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HomeMy WebLinkAboutMiscellaneous - 100 HICKORY HILL ROAD 4/30/2018Date l Q7V��� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... %�`� ................................................... ......................... . has permission to perform ....� .�'' � �� � �/',� ��� .. �? 'fit/�- ti, b ' ld' f 0/ 1 fT wrong// m e ul Ing o .......................................... at...l...d D /.1C y,r.%....../ (:..1.�............ Fee .. .... "......... Lic. No. -� g. ! %3 ............... Check it (— f 9-7UI.—/ ..... , North Andover, Mass. ........................................... ELECTRICAL INSPECTOR Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use pOnl i Permit No. ) Z 0 — l Occupancy and Fee Checked [Rev. 1/071 (leave blank 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 W INK OR TYPE ALL INFORMATION) Date: /� 2)(5 City or Town of: NORTH ANDOVER 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) 106 H/C)ew y #/LL Owner or Tenant TUh 11) 6 H d1' to Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building PA)6-f� 1 -Amyl y Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: //USS �l,�1 +��- SD/'��1✓�' i�EGCr�i1�I C� N4x PEEL, Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. of Emergency Lighting Units No. of Receptacle Outlets —Battery No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .......................................................... Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent 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 W-�OND ❑ OTHER EJ (specify:) �/ jL/ j Y �/`Ii" I certify, under the pains and penalties of perjury, thattheinformation on this application is true and complete. FIRM NAME: _ i� r- Pt -V- t-4 G "/2/C, JQ CZF LIC. NO.: doj Licensee: Illw,- (!apy Signature A, LIC. NO.: a �� 73 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.•�T Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent IPPAHIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the I permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed I on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be.deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS CTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: �.--__ Date: 744 DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 5 .: The Commonwealth of Massachusetts .. Department of IndustrialAccidents 1 Congress Street, Shite 100 - Boston, MA 02114--2017 www.mass.gov/dia eM svV Workers' Compensation Insurance AfFidavit: Builders/Contxactors/Electricians/Plum ers. TO BE FLED WITH THE PERMITTING AUTHORITY. A licantlnzormarxuu � � Y_ Name, (Business/Organization/lndividual): 11 Address: City/State/Zip: E`1��1}�� � (� OI �1'l y Phone #: 7 l :......: •., ,.. Are you an employer? Check the appropriate box: Type of project (z'equired); em to ees (full and/or part -tune . 1. [g.1"am a employer with �— P y ( �--- ) 7. ❑ Nevv'c6nstruction 2.❑ I am a sole proprietor or partnership and have no employees working for mo in 8. [] Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 ❑ Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my properly. I will insurance or are sole 11. ectrical repairs or additions ensure that all contractors either have workers' compensation with no employees. 12. I PXumbing repairs or additions proprietors 5. I am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. have comp. insurance.t 13`.0 Ro6f repairs These sub -contractors have employees and workers' 14 1Other---- ther6.Q 6.nWe are a corporation and its. officers have exercised their right of'exemption per MGL c. workers' comp. insurance required.] 152 § 1(4), and We have no employees. [No *Any applicant that cheoks bbic gl must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit• this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. $Contractors that check this lic;j 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. sation insurance for my employees. Below is the policy and)oh site X am an employer that is providing workers' compen information. Insurance Company Name: Expiration Date: Policy # or Self -ins. Lic. #: Job Site Address: Ab a ��/t T l City/State/Zip: VA -14 D, � Attach a copy of the workers' compensation policy declaration page (showing the policynumber and expiration date). Failure to secure coverage as required under MGL o. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under flee pains enalties ofperjury that the information provided above is true and correct -\,v,:COMMONWEALTH OF MASSACHUSETTS: rLEZISSUES THEFOLLOWING Ll,CENSE A S A,MARK JI PERRY2 LINDA -XVf: AuMETHUEN --MA' 01844-45211893 A, 07/31/16 7 77 ` omm BOARD PF PERRY 2 L\NUA~AVE- WEM � `Ol8 4 4-45 �`� .-.-- .,/ . -ml-Ix CERTIFIED FOUNDA TION PLAN LOCATED /N "o T ----T- � zD, z- ss. SCALE /= 40' DATE ►� 9� Scott L. Gi/es R. L. S. 50 Deer Meadow Road North Andover, Mass. Le7T Zro 23,1 5S.IF. Eusr. 4a),cp � N nw w� NIc R�( Ali LL K,�Aj> - / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUIL DING /NSPEC TOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OFZONING BYLAWS OF CONFORMITY OR NON -CONFORMITY 140_ A02M A, WHEN CONSTRUCTED. WHEN BUIL T. v o�ti\ � JOHN F. c ZAHORUIKO No. 20563 ,0, 018TICY' `�S�YJN AL • A PROPOSEI) SITE PLAN ., NORTH f�NJDovf MA SCALE': s%44, y w S i' Lao 1 0 23, apo 13gt sF 'tea o,, •. 40 7/ I(p v �o � : N ED T r Vic;` 86++.54 �8 S o•�� Z�.�'' •N SQa�i "- �• JVJ o o�ti\ � JOHN F. c ZAHORUIKO No. 20563 ,0, 018TICY' `�S�YJN AL FORM U - IAT RELEASE FORM 0 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant Hills out this section***************** APPLICANT: Phone��- 05' LOCATION: Assessor's MapNumber `Number C2- Parcel Subdivision `� i D �tll Lots) Z16 Street/ �O St. Number ************************Official Use Only************************ RECOMMENDATIONS OF T WN AGENTS: Conservation Administrator Date Approved/ Date Refected Comments r Town Planner Date Approved Date Rejected i Comments Health Agent Date Approved 7 Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department ) .Received byl-`Building Inspector i .a &/V��/yam Date ,0s r*0a v t `0 O z Aits N 0� ^10 fir AN& re or% olopwM 11& oit Alts I `! x A x v $ w V z z A IS o w o � v U c w z z o a: c ii CLI z u w oc P4 cn w O w z � w w x A m' c/ o c 0m C H � O 4, v o N c _- N C co _ Qo c : N R CD , ja m Q -o C ' N CO 'L CO) E CD CLCSi N CD O ID ID � s C, a CD N CDC 2 0 C� H H y... N m •O+ LL h D R H N �C,C = w.E C ,cm3 COD a 2 cc 0 C42 m H �= H L a$ a w=., m co CLN N 0 0 N C 0 0 os O 2 cm c m 0 cm c C N CD Z O Z 0 O Wd C) S a CO) co .E CD co C O co Q m raj CO) O O C3 CO) c O V 0 C.) co Q CO) C a� J Q z z 0 Q Cr LU Cn z 0 C-) O 66 C7 A Co ~� `. Z 0 � U CIO W O U Wd C) S a CO) co .E CD co C O co Q m raj CO) O O C3 CO) c O V 0 C.) co Q CO) C a� J Q z z 0 Q Cr LU Cn z 0 C-) aoload ul2ugpyng �- i 7 ,, dW JanoPW LIgjoN SSd2IQ(Iv ` 'PE TT?H AJGo OTH 98T oxzruoLleZ •Q sswogl Os. G2nSSI UVJILII.LH2[3 'A'IddV AVW SV SNOLLVrM9aH H3Hs0 HXIS (INV 3000 ONIIQ'ILAU UVLS S,LLdSf1H3VSSVW dH,L 30 SNOISIAOHd dH.L H.LIM 33NV(MoOav ILII H9VV9 TVIJ Z M mITIHma A IIwvq 3'I9NIS SV QdIdrMo M AVw 9Z '40'I MH TrM LWOW= OOT NO Qd,LVJO'I 9 IIG IMH IIH,L JLVH.L SMMZ2III3 SIH,L '766T 8T qa3 alga £66T 6T'7 jagwnN liwJad 6uipjing A3Nddn3oo V 3sn d0 3.Lvc)uIIH33 )i d Asof or 1�+r OS A ISS 1 ^10,ft jes AOPPNPOPWP • "it Am I & s �ad :O z �I M z LU CL d CL N M h i N C O Q> co cm m Lo cm c .0 N C L 0 Z 0 a J �� 0 y co 0'1W, W o W x v cn �_ � N O_ ,jCL C � � G) CM z w O •� � Q m ccl W z �� �W a v w � Q o to fit a, n w cn w° :3cz �° U w ° 7 > ° v c4 cn a w" ° u; C 0 7 ` co cn cn �ad :O z �I M z LU CL d CL N M h i N C O Q> co cm m Lo cm c .0 N C L 0 Z 0 a J �� 0 y co 0 co co t R� O i CO O O R 00 O R R V J 'a 'Q 04, CO2C Z CD C.3 y R C 0 Q J N CD z z z J Q z N W Q cr W U) T s � N O_ ,jCL C � � G) CM z w O •� Q �cm Q m ccl W z 0 co co t R� O i CO O O R 00 O R R V J 'a 'Q 04, CO2C Z CD C.3 y R C 0 Q J N CD z z z J Q z N W Q cr W U) Location No. Date Check # �'/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � 176v 3 Building Inspecto PkMdNWAbot .13 z«ft1 1.4 h000ft Dbusku/ m a z 0 Q L7wmw bp*mmxa m 13. mwz4"hfxm lipi6 LSEewm eDBpoIWSyo- y' PIM a MMM 0 midr zam Oi+ba um a maw* -0 O.sbwnpads)wm D SF,t.nON 2'-MOMM MMOVIAMOMM "M mt 11 Owwof ROW JoAlM L O Rd uf NIMePlid* AddieesfaSawice: &�Ame 2:20wwdRem No" ptw nddoa Ew Se Ww. Z X11 swumm SSMCK3 -. CONSTRUCTION SERVICES 3.1 LiccoW Cmwocdoa Supwdnw. NdAppGc" 0 Lioenaed Om&oation.SupeNisor: A C Cy Tdephoae. 3.2 Rego mW How lm;;;;u—w; Coa Not�►pQ6cati{e 0 v compw Name e E o !4 v m Wmbw m r Siaae Tdbobafte c cB�nwr'e _ atnvitt2ae rn�1vcA7T[1N (!Id /s i_ t� IR2 R' 2SrlL1 Waken Coq lasaranoo Wdik tmmt be a**W and m&AW vftlLis apAi wd n. Mm to:p w6h Ws wll m* in *t dwW of lbs isssaaoe of ide lkn4di"Aftdod Yes .....: SBCMON S Atli of "Owork' raw o Exi i g©. aapau(s) a Alteiatioas(s) a Addition AcoemMBldgs D Deatolitlar► 0 Outer 11 spea$� �Des�ar cf Prcposod w� Cal ST (u, 4ee�c �� l SECnON 6-ESTTMAmm CONSTRUCTION COST$ heat Estim*d Coal (DQW) to be i. Bne�d+ng .- i (e) .Btu�ding'pei�at"tFee . r Mnl 2 gleatocel M. Esfimabed ToW Cost pf . CCpOn: 3 PbmbingBsilda�gPemiitfoet+)x-() 4. Mmbanucel AC ' day 5 FheFirotW4m 6 TOW 1+2+344+5 CiieckNmnba SECTION 74 OWNERAUTHORVATTON TO BE COMPL M WHEN OWNERS AGENT OR CONTRACTOR APPLIES FORBUIWIKG PERIM as OwnedAWodnd Agentt ofsabjeotpapatY MybeW-I�C[Cby`8u�1011aC s 1AMxon fi in all mafts:rew, w, towarka>rtbm*d.byNsbuilftpe G*apphcatiam' Siegm of Owner Date SECTION' 7b :OWNEIi/AUTHORIM AGENT DEQ.ARATION amwA od Aged of u6ject Hereby deolae ih .ft sta weM mld infam0t Im thefrrgoft qpucwmaret"and aca>mte•, tn:6ue W of my lmowwp aad belief ; Print Nmne 3 Of. Dofir O.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TtMBM, ULs - 2f 3w SPAN DII+dEENSIONS OF•S)LhS .DIMENSIONS OF POSTS DRAMSIONS OF OMDM Z 7 HEIGHT OF FOUNDATION THICTCNESS SIZE OFFO07M X MATERIAL.OF CHMMY IS BU=J[dO ON SOLID OR FILLED LAND 15 BMDWG CONNECTED TONAMRAL GAS LM FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT -:ZA,11 C 5 �� �� r7 PHONE_7S- LP 7T -/ 3 LOCATION: Assessor's Map Numberl/ Oho PARCEL f7 !/_a SUBDIVISION_ LOT (S) STREET e G�-1 t I (��_ ST. NUMBER_I NO *****************************OFFICIAL USE ONLY***************** ** RECOMMENDATIONS OFT -OWN AGENTS: /COASERVATION ADMINISWATOR DATE APPROVED DATE REJECTED_ COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS _ FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm CERTIF/ED FOUNDA TION PLAN LOCATED /N • SCALE /". 40' DATE q3 Scott L. Giles R. L . S. 50 Deer Meadow Rood North Andover, Mass. a OCT 2 8 1993 1'z,� a3 ' 23,1s3S,�. DEC K .R Ex1sT �p � •� M ^-f L,L SAD • - / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS , OF THE BUIL DING /NSPEC TOR ONL Y SHOWN COMPLY AND SUCH USE /S FOR THE WITH THE ZONING OETERM/NQ T/ON OF ZON/NG BY LAWS OF CONFORMITY OR NON- CONFORM/TY ISL-)� MA, WHEN CONSTRUCTED. WHEN 80L 77 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 oJ-Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector L The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity }( I am an employer providing workers' compensation for my employees working on this job. ry 4-NrC ie C f= / • •� Address — �� m �l�/ C-SEY o—k City: Phone #: Company name: Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as.required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as _well_as_civil.penal iesinthefarmof-a..STOP WORK_ORDER..and_a fine.of.(.$10-0.00)-ajday.against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains Sig Print Official use only of perjury that the information provided above is true and correct. 0 4)k- V Phone# -:9 K, /—) 06 do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required 0 Licensing Board p Selectman's Office Contact person: Phone #.• F� Health Department o Other ACORD,M. CERTIFICATE OF LIABILITY INSURANCE A 2s/2004 PRODUCER John M. Sullivan Insurance 781-449-9330 P. O. BOX 920047 Needham, MA 02492 ONLY THIS CANDIFICATE IS CON CONFERS NOED AS A RIGH S UPONR OF INFORMATION THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Advantage Design and Construct dba Archadeck of Suburban Bost 165 Middlesex Turnpike #201 Bedford, MA 01730 INSURERA Western Q n$, Co. INSURERS: Associated Employers Mutu INSURER C: INSURER D: INSURER E: CnVFROCFS 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 LTR DD'L RD Suite 165 POLICY NUMBER POUCY EFFECTIVE D TE M / D POLICY EXPIRATION T LIMITS A GENERAL LIABILITY NPP823830-1 4/22/2004 4/22/2005 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PREMISES Ea occ rence $ 50,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FRI OCCUR MED EXP (Arry one person) E 1,000 PERSONAL & ADV INJURY $ 11000,000 GENERAL AGGREGATE $ GENLAGGREGATELIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ ANYAUTO (Ea accident) BODILY INJURY $ ALLOWNEDAUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIREDAUTOS - NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE E E DEDUCTIBLE $ RETENTION S WCSTATU OTH B WORKERS COMPENSATION AND WCC500443601203 4/15/2003 4/15/2005 TS FR E.L. EACH ACCIDENT $ 500,000 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 500,000 OFFICER/MEMBER EXCLUDED? IIye5 describe under SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25 (21J01/03) I- V ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION James Finlay DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 165 Middlesex Turnpike NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL Suite 165 Bedford, MA 01730 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTAT ACORD 25 (21J01/03) I- V ACORD CORPORATION 1988 Contract # 30 90 In THIS CONTRACT made and effective on the —Aa day of els kY 2�, in the Town of Bedford and the Commonwealth of Massachusetts, by and between gd'0 `4,4n (PURCHASER), at Ido h-l(c t ed Y H(`CL 4#4 D 64--fLA-)QJVA,I'— W QiSy,a'nd (.W...4 rn,-.�,) Advantage Desiggn & Construction, Inc..ddba Archadeck of Suburban Boston (BUILDER), for work to be performed at AWQ 4!/=404y Xl f c �Disi 2=/ t �DyJ)K/� �A (the PREMISES) in accordance with the written terms and specifications of this CONTRACT (the WORK). THE WORK shall include the following: )(Deck 0 Screened Porch o Sunroom o Gazebo 0 Other ) oQO���k /Z{si7H PIXY ,Ci4niD�ivo �rtiTlf S�c1�C► To GAL.447 1. BUILDER shall furnish the services and material for performance of the WORK on the PREMISES described on the Design Proposal(s) (signed by PURCHASER and BUILDER) and numbered 30 CSD and as specified on the Archadeck Specification Sheet (initialed by PURCHASER and BUILDER), each attached to and made a part of this CONTRACT, for and in consideration of the payment to BUILDER by the PURCHASER of $yzl" l'(5 d 0 for the WORK $for other (describe) for a total of s �/b ` C ( fvk dollars)) together with any amounts set forth in any addenda hereto (TOTAL CONTRACT SUM). rJ 2. The TOTAL CONTRACT SUM shall be paid to BUILDER as follows: est. star dates /est. completion dates/ Down Payment (due at signing this CONTRACT) $ y IS', UO Progress Payments: $�� due on - $ QQ due on_49CA�IcAlL $ due on Down Payment by 0 Cash Xcheck 0 Other 3. OTHER TERMS: $ .geP�— due on $ — due on substantial completion of the WORK 4. The Down Payment may be used to purchase material necessary for performance of the WORK. BUILDER shall be entitled to final payment upon substantial completion of the WORK. The WORK is substantially complete when all items described in this CONTRACT have been constructed or installed. Substantial completion shall not include adjustment, repair, replacement or cleaning of any item so constructed or installed or final inspection by code official. PURCHASER shall be entitled to one punchlist prior to final payment. Requests for adjustment, repair, replacement or cleaning of any constructed or installed item shall not be cause for delay of final payment, but rather shall be considered warranty items. After five business days from substantial completion, the unpaid balance of the TOTAL CONTRACT SUM may be subject to interest charges as allowed by applicable state law. PURCHASER acknowledges and agrees that this CONTRACT shall serve as the invoice for the TOTAL CONTRACT SUM and that no additional invoice will be provided to PURCHASER for any part thereof. 5. Modification to the WORK will be made only when a written addendum describing such modification has been signed by both PURCHASER and BUILDER. There may be an additional charge for any changes. 6. The WORK will be warranted by BUILDER in accordance with the terms of the Archadeck Warranty. Existing structures to which the WORK may be affixed to or interconnected are not part of the WORK and will not be covered under the Warranty. This Warranty is issued to and only applicable to the PURCHASER after payment in full of the TOTAL CONTRACT SUM. A sample Archadeck Warranty form is attached to this CONTRACT. 7. The WORK will meet or exceed the live load bearing capacity required by all applicable local codes, provided however, that installation of overweight deck accessories ( such as, but not limited to, screened porches or spas) that are not disclosed as set forth below (1) may exceed the load bearing capacity of the WORK, (2) may lead to damage, and (3) will void the Archadeck Warranty. When overweight deck accessories are specifically Identified in the CONTRACT (Disclosed Accessories), the WORK will be designed to accommodate Disclosed Accessories and the Archadeck Warranty shall be in force as to the WORK bearing such Disclosed Accessories, provided the use of the Disclosed Accessories corresponds to the part of the WORK that is designed to accommodate them. PURCHASER and BUILDER herebv sutecifically acknowledge the foregoing Archadeck Wamtilly limitations bv the execution and delivery of this CONTRACT. 8. PURCHASER and BUILDER shall each have the right to cancel this CONTRACT without penalty or obligation prior to midnight of the third business day after the Effective Date of this CONTRACT. Upon cancellation of this CONTRACT within this three -business -day period BUILDER shall return to PURCHASER any consideration paid to BUILDER hereunder and PURCHASER shall return any material or drawings provided by BUILDER. In order to cancel this CONTRACT, PURCHASER or BUILDER shall send a written notice of cancellation to BUILDER or PURCHASER, as the case may be at the address for BUILDER or PURCHASER set forth in this CONTRACT within such three -business -day period. This CONTRACT shall not be effective and binding upon BUILDER until countersigned by a duly authorized officer of BUILDER. ADDITIONAL TERMS ON BACK DO NOT SIGN THIS CONTRACT IF TI PURCHASER (Sign re) (Print Name) (signature) (rent name) 165 Middlesex Tumpike, Suite 201, Bedford, Massachusetts 01730 Home Improvement Contractor's Registration Number GC -SH (von While — lice COPY / Canary — Purchaser (countersigned) / Fink — Purchaser (at signing) A L a Q) LM V � � U MA � � � 1 C14 0 �, N Z3 •u 0 cv d) 1� O n -7— > > W Lu 0 0 =�Q)>o���oo�� (Y4tLLl�� �Q ml O c O > to i u L 'S Ln LM � � U OL N B C14 0 �, cri W = cv d) 1� 0 N U) � ��.LQ > > W Lu 0 0 =�Q)>o���oo�� (Y4tLLl�� �Q ml LM 0 i � m C 3• = m t soo a, d � o x 0 =' v =� LL N= om o W; �1 x a- a r m N h e, N �. - •. - -.•, CD a CL CL) 79 d Q L N x It, N C of OO O �� G Q O U x` x x x E x S w� XL Q N in N N •Q •--- N X O i '_ C6, �r Oa I I I I �� v T r NU= o=� 'c J m x x 0 ti ?" _ m 3 L�J L x N C• O m= a Q iEo LLJ_0 0 0— ..(- 3 U _ o C CL) — C -o 0 x A v E 94 Ouw a a a xa a � C � U w o G � � 2 . i tR c o m c O � O N Vor - C3 .Q C c W W m c �Z O O 0 Ea om �m o a EE m ts cm Xaa O �3 :o m C41 c W H m mo ccJ . N m m t Mc ge Q 0 mc = m : LS 0 F- W c «=•�Z W mi E!S .= d' C.2 a 0.0 c o •c = w IS �- a � m E 'O cri H c �O m M Co c m O cm C c N CD t O Z 0 F. C/) z 0 W W P-4 w OD a goil �s CD E v � Z y O Q C I cm CD O •— H Q � CD ■_ 'i m m }- 3 o Q o c_ov o a CL CL C Q o c O C C.3 y O C C_ ' C cc y O W U) 19 W LU 19 W Location (tet�L No. Date -13 SOWN OF NORTH ANDOVER p Certificate of Occupancy $Pd• * ; Building/Frame Permit Fee $ ' �+a" <�' '091 dation Permit Fee $! ��� s�cHust b Other Permit Fee $ Sewer Connection Fee $ -f3 2jV Water Connection Fee $ TOTAL $ 1044 Building Inspector 6675 Div. Public Works 1 / -� r � ,at1on fG' J ' { No. �/ , G Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ ii , O J Building/Frame Permit Fee $ Foundation'Permit Fee $ /4/9, Q J Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ s: 1 SEP T3Tt IS93 h 6564 t ` Building Inspector Div. Public Works S Lodation L2� � l-r'�A�C 172d f— No. Date /0+ Z(:�:, �-9-93 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit.Fee Vsewer Connection Fee Water Connection Fee TOTAL r l c 64°26 )Oj'' $ $ / ` ri -I . rt ' ' � Idiing Inspe for Div. Publi& Works J 'S APPLICATION FOR PERMIT TO BUILD —NORTH ANDOVER, MASS/�lyv //PACE 1 MAP K40. I LOT NO. Z (p ZONE SUB DIV. LOT NO. LOCATIO:o 1'i ;G,+ p` LIQ ' ZG 2 RECORD OF OWNERSHIP iDATE (BOOK 'PAGE D..��pit,11 10 7 PURPOSE OF BUILDINGI / OWNER'S NAME TDf MS f� 1_ 1'� •lJ r�ll/ Il6+�pLq'4J✓�dir NO. OF STORIES SIZE T OWNER'S ADDRESS �,,. i BASEMENT OR SLAB (O" ARCHITECT'S NAMES 'j1Qma `1� SIZE OF FLOOR TIMBERS IST ' .2ND I�1 3RD BUILDER'S NAME T S D. 4;1 ..fit_ `1\►_ ��,��1,� Ij( SPAN ],4 M�x DISTANCE TO NEAREST BUILDING Lt Jf DIMENSIONS OF SILLS POSTS S) lF J ' DISTANCE FROM STREET It, 'y J c .1 DISTANCE FROM LOT LINES - SIDES G �']o�.+ REAR Loo! + GIRDERSCL)` LI _k ko t� AREA OF LOT 2 ? 13 q =,fes i 1 i FRONTAGE � Q�� HEIGHT OF FOUNDATION � THICKNESS jof � IS BUILDING NEW SIZE OF FOOTING 2 y l l x) O ri IS BUILDING ADDITION ♦ ja iV MATERIAL OF CHIMNEY R �,,;' C IS BUILDING ALTERATION N0 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 7&-_S INSTRUCTIONS ' SEE BOTH SIDES S o rim rep /' IIUIIIB�F�Iwr PAGE I FILL OUT SECTIONS 1 - 8 FN FU .v /�� �rlV. F� r PAGE 2 FILL OUT SECTIONS I - 12 DRUE "L• KRMff $�5�7 y 0 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILD INSPECTOR DATE FILED w T /gf43 � MATURE OF OWN OR AUTHORIZED AGENT aD FEE P� 40 lo ,9'"O - 10 0OWNER TEL. #r'S/ 7 PERMIT GRANTED � CONTR. TEL. #-fiE3 ' 19 � -- CONTR. UC. # f(jZ 1 i to 6 0 s PROPERTY INFORMATION LAND COST G ,000 . 0c) EST. BLDG. COST I 0 P TGG EST. BLDG. COST PER SQ. FT. ��'" p U EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. N A t� 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN zzl�& ed"', BUILDING INfPECTOR BUILDING RECORD 1 OCCUPANCY 12 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. It 0 fmf*"j "dt....yyam.pp:1+ •, a]1��~i 0 i SINGLE FAMILY STORIES WOOD SHINGES MULTI. FAMILY KITCHEN SINK OFFICES SLATE APARTMENTS NO PLUMBING _ CONSTRUCTION 2 FOUNDATION ]� 8 INTERIOR FINISH CONCRETE PINE B 1 2 13 CONCRETE BL K. BRICK OR STONE HARDW D— TILE DADO x _ PIERS PLASTER DRY WALL 11 HEATING _ UNFIN. 3 BASEMENT AREA FULL 1 B'M'TAREA '/. 1/2 �/, FIN. ATTIC AREA _ NO B M T FIRE PLACES _ 1 HEAD ROOM MODERN KITCHEN AIR CONDITIONING _ 4 WALLS I 9 FLOORS CLAPBOARDS UNIT HEATERS GAS B _ 1 2 �_ 3 _ _ DROP SIDING W000 SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ CONCRETE EARTH HARDNPJ'D COMMON ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR POOR ADEQUATE I -i ONE 10 PLUMBING 5 ROOF GABLE I&/1 HIP i 11 BATH 13 FIX.) 1 ASPHALT SHINGLES LAVATORY 77 I 2 ' ' WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES 1W�• TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIM5ER('BMb&LQIq. STEAM STEEL BMS. d COLS HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL B'M'T 2nd _ 1 st 13rd I ELECTRIC NO HEATING Date... 40 TOWN OF NORTH ANDOVER imago PERMIT FOR GAS INSTALLATION -�ACHu� This certifies that ...f j ..,f. `. !.t.�. has permission for gas installation r , in the buildings of .. x�.�� . �. . �.. r..'. r ..... at .,�� �. 1. � 1'�! �! !�rr�(. !(North Andover, Mass. Fee.`ZLic. No../ . 3.... .......................... GAS INSPECTOR Check # 7�C! (/ 4,549 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ` I r� Date D. 7- 'O- Permit # Owner's Name ei r Type of Occupancy _ _ I� E51 -F) N T i Iq New ❑ Renovation ❑ Replacement 2 Plans Submitted: Yes❑ No ❑ Installing Company Name r1 AE (Z T m A T A �C Check one: Certificate Address 3 1?oA C H ih 14 ry i -NI, ❑ Corporation 111 E 7 N U E IJ 01 rl 0( ❑ Partnership Business Telephone /9 �92 - (7 9 "7 f 2-Firm/Co. Name of licensed Plumber or Gas Fitter 'i o (A Ek -T A - 5 A M -rd �r � INSURANCE COVERAGE: I have a current f bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 01", 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 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 pe ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. Title APPROVED O IC NL T of License: Plumber n ure of cen u or Gas Fitter r �33� er License Number Journeyman Y Installing Company Name r1 AE (Z T m A T A �C Check one: Certificate Address 3 1?oA C H ih 14 ry i -NI, ❑ Corporation 111 E 7 N U E IJ 01 rl 0( ❑ Partnership Business Telephone /9 �92 - (7 9 "7 f 2-Firm/Co. Name of licensed Plumber or Gas Fitter 'i o (A Ek -T A - 5 A M -rd �r � INSURANCE COVERAGE: I have a current f bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 01", 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 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 pe ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. Title APPROVED O IC NL T of License: Plumber n ure of cen u or Gas Fitter r �33� er License Number Journeyman NI W S U ►- I W Y N LL m J a i C7 Z• H f - L6 N Q O O a O f °C o W z a O W Z O t - Q U J a a Q W W W NI W S U ►- I W Y N LL m J a i 0. Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SSACNU9f This certifies that ./..l.'..�f .r:"..�......!�' ......'...r.:.`. _ _ _ has permission to perform ....� ...� !� ..�%/j�f%.. ...... plumbing /inithe buildings of . /.� _�hJ. %.. !'.1. �!........ at ..,�.1?;�����f��r,�/ />�(_�!J.. , North Andover, Mass. Fee. i..... Lic. No.. .17 .............................. 17 / J� PLUMBING INSPECTOR Check # //(6 / 5826 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) AA 1"W4 Mass. Dat eiflb 2CCC.3 Permit #� J Building Location tJ��Ay . Owner's NamedL/.���/d/fin ► Type of Occupancy, '2tr S 117 E �J New ❑ Renovation ❑ Replacement 2""' Plans Submitted: Yes ❑ No ❑ FIXTURES ` ` LN Installing Company Name AOt3Ee,T A - Check one: Certificate Address �% r2_ coogc N (nf') "J ❑ Corporation 1Y) E % Ni 1; Al a 01tf (A/ ❑ Partnership Business Telephone �,If Z - A77 tt 215i'rm/Co. Name of Licensed Plumber 2L,13 r=;P T )4 Asylm q rei,ee- INSURANCE COVERAGE: I have a current I�'ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L' No ❑ If you have checked ve, 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 ❑ Agent ❑ 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 ;e and that all plumbing work and installations ormed under the permit issuee¢¢�for this application will be in compliance with all provisions of the Massachusetts State Plum 'ng a and Cljapter K of the Weral Laws. r--� By J TifJe re of Licensed Plumber Type of License: Master Journeymah ❑ City/Town APPROVED OFFICE USE ONLY) License Number � 3 j Y • • • • • • • Installing Company Name AOt3Ee,T A - Check one: Certificate Address �% r2_ coogc N (nf') "J ❑ Corporation 1Y) E % Ni 1; Al a 01tf (A/ ❑ Partnership Business Telephone �,If Z - A77 tt 215i'rm/Co. Name of Licensed Plumber 2L,13 r=;P T )4 Asylm q rei,ee- INSURANCE COVERAGE: I have a current I�'ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L' No ❑ If you have checked ve, 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 ❑ Agent ❑ 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 ;e and that all plumbing work and installations ormed under the permit issuee¢¢�for this application will be in compliance with all provisions of the Massachusetts State Plum 'ng a and Cljapter K of the Weral Laws. r--� By J TifJe re of Licensed Plumber Type of License: Master Journeymah ❑ City/Town APPROVED OFFICE USE ONLY) License Number � 3 j N Z j O ¢ W In J d ¢ O V W a N z Z m J O Z a O O W p N O � � Vf.. O = C O ¢ u. O 316 o = J O W m P � V J' ka W t V Y N ¢ W In J d ¢ O V W a N z Date.. 7.....� , . . ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....>.................. �:..' ............... 'has permission for gas installation . x%`... 1 !........... in the buildings of . ! �.. ............................... at.. ..... t -a ..... , North Andover, Mass. J Fee......... Lic. No........... G"/L / .. ,... . .. y. '. GAS INSPECTOR Check # 45 1 9 MASSACHUSE7IS UNNORM APPUCATONFOR PERNIITTO DO GAS FTNING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations GYM / Q Permit "# --- ,l 'A -mount $ Owner's Name �Dj i New ❑ Renovation ❑ Replacement Plans Submitted ❑ (int or type) e, Certificate Installing Company Name Andover P1 bq . & ft. Co Inc.. L=! Corp, -2122 Address 20 Aegean Dr. Unit 110 ❑ per. Mnthnpn� Mla njQAA Busuress Telephone ( 97R ) 6Rr_R�R� ❑ Firm/Co. Nanfe of Licensed Plumber or Gas Fitter George Larose INSURANCE COVERAGE I have a current liability Insurance policy or it's substantial equivalent. YeessNo ❑ If you have checked B& please ' rate t2�e type coverage by checking the appropriate box Liability insurance policy E 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 requir anent. Check one: Si1nature of Owner or Owner's Agent Owner [71 ALem n =w -T --_.y ",� an u :ung nizu raucu s nave suvauuku tur cuua ) in anove appuc attron are true and accurate to the besicof my knowledge and that all plumbing work and installations perfumed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas CA& and Chapter 142 ofte General Laws. (OFFICE USE ONLY) Signature of Li ed Plumber Or Gas Fitter Plumber 'Of ZQY ❑ Fitter cense um ter ❑ Journeyman 4 • 1 � =�O��o������i����i�»� e (int or type) e, Certificate Installing Company Name Andover P1 bq . & ft. Co Inc.. L=! Corp, -2122 Address 20 Aegean Dr. Unit 110 ❑ per. Mnthnpn� Mla njQAA Busuress Telephone ( 97R ) 6Rr_R�R� ❑ Firm/Co. Nanfe of Licensed Plumber or Gas Fitter George Larose INSURANCE COVERAGE I have a current liability Insurance policy or it's substantial equivalent. YeessNo ❑ If you have checked B& please ' rate t2�e type coverage by checking the appropriate box Liability insurance policy E 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 requir anent. Check one: Si1nature of Owner or Owner's Agent Owner [71 ALem n =w -T --_.y ",� an u :ung nizu raucu s nave suvauuku tur cuua ) in anove appuc attron are true and accurate to the besicof my knowledge and that all plumbing work and installations perfumed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas CA& and Chapter 142 ofte General Laws. (OFFICE USE ONLY) Signature of Li ed Plumber Or Gas Fitter Plumber 'Of ZQY ❑ Fitter cense um ter ❑ Journeyman • JJr I Date. e....:. ... `..... . i' MORTM TOWN OF NORTH ANDOVER py`tt.to16 p PERMIT FOR GAS INSTALLATION This certifies that. �. ::..'. �G ..... l ............... . has permission for gas installation .....,......:.. ............ . in the buildings of .......................................... at ..:". `... ' .......................... . North Andover, Mass. Fee...`'.. ` . Lic. No..l...'...... ............. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer n MASSA I i APP CATON FOR PERMIT TO DO GAS FITTING c� or print) PARCEL Date — 19 ( I tvuxIH A0 UV -1411t -3312- Building Locations 1 f)n t L� (ZI/ IfLa Permit # Amount S a6 Owner's Name New Renovation ❑ Replacement ❑ Ty& ?A) Plans Submitted ❑ (Print or type) �� I I Check one: Certificate Installing Company Name %' 1 C.(� L I C`i� l 1� Up'1�01 A) �o ❑ Corp. Address �V P1 U_r �_PJ ❑ Partner. Business Telephone 97,4,-S'I,�gy� r��Firm/Co. Name of Licensed Plumber or Gas Fitter ��� PI L 9 e 0 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Lea[_ pe type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. [ am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the iutass. General Laws, and that my signature on this permit application waives this requirement. of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ I hereby certity that all of the details and mtormation I have submitted (or entered) in above application are true ana accurate to me best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M�Pslc` us tts StateGas Code and C apter 142 of the General Laws. By: Title City/Town APPROVED wl,ncl, use ONLY) Signature of Licensed Plumber Or Gas Fitter __--=--P-(umber ❑ Gas Fitter License Numoer �ster�'_, Lla �—'i Journeyman