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HomeMy WebLinkAboutMiscellaneous - 102 FOXHILL ROAD 4/30/2018 (2)11541 DateA.2._.I�. e. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . It Z�c ............................... A.. This -certifies that ...... ha's'permission to perform ......................... ...... . ....... ... .............. plumbing in the buildings of ... .. .. e. . ... ... .... t. ................................................ 4� at .......... . .................................................. . .................... North Andover, Mass., Fe&......t, PLUMBING INSPECTOR Chedk M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -1 1 - 11—b MA DATE 0l I ( PERMIT # , JOBSITE ADDRESS Q H xI OWNER'S NAME 1 OWNER ADDRESS / TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT:ZL PLANS SUBMITTED: YES® NO Ell FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ► _n_ I _ _� { __._ I ___.._ i __I ! _ _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _.__.1 ____._._I _---._ l LAVATORY =[-__1 __....._...J ___J1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET ! i _ I _ f: �.._! ._ URINAL _.'._j __i ._...__J --____f _-.____.f WASHING MACHINE CONNECTION — i _ 1 ..._.-_._ ' 1__1 __$ ..__ ._._ _ _N'===== _._. _1 WATER HEATER ALL TYPES WATER PIPING _ ! _.._ t __.._ _ f 1= f OTHERS _.._�J ._- -..I _ ..i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE-9d;?NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND MJ 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are ue n accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pli II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE # A0a3 p SIGNATURE MP,,K- JP CORPORATION R# ©PARTNERSHIP � 1 # _ ( LLC D� j COMPANY NAME ADDRESS O Odx CITY �ifvv _ yis ZIP Q? i TEL ( j EMAIL FAX CELL �� �� �. �----..__.----__.___._------------._-------....__------.__.....----------..._------...._I w �El W Ix iii w Date ........Wt.t©.....1 5........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... ..................................................... has permission for gas installation ... P .................................... in the buildings of ............... - t2 ' c i!1 ......,.............................:......................................... at 4 Z _ t , North Andover, Mass. ................................................................................................. Fee .... Lic. No. GASINSPECTOR Check # I q �4 1 �66 C\ f� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY�. c?�" �� _ �� MA DATE PERMITlow JOBSITE ADDRESS OWNER'S NAME .T OWNER ADDRESS P _?x - TEL- b 3 �,�FAX TYPEOR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Di RESIDENTIALO PRINT CLEARLY NEW - E] RENOVATION: El REPLACEMENT PLANS SUBMITTED: YES NO APPLIANCES"I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -- BOOSTER BOOSTER CONVERSION BURNER COOK STOVE .. ..._ I DIRECT VENT HEATER I -- (_ DRYER FIREPLACE 1(._� - l f FRYOLATOR_-��_ I _ FURNACE GENERATOR r 31177711 I J GRILLE INFRARED HEATER LABORATORY COCKS _ I�=I m_ _ I l _.1 (�- -.�! [TJ ( I - ! I==31 MAKEUP AIR UNIT( - OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I UNVENTED ROOM HEATER _ _ .- I . _ _ _ li_ 1 WATE9 HEATER ._-^, _ _ -f OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES 1 NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY.. OTHER TYPE INDEMNITY Ej 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 M AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr a an a urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co plian e h Pertinent provision of the Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,� –�—�, �'�t LICENSE # SIGNATURE MP1GF JPD JGF [] LPGI 0 CORPORATION Q# = PARTNERSHIP EI #= LLC D#!. COMPANY NAME: ADDRESS , 0. CITY pJS ..✓ � STATE ZIP TEL FAX CELLEMAIL W H O z 0 H� U W w 1. v w O ' � Z w } � w w W < w w a O w w w w C a o a, a a ��. U F. a CL Q L w x w LL °z 0 H U W a C�7 The Commonwealth ofMassa chusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia s�• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER UTTING AUTHORITY. Name (Business/Organization/Individual): )6kk b� A t e"2 Address: City/State/Zip: Mp SkGcJ Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1 am.a employer with employees (full and/or part-time).* y, [J New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in g. F� 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 property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12.Plumbing repairs or additions 5. I am a general contractor anI have rethe sub -contractors listedon e attached sheet. ❑ d hidb ttth 13. n Roof repairs These sub -contractors have employees and have workers' comp. insurance.# 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. F1 Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not_ those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am., an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. p Insurance Company Name: � "G o, Lt SbLA-q,,3 'Pi O& L J QUA C53 W 0 Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 109 �x ft City/State/Zip: Iv24 AJGO-V , AAttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 vio at r. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificoi n� I do hereby cer ify un r t pains and penalties of perjury that the information provided as ovee s true and correct. CiornnfiirP• Date: /�/ IL '� Phone #• Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 4h'ire, express or implied, oral or written." t An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensatioii'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I I Date ........�..�... / TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ........... .. �'/.... .................................. ........................... . tel//¢ E' has permission to perform ............. .......................................... wiring in the building of, ................................................ �' r........................................................... + 02' X North Andover, Mass. at .....`/....`�........ .......... .... L-.......................�f.................... Fee.`Y....:.......... Lic. No...5�fh..............i ELECTRfCAL INSPECT6R Check It 13110 Commonwealth ®f Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ,j l f 0 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 ININK OR TYPE ALL INFORMATION) Date: 41 l3 -1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrical work described below. Location (Street & Number) O'2... Owner or Tenant��rj-er-� 1.iecZ�q.� Telephone No. Owner's Address Is this permit in conjunctio`nrwith a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building +{off -cam 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:�- �o 4 S,, Completion ofthe following table may be waived by the Insoector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators i KVA 2 Z No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency mg ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices 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 Equivalent 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 Equivalent OTHER: f Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: Z--J� (When required by municipal policy.) Work to Start: `LPl _iS� 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 �9 BOND ❑ OTHER ❑ (Specify:) I certify, under th 4 ains and penalties of perjury, that the information on this application is true anti complete. FIRM NAME:. r c. Iu c +�e� mac_ LIC. NO.: 41Sf2f Licensee:44 ,J,� Signature LIC. NO.: /f 15 pLS 1 51 (If applicable, enter "exempt" in the lice ,fie number 1'ne.) Bus. Tel. No.. (0o3 - ti 5' 2- 4 SL & Address: j�-�cr�.Ql� {-_ S� er...., I�J1f o ? e 7�i Alt. Tel. No.: teas' - 2.33- �►S *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 Signature Telephone No. PER1tlIT FEE. $ . ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance. -with the provisions of M.G.L. c. 143, § 3L, the 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 IN 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Inspectors Comments: Failed 0 Re- Inspection Required ($.) ❑ 4, Inspectors Signature: Date: FINAL INSPECTION: . Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Hassaehasetts Department of lndustrialAcciclents Office o f Investigations 600 Washington Street Boston, .IIIA 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contract Name(Business/Organi'zaiion/individual):_�t��,r��•.�! -ere ��,r Address: ---7 f �c l L S.�-. T City/State/Zip: S �t E �J If -S6--?9 Phone #: % S Z- `-1 S'% � Are your an employer? Check the appropriate box: 1. I am a employer with 4• ❑ I am a general contractor and I 'Type of project (required): 6. ❑ New construction employees (fail and/or part-time).* 2. [] I am a sole proprietor or partner- have nedthe sub -contractors listed on the attached sheet I 7. [� Remodeling ship an&lave no employees These sub -contractors have 8. ❑ Demolition working forme in. any capacity. workers' comp. insurance. 5. ❑ We are a corp oragon and its 9. ❑ ]3uilding addition [No workers' comp. insurance required.] officers have exercised.their 10.❑ Electrical repairs or additions 3. ❑ X am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing. repairs or additions Myself . o workers' bom . [N y p c. 152, §1(4), and we have no 12.❑ Roofxepairs insurancerequired.] employees. [No workers' 13.❑ Other comp. insurance required.] ,Any applicaatthat checks box#1 must also fill outthe section below showingtheir workers' compensation policy information. I Homeowners who submit this affidavit indicatingthey 9: doing all worK and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheAthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp: policy information. I am are employer that is providing workers' compensation insurance formy employees Below is the policy and joie site information. Insurance Company Name% Policy # or Self ins. Lie'. #: V�� 0 L *3 2- ExpirationDate: - i k e % IX Job Site Address: t 2 City/State/Zip:_ JU "xk A_ Attach a copy of the workers' compensation-polley declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL e.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 civic 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 ceM undWlze pains andpenalties o fperjury thatfile information provided above is true and eorrect. Phone #: (-Qz3 - q S Z - 4r6 -Sr Official use only. Do not write in this area, to be completed ny city or town o le a . City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Ciiy/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an e�r�ployee is defined as "...every person tri the service of another under any confract of hire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, ox 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 aria individual, partnership, association or other legal entity, employing employees: 96over 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 sucli'dwe11ing 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' compensaiion affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees ofFier than the members or pariuers, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that thisaffidavit maybe. submitted tothe Department of Industrial Accidents for condrmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for thepermit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain. a -workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. ' City or Town Officials Please be sure thatthe affidavit is complete andprinted 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 bo -sure to Of in the permit/Rcense 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in.(city or copy of the affidavit that has been ofdxcialIy stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit•is on file .for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `z'he Commonwealth ofW-ma r hmPtts - Dopafteat QfThdusGxial Accidents Qfoe dI'Awstigat iom 60 Waftgtm Street Boston, Ste. 021 It Tel,, # 617-7.27-49OQ ext4Q6 ox z-$77, MAMAS Revised s -26-o5 Fay # 617-727-7749 • 4vifi4v.�1•aSS,gQ.v�d1a QT/09/2014/THU 12.40 PM FAX No, P,001/002 'r ACOR©,m CERTIFICATE OF LIABILITY INSURANCE 10/9i2014Y PRODUCER ' (978) 664-2000 FAX: (978) 664-0180 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Linnane Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 280 Main St. #101 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N. Reading MA 01864 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Harleysville Ins. �P,lpl ne cera cal SeV1C2S—III'C INSURER B: Travelers 7 Deerfield St. INSURER c Safet INSURER D: Salem NH 03079 INSURER E: COVFRAGFS 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 ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MMIDD/YY LIMITS A GENERAL LIABILITY Amon '1A i-nn4 moi EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50 000 PREMISES Ea occurrence $ MERCIAL GENERAL LIABILITY CLAIMSMADE aOCCUR 4—clom SPP94317K 1.0/01/2014 10/01/2015 MED EXP An one person)$ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COM/OPAGG $ 2,000,000 PRO- POLICYEI JECT LOC F_� C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO 6226443 11/19/2013 11/19/2014- (Ea accident) $ 1,000,000 BODILY INJURY ALL OWNED AUTOS X SCHEDULED AUTOS (Perperson) $ X HIREDAUTOS BODILY INJURY X NON-OVVNEDAUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC $ TGELIABILITY Y AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRFNCF $ AGGREGATE $ OCCUR F-1 CLAIMS MADE DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND UBOC432796 07/18/2014 07/18/2015 TORSLIAMITS OER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE$ 500,000 If yes, describe under E.L. DISEASE-POLICYLIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSfLOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (978)688-9542 SHOULD` ANY ,OF,THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town Of North Andover EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1600 Osgood St. 10 North Andover, MA 01845 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Michael ` -- Amon '1A i-nn4 moi v AGUKU CORPORATION 1988 INS025 (011 psa Page 1 of2 Date ...... .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................................................. w ............................................... has permission for gas installation ........................................... inthe buildings of..... n. .. 4................... A................ .... .... .................................... at ............................. North Andover, Mass. .......... . Fee .!�.......—.. . Lic. No. .. GASINSPECTOR Check # 9823 ILI MASSACHUSETTSUNIFORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A01d-O MA DATE PERMIT# I Zaj JOBSITE ADDRESS r_-�® OWNER'S NAME I��_ it G OWNER ADDRESS TELF�JFAX -� - - - - TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: _. RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES r---Jl NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ .... r� ,.. -1... _-.. _ . { L:._ .{ _. F--1 - - =j =,.,..1 !:::j . _ . BOOSTER CONVERSION BURNER J _ r_ _: .-1 =_— I —_ I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE �1 {( { I �J _ —� 1 �- ._ ( _ I _ --B F ---J FRYOLATOR- FURNACE GENERATOR L..._... _. I ..—__ .. ( I I1 GRILLE - INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER WNVENTED ROOM HEATER WATER HEATER THER I .... .... .............. — INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES JOU IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA 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 Q AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE # SIGNATURE MPO MGF Ejl JP D JGF gfPGI CORPORATION Q# r ig PARTNERSHIP ©#= LLC E{#�� COMPANY NAME:--. _�- �,�{ _�� ADDRESS _ / . CITY STATE ZIP TEL Lf�C FAX L= CELL - EMAIL I - _I ILI The Commonwealth of Massachusetts ;/ Department of IndustrialAccWhts Office of Investigations 600 Washington Street Boston, MA 02111 UV www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �hol r(� Address: NA r'K City/State/Zip:1k5--? Phone #: ��o 'y2�1 Are you an employer? Check the appr 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and'haveno employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] i riate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:. 1/ � Policy # or Self -ins. Lie. #: Expiration Date: � Job Site Address: l� " �X/` I �dl City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 certo under the pains and pe adties ofperjury that the information provided above is true and correct. Sicnature: �Kz ^ AF Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone �; 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed. below. Self-insured companies should enter their self-insurance license number on the appropriate line.' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massarliusetts Department of Jndustriai Accidents Office of Investigations GOR Washington Street BostQn., MA 02111 01. # 617-727,4900 ext 406 or 1-877rMASSA]FB Revised 5-26-05 Fax # 617-727-7749 www.mass,gov1dia 1 rri- "111111111� DATE: 0-/a l-5 LOCATION: /D OWNERS NAME: GENERATOR kw t1' - �I� I� +�' �� ' �Ii �,;` � ,� 1 ti , �-: ,' � ��d � �. � f.' : — �I} 1'� � �I � ,� r•: ,/ .1� i `� CONTRACTOR: /4I �1ic- i �cc1 c- / 4 PHONE NUMBER: ELECTRICAL RESIDENTIAL I CO3-sclb-q`7G1� GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: _ ej�� stdc, of d *ZONING DISTRICT: "'PLANNING APPROVAL (IF IN WATERSHED)d "'CONSERVATION APPROVAL-": - )L-0— A, \:�z b North Andover MIMAP t„#w V I - 4' � �' � •. -tl y �� w” y #w ' .ti k?•'Six R Y aye ZVI rt r 1 y n � e •4 k � g �, �' , ; �`✓" � �. 'fit Y �` 4*"4 � • it U f a.---- Interstates - - - SR Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, :- Roads - - Meters Data Sources: The data for this map was produced by Merrimack L r Easements- Gf MORTI♦ q Valley Planning Commission (MVPC) using data provided by the Town of - t�s D - ti North Andover. Additional data provided by the Executive Office of �MVPC Boundary r•s• OD - Environmental AffairslMassGIS. The information depicted on this map is QParcelsF ... p - for planning purposes only. It may not be adequate for legal boundary . definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED CONCERNING # # - THE ACCURACY, COMPLETENESS, RELIABILITY OR SUITABILITY - - • s # OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION sSACHUS�t 97 ft February 12, 2015 1 t„#w V I - 4' � �' � •. -tl y �� w” y #w ' .ti k?•'Six R Y aye ZVI rt r 1 y n � e •4 k � g �, �' , ; �`✓" � �. 'fit Y �` 4*"4 � • it U f a.---- Interstates - - - SR Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, :- Roads - - Meters Data Sources: The data for this map was produced by Merrimack L r Easements- Gf MORTI♦ q Valley Planning Commission (MVPC) using data provided by the Town of - t�s D - ti North Andover. Additional data provided by the Executive Office of �MVPC Boundary r•s• OD - Environmental AffairslMassGIS. The information depicted on this map is QParcelsF ... p - for planning purposes only. It may not be adequate for legal boundary . definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED CONCERNING # # - THE ACCURACY, COMPLETENESS, RELIABILITY OR SUITABILITY - - • s # OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION sSACHUS�t 97 ft February 12, 2015 1 , v" Location No. —-�-- Date TOWN OF NORTH ANDOVER Certificate of Occupancy C. - . EBuHding/Frame Permit Fee $ Foundation Permit Fee $ `------- Other P rmit Fee $ U C� ` IAy, `j�l 85ejW,&nnection Fee $ Mater Connection Fee $ -6071 TOTAL /J$�j �1/C�� /7,% Building Inspector Div. Public Works PE & 1 A`O. MAP KVO. +' APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. INSTRUCTIONS SEE BOTH SIDES PAGE i FILL OUT SECTIONS 1 - 3 - { PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 0 SIGNATURE OF OWNER OR AUTHORIZED AGENT F E E s c) d PERMIT GRANTED 19 OWNER TEL. #�- CONTR. TEL # CONTR. LIC. #a 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST `I $;Co' � EST. BLDG. COST PER OQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN �8�UILDIWQ INSPECTOR LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. r - LOCATION PURPOSE OF BUILDING OWNER'S NAME'` `�^1 YXJ� 1 ,--rte NO. OF STORIES SIZE /1 OWNER'S ADDRESSJw�Jnt1 BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST1'1 _`c; 2ND 3RD BUILDER'S NAME n! _ r 1� SPAN_7—Tj� DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS 3r'z Lt1(S,� r�c�►�_� DISTANCE FROM LOT LINES - SIDES REAR " " GIRDERS AREA OF LOT _ FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE If/_C T `•/•i IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE i FILL OUT SECTIONS 1 - 3 - { PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 0 SIGNATURE OF OWNER OR AUTHORIZED AGENT F E E s c) d PERMIT GRANTED 19 OWNER TEL. #�- CONTR. TEL # CONTR. LIC. #a 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST `I $;Co' � EST. BLDG. COST PER OQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN �8�UILDIWQ INSPECTOR BUILDING RECORD • 1 OCCUPANCY 12 SINGLE FAMILY TORIES —1 MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETE_III a 1 2 13 CONCRETE BL K. PINE BRICK OR STONE RDW D PIERS PLASTER _ DRY WALL UNFIN. _ 3 BASEMENT AREA FULL Y, 1/2 1/ FIN. B M TAREA FIN, ATTIC AREA _ N_O B M T FIRE PLACES _ _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 2 �_ 3 _ _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARMU'D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. 8 FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I- I POOR ADEQUATE ONE 10 PLUMBING 5 ROOF GABLEHIP BATH 13 FIX.) GAMBREL I MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GOAL il B'M'T 2nd _ 1.f 1 311 ELECTRIC 1 NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. i tS,T rk 14-W rn5— — Il --------- �j --- ----------------------- ---- - -- $GGCG - = --- --------- Il --------- `�`- ✓/ie i�o�nz�n�2cuea(,Ch °�✓!ilaaa�chuae��i HOME IMPROVEMENT .1=:ONTRA1--TOE'S REGISTRATION Beard of Building Regulations and Standards. ' One As}eburton -Place - Room 1301 BOst.,n, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR _ Registration 100757 Expiration 0E/23/94 o Type — INDIVIDUAL !76 HOME IMPROVEMENT CONTRACT Registration-, 100751 Steven J. Langlois Type - INDIVIDUAL :8 Winter St. Expiration 06/23/94 Amesbury. MA 01913 Steven J. Langlois 28 Winter St. ADMINISTRATOR Amesbury MA 81913 :r:. COMMONWEALTH — ` rtJ5ARTMENT OFP1y8L1�SAFETY _ �t OF. 1010 COMMONWEALTH AVE Ii MASS IICHUSETTg . I BOSTON, MASS. 02215 , ' . °' LICENSE i ENCLOSE CHECK OR MONEY ORDER EXPIRATION DATE 06/30/1951;, - CONSTR. SUPERVISOR y FOR REQUIRED FEE, }MADE RESTRICTIONS :.,.,' ;:" . . • r:. EFFECTIVE DATE LIC -NO. PAYABLE TO OMMI 06/:Bo/1991 ., `�� al IONER PUB�IC'SAFETY•' J r DON T S AS `� Hl 02 44—Q(.L STEVEN LAN►= LO I.:_ JU�i G q e8 WINTER ST _ _.� PNoro teusTwD 1t,i,.(,,, AME .BURY MA 0191 � �' x ' � � f' LD (3 . HEIGHT; NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY STAMPED DOB: • OR SIGNATURE OF THE COMMISSIONER 01/2-'4/1 QTNERi • RgNT THUMB PRINT THIS DOCUMENT MUST SE CARRED HOLDER THE PERSON 4. THE INTTI WHEN E ATI01, ED IN THIS OCCUPAT10� SIGN NAME IN FULL•ABOVE SIGNATURE LINE NATURE OF LICENSEE � $J$J$J t ,/ COMMISSIONER MOR -2-87-81429, •: ":. � ... �� I A :r:. STEVEN J. LANGLOIS Building • Remodeling • Restoration 28 Winter Street AMESBURY, MASSACHUSETTS 01913 (508) 388-5802 689.8229 TO 1c�2�� is �c RSD JOB ESTIMATE PHONE DATE (-' Ga 5 3 JOB NAME/LOCATION JOB DESCRIPTION: 111 ........ � J THIS ESTIMATE IS FOR COMPLETING THE JOB AS DESCRIBED ESTIMATEDJOB COST ABOVE. IT IS BASED ON OUR EVALUATION AND DOES NOT IN- CLUDE MATERIAL PRICE INCREASES OR ADDITIONAL LABOR AND MATERIALS WHICH MAY BE REQUIRED SHOULD UNFORESEEN PROBLEMS OR ADVERSE WEATHER CONDITIONS ARISE AFTER THE WORK HAS STARTED. ESTIMATED BY 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: � A n mzt o.&\/A LOCATION: Subdivision Phone (S -.12_62_q0 Assessor's Map Number Parcel Lots) 37 Street _T� sl_ \A l LC- fVQ . St. Number /0 2 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date n n n z A Z z D � 'n X3 T Z m z T Z D r v y C � CA C7 CD a Z CA r O. O n. cm M o CL y nC O Cv CD CD o CLQ CD Ma CD O CD a C O V1 CD Q O y O I cfl CD F v CA O 1 Z O O O CD O CD XT d o m 2 O �• to O CS H r do C m .o y y = 0 � m co Z =r'p E --I Co =r to = y CD -40 O N p N O Wim' _ W C Cfl -oi. O O O o y c) =ro 7R� m ay � a aco C C c•� � CD COte N ►-� o. m M m l •, O N nom• Cv N _ C � 0 00 n H OCD CIO In co O V J y H CD CD O umCDO O �3ot CD Z mss31Lp ^�W. 0 a . o CD m m o� �. o Cn re CC/ •sGm+ z ►z-3 - O U?G c � (n . O pq a• y � m n 5 ::r O. 0zr- l� r y Cnn cn R 'p= 7 OwL a x o Ev *t )Nq 0 O C SUBDIVISION PLAN OF LAND IN NORTH ANDOVER Frank C. Gelinas & Associates, Surveyors September 12, 1980 I /0 Plan .33537 C / l g I� • I f it 'M � E s► AM 33537C a6 o 0 r f S381 o N �dY 4yoa Q, V• . •� 1 ?�23� de`�`'� Fes•• Q 37 I S TOa Op ti )4`o ti `fls h 3 \ i B ubdivision of Lots 33, 35 and 36 hown on Plan 33537F and 33531-G sled with Cert. of Title No, forth Registry District of Essex County 4parate certifcates of title may be issued for land Oivn hereon as 4.0ts_37-thru___________________ e the Court. ` -`-`.-�-Jam'-�c - EG/01/980_ - Re oder. LCB -S-3. 3000-7-76 Plan 3 537A Cert. 6447 �f h DECEIVED FOR MIS'17RAMN NOTED ON C5#fftv"-M REGIS-MATION 66GK.,�6-.PR6,9.../ .q Copy of pact of plan filed in LAND R£GISTRA TION OFF/CE DEC./0,/980 Scale of this Plan 80 feet to an inch R. L. Woodbury, Engineer for Court fl, 3737 A Date .. ... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... :2. 114 .... �4 ! ............ ........................ has permission to perform ....... ................................. wiring in the building of ......... ......... ) Id - at............ ................ ........... ........ . North Andover, 1� ................ ......... Fee ... ... Lic. Nod�.�/��3 ......... . .... . a—'— ELECTRICAL INSPECTOR Check # I ';� � 4— 7 14t &MMIJnWralo of 4fl.u� �rl�usri Mepartment of Public 0a&tg BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only ��� % . Permit No. (' Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 52:Ppe Z12-0 (PLEASE PRINT IN INK OR TYPE �� /ALL I=91A0 Date &&Z - City or Town of. /VC) To the Itor of Wires: The udersigned applies for a permit to perform the Location (Street & Number) Owner or Tenant Owner's Address work described below. Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) 5 Purpose of Building 1 Utility Authorization No. Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ New Service Amps _� Volts Overhead ❑ Undgrnd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ) No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting I Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Ranges No. of Air Cond. Total tons of Disposals No.of Heat Total Total Pumps Tons KW N(1,. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal ❑ [I Other Connection No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: 1Nry UHAIVGE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES IX NO CZ 1 have submitted valid proof of same to the Office. YES K NO ❑ If you have checked YES, please indicate the tye of overage by checking the appropriate box. INSURANCE X BOND ❑ OTHER ❑ (Please �c�ty) T�/�f� �it�a.> �y 3 Estimated Value of E! trical Work $ p ( iration Date) Work to Start Inspection Date Requested: Rough Final Signed under the Pe alties of pedury: FIRM NAME _' G �P/C (�(% 1 /J/G LIC. NO. s 3j Licensee S, Al, -,/uR.9 2 Signature �- __LIC. NO 4-r93 3 Address -3 7S7 L. &1U1C1.7/CJ/YCa- /Cj;) 4& "I -),VZ /l�E/ a/9� It. Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner A (Please check one) Telephone No. PERMIT FEE $ lJ (Signature of Owner or Agent) X-6565