HomeMy WebLinkAboutMiscellaneous - 1 MEADOW LANE 4/30/2018Date..... 4 ....... .... ... I .....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that)RA 4P -,"-a0
... ............ ......
................. �/
has permission for gas installation A ns cz-.,4
.......................................... ........
in the buildings of � o-, --)
... ............. ... .
at ........ ........... M. -Pa w L- t -j
.................................................................... . North Andover, Mass.
Fee(O.)..� ..... Lic. No. ... ... I �-r . . .................................................
GASINSPECTOR
Check # LWK
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I North Andover I MA DATE 411512014 PER-M.I.T-# Z to
JOBSITE ADDRESS 1 Meadow Lane OWNER'S NAME�� �i✓`- _
GOWNER ADDRESS Same IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL❑
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER (—
BOOSTER j �-
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR _
FURNACE
GENERATOR _
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER 771
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
.OTHER
Replace 1 Gas Meter x
and Pi ing as Needed
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITYE] 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 a 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 c m fiance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME Joseph Marino LICENSE #8736 I ATURE
MP 0 MGF ElJP ❑ JGF ❑ LPGI ❑ CORPORATION [:]#3285C PART RSHIP❑# LLC ❑#
COMPANY NAME: RH White Construction Co ADDRESS 141 Central St
CITY I Auburn STATE= ZIPI 01501 TEL 1 (508) 832-3295
FAXI 508-926-4347 CELL 508-832-4614 JEMAILI JMarino@RHWhite.com
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1J4/UJ/21J14 14:U4 51 883 31b lbl KH WHl I t GUNS I HUG I HAUL 151/ 02
® CERTIFICATE OF LIA,BILITI(iNS �1� DATE(MMlDD/YYYYJ
U" �^��� Page 7. of 08/29/2013
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TH6 CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(jos)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditionsof the policy, certain policies may require an endorsement. A statement on this certii7cate does notconferrights to the
certificate holder In lieu of such endorsement(s),
willia o£ Massachusetts, Inc.
c/o 26 contusy Blvd.
E. 0. Box 305191
NRChville, TN 37230-5191
R. X- white Construction Company, Inc.
41 Caner*l Street
Y. 0. Box 257
Auburn, MA 01501
u�aurtGnl� Hrivi�uin+IGV VERAGE NAIC rF
INSURERA:The Cbartor Oak fire Iaauran09 Company 25615-001
INSURERS:Travalmrs Property Casualty Cotgpany of Am 25674-003
INSURER C:NatiCAA1 Union Ping Insurance Company of 7.9445-001
INSURER 0;Travelere Indamni,ty Company 25658-DOl
INSURER F:
OVERAGES CERTIFICATE NUMBER:20287680
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN [$SUED TO THE INSURI
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER I
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
A
B
C
D
D
DES
Y TYPE Or INSURANCE
ADDIL
SUB
POLICY NUMBER
GENERALLIA6ILITY
EACH OCCURRENCE
2,000,000
VTC20Co 977RD948-13
X COMMERCIAL GENERALLIA111LITY
MED EXP (Any oneperson). F
1p� 000
PERSONAL&ADV INJURY $
CLAIMS -MADE OCCUR
GENERAL AGGREGATE $
4,Q00 000
PRODUCTS -COMPIOPAGO L__,4,
000 000
$
GENLAGGREGATE
LIMIT APPLIES PER;
2,000,000
POLICY PRO 7LOC
BODILY INJURY(Peraccldent)
AUTOMOBILE
LIABILITY
$
VTaC'AP 977K955A-13 '
x
ANY AUTO
AI,I,OWNED SCHEDULED
—P-, 000, 000
$
XQ -
TAC�Y LI
AUTOS AUTOS
HI;1CDAUTOS X NON -OWNED
1,000,000
E.L.DIBEASE-EAEMPI,QYFE $
1,000,000
X
1,000,000
AUTOS
Co Ded X Cgx1 Ded
99 000
7t
UMBRELLALIAB X OCCUR
EXCESS LIAa CLAIMS -MADE
B38766140
X
DED j[ RETENTIONS 10,000
WORKERSCOMPENSATION
-LIABILITY
V�RItTJ}� 62057185-13 t
AND EMPLOYERS YY//Nt1
ANYPROPRIETORIPARTNFRIFXECUTIVEn
NIA
VTC21CUB 8208A71A-13 c
OFFICER/MEMBEREXOLUDED7-
Myandatmrydt In NH)
UEt V K1IIB I IUN u d UPURATIONS below
- -------- ��_,.•.�,. ••, ..., .. ••��•. ,....ami, nsv,u, . vm. upl RtllfltllRC dGOQO1,IN,
)/1/2013
'9/1/2014
3/1/2013 9/1/2014
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epaco
CERTIFICATE HOLDER CANCELLATION
Evidence of Inmurance
REVISION NUMBER:
_D NAMED ABOVE FOR THE POLICY PERIOD
)OCUMENT WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS,
LIMITS
EACH OCCURRENCE
2,000,000
pqq TO RENTF,Q
PR� I��B(Eeocemencrl „"�
- 300,Q00
MED EXP (Any oneperson). F
1p� 000
PERSONAL&ADV INJURY $
2 0 -. ,000
GENERAL AGGREGATE $
4,Q00 000
PRODUCTS -COMPIOPAGO L__,4,
000 000
$
OMBI EDNGLEUMIT
. ecc�Cent)SI$
2,000,000
BODILY INJURY(Per person) $
BODILY INJURY(Peraccldent)
tFrqur $
$
EACH OCCURRENCE L-5
1 000, 000
AGGREGATE —L
—P-, 000, 000
$
XQ -
TAC�Y LI
E.L. EACH ACCIDENT $
1,000,000
E.L.DIBEASE-EAEMPI,QYFE $
1,000,000
El. DISEASE. POLICY LIMIT $
1,000,000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORILL!D REPRESENTATIVE
Col1:4197604 TI)1:1694012 Ce7:t::20297680 ®1988-2010ACORD CORPORATION, All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
It
Date..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... ........
has permission to perform .............................
wiring in the building ofs. �.I—A�.. I -W. ......................................... j�z-_
at ..... I ....... ...................... North Andover, Mas s.
Fee:-��..f ... Lic. No. 74 .......... -Jez� . ...........
'i�ECTRICAL INSPECTOR
Check
10840
C.oandronraraith a��a33tu:/jft
M DI
BOARD OF FIRE PREVENTION REGULATIONS
OfificialUse Oafy
PermitNo. I D S &
z
cupancy and Fee tamed
b*k
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AU wo* to be pafam ed m ammbmcx with gmM l ?.ode (MSCI 527 Oa MOO
(PLEMPMff"EVW OR i7PPEAU INFORIfM0j* Datan 3 / / -c 11.2
0r
City or Town of: NO /� �V Q o U e R To the Inspector of Wires:
By this application the undersigned gives notice ofhis or heri�tion to
perfomztire electrical work demrfta below.
Location (Street & Number) / /%L- 0a I Cyd ,U�s
Owner or Tenant Sc T T C,,3 ,t, A: A! Telephone No.
Owner's Address S IV n ti,
is this permit in conjunction with a building permit? Yes ❑ No Q-- (Check A riate Bot)_
Purpose of BuRding_ Q W -.t_ I &I IItr'hf' y Anthu],. aI ion NO. f 7
Existing Service c o Amps 120 Volts Overhead [�" Un —
dgrd ❑ No. ofineters %
New Service v0 Amps t,6 I2 -t' Volts Overhead 0— Undgrd❑ No. ofMcen
Number of Feeders and Ampacity
Location and Nature of Proposed Elecbicat Work `S -e k (JI e e Crro C A n rsL
No. ofRecessed Luminaires
No. of Cell.-SnspL (Paddle) Fanso.
--r V erre ffv=
No.o
ormers HVA
No, of Luminaire Outlets
No. of Hot Tubs
%[VA
No.ofLmres
SwhmmfmgPool e ❑d. ❑
01 ANG�ency
Ba IInits
No. of Receptacle Outlets
No. of On Burners
FM ALARM
No, of hones
o. ofSwitches
No. of Gas Burners
N06 0
I1IMCn OR and
N06 ofRanges
Na of Air Cond. Total
Tons
o, of Alerting Devices
No. of Waste Disposers
P er ons
a o mt$m
SpacelArea Heating KW
etection/Alertin Devices
No. of Dishwashers
Muni
Local connection ❑ Other
No. of Dryers
Hez a Appliances KW
security
No. �'
Heaters KW
o. o o. o
Na of ccs or ear
Si Ballasts
No.. o Devices or Egftalent
No. Hydromassage Bathtubs
No. ofMators Total lap
Na of Devices or emt
OTHER:
izu"L saaauwaaraeim[ gaesuW4 eras regz&edhyfhehapectaroflfh+ec
Estimated Value ofElectdcai Work (Nina required by ummc W policy )
Work to Start: Imspec tions to be requested in accordance with MEC Rule 14, and upon completion.
1 WMMCi: COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof ofliabMW insurance; inetudmg 'completed oPMEtiod" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing offrce.
CHECK ONE. BMIRANCE12 BOND ❑ OTMR ❑ (Specify:)
I clY, under&ePaba andpenalfresofPerjwy, &&Ae infonnaffon on ff= appficadan is true mad complete
FIItMNAMM-Buddy Electric Inc. UC.NO--12017 A
Liam Vincent B. Landers JrSignature LIC .No, �3 84 E
MMUcaW enter Wit" m ft kcww nwnber ime.) Ens. TeL No 9'7t=9'75=�"4 5 5
Address-. 24 Colgate_ Dr N.Andover, Ma 01845 Alt Tei.Nr�
*Per M_G.i.. 0.147, s. 57-61, seem* work requhw Department ofPublk Safrty "S' License: Lic. No.
OWNER'S RW3RANCE WAIVXR-. I am aware that the Licensee does not have tine Habtity incnrance coverage normany
requited by law Bymy signature below. I hereby waivethis rent i amthe (check one) ❑ ownw [3owner'sageaL
Owner/Agent
Siguatare Telephone No. PE MTFEE• $
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: ';L- L/ Col g 7 C
(,1d,:57(_!101 Ire /-I 'C_
C)r
C_
City/State/Zip: 5' Phone #: % ;75--�4l �5
Are you an employer? Check the appropriate box:
1. E? I am a employer with 4. ❑ I am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
have hired the sub -contractors
6. F1 New construction
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g. ❑ Demolition
workingfor me in an capacity.
Y P tY•
employees and have workers'
comp. insurance.$
9. r-1 Building addition
[No workers' comp. insurance
required.]
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
11. ❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12. ❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13. ❑ Other
employees. [No workers'
comm. insurance reauired.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
fi 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:
Policy # or Self -ins. Lic. #: 1) Expiration Date: %/a�� /c2 O/ 3
Job Site Address: Gf Cu/
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone #: 9% P 3;7 6-- O 7)� ->-
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Loc�tion
No. — 503 Date
ORTH ANDOVER
pancy $
mit Fee $
Fee $
Fee $
Water Connection Fee $
TOTAL $
L/ Build'ing I'nspector
Div. Public Works
PERMIT NO.
I
l
5d
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
110i
AP
4-40.LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE
ZONE I SUB DIV. LOT NO.I
LOCATION / PURPOSE OF BUILDING
OWNER'S NAME NO. OF STORIES SIZE
OWNER'S ADDRESS BASEMENT OR SLAB
ARCHITECT'S NAME (/ SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME SPAN
DISTANCE TO NEAREST ILDIN DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES - SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
t
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
PERMIT GRANTE
(kze 19
' ,r%Y - 91905
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST rJ i1 C�
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOMBLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
OWNERTELJ C.1
CONTR. TEL. # • �" �J
CONTR. LIC. #
H.I.C. # `� l ,o
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
t
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
PERMIT GRANTE
(kze 19
' ,r%Y - 91905
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST rJ i1 C�
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOMBLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
OWNERTELJ C.1
CONTR. TEL. # • �" �J
CONTR. LIC. #
H.I.C. # `� l ,o
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILYSTORIES
MULTI. FAMILY �-
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
S INTERIOR FINISH
d 1 2 13
PINE
CONCRETE
CONCRETE BL'K.
BRICK OR STONE
P
_
PIERS
PLASTER
DRY WALL
_
UNFIN.
3 BASEMENT
AREA FULL
FIN. B'M'TAREA
_
1/1 1/2 1/1
FIN. ATTIC AREA
_
NO BMT
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
4 WALLS I
9 FLOORS
CLAPBOARDS
B
1
2 3
_
_
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
HARMWD
COMMON
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
11
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR _
CONC. OR CINDER ELK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I -I POOR
ADEQUATE NONE
10 PLUMBING
5 ROOF
GABLE
HIP
BATH (3 FIX.)
_
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
10 13rd
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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