i�sa �� Is this permit in conjunction with a building permit: Yes1'No F1 (Check Appropriate Box) Purpose of Building p C�, J P Utility Authorization No. Existing Service cvG Amps//dd-raVolts Overhead Underground �— No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work xc' - No of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No of Lighting Fixtures Swimming Pool Above Below Generators KVA roundg1:1round No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Lighting Battery Units No of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Locala Municipal Other No of Dryers Heating Devices KW Connections a No of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER • - -- hua -ice Co%eage. Laws --- I haw a arret Liability Ir uwm Poh y uiduding CaTFkl t Coag cr As a bswtd e4 uvalat YES � NO I ha est bmMdvaIidptoofofsamebthe0foe77� YES CIf}Duna%edvdWYES,pkaseQdc*thet WcfwmaWbydmk%the L 1 E BOND a OMi R a ftmSPeffy) ' //ectridff tW rkrte •� Estimated VahteofE7t�trical Wait $ WroIk to Start0./—/,9 Inspection Drama Ra*xsted Ro# Frd Signodands %wiesofpajtry. / 1 FIRM NAME �'!f c 7 'i^ C L=,SeNa .1i Sili BtsQress Tel Na -- Cp(5F�19 AIZ TU Na i o OWNER'S INSURANCE WAIVER; I am aware do dr L wtise does not laws and that my sigroi eat this petmil application wanes this MgtilenaTt (Please check one) Owner a Agent Telephone No. PERMIT FEE $ Id -O "f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Q Mass. Date j L 1 — 2-9 19 [Permit h G Building Location` .Q Owner's Name / r ► I �— 4 COyrr k � , ` `1 I �Type of Occupancy e. s t CSU\ 00 New Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No p Installing Company Name 121 tA9 C T -0—K= Check one: Certificate Address RIC) Rf)X 666S Corporation N1;/F��RS,�MA Oj993 El Partnership Business Telephone yCUC1"�_ t (�b�[1D ElFirm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a Curr t ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked rtes. please indicate the type coverage by checking the appropriate box. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owners Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By T of License: umber Signa ure of Licensed Plumber or Gas Fitter Title stetter /+� 3 q ` Master License Number (9— / J City/Town APPROVED O Journeyman IC UNL ■■■■■■■■■■■■ ■ t■■■M■■ ■■■■■■■■■■■■■■■ ■ on ■■ ... ■■■■■■■■■■■■■■ ■■MEN ■�■■■ ••- ■■■■■■■■■n■■■ ■■■ ■■■r •• ■■■■■■■■■■■■■■ ■a■ ■■■ ■■E Installing Company Name 121 tA9 C T -0—K= Check one: Certificate Address RIC) Rf)X 666S Corporation N1;/F��RS,�MA Oj993 El Partnership Business Telephone yCUC1"�_ t (�b�[1D ElFirm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a Curr t ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked rtes. please indicate the type coverage by checking the appropriate box. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owners Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By T of License: umber Signa ure of Licensed Plumber or Gas Fitter Title stetter /+� 3 q ` Master License Number (9— / J City/Town APPROVED O Journeyman IC UNL Z V r- _r b z m A lz `. -1 O rt V r- _r O z `. A c Oz a o m O > Z r n m > O -� v O 4 .{ O :3O m m In > 3: n � � O o a D O N • O D N tl N � T A f � rt 4- V 5 ' Date !... ..:...'.... ... . x 0 NORTH TOWN OF NORTH ANDOVER 9 py`4.ao ,a16 PERMIT FOR GAS INSTALLATION ' e � 0 This certifies that ... .... :'.-.:.. �� ...... -!�"" has permission for gas installation ............... fs . L in the buildings of ..::'..: '. `. .'...................... Q . at ... :.......... .'........I North Andover, Mass. Feer.. '.... Lic. No.'.: ?.......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer