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HomeMy WebLinkAboutMiscellaneous - 102 WINTERGREEN DRIVE 4/30/2018Date ..*7.15. ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This cerlif that .......... ..................... f ...... .................................. .... ... .............. L r ga— has permission fo s installation . ....... .......................................... ...................... inthe buildings of ............... C ... .................... ; ..................................................... at ..... /....... / ....... �n2.......................... North Andover, Mass. Fee -3p ..Lic. No . ...... ... ... ;..� .................................................. GAS INSPECTOR - --Check # 3m U S86'0 Dat ilk X0/5 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1 lis certifies that...........'......'s..................1?........................................I...................... has permission for gas installation ....... .....r1...�..q...�,A in the buildings of ........f%r2,,..... ....... at ........ ...... !. ..... �,1...................... North Andover, Mass. t � L� n . ..........................................Fee k....... Lic. No. /%�....... GAS INSPECTOR Check #"--3 - 1 �,-- f v\ �T\� - ✓Y' . 3 MASSACHUSETTS i NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE J3`� U ERMIT # I JOBSITEADDRESS,JOWNER'SNAME GOWNER ADDRESS _ TE FAXE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: F—j RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES E --J1 NO'`9 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ ._._. 1 —I J _. ___ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR, GRILLE �..-- INFRARED HEATER LABORATORY COCKS I (� J �. _1 =—J J ( ! r. _.� J — MAKEUPAIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER . - - I _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES *0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND F 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 Ell SIGNATURE OF OWNER OR AGENT 1 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 y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com lian a with all Pe n n r is! f Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME A��,� ICENSE # ( SIG ATURE l' - MPMGF JP ® JGF D LPGI CORPORATION #EAIM PARTNERSHIP ©# LLC E]# COMPANY NAME: DDRESS CITY T _� STATE ZIP JTEL FAX �' CELL _ EMAIL �,-- f v\ �T\� - ✓Y' . 3 H W rH� O Fri A z❑ ° 0El W 0 W o H au LU z m a W � co a W a > Rr LU W c a C7 zz w CA a U J H CL a � Q z w F- LL. W H °z 0 H W W .) The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/individual): 1 lM C_ Address:�- City/State/Zip:,f � G� Phone #: 7 � 7lEf Are ou an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part -tine).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9, ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. [1 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. Roof repairs insurance required.] employees. [No workers' 13.n'Other comp. insurance required.] *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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that checkthis 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 anal job site information. Insurance Company Name: IES21 f t`Yt`Y.YgC�� > �� Policy # or Self -ins. Lie. #: I � '�' / �/ o ; �7' Expiration Date: i Job Site Address: IVO 10�t l% City/State/Zip: Attach a copy of the workers' compe tionpolicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under thepains a d p alt's perjury that the information provided above is true and correct. Sienature:�Jl 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 M Informati®n 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 suchemployment-be deemed to bean employer." w MGL chapter 152, §25C(6) .also states that "every state or local licensing agencyshall 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 producedacceptable 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 andprinted legibly. Tlie 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 permithicense 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. r The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .A,ccidents Office ofInvestigatlons 6.00 Washington Street Boston, MA. 0211.1. `del., # 617-7274900 at 406 or 1-877rMASSAFB Revised 5-26-05 Fax ,# 617-727-7749 __www-mass,gov1dia ii -IML NUMBER -IML NUMBER Date... P 1 .. U 3.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....A.�? �.n� P has permission for gas installation . I !r w . � .... in the buildings of ..CO.N' ........................... at ..!. d.a . (!� (A'.�.q (°.P 7' `.°.A. ....... , North Andover, Mass. r Fee.. S ... Lic. Nog .C-& Cn ... .Ak,,q -` GAS INSPECTOR Check # (06-1) 4488 MASSACNUSc i I S UNIFORM APPLICATION FOR PFr�,1+11T TO DO (Print or Type) N Andover .M,A, D--t-10Z24 � -. P°~rnft Cwne%sName Jack Lot:_ Zone: Installing Camoany Name EAS'I'ER -N PROPANE & (DIT,, � ISC Address 131 WATER ST DANVERS 01923 Estimate Valueaf Wcrk: SusinessTeieahone 800-322-6628 residential checkane: casiifcate f Carporatfon ❑ PartnerahiP Nameaf Licensed Plumber arGao Etter s CI Firm I Q. Chris AleLP 86 INSURANCE COVERAGE: I have a cirren lability insurance policy or its subsartttal equivalent which meets the requirements of MGL Ch. 14Z Yes No ❑ if you have Checked Yes, :17indicate the type cavernae by checking the appropriate box. A Ilabillty insurance policy Outer e of indemnity ndentnity ❑ and (OWNER'S INSURANCE WAIVER: I am aware that the licensee does not 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: Stanaturs of Qwner or Qwnars Aaerrt dwner Q AgentC 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 my knowledge and that all plumbing work and installations performed underthe permitissued forth li tion will be i mpli cz all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the C ral ws_ By Type of License: Tide Plumber Si r ed Plumber or Gas iter Casitter City/Town I Master License Number LP 986 APPRCv� !GFFiCc USc ONL'') Jgumeyman J r f A. =17= 4 m n n a ,t m m ; cl ' m S m m a r n D m m O_ r p O O 4 m G D � m 3 m rn O m a m O a p = > r 12 ,Y'Location p No. A0 Date � I r NORTH TOWN OF NORTH ANDOVER p Certificate of Occupancy $ , Building/Frame Permit Fee $ cMusE� Foundation Permit $ -Other Permit Fee Sewer Conned*K Fee $ ` Water Connection ` $ TOTAL Building Inspector 12307 Div. Public Works �,ocation No.� Date v NaRTh TOWN OF RTH ANDOVER O?O�`<`•D '•,AOR n Certifik of Occ ncy $ * i Buildingame Per Fee $' �i�s'•"°' Eta Foundatio' Permit F $ s�CHus Other Perm Fee $ s Sewer Conn ion Fee $ R i, Water Conned Ion Fee $ TOTAL $ 4,,;�57 Building Inspector ni„ rh,hli, AM -1— 0 m m m 0 wow v A n c n n Si SF r z A r -R a © a m o m y m VV � N � O G O y wow v A x w 41 41 N M Z n c n c n n Si SF r z y © a m o m y m � O G O y O z. O O O W O z D O O �T �o G y � � r � Z m 0 x w 41 41 N M Z n c 7 llitlaciture; DEPARTMENT OF PUBLIC SAFETY j y ONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate; CS 884418 89/38/1999 89/38/1957 Restricted To: 88 LOUIS M KIIPPER 6 LINDA ANN WAY MIDDLETON, MA 81949 j The Travelers Indemnity Company The Aetna Casualty and Surety Company MM,bes a TravelersGroup'T The Travelers Insurance Companies (Each A Stock Insurance Company) Hartford, CT 06183-4040 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER RENEWAL OF INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA 1. INSURED: 83H -UB -824K675-3-97) 83H -UB -824K675-3-96) PRODUCER: NCCI CO CODE: 13439 CROCKER SALES COMPANY INC. PREFERRED INS AGENCY INC JET REALTY TRUST 10 NEWSUITE ENGLANDBUSINESS CENTER WOBURN MAHIGH STR01801 ANDOVE�t03 MA 01810 Insured is A CORPORATION Other work places and identification numbers are shown on the schedule(s) attached. 2. The policy period is from 08-03-97 to 08-03-98 12:01 A.M. at the Insured's mailing address. r '+ 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100,000 Each Accident Bodily Injury by Disease: $ 500,000 Policy Limit Bodily Injury by Disease: $ 100,000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL, AZ, AR, CA, CO, CT, DE, DC, FL, GA, ID, IL, IN, IA, KS, KY, LA, MD, MI, MN, MS, MO, MT, NE, NH, NJ, NM, NY, NC, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WI, HI D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be C made ANNUALLY DATE OF ISSUE: 05-27-97 JM OFFICE: TPACOMP 715 DISTRICT: C-01 PRODUCER: PREFERRED IN AGENCY INC 00715 FORM U - LOT RELEASE FORM �r C INSTRUCTIONS: This form is used to verify that all necessary approvals/ r its from Boards and apartments 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 ✓LOCATION: Assessor's Map Number SUBDIVISION SHONE q—/� " 7 qq-3" I p+ARCEL01'4� **"-***OFFICIAL USE ONLY TIONS OF TOWN AGENTS: TOR DATE APPROVED ,DATE REJECTED_ LOT (S) . NUMBER PLANNER DATE APPROVED DATE REJECTED �.A f FOOD IN CTOR-HEALTH DATE APPROVED DATE REJECTED EALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR GATE 50 AUYVII JOAN AND KATRINA CARNRY • ... i�cR•TI-� t3o,o0 1 • •.•-it; ; ,�, leg, &Z • 1 f �r � lid I N •//7,D, a 1 L4T. I& i ` ;;HT�Rr1RY \ 43,546 lit GV I.- I7L• �S�•� ISII QMV,(fA ZEt--W u;)RIVl_= I Dalry var pit OU6DM vim b0 ( i OOIfpW >a f[ANlgl IIEQIpFINJ11f LL (r1 f Sm t ITEM 6tA►AON;w iN }ip�7p Ap�y�, N 0 1 t K vrnn � ftno 77. PI��IFSJIRtfM MOQJUIf�1+iN1�0ACWWE ACIION UNDiR 4Ki. Q1. R MASSACHUSETTS I C My 1NIAT ONS PRDPIM 13 NOT LOOAlw N M tNTANLWU rLOOO LW 11AZM ~ C0WUNITY P'ANM �• MM:250090 00016 DAM 6-2-93 DEED llr6 carANY IS NOT t t� IOR ANY WMRNMA UW pAwt0{ ar lopig RWMW OAR W M t 0:09"W= EtO O► RECOID. NOoII 2242 ¢1�! WR lL4LWW AAE 6100tH tM THAN CKfool TROY TqE 1-o1'atY U K IT It AOMSM MOAT AA MOUE 1hNM6C PAW K NAM To VpNOF�Y- VILK NLASMi1ML j` A:INRM PAR Silt, N4 M66 t »IAOA��,dE�IITY pv 00A1R oF`trllA•� iY �IARiQ�! or oASRg AND ooE6 Per Km N6: PAW MAY K AooDINV611tO oliY OY AN ACCUMIK, RIrldIn . t At0 OKRtk A6 slooK KA1I X10032 DAar190S USED FOR TIS EStA9t1S1 i' •" {e ES JA6N:5 W. NOUCK MCAS R.L.S. jlS29 "s 16. 1991 . so" r• 701 BRADFORD ENGINEERING CO PA PM 4311 IUWMr1L NA 0431 AL. PM 715-1,w6 �•�. .... ic'�Sr • K r _....zeta. ►z,sr es�et.ca Di19GB98eG ............................................................................................................................................................................. E I LOT f 4- Aw 43 568...6-F M rt i -or /5 £8'd F.Z:to 86/14z/rLe ............................................................. .................................. � — - , . . ... . .1. 1f 4 YD H ADW-ILZ Ar ofi? pill .................................. ... . ...... 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CD CO) 0 O CD 0 G CD O trios ori QO�m CD N O�mC n O ono m Z ,, �� CD = s; I c T CD � ? °' CO) I O m p O O m CD m n O _ O mCD �p O n C�C W r ate' C/ ec o CD r V J CD O c N P � m 1 n� o am . nyC_ O d H O t^f crc d C 0 ;L a ^ N C O rn 5 m H CD d o�n =� co r a�� 0 �o n CD a,3�� ) o 0 0 CDCD' � ny 0 r: CS m d W-9 � ate: � C2 00 o 0 o o =' � o m �E 0.3: �q cn O o r, cn 4 rtm z t `-; ►� ;v C aa Ci y ^n a0i0 cn < ; 9z C a Com" (7 H � a of � ;� � �- '� r C PIC _? m n 3 C of C a o W '� r � W cn a v, R ^n O x n^ O y a �O 10 91 Y L! 0 c TQ0oz5 iS . 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: Phone LOCATION: Assessor's Map Number Parcel Subdivision wince& 69E,= -X( 57M476 -S Lot(s) Street St. Number /C C -- ************************Official Use Only************************ RECOMMENDAT NS OF T ENTS: OF; Date Approved Conservation A/% d�ministr(aatorf Date Rejected Comments `� Ute, Le NO L till leg D Date Approved Town Planner Date Rejected Comments Food Inspecct_o�r--Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved /a Date Rejected Received by Building Inspector Date :JVV.7ZVZ 0 41M v cou s II -t .,M M N ,N N N N N N U �w N N N N' N N N N N N J2Ir-wz w a Vo D o h o 0 0c 0 o wz�o 0o M o M N o 0 o N N �V3Z � N N N N N N N N N N gwwU �`'JgEs►s d��y Ij N M V h gwO(wi)O \• is 0Qc 44 44 L,4 O �- L 4 a U 'r ~ Q� wD W i z '' o 0 0 0 Cl iQZW� ~ Ll emu--� J ti ti? O j j Z)? ~WW O Z U U >C '54", •. ooD m �m2M ti 4 4 N ~stn � vwj y O D p p O O D �Qi�Q o Q Q a Q o 0 0 0 0 � Z U�DDO a m m a 4 w w w w w J z O O O O O Q Q Q 'Q Q k�QWW in } ZI�Z�a !} 1 ' 0 :a 54.24 SO \ w m I to D N "l -J- 233-82 Q U W m z ' a, y,A 4 �f 152-82 O O in } \ w m I to D N "l -J- 233-82 Q U W m F7_ z ' a, y,A 4 O O in F7_ N/F Dorothy Arsenault 199.62 Lot 16 N Are , 568 M Lot 17 N ; Existin Foundation 'IPIELD g5'Tc SES �Tnv\c 90/ To L.EAr-'4'r V-1 200.00' WINTERGREEN CI'IEsm G s MOMR N •e �31342�'Al '01 W Ed FA AV If 10"X Commonwealth Engineering Associates, Inc.:.;:' 16 Old Post Road E. Walpole, MA 02032 Phone: (508) 668-5136 Facsimile: (508) 660-1457 Zy��t• DRIVE N co Location NORTH ANDOVER, MA. Date June 25,1994 Scale: 1 inch= 40 feet Deed and Plan Reference: Deed Book_Page Pian Book 10032 Page Certification is hereby made to: Stoneham Savinas Bank - that the existing structures as shown are situated on the'lot designated and are in compliance with the applicable Building and Zoning By-laws of the municipality when constructed. Certification' is hereby'made that the structure shown on this plan IS NOT located within a Special Flood Hazard Area as delineated on the FIRM map of Community Number 250098 0007C Date 6-2-93 _ Location/yr — /0� W�� tT'U DQ�✓ir No. 9-Z 4'" Date TOTAL 0 LI 7420 $ ,Building Inspec or Div. Public Works TOWN OF NORTH ANDOVER Certificate of Occupancy $ �'- -7` 144— .; } o.Buiiding/Frame Permit Fee $ i4gS.�o y�ss�cHusE�h Foundation Permgej_t4 Other Permit. Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 0 LI 7420 $ ,Building Inspec or Div. Public Works Location No. Date 14ORT1y .TOWN OF 'NORTH ANDOVER Of,,,so ,x,41 '.4 p Certificate of.Occupancy > ; ; Building/Frame PermitFee$ 9 S <� Foundation Permit Fee $ ° Other Permit Fee $ k Sewer Connection Fee $ ,,,Water Connection Fee $ W v . ` TOTAL 'lL / $ S G. 6 ;/Lou Building inspector L�: 7406 Div. Public Works Location . D. 2 G --Date �' - V d7 �a y 6964 TOWN OF NORTH ANDOVER Certificate of Occupancy $ , .Building/Frame Permit Fee $ *0undation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ �! TOTAL 9i "sp ctor / Div. Public Works m m A m m z v i \ i m ii _r > A m r 0 �0p -1 r 0 a v � O (� Z A � A > ^` _ � A 0 a .. c i A A 0 i 20 �0p -1 0 i 0 a o � O N S � A r C C A J O y r m a > m 0 m m m 0 I r N r 0 o c m i N N m n 0 z N w i > a n m a m v v o o o 0 Z N 1 A c n 1 0 Z N w A a �, ,� i A A 0 i 20 �0p -1 0 i 0 a o � O N v a � A r C C C > G D D r I Z Z � 1 Q 0 m a �, ,� N> o o � D o o r N 3 A r C C C > G D D r I Z Z n 1 z 0 0 0 0 M 0i m 0 m n m O M n w 0� D r Z Z 'n 2 O r A A O N Z i> N 0 Z > I m > Z n > r i D O ° z m f 0 3; r '0 N m > D 3 m Z m m ^ N ZA ° i z = \ 0 i r A m e m f �, ,� N> o o v m> o o r N 3 A r C C C > >I D D r I Z Z n Z. m� 0 0 0 0 M 0i m 0 m n m z M n N 0� D r Z 'n Z 'n 2 O r A A O N Z i> N 0 Z > m > Z n > r i D O ° z m f 0 3; r '0 N m > D 3 m Z m m ^ N ZA > i z \ 0 i r A m -ni A 0 `-Ay Z ? 0 0. 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N W y H Z n 3 Q¢ 5 Z m¢ Z 0 w U O S Z _ J S H v O Q CI _ W V K Z C N W p 2 Z O Q w 0 W o f 3 Z p Z= Q LL U N ?¢ N Z z Z Q 0 01 O a a 2 0� U : °� d j O 2 a O Q a Q a= 0 wQ 0 J J V a p- 0 U ¢ Z Q W S J O N p l 2 Z C 0 y y V w 2 U Q Q N Q m H 3 Y Z N H 1 W n S p W Z —11 1 TT I T1-1 I I I I I c z I 0 N — U O p> 4 uZi Z W } Y> Z W n. v¢ a Q O w Z � J J 0� O a[ J J O YZ W Q -Uz �QO�o� f O Si npv at n O cv� �<N m m0 i ^ ; NOt�oo0i Z W QQ<Zf LL K Zp iZ " y °e,eF < ¢ a z O W 0 0 m J LL' 0 Z o 2� QN"' IN 0 jOw Z Z 9 0 Z 0 w z z� 00000 V z z ; S Z c�0 _� N m nc Z ww� - OC OC �� O O ti O O W W b JN O K 0 K m Q 0~Q ZIEa NOO�u G ZUo�c c� w m0 da02Nuv�UzzZ Q�ONNw���-000 mi 20��� tGO O mJp :E 0 r% `- fr N Q U U m a K Q= Ow ZIS U 3 Q Q> N 0 m m V N N QQQNOa° 00 FORM U - IAT 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*****2* ********* APPLICANT: C.C1�-U/ivh�i �1�r/, ➢�1�L Phone 5�5 �7 LOCATION: Assessor's Map Number / O`'% Parcel i Subdivision 2.J5�'r/PS Lot(s) J Street o dd�G'�e-�,r� St. Number * if Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation AaMinistrator Date Rejected Comments 16 L�s wmik Town Planner Comments Food Inspector -Health Z ti Septic Inspector -health Date Approved Date Rejected Date Approved Date Rejected J % Date Approved Date Rejected Comments 5� Public Works ---� - c Fire Department Received by Building Inspector 2T Date %y Commonwealth Engineering Associates, inc. MORTGAGE SURVEY This certiflcation on this plan is made for mortgage purposes only. The undersigned will not be responsible If this plan is used for boundaries, fences, plantings, special permits or variances. Lot 17 N/F Dorothv Arsenault in. OF Location NORTH ANDOVER' MA. a CHESM G REDMOND �' Date June 25, 1994 Scale: 1 inch = 40 feet •o No. 31342 �d 9-ofsToP�� Deed and Plan Reference: �����AL LRf10 6 Deed Book Page Plan Book 10032 Page -Certification is hereby made to: Stoneham savings Bank - that the existing structures as shown are situated on the lot Commonwealth Engineering designated and are in compliance with the applicable Building and Associates, inc. Zoning By -taws of the municipality when constructed. 16 Old Post Road E. Walpole, MA 02032 Certification Is hereby made that the structure shown on this plan. IS NOT located within a Special Flood Hazard Area as delineated Phone: (508) 668-5136 on the FIRM map of Community Number 250098 0007C Facsimile: (508) 660-1457 Date 6-2-93 „1 m D m DO z D m D m z m r z z PrA l J O z cn m D O z 9 • 'r•� 0 C• C4 rV1 $ a o `o: `° CD 0 CD Cl) v, o ymaC �. .► fi a) — CL 0 T _ ,.* n fli � 0 d C=D H y CD o -i 0 5 CD CD 0 co CO*, n CA Cl) L, o gin; n CD CD C7 Z t/) c CCD .`O =CO 03 CD 0 H o oo ED CL CA _ CD cn .o CO) CL o C CD o: CD _ _ y Hcr 0 y CD CD a)rA r� CQ CCD CD O CD ,� o CD0 O m� a C CD y� CD0 H 3 fl. Ov y -0 0 W CD- .. � a � cm 3 y '0 4� CD Z �' CCD CD z" o z l -"o CSDAcro:41* Quo o G Co i s Allk; y 0 0 C (D �s 7 d zz y 70 w G41) � w �o� < 9 GO y O 7d w G O 0 w G G O c �� O O x 0 C (D �s Location/of '1114 W r" -M7 mae-, U f3 ( No. Date 3 `� " TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �'ssA�NUSE�� Foundation Permit Fee $ Other Permit Fee c Rsh4N� y$ S " Sewer Connection Fee $ Water Connection Fee $ TOTAL 09:43 _I 7508 Building inspector 6.00 PAID Div. Public Works •+1 1 1\.1. +\I1 . l3l SII .t)IN( � (::ON I :I I VATIC )N I I J:A1:1'I 1 I'I.ANNINU ATE , )CATION ,4 �.ANDOVE It 1►IVINII IN 111' NN1NG. & (j'W1I%IUN1'1*Y Di's\'1:1101'A11 N'1' 1:: HWNI 11.1'. NI:I.ti1)N. I )IIt1 GI (M CHIAINEY APPLICAHON ANU I'ERAll f FERN 1'1'. # LINER'S NAME: 1ILDER'S NAME: " ' ' 1 j LLO() P, N im & tit .: iSON' S NAME: kSON'S ADDRESS: l�;' ISON' S TELEPHONE: 1W JERIAL OF CHIMNEY: IFERIOR CHIMNEY: l( �,�,_� EXI LRIOR CHIMNEY: IMBER AND SIZE OF FLUES: IICKNESS OF HEARTII: ' 1�-•.--.-----.'... -_-._ . chilliney oa ()iAepence conomill to 4he. Acqu•iAcIfic►I.ts ur the code cull! have -u1Ce.6 and :g utat i ow been neee.tived: vtS -- -- --r TE: GRA I:RAIIT GRANTED: f'BERT NICETTA .'ILDING INSPECTOR P• E EalloZ��=-• SPECTEO: -- 'MARKS: SOLID ttLc�Ulltl a au ck- ygz 3 —7Sd8 THIS PERMIT MCISr GE VISPLAYLU 014 11IE I'IZ MI SLS TE �� RHONE �.. QlT�EA CODE NUMBER EXTENSI MESli SIGWIV V . FORM 4003 NOTES J { NORTH •9 16.g Np 6 O O (b O LAKE 1 COCHICHEwICK V A_\ ADRATED PPS �� �SSACH1)E- ' APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: DATE REQUEST FILED/READY FOR INSPECTION: V CLOSING DATE ON PROPERTY:/O /,� Z-2 'j^ FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED. ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED: //il,/'� /� /,� _. f .2` 'lv CERTIFICATE OF USEA. OCCUPANCY' Town of North Andover St ildhig Permit Number 264 Date om. RFR 5, 1994 THIS CERTIFIES THAT THE BUIWING LOCATED ON 102 WINTERGREEN DRIVE - LOT #16 MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W2 -CAR GARAGE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Colonial Vi 11nge T)Pu, Corp .• o �� 4 Roach Cir. A ' p ADDRESS Ne . 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Y S o w G O C �w :: Tl n p re to d O <1 �' rD t7l \n - a- Oa p :7 c 0 [� p G\ '"' ro w < G �j p C On o w G O C :: Tl n p re to d O <1 �' rD t7l \n - a- Oa p :7 7 Coz !. aj �g y %C O 0-4 CA � i NN ^�'B �F, iia •� S? � O g ZIT it < 4•.irril.Y n. �i ..,....,,.�..,....... i �_... v w y 0 I lip G ,« MASSACHUSETTS UNIFORM r PFUCA iGN a=Gn FEFW.1T TO GO Gr;SriTTiI�G ® (Printor T e) r —r �6f.:zss. Ca`e t 1 1 Permit Building Location I Owner's Name clafiu n n Type of Occupancy New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No Installing Company Name E?.stern Pronane Address 1.31 Water Street Danvers. M 01923 Business Telephone (50,-)) .774-1930 Name of Licensed Plumber or Gas Fitter Check one: ,N Corporation ❑ Partnership ❑ Firm/Co. Certificate INSURANCE COVERAGE: I have a curr n liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy A 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 ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi ' s d fo a plica n will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th al By TR of License: Plumber gnature of Lice7i Ply bio Gas Fitter TitleGasfitter 0!JX p Master License Number City/Town Journeyman APPROVED —(O—FTI—C—E 70—(O—FTI—C—S E 0 N L N C Y y 0 0 U N G N C O V O Q Q C O M 0 h W < W w O h -� n G C > h Q N C La J V 2 U W = = y Z W O W tJ W N Q W V V OC > W L U J W C< > C w 7 ~ <=<O O O W h — = O — — = v > = I _ F c SUB—BSMT. i BASEMENT 1ST FLOOR 2ND FLOOR I I ( I 3RD FLOOR J 4TH FLOOR 5TH FLOOR ( I 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name E?.stern Pronane Address 1.31 Water Street Danvers. M 01923 Business Telephone (50,-)) .774-1930 Name of Licensed Plumber or Gas Fitter Check one: ,N Corporation ❑ Partnership ❑ Firm/Co. Certificate INSURANCE COVERAGE: I have a curr n liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy A 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 ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi ' s d fo a plica n will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th al By TR of License: Plumber gnature of Lice7i Ply bio Gas Fitter TitleGasfitter 0!JX p Master License Number City/Town Journeyman APPROVED —(O—FTI—C—E 70—(O—FTI—C—S E 0 N L • 3 r co m A O 2 X rn A - n N r o > n o ° p -> m > m r m ren O � •0 2 ° =a a o m a O m m > :•. -I p m ° o } o r o > N 'Nit z � � N rn p A -I Lei A �.Ta 1966 r - Date.. NpR,M TOWN OF NORTH ANDOVER pF �•ao ,e 14, "PERMIT FOR GAS INSTALLATION p a �9SSAGHUS6 _ ° Q This certifies that .. c : �✓ .. ° ........... t • has permission for as inst k�lation ... 614 . ' in the buildings of . . ' ....................... at../.... ., . �.. Y✓..... f/ ... , North Andover, Mas Fee . 22 1�U .. Lic. No. I & 7 7 ........................ .9 7�Z� GAS INSPECTOR C 'r r WHITE: Applicant --CANARY. Building Dept, PINK: Treasurer GOLD: F110 i J v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ( rint or T e) ' Mass. Date 21/41 Permit Ck#�'"� Building Location --/L/ � JI 1_//'t' Wr (effi ner's Nam / Type of Occupancy New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No Installing Company Name E^.stern Pron2.ne Gas Inc Address 131 Wa.ter_ Str-et Danvers, MA 01923 Business Telephone ( 5 0 8) 7 7 4 -19 3 0 Name of Licensed Plumber or Gas Fitter /� �Le/% �j Check one: Certificate I Corporation ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No ❑ If you have checked vees, 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: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this a p' alio ill a in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the ener:U BY Te of License: Plumber Signature of Licensed Plumber or Gas Fitter Title asfitter Master Master License Number City/Town Journeyman APPROVED OFFICE USE ONL A i ®■■■■n■■■NS■■s■■ ■ ■ ■ ®■■■■■■■■■■■■■■■■■■ ■ ■ ■■■ MR •• ■■■■■■■■■■■■■■ ■■ ■�■ ■■■ REP. - ■■■■■■■■■S■■■■ on ■■ ■�■ • • ■■■■■■■■■■■■■■■■■ monsoon • • - SEEN■■■■■■■S■■■■■E■■NN■■■ Installing Company Name E^.stern Pron2.ne Gas Inc Address 131 Wa.ter_ Str-et Danvers, MA 01923 Business Telephone ( 5 0 8) 7 7 4 -19 3 0 Name of Licensed Plumber or Gas Fitter /� �Le/% �j Check one: Certificate I Corporation ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No ❑ If you have checked vees, 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: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this a p' alio ill a in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the ener:U BY Te of License: Plumber Signature of Licensed Plumber or Gas Fitter Title asfitter Master Master License Number City/Town Journeyman APPROVED OFFICE USE ONL T m m N X m A x m N m m r O T O m O T T_ A m C N m 0 z r lr\— ONICR use Only The Commonwealth of Massachusetts p' Deportment of Public Safety ?� Occupancy s r.t oKwe n BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12:00 3/90 (taave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AU work to be periormed In accordance with the Mauachuseru FJeetrical Code. $27 CMR I :00 (PLEASE PRINT IN INR OR TYPE ALL INFORMATION) � Date City or Toon of .9 4L p 4T To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) �o lr�'o�Tyf�� •�' 4&0I0Y Owner or Tenant ` gyem- Owner's Address_ S&4, Is this permit in conjunction with a building permit: Yes M No ❑ (Check Appropriate Box) Purpose of Building 1"A MQ 6q'%, , & A Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters V New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Ne:mber of Feeders and Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total INA No. of Lighting Fixtures Swimmin Above In- g Fool grnd. ❑ grnd. ❑ Generators . INA No. of Receptacle Outlets No. of Oil Burners No. of Emergeney Lighting Batte Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices of Sounding Devices No. of Sell Contained Detection Sounding Devices Local❑ Municipal ❑ Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No. of Neaps Iotas TotalTonsNo. No. of Dishwashers Space/Area Heating ilii No. of Dryers Heating Devices KW No. of Water Heaters KWSigns Ballasts Voltage Low ng No. Bydro Massage Tubs No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Lays I have a current LiabilityInsurance Policy including Completed Operations Coverage or its substantial equivalent. YES* .NO [ I have submitted valid proof of same to this office. YES,M NO [IIf you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE U BOND ❑ OTHER ❑ (Please Specify) MERCHANTS . TN,R-bRANCF. 96 cp ration Estimated Value of Electrical Work $ ate Work to Start Inspection Date Requested: Rough Final Signed aLAer the penalties of perjury: FIRM NAME Licensee -GREGORY TAYLOR Signature Address F LIC. NO. LIC. N3.32268F. No. 50.8-250-001 7 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its su - atsntial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent Gk -366( '.j Date.... .. ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING J.& ........................... This certifies that .... . ....... �—q //4 has permission to perform ........ &.h....... ...... ................................... wiring in the building of .... . C. C'r. .................................... at ...... ►'A. PAL 00 ...................... . North Andover, Mass. Fee—K r. D. 0.. L i c. Nz............... - '***INSPECTOR- ........................... ,* *-'- ' ............. ELECTRICAL WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File -A* Date ...... .r , ....... ..r . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION- In This certifies that .. �. �. r.(.f .:..�.-�...... J .............. Q. �� +� r • . o+ has permission for gas installation . ... .,• . I .............. . in the buildings of .. . (� o % ati` .t ? ... C.. f . --. J, North Andover, Mass. Fee. ` : Lic. No,, '`..%.. . .......................... �l f / GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File