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HomeMy WebLinkAboutMiscellaneous - 100 FLAGSHIP DRIVE 4/30/2018 (2)N " O o C) V T ' O � N = O � o m 0 CD 0 (0 00 0 TI CD CD (D tea, Ln D �' a O cn cD cn C) ZT D v ( cn 7 � O D 3 IM Zn O O _ 0 < O m E D cD cn a o O -< O 0; o < CD C) °— C C. o O o CD m z cn o X 0 77 TO , 1 3 N z 7 CL0 `m Z =3 03 O ®CD T v N n 2.5 n o z Q 0 v c O mCL C N O Ut O j R(D L D CD O N N O Date ..... 1/;-/n ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................................................... hvds permission for gas installation .... va,.S............... )4, inthe. buildings pf ................................................................................................................... ... .... Afto . . ........................................ . No Afldover, Mass. .Fe . JPP ...... Lic. No...', f0...... ... ............................ A INSPECTOR Check.# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TYPE OR PRINT CLEARLY' CITY [A MA DATE ,f y J PERMIT # 7 JOBSITE ADDRESS OWNER'S NAME A OWNER ADDRESS �FAX OCCUPANCY TYPE COMMERCIAL'S EDUCATIONAL RESIDENTIAL NEW: RENOVATION: REPLACEMENT:O— PLANS SUBMITTED: YES F—Al NO APPLIANCES`1--FLOORS- BSM 1 2 3 4 5 6 7 8 10 11 12 13 14 BOILER —9 BOOSTER CONVERSION BURNER ED COOK STOVE DIRECT VENT HEATER ------- -I DRYER J FIREPLACE FRYOLATOR FURNACE 77 GENERATOR GRILLE 7. 171 INFRARED 'HEATER LABORATORY COCKS -7 [77:1 —1 MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT =IF . ..... 11 TEST I E.,! UNIT HEATER I UNVENTED ROOM HEATER -i F ----11 ----- --- 1 WATER HEATER INSURANCE, COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 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 [,Jl AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and Information I have submitted or entered ding this application are (rue and accurato to the best of my knoviledge and that all plumbing work and Installations performed under the permit Issued forltiis application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ILICENSE # SIGNATURE IMP �d MGF JP]I JGF LPGI CORPORATION [# L PARTNERSHIP J#[ # L LLC COMPANY -j ADDRESS[ CITY STATE[ zip TEL FAX 1 CELL EMAIL Date .. �C.`.�L ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... ......✓'?�.............. ...... has permission for gas installation in the buildings of ...%�.re� ...... • ..... . at ... l ./� �'!� ?'.. 005 ...... j North And- over -Mass. Fee. `?S `' Lic. No. 4� %/u�?�.--r�. GASINSPECTOR Check # Z % s • � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYf�tt/��l —II MA DATE PERMIT # o JOBSITE ADDRESS O — OWNER'S NAME a GOWNER ADDRESS TEL _ ---IFAX l TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL F1 RESIDENTIAL Q CLEARLY NEW: [l RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE .__ F I _. _ �1 1 = ! DIRECT VENT HEATER DRYER FIREPLACE_ _ _ _ _ _ _ FRYOLATOR ( I FURNACE GENERATOR GRILLE INFRARED HEATER r �� LABORATORY COCKS r - �! - -_- - -. MAKEUP AIR UNIT OVEN POOL HEATER - ROOM / SPACE HEATER ROOFTOP UNIT lkvil TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER_ OTHER_ INSURANCE COVERAGE have a liability insurance its current policy or substantial equivalent which meets the requirements of MGL. Ch. 142 YES..._ NO [] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OFCOVERAGE NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ©I BOND �I 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 Ej AGENT 0 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,4est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli with all Pe ' provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �' $ �y,/ - -- LICENSE # o%g/..: SIGNATURE MP El MGF JP 0113F [ LPGI 0 CORPORATION 0# PARTNERSHIP 0#= LLC E I # __- I 4---� ADDRESS G COMPANY NAME: -,� CITY STATE RHO ZIP 6,� �% TEL FAX _zli V101 CELL -EMAIL - -- -- - — -- — -- -- O z z 0 H U a rAw E O N El W >- F_ W H a z° W = ~ 00 a W 5 j ® > a F� w W C W zz a a�, a J o - a � w x w W H O z z 0 H , x The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le>=ibly Name (Business/Organization/Individual): Address:- City/State/Zip%_�l'lAA i ���✓I ' 01 Phone #: y� Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I'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 me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We area corporation and its required.] 3. ❑ I am a homeowner doing ofcers have exercised their all work right of exemption per MGL myself. [No workers' comp, C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' • .. comp. insurance required.] �-Ljr EYaI.'Cant that CieC:.S bas t m, --t E1S0 lYil out ICC SPCp.On b l( ct,n n;n.T 4ti Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. E] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 Dumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 isproviding workers' compensation insurance for my information. employees Below is the policy and job site Insurance Compiny Name Policy # or Self -ins. Lie. A Expiration Date: Sob Site Address:�d City/State/Zip,4,) , ri%"'o • 114 A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $ 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under pails andpenalti fperiuty that the information provided above is true and correct Signature: �t Date.: Phone #: Official use only: Do not write in this area, to be completed by city or town official. City or Tow Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector S. PIumbing 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, 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 cerdficate(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 anLLC or LLP does have employees, a policy is required. Be.advised that this affidavit maybe submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date -the affidavit. The affidavit should s...�.e .t- 1. •a. dl...c s M t,. aL be re am li 6o the, citf or to n that the &iuilitGfietQn tui �e Ec S or license i� 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 fature 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 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 Commonwealth. ofMassachusetts Department ofFndustrial Accidents Office oflnvestibatjons 600 Wasbington Street Boston, IIIA 0.21.11 Tel. # 617-72.7-4900 ext 4406 or 1-8.77 MASSAFE Revised 5-26-05 Fax 9 6.17-727-7'749 Date.............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ) ...... -.. q ............................................ has permission to perform—. --4—;-- ........ wiring in the building of ... ................... at ...... ............... North Andover, Mass. Fee RN5.1 . ... ..... ...... ....... Lic. NoA ... 11.1. �O/ ..... ........ PL. ic INSPECMR Check # 8554 5 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Utt,cial Use Only Permit No. (� Occupancy and Fee Checked . :ev. 9/05) (11,, hlanIA 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 PRINT IN INK OR TYPE ALL INFORMATION) Date:d City or To#0rA ,9y, cL L, e i,.. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) :ta Owner or Tenant e Y C �> ah cfp, Telephone No. Owner's Address �.� �„ �� Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building 61114A-�,z Existing Service Amps / Volts New Service . Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No L!J- (Check Appropriate Box) Utility Authorization No. Overhead ❑'1 Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters PP- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: /c7 Ar. /Og LIC. NO.: Licensee: Wq / lr y '. /'u >" 5 Signature ' IC. NO.: (If applicable, enter 11 " in the license r mI - lige.) ,4 /l/ P� Bus: Tel. No.: �0 3 -0 Address: 7` yt i /f-® ' Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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 a-ent. Olyner/Agent Signature Telephone No. FPEZ ffT FEE. $ -—uwus aume MGoe watvea by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans °• °Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ - ❑ o. 01 Emergency Lig g rnd. grnd. Battery Units No. of Receptacle Outlets a No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o etechon an initiating Devices No. of Ranges No. of Air Cond. Total Tons N o. of Alerting Devices No. of Waste Disposers WR75-m-- e umber. ons o. of Self -Contained Totals: I I I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local umcrpal ❑ ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: * No. of Water Heaters KW No. o o, o No. of Devices or Equivalent Data Wiring: Si s Ballasts N of Dvices or Equivalent No. Hydromassage Bathtubs No. of Motors. Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: /c7 Ar. /Og LIC. NO.: Licensee: Wq / lr y '. /'u >" 5 Signature ' IC. NO.: (If applicable, enter 11 " in the license r mI - lige.) ,4 /l/ P� Bus: Tel. No.: �0 3 -0 Address: 7` yt i /f-® ' Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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 a-ent. Olyner/Agent Signature Telephone No. FPEZ ffT FEE. $ Date ../.;/. HORTM o� TOWN OF NOOT+ ANDOVER �• PERMIT FOR -GAS INSTALLATION SSACNUSEt I This certifies xhat .. ; .. .... .. ...:... . . has permission for gas installation ............ .. '. in the buildings of .. . . at ..,OfJU. Lit. .............. North Andover, Mass. Fee. Lic. Nol ? ? �.... ..... h . ..... GASINSPECTOR Check # ! / 6674 .� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING _ (Print or Type) Mass. Date �A� �� Permit # LJ e rs Na V,4 Agr Building Location- /-)/J,ad Vb 7k mg g Type of Occupancy, 10 New p Renovation ❑ Replacement Pians Submitted: Yesp NoX Installing Company. Name-, BRADFORD PLUMBING & Check one: Certificate Address HEATING MECHANICAL INC. corporation Lic. #12580 Tel. (978) 521-0262 — P.O. Box 5269.. _ _ ❑ - Partnership Business Telephone Bradford, MA 01835 L7 Firm/Co. Name of Licensed Plumber or Gas Fdter1 f� MSS Al INSURANCE COVERAGE: I have a cuqqg liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ . - if you have.cfiecked rtes. please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond 0 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: OwnerO Agent ❑ Sionature of Owner or Owner's Aaent I hereby certify that all of the details and information 1 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 or this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Generale.y �.; •_••••- ��, By'. T of Ucense: umber Sigr agure� a ofL sed Plumber or Gas titer Title Gasf-fitter ��s-�v er License Number City/Town Journeyman NL Z c O J � O � 1- W. F v O W = IL O O IL 6 W p. ae O Cf m � < .. v J ..a a of W Ao W O r p W - _ Y W c O 1- W 6 ae Cf � 2 O p W < m, am .pJ O atua O r c c ID C W - _ i f Date. J . . TOWN OF NOR 01 ANDOVER OA PERMIT F PLUMBING SSACNUS� This certifies that ... 1 / c� GJ� ..... , . 4 ..... , ...... . has permission .to perform ......r/. .. .�..................... . plumbing in the buildings of ./%��.>".�' 11 ��i� ........... at .f.Gd:.�f'.S..r. �:.>................. North Andover, Mass. Fee:4��.... , Lic. No../. ?.L t : . .. �..:. . LUWING INSPECTOR Check # 7962 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date 20 aPermit #-2- 6 Z Building Location IDD -11q&`� j0 Owner's Name AA 11i9/16 C fQOr�c 0 Type of Occupancy_ L rJeL//&�.�3/ . New D Renovation O Replacement Plans Submitted: Yes O No FIXTURES d x � f- ..� O Z W Y J W Z N < ¢ CC ¢ = r = O Z H a O- W H W Irl CC V ¢ N f - v N 0 m Ut v x ct r< F avi a o< d< o x us p C p 0 1= 3 z n i= Y Y< W U- 0, x < `< = N N Q < ~O Z O O N __ _ ,yr F O V S Pp Y J m < J < IL' iL < O < H stir—BSMT. BASEMENT 1ST FLOOR I 2ND FLOOR 3RD FLOOR -4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Address Business Telephone y BRADFORD PLUMBING & Check one: Certificate HEATING MECHANICAL INC. — Lic. #12580 Tel. (978)-521-0262_ Corporation o�J� P.O. Box 5269 D Partnership Bradford, MA 01835 _ D Fmt/Co. Name of Licensed Plumber INSURANCE COVERAGE: I have a curre .91 liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have c ecked Yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity O Bond D OWNER'S INSURANCE WAIVER: t 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: -...-- ^ --- -- ^ ----- Owner 'D Agent D 1 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 knowiedge 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 Plumbing Code Ater 142 of the General Laws.w , Title Ngnature� f City/Town U I ber Type of Ucense: Master Journeyman E], APPROVED (OFFICE USE ONLY) License Number A 7C > 'a m V T O > n a w� r m m o; z m O O x o O � � n m � o c e N' o m 0 t to. • � z r O r C -c m r z Z. z .l O' A 7C > 'a m V n a w� m a o; z :Ev O O O � n m � o c N' o m 0 0 • � z r r c -c m z a (.-.. '-, Date.............. U TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SSA�NUSE` // This certifies that .. ....... .... ....`... .... ........... . has permission to perform.. ...... `.... ^................. plumbing in the ,buildings of at ..�. .. .:!�-\.� .. , North Andover, Mass. •� h�� ��� Fee��.....:.. Lic. No.. d ...... �' � ............. PLUMIBIN� INSPECTOR Check nx MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print Type) IV 4dj bM . Mass. Date L.F2Qfl Permit # Building t_ocation„�„��_��91�//� X/ d� Owner's Name /%l�f//�?V(%L� jl' ° ,G�iii� /�i Type of Occupancy New ❑ Renovation ❑ Replacement , Pians Submitted: Yes O No FIXTURES Installing Company Name BRADFORD PLUMBING & HEATING I Check one. Certificate G Address Lic. #12580 Tel. #(978) 521-0262- P.O. Box 5269_ �� BRADFORD, MA 01835-0269 ❑ Partnership. Business Telephone - _ -- --- - - _ - ❑ Frmm/Co. Name of Ucensed Plumber _ 1 is /W ES _AZ/ / C/2:ZZ- INS URANCE INSURANCE COVERAGE: I have a curr liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IQ No ❑ If you Have chicked ves, please indicate the type coverage by checking the appropriate box A liability insurance policy 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: -- - -. - -- Owner'O Agent ❑ 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 Plumbing Code and ter 142 of the General taws. BY Title Signature censed r� City/Town Type of license: Masts Journeyman ❑ APPfK7VED (OFFICE USE 0NLicense Number . z ' N ic in cc O Z 4 .� In.. I c O -n j O. N O O O • L7 3i N • • N • - 111 02/06/2007 10:00 9785212751 .CSN CERTIFICATE OF LIABIL PRODUCER (978)373-5623 FAX (978)521-2751 ANTHONY & MALCOLM INSURANCE AGCY., INC. 3 SO. CENTRAL ST. PO BOX 5128 BRADFORD, MA 01835 INSURED PO BOX 5269 BRADFORD, MA 01835 PAGE 01/01 ITT INSURANCE DATE (MMIDDIYVYY) 02/06/2007 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURERA: Hanover Insurance INSURER B Travel ers INSURER C: INSURER D: INSURER E; E47 -- THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P, ANY REOUIRErMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHI! MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ::p CLAIMS MADE a OCCUR A GEML AGGREGATE LIMIT APPLIES PER: POLICY JER-COT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS A X SCHEDULED AUTOS X HIRED AUTOS X NON -OWNED AUTO 1 GARAGE UABINTY I ANY AUTO PESSILIMORELLA LIABILITY OCCUR 13 CLAIMS MADE A DEDUCTIBLE RETENTION E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY B ANY PROPII ETOR/PARTNER/E7CECUTIVE OFFICERIMEMBER EXCLUOE07 It yes. desetibe under SPECIAL PROVISIONS bnl— i Ming ng & HeatOF OP eatERATI�ng S! LOCATIONS 1 YEHIC4ES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS & PLUMBING INSPECTOR TOWN OF NORTH ANDOVER ATTN: PLUMBING INSPECTOR TOWN HALL, 400 OSGOOD ST. NORTH ANDOVER, MA 01845 ACORD 25 (2001108) FAX: (979)521-026-2 7 )LICY PERIOD INDICATED. NOTWITHSTANDING :H THIS CERTIFICATE MAY BE ISSUED OR NS, EXCLUSIONS AND CONDITIONS OF SUCH LIMITS EACH OCCURRENCE_ E 210001000 DAMAGE TO RENTED S 300, OOO MED EXP (Anyone person) E ILS, PERSONAL d AOV INJURY DO GENERALAGGREOATE E 4.000 OO PRODUCTS - COMPIOP AGO E 4,000.000 COMBINED SINGI.E LIMIT E (Ea a=idnnQ SOOILY INJURY E (Per person) SOD'o 00 BODILY INJURY E (Pm Pcck%nU 500.00 PROPERTY DAMAGE E (Per uua�) 2 50 000 AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY: AGG S EACH OCCURRENCE $ 1,000,00 AGGREGATE S 1,000,00 S E S WC STATU• 0TH. E,4, EACH ACCIDENT S 500,000 E,L DISEASE • EA EMPLOYE S 500 ON C.L. DISEASE - POLICY LIMIT 5 500,000 SHOULD ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1,0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Frederick Malcolm Ir.13A (DACORD CORPORATION 1398 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ! ..:.......?.... . has permission. to perform` -N" plumbing in the, buildings of . .... ....... at ......:.:�-'�'?.. ,North Andover, Mass. 9 Fee Lic. N 1 . ................ ...--� �v PLUMBI' G INSPECTOR Check # ,-ad 7Q ! 6 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location �� ,�� L\Jle Owners Name Date Cin C0-Q�!) Permit # 7, Amount Type of Occupancy New Renovation rl Replacement Plans Submitted Yes No ❑ FIXTUR FN (Print or type)�46� � Check one: Certificate Installing Company /Na�me_n ' r'r ff ❑Corp. Address ��'1./ 1"� /7yL% /%�!�.�.9P� /%%�. d���� . ®Partner. usmess Telephone. % _ Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the ty e of insurAnce coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ® Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature IOwner ❑ Agent ❑ 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 Perfiorined under Pe 't Issued for this application will be in compliance with all pertinent provisions of the Massachusetts ate- umbing Code d hapter e General Laws. By: ignaure o1 --nisto numoer Title Type of Plumbing License n 60 City/Town - cense um Der MasterF-1Journeyman APPROVED (OFFICE USE ONLY L/I 60 Date .. .........r....... . NpRTN - TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION his certifies that . ........... ................... has permission for gas installation .... ..............-?.G -G�- in the buildings of . 't T�^—��'�. f 8 a at ..... .. ... ... . � `.�-: , North Andover, Mass. c Fee.... ''. Lic. o. ;.�. rL GASINSPEG A • Check # :-)217"d 6505 MASSACHUSETTS UND-ORM APPUCATON FOR PERMIT TO DO GAS FrrnNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS l� BuildingLogations Owner's Name New Renovation Replacement SU B-BASEME NT BASEMENT rA FLOOR 2ND. 3R D. FLOOR FLOG R 4TH. 5TH. FLOOR FLOOR W, FLOOR 7TH. 8TH. FLOOR. FLOOR w z z d W .0 SU B-BASEME NT BASEMENT IST. FLOOR 2ND. 3R D. FLOOR FLOG R 4TH. 5TH. FLOOR FLOOR 6TH. FLOOR 7TH. 8TH. FLOOR. FLOOR Permit # Amount $ Q c Plans Submitted 0 or type) Name /Jn hp ¢�" Check one: Certificate Installing Company ( (j� M 0 Corp. Address + ale 0AV,-,1 1994, Partner. Business Telephone _ Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes E3-- If you have checked es please indi he type coverage by checking the appropriate box. No� Liability insurance policy Other type of indemnity ID Bond 13 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. Signature of Owner or Owner's Agent Check one:Owner 0 Agent ri I hSreby 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 rmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts 5tafe.Code and Chapt 42 of the General Laws. IC y: itle ity/Towm PPROVED (OFFICE USE ONLY) Signature of Licensed Plumber OrGas F' )slumber2 e Gas Fitter Licenal. 114UMUCr Master 0ourneyman w O Z z wa p � W x i n a a fi CF F F «] 3 A 5 O C9 > a Q c or type) Name /Jn hp ¢�" Check one: Certificate Installing Company ( (j� M 0 Corp. Address + ale 0AV,-,1 1994, Partner. Business Telephone _ Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes E3-- If you have checked es please indi he type coverage by checking the appropriate box. No� Liability insurance policy Other type of indemnity ID Bond 13 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. Signature of Owner or Owner's Agent Check one:Owner 0 Agent ri I hSreby 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 rmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts 5tafe.Code and Chapt 42 of the General Laws. IC y: itle ity/Towm PPROVED (OFFICE USE ONLY) Signature of Licensed Plumber OrGas F' )slumber2 e Gas Fitter Licenal. 114UMUCr Master 0ourneyman Date ... . tom. ...... ;� f NORTIy , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. _ ....... .... . has permission for gas -installation in the buildings, of ........ . at....... Fee GAS Check # �'� g 5895 i forth Andover, Mass. MASSACHUSETTS -UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING _ (Pratt or Type) Mass. Oates? l +`'?P ':�G' Permit Buttering Location ti fid® AShli,'° me/ V__ "rs Name ✓i��% ����l u� 1�.r75 Fir - I ype of Occupancy G New 0 Renovation Q Plans Submitted: Yeso No0 Instaukrg Company Narnk BRADFORD PLUMBING & HEATING Checkone: Certfirate /drCss Lic. #12580 Tel. #(978) 521-0262 Corporation P.O. Box 5269 Parfiersttip BRADFORD, MA 01835-0269 _ Business Telephone - -- -- - - - - — -- _ _ _ _ �} Firm/Co. Name of Licensed Plumber or Gas Fdier 1-'1 �s D 7 tCG INSURANCE COVERAGE: 1 have afrability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YM No 0 - If you have. ed,Xes. please Indicate the type coverage by checking the appropriate box A frahgtty insurance policy Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the frcxnsee does not have the insurance coverage required by Chapter 142 of the Mass. General taws. and that my signature on this permit application waives this requirement. Check one: Owner© Agent ❑ Signature of Owner or Owner's Agent I hereby certify that as of the details and information I have submitted (W entered) in above application are true and accurate to the best of my --lanovrledge and that as plumbing work and antattations performed under the permit issued for this application will be in compliance with all pertirten provisions of the VAssactunetts State Bas Code and Chapter 142 of the r � ' Laws. t3y- Tamd of License: az,:-� mbar or Gas rtter TrtN Gasfr�er License Number %75x0 City/Town J!wmeyman i ■�����������0�����■111111 Instaukrg Company Narnk BRADFORD PLUMBING & HEATING Checkone: Certfirate /drCss Lic. #12580 Tel. #(978) 521-0262 Corporation P.O. Box 5269 Parfiersttip BRADFORD, MA 01835-0269 _ Business Telephone - -- -- - - - - — -- _ _ _ _ �} Firm/Co. Name of Licensed Plumber or Gas Fdier 1-'1 �s D 7 tCG INSURANCE COVERAGE: 1 have afrability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YM No 0 - If you have. ed,Xes. please Indicate the type coverage by checking the appropriate box A frahgtty insurance policy Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the frcxnsee does not have the insurance coverage required by Chapter 142 of the Mass. General taws. and that my signature on this permit application waives this requirement. Check one: Owner© Agent ❑ Signature of Owner or Owner's Agent I hereby certify that as of the details and information I have submitted (W entered) in above application are true and accurate to the best of my --lanovrledge and that as plumbing work and antattations performed under the permit issued for this application will be in compliance with all pertirten provisions of the VAssactunetts State Bas Code and Chapter 142 of the r � ' Laws. t3y- Tamd of License: az,:-� mbar or Gas rtter TrtN Gasfr�er License Number %75x0 City/Town J!wmeyman • r } x co nt 'Q ` v lop 10' - O - 32 . . _ y TOWN OF NORTH ANDOVER -Iwo- This PERMIT FOR GAS INSTALLATION '!� fact ��h i"-) )- � certifies that .. ........... ..... ................ has permission for gas installation ...�.�!#.:.G�!.'.......... i in the buildings of ..r :�: .`aF^. .::. ..... . ........... . at .� u : .. rl.� 5... :r ........ , . , North Andover, Mass. Fee.:a...'. Lic. No........... ... .. (> ,.,--�....... . // AS INSPECTOR' Check # 3) � )' 36°3 j � i �" .. � � � 3 �� . _. . � s � �_ f s '� — � +� �' _Tt i .f �` j � � � S ' � Q` .. -�� x Nt y; x# � �� � � �� �� � �. �. ��_ � n' ��� � y�y i � r d .V q A "t x H 1 J t 1�l' � � � .i 1 � a ` f �, `. jj$ �, �,t w ` � d ��,� '>q .. r � �I � � � � �- .�. � - j � � k. �" .. � � � 3 .� _. .. .. Y� .fix' f. � �-4� t f s � �`. ; ` �' _Tt f + M" , � - Q` .. x Nt �. r � x � � � � � �; �7 � �� �' $6 ht Q � � Y i't p g�y. � # 6 �_ 5€ ;> f aka �3 M �, i � �r �. pqLq� VI 1.r �.� - ®' .. �{ .O rn �, �' - �: .. .. t ^� .. '� 4 I � T� '- d� 6.�. ., .f. t .. '.. ' j � � k. �" .. � � � 3 .� _. .. .. Y� .fix' f. � �-4� t f s � �`. ; ` � _Tt f + M" , � - Q` .. Nt { NORTH TOWN OF NORTH ANDOVER p� PERMIT FOR CAS INSTALLATION F s This certifies that ..Tse . . has permission for gas installation .. JA(. ......... in the buildings of. ... �....P 12... ................... . at ............ North Andover, Mass. Fee.. .? .... Lic. No../.' : t �? .....�:. :�_....... . ,GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ASSACHUStM t1N1FoRM AMItATION FOR B'EiftlV#�T O 1D� �AsFii`TINC (prrrit of tyi�elf' Date _ z �_w../y 9. i'errnir 3' 3 l r — -- # .._�. - ' }' Building Ctii`ati��n_��:� / LASljip� {owner's Naiile%�1//�lU._._ l ype of 0aupaincy_-4A, 11 4 1 04990 New 0 Renovation CI ttepi�ttemenT� Plarns Sufimilled: Yes 0" . No�Q MILT tAfM (}VEFt710Ei 0 have aX gt�` t tFatyiti y ltiwmnce j'yP)ticy fir its ttih5l:Inti it eryuivalnnt which mpt•tt file re4juirenleni4 bt M61,Ch. 142. f 60 JA4-V0 cher ittci tre>T, tsti ate inil tato the Type rPlver,1Re by i hC king the aptsropriate hr1x. A tfxthlity iiicUr it p Fmlicy"K, 016i tyke of indemnity l] Bond t„l ' fFfS1JflAtV� FdVAlitfitt I 'min Awaii 111,11 thit- lir nnci'fi dt169 not hA%,e this f1je.1' nre tr3vhta�C rl tluf.refl by ("hnfitl t i 42 tlf file- M cc, dstsrtetat tavr5, arts! that lriy SIf¢natura on this perntil 1pplieatilin walves rhis teglfiremprit ' Check eine: 5ighitU14 of 0WO't et Olklidt's Alit=rot a _._ _ ___ _ Owner i, l Agt�t9t C 1 til "i,l ^+iti ry. ttv 811 fir ihr r'1✓gAits 5nti ;rtirtimaiihn 1 h vn :,r�i mitr+wl 4.>r nntrepttl in dx+ efwtpt appflr:alli»t are iru� Aitrl at'riume t6 Itr! omf tit .Pity Wnwloly,F And Illit all 1 tntl . srrT ivvirnttaf: vz ttwtfn.ir'tnt itralr+r the• t�rmil kmtretl 6. fW% al'i'Vnitlnn �oill l.F in (.0Mtt118tieA W101 All �tertinntil tilUvi�(tmi til ffic Mritear'hii5eth State r;as l'txtF anis (ltaltlei 142 tit Ihp (Pr et, itat' 4 •..:. - -.- _- l IK' if 'Ov ei lnorrteyinan p '�tfy ,.Alf �nir Nutntir`t Ar'F^iT<)V11) 4l'1t134 F t t[F titJi Vt z i w d k q� . ¢ ; .§ �� § b � � \��� , ��°�w°� o z. � . . > / . .. .- . /^ e � ) . d / \ � . .. ,. 7 � .�� 7 � � � g � �/\ !. .� � . ; | : � . � - � d �\ � \ §��� y � � <�.»�`\$�? . � � ° /- <\ b. . . � | � �. °� :\ �. ^ . . � . � � �. � . . \ §° � � . . ! <�\ . \�\ .. � , \°.\\. , [ ( . . � . �y . � �|� | |.. . �� . : . � � L , � \� . . . \� { \ � \� \ � � . 2 \ > . �� . ; !�\\. \�� y..��� . z i w d k q� . ¢ ; .§ �� § b �§. \. § o z. q . § > / \ ��` � ) � d �. � . m � .� z i w d k q� . ¢ ; .§ �� Date. 5�'. - N2 4454 0. TOWN OF NORTH ANDOVER oo` PERMIT FOR PLUMBING � JSACNUSE / This certifies that has permission to perform ..../9 ! .......................... plumbing in the buildings of .``.... fl :.!7 atNorth Andover, Mass. Feehr✓h r. Lic. No.......... `� .. ........... �1 PLUMBING INSPECTOR Check #-30-;,--- WHITE: -3U>'— WHITE: Applicant CANARY: Building Dept. PINK: Treasurer z r.v. DOX 5Lb`J i BRADFORD, MA 01835-0269- a p' i-i�iimyCo t �1?trS-sSihbtie ` t. s , _ v I tBfi�+1�h�i� I _ k ty ttti€ttte its Ce �:ii Oita polios 6t subSt3tri{iR egt�iv�t }+Ori �jt�� ��1� � Ye filoi ; �t �+� ihct���ic lhe:typ�� t0vera9d by dh6d lnq thea 5 tk •.k iippres mate b6x Z'.ti Ah fii5 y Cyttler type of #rtt;ferrtt�itY .. 9 Bond b41 t ani aaiare that the ircentye t��,et itbt hive the irisurahe the �� t t.F3VY r�6� 1�d1 hey ��ve"re ieui�ed t5; Ctra f r y _ {�¢Iit4natore on this 0errriit fliCatl(1i1 waives ttll$ egtJi%�ftt�r�t _ heok�e. tt 11i�vr� Location lV v �A,y SA f p No. Date t -p �oRTM TOWN OF NORTH ANDOVER 3? .. o .. a Certificate of Occupancy $ CMusEt� Building/Frame Permit Fee $ ,. Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ S C) Check # ! C/ v 15791 110114 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING E Section for Official Use ®Dgl :,•� � ��_�� .� .� . ��' � � k ����� :,�_ . �� .,,, BUILDING PERMIT NUMBER: DATE ISSUED: , SIGNATURE: Buildin Commissioner/I or of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number. too F laci sh i ma7 v -e a7C 4P Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Rewred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System- ystemPublic Public❑ Private ❑ Zone Outside Flood Zone ❑c Municipal On Site Disposal System ❑ T5 �✓� r. Gr ..;� � !Z x.� ., .,.5 ,a iaC.. .. .aJ _4ft--C _ ..: . 9ii i aAL•a: r:a �... �, 9 .. $ n �. 2.1 Owner of Record RRavollex R eorod mac,+�crns �.o r�(Jt) Address for Service: 979=69s_- 2911 Signature Telephone 2.2 Authorized Agent Name Print Address for Service: Signature Telephone _ s T ,"icensed 3.1 LConstruction Supervisor Not Applicable ❑ Sam CAA. onesC lcj CS O 3,-9"1 Address ILicense Number Licensed Construction Supervisor -7113103 Expiration Date '7 O Signature7 Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name- Registration Number Address Expiration Date Signature Telephone '0 M X Z 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 pe. mit. Signed affidavit Attached Yea ....... No ....... ❑ SEC"X 1E4PT S ;PlttiD.S©N , YfSICaN Gi�TSTRiTC ISN)RIC) lE� (;rl Bfiilf?IaGS ,iu p 5ItUt:'t5t9f T{) GONSTBi+viDi€3N C43]t3I:'' %Ila €R 11 r+Cil!trfl�? 1 ,OQ6 CF O 1,3Sll�b At) 5.1 Registered Architect::.? " Name: Address Signature ., f Telephone s �� SRTl'MOi Q$],�S�TL <✓� 'oaf re { Area of Responsibility Registration Number Expiration Date Name: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Wilk gl �r N� Not Applicable ❑ -. Company Name: Responsible in Charge of Construction New Construction ❑ Existing Building Repair(s) 0 TAlterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 0 A-3 ❑ 1 /57 BUILDING AREA Number of Floors or Stories Include Basement levels Floor Area per Floor (sf) Total Area (sf) Total Height (ft) Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, PROPOSED Owner of the subject property Hereby authorize J aft?d l J. 6u.,4?Wd ii eSC!c , , to act on My behalf, in all matters relative two work authorized by this Building permit application L Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 0 A4 ❑ A-2 A-5 0 A-3 ❑ 1 ❑ IA 1 B 0 ❑ B Business ❑ 2A 2B 2C 0 0 ❑ C Educational 0 F Factory ❑ F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional ❑ 1-1 ❑ I-2 0 I-3 0 M Mercantile ❑ 4 0 R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ S-1 0 S-2 ❑ U Utility M Mixed Use S Special Use ❑ ❑ 0 Specify: Specify: Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: i Proposed Use Group: Proposed Hazard Index 780 CMR 34: BUILDING AREA Number of Floors or Stories Include Basement levels Floor Area per Floor (sf) Total Area (sf) Total Height (ft) Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, PROPOSED Owner of the subject property Hereby authorize J aft?d l J. 6u.,4?Wd ii eSC!c , , to act on My behalf, in all matters relative two work authorized by this Building permit application L Signature of Owner Date I, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name > .... _ R Signature of Owner/Agent Date Item Estimated Cost (Dollars) to be Completed by applicant permit 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction from (6) T' Plumbing Building Permit fee (a) X (b) / 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) (05000 _ Check Number } �.'��it`�'!� �R6'�Fd� }a�': A�l tit tl'i''i,��p ""t -'4-'S '.+a�.�r�.4 ?! �Zu ,'>,!&^"t ?, i`•..� r t'a wce`:`. :rh . [�. S a3"»...;£ .1.. :"i 134i13, g r'Y 3.lz1t`jt •-w b F:3 V /4 i.f ! Y 5 11. `7y 31 'iH T �`i 5 Llit 4'v. Y'n § 9 , �� i` i � f f ' {" �^ .�, • !� +.s'n ' Y 4� �-.'� �. K'., s l�'t'}' xrix$.'a. [ ., ' "l'%f�, 43:,.„? +�a. 5 e�. 4 .9 '� v''�i .� s, i•�551 . �� j, . �," v f NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TWBERS 1ST 2 ND 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DMffiNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CIMMEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i ��. h� }`•�'. .:},�i"�` { ��.& "r`]-,.�f` .s.. `�,�{�' N-$ '�•� ��� ii�'ye%'.T`s 5 -}hS+p.. � ��.. , .L PT '. ' :a�� -' K" .v 1. >'F ✓ iy.d2 t 'ftia � �! ?:i'2. A'?'�x t�,,...^.'a. `§.-i�se '.-r .S*..ta" �'S }-1 �¢ } F� IXC' h~1�� n ��� � '�+ i ��'�va k � ✓le '�u�rsira�trrwr�l� n!,_/�iaurrrfiudnl/d RODE IRPROAERENT CONTRACTOR Registration: 100614 Expiration: 06/23/2002 Type: Private Corporatio URI -PLY ROOFING INC. Saouel Caaponesch G� &#--Woros Uay ADMINISTRATOR Riddleton NA 01949 .---'-- ✓tie %�o��ronalru��ll�. nj'� l��r:r�.r,�.rufP,d.6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 035819 - - Birthdate: 07/13/1946 ' Expires: 07/13/2003 Tr. no: 11797 Restricted To: 00 SAMUEL J CAMPONESCKI _ 12 CATALPA ST WAKEFIELD, MA 01880 Administrator. -.� ✓s7e ija�stmzonuin,2l/�of .h �l ��J:7rzrl,.uJe%f.0 DEPARTMENT OF PUBLIC SAFETY License: HOISTING ENGINEER LICENSE Number -HE 049874 Birthdate: 07/13/1946 kt Expires: 07/13/2003 Tr. no: 23808 Restricted To: 1B,2A,4A SAMUEL CAMPONESCKI 12 CATALPA ST WAKEFIELD, MA 01880 Commissioner "0170 CERTIFICATE OF LIABILITY INSURANCE BJ DATEIMRDDNY) P-1 1 07/02/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McSweeney R Ricci ins Ag Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 420 Washington Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 850984 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Braintree MA 02185j Phone:781-848-8600 Fax:781-843-8807 f OISURERSAFFORDiNtiCOVERAGE INSURED A: Acadla Insurance C les INS: uni-Ply Roofing, Inc. INSURERC: Sam Camponesckl Niddiet naL 01949 � ¢ @ISURER e: _ C(WFRACES THE POLICIES OF INSURANCE LISTED BH.OW HAVE BEEN ISS TO THE NAMED ABOVE FOR TM POLICY PERIOD RNICATED. NOTNRitFSTmwm ANY RMUW--M Dff M M1 OR CXINDL MOF ANY CCLYTRACT OR OMM DOC i VMM ATO WHCH THIB CERTIFICATEMAYBEISSUEDOR MAY PERTAIN, THE INSURANCE. AFFORDED BY TTE PC UCIES DESCRIBED HERIM ISSUBJWtTOALTMTUWADMUMMAMCGNMKMOFMM POLICIES. AGGREGATE LWMTS SHOWN MAY HAVE SEEN RMUCED BY PAW C:LAIMB. NSR ILTR TYPE OF INSURANCE POLICY NUNmm PDOANAW PEAMEOWNWIN Lmrs A GENERAL LIASUM R COMMERCIAL GENERAL LIABUTY CLAIMS MADE ®ocCUR X Blank Add ins _ .. --_ _-_ CPA0074506 _._. _ 02/15/02 02/15/03 EACH OCCURRENCE a 1, 000, 0.00- FIRE DAMAGE (Aryworn) $50,000 MED EOP (Ary am pmm) $5,000 PERSONAL& ADVKIURY $1,000,000 GENERALAGGREGATE $2,000,000 GEWL AGGREGATE LICIT APPLIES PER: POLICY M WT LOC PRODUCTS - COMPIOP AGG $2,000,000 A AUTOMOBILE X ][ X UABNJrY ANYAUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS N0*OVVNED AUTOS XRF007447610 02/15/02 02/15/03 Me80idengR�tGtELIYIT $1,000,000 SO BAY $ iBODLYRUURY S l IP -)PROPERTY $ DAMAGEri GARAGELAIWHY ANYAUTO AIMOLaY-EAACMDENT S OTHERTHAN EA.ACC a AMONLY'ONLY: AGG $ EXCESS LIABILTiY OCCUR Q CCAIMSMADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE S AGGREGATE $ $ S WORKERS COMPENSATION AND EMPLOYERS' L IABGM I WWI I ER EL EACH ACCIDENT $__ EL DISEASE -EA EM0 a ELDfSE&%-POLICYumrr a OTHER DlDSCRPTLON OF OPSRATLONSR OCA ADDED BY EMORSEMENTISPISCIAL PROVOONS The Workers Comp will be forwarded to you under separate cover by the ins carrier as per MA Pool Performance Standards, agents are no longer allowed to issue certificates. RZ: DPW. CERTIFICATE HOLDER IN I ADDITIONAL INSURM. R NmR LETTER CANCELLATION --...__.__.........—_ ...._........ ...... TO1=F2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRAMM DATE THEREOF, THE mmmG LNSLRER WILL ENDEAVOR TO MAIL. 10 DAYS WRITTEN NOTICE TO THE CERTUCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL UWOSE NO OBLIGATION OR LABRJTY OF ANY KIND UPON THE INSURER, trS AGENTS OR REPRESHNTAUVES. 0 ACORD 25-S (7197) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CER71FtcATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND. EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. is to Certify that UNI -PLY R( OFING, . PRODUCER OF RECORD: 3 FORMS WAY MCSWEENEY & RIC CI INSURANCE MIDDLETON, MA 01949 AGENCY, INC. PO BOX 850984 BRAINTREE, MA 02185 e Isst date of this certilicare, insured by the Mpany under the poticy(res) listed below. The insurance affordedby the listed po li cy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be issued - TYPE OF POLICY POLICY DATE POLICY NUMBER LIMITS OF LIABILITY Law of the Following covWC . 02-26-02 TO WC1-31S-332981- States: MA bodily injury By WORKERS 02-26-03 012 Accident Each $ 500,000 Accident COMPENSATION Owily injury By Disease Each $ 500,000 Person $ 500,000 Policy Limit GENERAL LIABILITIf- $General ggrega r than PrRaWMiripleted Q $u e era ons Aggregate N/A N/A BW!ly Injury and Propertymage Liability $ OCCURRENCE Per Person/ Organizat Ion AU UIUMOSILE LIABILITY Each ccien - Single B.1. And P. D. Combined.:. Limit - ; OWNED Each Person NON -OWNED N/A N/A .. Each Accidentor Occurrence o HIRED Each ccien or Occurrence Ulf HLK PROJECT: THIS WORKERS COMPENSATION POLICY PROVIDES COVERAGE ONLY FOR THE STATE OF MA AS NOTED IN SECTION 3A OF THE ` POLICY HOMY OF ANY KIND UPON :ERTIFlCATE T HOLMER .,ertifica a is execu c Fi, WOW Im F=1r:ftXPM1;0mrM--- TTO TT � Liberty. Mutual MW OR Insurance Group M A AUTHORIZED REPRESENTATEVt�:: March 11, 2002 WAUSAU, WI FAA_rGa -1insurance as is afforded by Those Companies BS MR6 m m m < m m cn c CD _ p a O cc CD CO! 10 CD 0 Y a) ra d -m O y C7' c O c H n CD 0 �F CD CD N1 CD H O) cr C4) Q d d9 �.®ca _ 10 S - ® CL � CD m C2C m Z CO) ® c a -O vi ®:mCA a a CL o -10md G y N ohm: s O m H B OC n O co C y: n .� ? CD _ter a0�` CL =r ('/^� so o _a `''+^^i' CD� VN / c 1 O m`:� C Q 1 0 er. O N H O.d Q C CrD y `c A /^ a o � : �• vJ y`y d f�A z 1�o 7�� c Cf) C=. CD CD �j N CD Im a MA F D • ti n El O d c z � M M � '�] w 0 C O � �7 w c "XI G F H �1y w 7U C - Z z PL n "jq G x 'r7 G C r., z b C) z Cn 'O n �' cn 81 0 a x g d o t9xi'�. 7d • • 0 m o a. Date -0- ..... N04. TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION This certifies that 1.5 .... has permission for gas installation ... ff� ..... ......... in the buildings of .......................... at . / .4 k-.4 /1.'. -$......... North Andover, Mass. Fee.. Lic. No.. GAS INSPECTOR Check# A MASSACHUSETTS UNIFORM APPUCA _ (Print Type) /Ifi —Mass. �Dlati �. Building Location AZA-, Stn/� 1 IM New 0 Renovation [] It., FOR PERMIT TO DO GASFITTING o2a _.��266J Permit # 1? 7 Owner's Name 'q �Ff,eo0ucTi�a> — Type of Occupancy__! ®" iii Pians Submitted: Yes[] No'& installing Company Name Address Business Telephone BRADFORD PLUMBING & HEATING Lie. #12580 Tel. #(978) 521.0262 P.O. Box 5269 BRADFORD, MA 01835-0269 Nanta of Licensed Plumber or. Gas Fitter Check one. Corporation Q . Partnership j D Fum/Co. Certificate G INSURANCE COVERAGE: I have a c liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No 0 If you have. ed yes, please Indicate the type coverage by checking the appropriate box A liability Insurance poiicy� Other type of indemnity 0 Bond Q 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 requiremenL Check one: Owner[] Agent 0 Signature of Owner or Owner's Agent 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 wits be in compliance with all pertinent provwons of the Massachusetts State Gas Code and Chapter 142 of the General By Tjj oflicense: imber Si tensed Pl or Fitter Tette er !cine Number %a`Lsa C� City/Town .foumeyman .::....::....:..:........ � .......................... NEEKEE installing Company Name Address Business Telephone BRADFORD PLUMBING & HEATING Lie. #12580 Tel. #(978) 521.0262 P.O. Box 5269 BRADFORD, MA 01835-0269 Nanta of Licensed Plumber or. Gas Fitter Check one. Corporation Q . Partnership j D Fum/Co. Certificate G INSURANCE COVERAGE: I have a c liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No 0 If you have. ed yes, please Indicate the type coverage by checking the appropriate box A liability Insurance poiicy� Other type of indemnity 0 Bond Q 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 requiremenL Check one: Owner[] Agent 0 Signature of Owner or Owner's Agent 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 wits be in compliance with all pertinent provwons of the Massachusetts State Gas Code and Chapter 142 of the General By Tjj oflicense: imber Si tensed Pl or Fitter Tette er !cine Number %a`Lsa C� City/Town .foumeyman r