HomeMy WebLinkAboutMiscellaneous - 10 EMERSON COURT 4/30/2018---7
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Date .... 5?� -9�4 .........
x. �' - - - ' ,;,. \-, 00\' TOWN OF NORTH ANDOVER
100 PERMIT FOR GAS INSTALLATION
This certifies that h'. ........
.........
has permission for gas installation ................
in the buildings of ... ............
at A? North Andover, Mass.
Lic. No.
GAS -INSPECTOR
Check # 61
me
MASSACHUSETTS UNIFORM APPUCAT6N AOR PERMIT TO DO GAS FI1TI'ING
(Type or print) VDate L/
NORTH ANDOVER, MASSACHUSETTS
Building Locations/ ��5 J� C—� �Y. ��`�� ��� ' Permit #�
Amount $ c
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L�
Plans Submitted ❑
Owner's Name
New ❑ Renovation ❑ Replacement 0
(Print or type
Name
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Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
Firm/Co
INSURANCE COVERAGE unec o :
I have a current liability Insurance policy or it's substantial equivalent. Yes Non
If you have checked yeple.
s, e' dicate the type coverage by checking the appropriate box.
Liability insurance c
poliy 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 Owner's Agent Owner ❑ Agent ❑_
I hereby certify that all of the details and information 1 have submitted (or
best of my knowledge and that all plumbing work and installations perfo
compliance with all pertinent provisions of the Massachusetts State
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of:
Plumber
Gas Fitter
Master
Journeyman
in aDove appncanon are true ana accurate to the
VPermit Issued for this application will be in
;hanter 142 of the General Laws.
sed Plumber Or Gas Fitter n
Icense Number `�
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SUB -BASEM ENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4 T H. FLOOR
5 T H. F L O O R
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type
Name
---- • D
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Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
Firm/Co
INSURANCE COVERAGE unec o :
I have a current liability Insurance policy or it's substantial equivalent. Yes Non
If you have checked yeple.
s, e' dicate the type coverage by checking the appropriate box.
Liability insurance c
poliy 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 Owner's Agent Owner ❑ Agent ❑_
I hereby certify that all of the details and information 1 have submitted (or
best of my knowledge and that all plumbing work and installations perfo
compliance with all pertinent provisions of the Massachusetts State
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of:
Plumber
Gas Fitter
Master
Journeyman
in aDove appncanon are true ana accurate to the
VPermit Issued for this application will be in
;hanter 142 of the General Laws.
sed Plumber Or Gas Fitter n
Icense Number `�
Date..
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that /V/ . ........
�as permission for gas installation .
71, ...............
in the buildinp of .................
i
at ................ N,,or7thn Andover, Mass.
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FeeA.57—.. Lic. No./:�,.�?.. 10 � ............
Check# 4� �A � CT� R
4607
MASSACHUSETTS
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
FOR PUMTI'TODO GAS FfF MG
Date' Al"- 0 L
Building Locations /0'1
.&_CW 5 L'I C—T L% 0 0 VC +e Permit #
Amount $
Owner's Name Jvl�Q
( ,Le
New Renovation ❑ Replacement0 Plans Submitted
(Print or typn p Check one: Certificate Installing Company
Name IL—
e17 �\ `�Vt'� t`1 t° Corp.
d
Addres t ❑ Partner.
b °3 6 7
Business Telep one 3- y — ' IR3 1 F[Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Chec on
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checkedLes, plea e i icate the type coverage by checking the appropriate bo
Liability insurance policy Other type of indemnity F-1Bond�.
Owner's Insurance Waiver: t 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 cernty tnat an of the details and mtormation 1 nave submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations 110 e under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter License Number
Master
Journeyman
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SUB -BASEM ENT
BASEMENT
1ST. FLOOR
2 N D. F L O O R
3 R D. F L O O R
4TH. FLOOR
5TH. FLOOR
6 T H. F L O O R
7 T H. FLOOR
8TH. FLOOR
(Print or typn p Check one: Certificate Installing Company
Name IL—
e17 �\ `�Vt'� t`1 t° Corp.
d
Addres t ❑ Partner.
b °3 6 7
Business Telep one 3- y — ' IR3 1 F[Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Chec on
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checkedLes, plea e i icate the type coverage by checking the appropriate bo
Liability insurance policy Other type of indemnity F-1Bond�.
Owner's Insurance Waiver: t 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 cernty tnat an of the details and mtormation 1 nave submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations 110 e under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter License Number
Master
Journeyman
Date ... ///� /A/ ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that -,Z . ..... ....... .....................
........................ ..... ..eq��zNvj
has permission to perform ......
.......................................
wiring in the building of ..... ......... 4.2-0 .... .......................
- 14� ... ..
at ...... .. .... .
North And Oer,jbla�,
It
iL: 7
Fee.;.5� ........... Lic. No . ............. ......... .... ............... jv .............
Check # > ECT C SPECTOR
40/57
k
I
ul�e C�onlulau�uea�tll of Magoadjugato Permit Nonlce use unf
;X 113e>partment of Public eafetq Occupancy A' Fee CheRcYred
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank)
APPLICATION FOR PERMIT TO PBRFORM ELECTRICAL WORD
All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR.TYPE ALL INFORMATION) bate
(fi* or Town of NQRTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street F
Owner or Tenant
Owner's Address
1s this permit In conjunction with at building permit: Yes I- No LJ (Check Appropriate Box)
Purpose of Building R 5, Utility Authorization No.
Existing Service Amps _._/ Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work �(
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liabillty Insurance Policy Including Completed Operations Coverage or Its Subslantlal equivalent. YES C NO [ 1
have submitted valid proof of same to the Office. YES C
checking the appropriate box. !— NO G If y u haaave checked YES, please Indicate the type ole erage by
� � / __,,[[,
INSURANCE BOND C OTHER O (Please Specify)// /b Q�
Estimated Value/of Electrical Wo'rk/S _ ����ation�IOam
Work to Siert f "— / Z D y Inspection Date Requested: Rough //L // Final N
Signed under It^ Penalties of p h
FIRM NAME LIC. NO./_2Y15S'
Licensee C Signature
f LIC. NQV_O!i=�<p,�/
fj%j9 i `� Bus. Tel. No. T2V ?iii �
Address '
% r Alf. Tel. No.
OWNER' INSURANCE WAIVER: 1 em av,are that the Licensee does not have the insurance coverage or Its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner AQUI
(Please check one) GJCJ/1
(Signature of Owner or Agent) Telephone No. PERMIT FEE $ Agent)
X-6565
No. Lighting Outlets
No. of Hot 'Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
❑ ❑
grnd. grnd.
Generatora KVA
No, of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of Ranges
No. of Air Cond. Total
i
tons
Initialing Devices
No. of Disposals
No.of Heat Total Total
Pumps Tons KW
No. of Sounding Devices
No. of Dishwashers
Hosting KW
No.
No. of Self Contained
Detection/Sounding Devices
No. of Dryers
Heating Devices KW
LocalMunicipal
❑ Connection []Other
No, of Water Heaters KW
No. of No. of
Signs Ballasts
.
Low Voltage
Wiring
No. Hydro Massage Ibbs
No. of Motors Total HP
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liabillty Insurance Policy Including Completed Operations Coverage or Its Subslantlal equivalent. YES C NO [ 1
have submitted valid proof of same to the Office. YES C
checking the appropriate box. !— NO G If y u haaave checked YES, please Indicate the type ole erage by
� � / __,,[[,
INSURANCE BOND C OTHER O (Please Specify)// /b Q�
Estimated Value/of Electrical Wo'rk/S _ ����ation�IOam
Work to Siert f "— / Z D y Inspection Date Requested: Rough //L // Final N
Signed under It^ Penalties of p h
FIRM NAME LIC. NO./_2Y15S'
Licensee C Signature
f LIC. NQV_O!i=�<p,�/
fj%j9 i `� Bus. Tel. No. T2V ?iii �
Address '
% r Alf. Tel. No.
OWNER' INSURANCE WAIVER: 1 em av,are that the Licensee does not have the insurance coverage or Its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner AQUI
(Please check one) GJCJ/1
(Signature of Owner or Agent) Telephone No. PERMIT FEE $ Agent)
X-6565
0/0& WAUeRLq
Location
No.
Date 1-& 7 -0-
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ -6-b
Check #
16569
-.1 /W A ( C--,
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: ✓�vC
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
y
�y
V d `�
Map Number Parcel Number
` ^ 1 04,�j �� +� �jn�e
(,U {�'
1.3 Zoning Information:.
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Re red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
w"6�y� �� c� r� VX
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 L'nsed Cons'tru ion Su or:
(I
Not Applicable ❑
C 15` " �
Licensed Constructionrvisor:
L-1 �fl // � 4 n t- f;+
{
License Number
f
Address C
P kk)�
//U v
-
Expiration Date
Sign re Telephone
3.2 Registered HomeImprovemen Contractor
Not Applicable ❑
ofu1�,0-�"i�l
Company Name
' ! { Kai5ir"n 4— 0
Registration Num
Address t?i�®
o t
(5
Expiration Date
Signature Ic Telephone
ou
M
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SSI
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
0 NOye afI 5; �V`�°� V-od ravw,
j ✓X
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to he
Completed by permit applicant
CIA)l,
SE�(iNLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee tel X tbl
�D
4 Mechanical HVAC
5 Fire Protection
6 Total • 1+2+3+4+5 - r :i.i
i -- U Z
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, NIV �,� (� J /V vVII 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 Name � ��/ � � C)�
Signature of Own r/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST2 ND3RD
SPAN
DRAENSIONS OF SILLS
DINIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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A C-ERTIFMATE Of LIABILITY INSURANCE
978-975-4 A4
3 THIS CERTIFICATE 16, NC 153IJ
VIALLtYWS 4N S URANCE A8E N""Y4 ONLY AND CONFERS
$22 CHICKERING ROAD QMTIRCA
ALTER THE WER8GE A]
1 NORTH ANDOVER, MA 01845
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MAX PERTAIN, THE IN*URANCE AFFORD6.0 BY tHE POLICIES DESCRIego HEREIN IS SUBJECT TO ALL THE TERMS. eYCLUSIONS AND Gow;mons or sUcp
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NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debrisresulting from this work shall be disposed of in properly
licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A.
The debris will be disposed of in:
F4 rd -0 1-61 A -
(Location of Facility)
SiXature of Permit Applicant
ate
NOTE: Demolition permit from the Town of North Andover must be obtained for this project
through the Office of the Building Inspector
Date......................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that X, ... 1:4 .........
has permission for gas installation ............................
,in the building� of
at ............ -
.......................... North Andover, Mass.
Fee—:-"- o./
...... Lic. N ......
G6 ...........
AS 119 P6TOR
Check # r I/,-
4 6 1,", 4
MASSACHUSEM UNIFORM APPLICATONFORPERAUrTO DO GAS FITTING
(Type or print)
NORTH ANDOVER,
Date
Building Locations eS Permit #
Amount $ °
Owner's Name k�® Jd a," J f f/ its C �
New Renovation Replacement Plans Submitted
-' 0,'d; ep; e r✓ A—t' .
Name of Licensed Plumber or Gas Fitter
CSC one: Certificate Installing Company
❑ Corp.
.I
E] Partner.
INSURANCE COVERAGE CheA o :
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked , pl dicate the type coverage by checking the appropriate
Liability insurance policy Other type of inJernnity ❑ Bond ❑
Owner's Insurance Waiv . 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 ❑
t i hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and inst i
compliance with all pertinent provisions ofthe Massachpsel
(OFFICE USE ONLY)
(or entered) in above application are true and accurate to the
fonp4mder Permit Issued for this application will be in
antT>r`hanter142x€ e—General Laws.
s' Signature of Licensed Plumber Or Gas Fitter
rtpf Plumber
riGas Fitter License Number
0 Master
Joumeyman
Location / t2 I-,kil E I? _S 0
No. 41sv Date
�0,1 Z�
TOWN OF NORTH ANDOVER
11
Certificate of Occupancy $
0,
Building/Frame Permit Fee $
CH
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
15-0 1---
6-0
17008
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
7-7— �z
BUILDING PERMIT NUMBER: DATE ISSUED:
Lf —C,
SIGNATURE:
Building Commissioner/IEf of Buildings Date
.�Etor
SECTION I- SITE INFORMATION 1.
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
c7
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dis—Vict Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage (fl)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private ❑ Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
W 0,1)j V
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
SinatureTelephone
SiCTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Loa Y,(vp
Licensed Construction Supervisor:
Address l
q7xV6 7((5'
Signature Telephone
Not Applicable 0
62
License Number
0F ()
Expiration Date
3.2 Registered Home I provement Contractord
JaV
Not Applicable 0
Co
Company Narr( .
i .
Address
-IO;Lo
Registration N7;r,
If
Expirat& 'Dt
Signature Telephone
00
M
X
z
0
X
SECTION 4 - WORKERS COMPENSATION (M G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the ilding permit.
Signed affidavit Attached Yes ....... o.......❑
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑ 1
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Worrk:,, V"'-"
w Y "`720,4 2U c Y)� y1R � YV1���s
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
'
Item
1. Building
Estimated Cost (Dollar) to be
Completed by permit applicant
® ®
r OFFICIAL ITSE O1NLY
y
(a) Building Permit Fee
Multiplier
2 Electrical 10 CY-4- rn
a � L� a
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee lel X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
` 0
Check Number
SECTION 7a OWNER AUTHORIZAT ON TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
H eby a to act on
a a er reiativ to work authorized by this building permit application.
Signature of Wer Date
i MSEC -TION 76 OWNER/AUTHORIZED AGENT DECLARATION
I
D -ft
L �" s rl'a 0 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 Name
Aw f�
Signature of O er A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T11vIBERS iST2 ND3
SPAN
DIN ENSIONS OF SILLS
DIN ENSIONS OF POSTS
D11V ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
(2/
- I..
�* = mob .ice
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
Signature of Permit Applicant
ti l> d
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
ACORDn„ CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYM
PRODUCER 978-975-4344
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INTERNET INSURANCE AGENCY, INC
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
522 CHICKERING ROAD
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NORTH ANDOVER, MA 01845
AUTHORIZED RES TI
INSURERS AFFORDING COVERAGE NAIC #
INSURED
D.G. CONTRACTING, INC.
INSURERA: ARBELLA PROTECTION
INSURER B: NORFOLK & DEDHAM
DAVID
INSURERc: ARBELLA PROTECTION
428 PLEASANT STREET
I INSURERD: AIG INSURANCE
NORTH ANDOVER, MA 01845
INSURER E:
Lfiella:f_[t1:&I
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
TR
DD'L
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
POLICY NUMBER
POLICYEFFECTIVE
POLICY EXPIRATION
DATEIMMIDDIYYI
LIMITS
REPRESENTA ES.
AUTHORIZED RES TI
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE FxIOCCUR
8500013549
07/01/2003
07/01/2004
EACHOCCURRENCE $ 1,000,000
PREMISES Eaoccurence $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMITAPPLIES PER:
PRO' LOC
POLICY F J CT
PRODUCTS)COMP/OPAGG $ 2,000,000
B
AUTOMOBILE
LIABILITY
ANY AUTO
90151692
06/12/2003
06/12/2004
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
X
ALLOWNEDAUTOS
SCHEDULEDAUTOS
BODILYINJURY $
(Per person)
HIRED AUTOS
NON>OWNEDAUTOS
BODILY INJURY
(Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AI:'Y AUTO
!
AUTO ONLY) EA ACCIDENT $
OTHER THAN EA ACC $
1
AUTOONLY: AGG $
C
EXCESS/UMBRELLA LIABILITY
X OCCUR � CLAIMS MADE
4600020399
12/10/2002
12/10/2003
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
$
$
DEDUCTIBLE
$
RETENTION $
D
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
WC333-27-74
03/31/2003
03/31/2004
WC STATU' OTH>
TORY LIMITS ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE > EA EMPLOYEE $ 100,000
OFFICER/MEMBER EXCLUDED?
SPes escribe under
EC AL PROVISIONS below
E.L. DISEASE) POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER rANrF:l I ATInN
ACORD 25 (2001/08) v ' T7" '�RD CORPORATION 1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTA ES.
AUTHORIZED RES TI
ACORD 25 (2001/08) v ' T7" '�RD CORPORATION 1988
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation .Insurance Affidavit
Please Print
City Phond #��5` L
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity •
1 am an employer providing workers' compensation for rlry employees working on this job.
Company name. 5
I
Company name:
Address
Cott:;_ Pf>zu►i�#
Failure to secure coverage as required: under Section 25A or MGL 152 care leatl to'theiiipoWm oi' crim�pe cf axfitw i
and/or one years' imprisonmimt-as-wel-as. peaaltiesja-Ib& AI iataM ?F j k wsd-4SIWmj_jdWA
understand that a copy of fts statement may be forwarded to the Ofrice of Investigations of the DIA for coverage ve ji;cation.
do hereby cerify under the j##11d pen flies of pefjury Hmt Me iviharmatiarr provideal above its true and caffecit,
Sigriaturp
Print
Official use only do not write in this area to be completed by city or town dridar
City or Town.
E! Other
Wood Ridge
10 Wood Ridge Drive
North Andover, Massachusetts 01845
Telephone 682-7093
TDD Line 1-800-545-1833 Ext. 143
January 12, 2004
Mike McGuire, Town Inspector
27 Charles Street
North Andover, MA 01845
Dear Mr. McGuire:
The purpose of this letter is to verify that Barkan Management, as agent for Wood Ridge
Homes, Inc. has retained the services of David Gulezian General Contracting to do repair
work in the following units; 8 Ardmore Court, 11 Briarwood Court, 12 Briarwood Court,
7 Colby Court, 10 Emerson Court and 11 Emerson Court. Please feel free to contact me
should you have any questions regarding this matter.
Assistant Property Manager
01/12/2004 MON 12:42 FAX 978 687 6616 Woodridge Bones
Wood Ridge
10 Wood Ridge Drive
North Andover, Massachusetts 01845
Telephone 682-7093
TDD Linc 1-800.545.1833 Ext, 143
January 12, 2004
Mike McGuire, Town Inspector
27 Charles Street
North Andover, MA 01845
Dear Mr. McGuire;
The purpose of this letter is to verify that Barkan Management, as agent for Wood Ridge
Homes, Inc. has retained the services of David Gulezian General Contracting to do repair
work in the following units; 8 Ardmore Court, 11 Briarwood Court, 12 Briarwood Court,
7 Colby Court, 10 Emerson Court and 11 Emerson Court. Please feel free to contact me
should you have any questions regarding this matter.
Assistant property Manager
01/001
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