HomeMy WebLinkAboutMiscellaneous - 103 LOST POND LANE 4/30/2018cation1a7
Ro. 113 Date g 7
3 Other Permit Fee
to Sewer Connection Fee
p, 7oO W&F Connection Fee
TOTAL
920 ���.�„�
Div.
0
,ORTI,1
TOWN OF NORTH ANDOVER
C?Oatt�a° .a ah•�p�
►-
Certificate of Occupancy $
i� ; ,'
Building/Frame Permit Fee $ S
Foundation Permit Fee $ ! DU
3 Other Permit Fee
to Sewer Connection Fee
p, 7oO W&F Connection Fee
TOTAL
920 ���.�„�
Div.
PERMIT NO.
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE 1
MAP KBO.
I LOT NO. � � % 1 .f.l�
2 RECORD OF OWNERSHIP iDATE
K 'PAGE
ZONE ,.
SUB DIV. LOT NO.�
—Fl, N � I ct r,/ INC `f�'
t�
77—a13
LOCATION OS OfyQ dA/
! G e
PURPOSE OF BUILDING
,NF,,7 1,
OWNER'S NAME FN�L 0 (C //V C'.
/
NO. OF STORIES a SIZE 'y b
OWNER'S ADDRESS 0 /Q�X s'3� f�/I/f��(/�e
BASEMENT OR SLAB e,-7 e.4./7
ARCHITECT'S NAME �� r) �iiS�N
SIZE OF FLOOR TIMBERS IST 8 j 2ND k j Q
3RD 9
,(
BUILDER'S NAME/�. N •%` K N-�
SPAN 13 / -
DISTANCE TO NEAREST BUILDING 7 Z
DIMENSIONS OF SILLS
POSTS J Q Ox 5
?O /
DISTANCE FROM STREET 130
DISTANCE FROM LOT LINES - SIDES•� ` y•7 I REAR V /
" GIRDERS
44-7
AREA OF LOT 66, S'l q FRONTAGE 1601
HEIGHT OF FOUNDATION o THICKNESS
IS BUILDING NEW /e t
SIZE OF FOOTING / b " f� Z Q /' X
IS BUILDING ADDITION N V
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION // 0
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE1/C 5
f
IS BUILDING CONNECTED TO TOWN WATER ye
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER N0
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED'AND PPROVED BY BUILDING INSPECTOR ,
DATE FILED `I 7
SIGNATURE OF OWNER OR AUTHORIZED AGENT
FEE
PERMIT GRANTED ryry�p�
3 /3 19tir (fes
LESS -/00
012
SAME PERMIT $K�..�.....
3 PROPERTY INFORMATION
LAND COST ® 000 0 J1
EST. BLDG. COST l//s lJ
OV-\
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC -PERMIT NO.
4 APPROVED BY
j SWLDING INGPRCTOR
OWNERTEL.�I
��'�5��
CONTR. TEL. N
CONTR. LIC. N
H.I.C. #
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILYSTORIES
MULTI. FAMILY
OFFICES
APARTMENTS
_
_
CONSTRUCTION
2 FOUNDATION
CONCRETE
CONCRETE BL K.
BRICK OR STONE
PIERS
_
8 INTERIOR
_ 3
PINE
HARDW D
PLASTER
DRY WALL
UNFIN.
FINISH
I
2
I3
_
3 BASEMENT
AREA FULL
FIN. B M AREA
_
1/1 1/2 l/.
FIN. ATTIC AREA
N_O 8 M
FIRE PLACES
_
_
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
2
3
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
HARDV4'D
COMMON
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
CONC. OR CINDER BLK.
ATTIC STRS. 8 FLOOR I_
WIRING
STONE ON MASONRY
_
STONE ON FRAME
SUPERIOR I� POOR _
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
I
I HIP
BATH 13 FIX.)
_
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
1
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
I 11 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
GAS
OIL
B'M'T2nd _
13rd
ELECTRIC
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.
1 sf �
TIAf H,.2'iL 2.144
FORM U - VERIFICATION 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*****************
APPLI CANT : ) � j L 0 t .T AJ C -
LOCATION: Assessor's Map Number /6
I �
Subdivision L 0 Pojyp
Phone Ag - b ss o
Parcel i,7qcJof )Z/ I,6',23*)7s
Lots)
, IL
Street Z05T POND LgeVL St. Number /03
************************Official Use Only************************
RECOMK9NbATIONS OFTO AGENTS : :
Date Approved /
Y Conservation Administrator Date Rejected
Comments
Date Approved
:21 ZEl-
Town Planner Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved
Date Rejected _
Date Approved a
Date Rejected
✓r -
Public Works - sewer/water connections 34-27
- driveway permit
Fire Department vtfto kf L-Ceg.Thrk,0 j0damer
U4 AJ
Received by Building Inspector Date
N° 700
APPLICATION FOR WATER SERVICE CONNECTION
North Andover, Mass. /"«, 19
Application by the undersigned is hereby made to connect with the town water main in 20 7 7 xee� Street,
subject to the rules and regulations of the Division of Public Works. _
The premises are known as No. l0
or sub iiyision lots no. ( _
/— // 'zf
Owner
Contractor
0
Address
AAddrSignature
PERMIT TO CONNECT
//WITH WATER MAIN
The Board of Public Works hereby grants permission to
to make a connection with the water main at Z-42-2
subject to the rules and regulations of the Division of Public Works.
Inspected by
Date
L---;�' 17 "p—
Street
"eg - C 55-g
Street
Boafd of Public Works
By (Z
See back for rules and regulations
RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES
1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town
of North Andover without a valid permit from the Division of Public Works.
2. All water services shall be installed a minimum of five feet below the finish grade.
3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964.
4. Service connections shall be 1" type k copper tubing.
5. All fittings shall be brass flange type Mueller or equal
H 15202 Corporations
H 15212 Curb stops
H 15402 Three part unions
H 8185 stop and waste valves
6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4'/z foot rod and brass plug
type cover.
GEORGE PERNA
DIRECTOR
TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET. 01845
DRIVEWAY PERMIT
Telephone (508) 685-0950
Fax (508) 688-9573
Date:
LOCATION:
BUILDER: phone:
OWNER: �1���c� / .�� phone:
The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the
grade and set -back from street established in any driveway entry onto any street or way maintained by
the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval
of such entry.
FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT.
■ Remarks:
Approval:
_ _ _ _ .. _ ✓fie Eauvrna�uaea�C� a6 � `ltr�tic�r%1efCs
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
ry Muoher: Expires: Birthdate:
CS 005693.- 01/13/1998 01/13/1954
Restricted• To:- 00
DAVID A KINDRED
'..rr 40 MARBLERIOGE RD POBOX531
M ANDOVER, MA 01845
Restricted To: 00 17650
00 - Mone
lA - Nasoory oily
1G - 1 S 2 fatily Holes
failure to Possess a current edition of the
Massachusetts State 8uiildiny Code
is cause for revocation of this license. !
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building hermit Number
Date
THIS CERTIFIES THAT
1i THE BUILDING LOCATED ON 0�-� -� Q� p0 I)
MAY BE OCCUPIED AS N G a 64'" IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS ST TE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO
ADDRESS
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'MASSACiMSETTS UNIFORM APPEtCATIOU.FOR PERMIT .TO.DO PLUM131t4G
C �YPe or Print)
NORTH ANDOVER ,Mass. Date. r
-` Betiding Location-- ( Permit I
. w _ t••r� G
C wners Name � t��c�-t �� oZ//t
New Renovation Replacement [] Plans Submitted
FI TURF
i
I
(Print or Type) Check one: Certificate
Installing Company Name �G����de ru_ [-] Corp.
Ad d re s s_� !ingcs. �_ __ o—_ F 'a r t n e r.
L rm/Co.
Business Telephone�{C'�
Name of Licensed Plumber:��
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy ❑ Other type of indemnity O Bond El
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 'E1 Agent 0
1 hereby ecttiry that all or the details and in(otnutiort 1 lu.c snboniticd (or entered► in aho•c appticalion are tine and 3mcm2tc to flit lr.it of tr.y
• knowledge acid tttat alt rlumbinr work 2nd installations l+er(ormcd undet rcrmit i<nrcd for this applicslion will be to cornpllarice with all pwillent pro• r
visionit or the Man3citusetts Stitt rlumwng Code and Cluptcr 142 or flit Ccnetat laws.
By
TitleMAY I % 1997
City/Town:
APPROVED iorr-tcr use ot(LY)
`Lt%
siclnature of Licensed Pllu bei
Type of Plumbing License
t..:i_cense. tJurnber Master 0 Journeyman
x
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SUB- BSMT.
BASEMENT
IST FLOOR
T'
1
2ND FLOOR
3RD FLOOR
4Ttt FLOOR
STH FLOOR
GTH FLOOR
7Ttt r-LOOR
OTH FLOOR
—
—
(Print or Type) Check one: Certificate
Installing Company Name �G����de ru_ [-] Corp.
Ad d re s s_� !ingcs. �_ __ o—_ F 'a r t n e r.
L rm/Co.
Business Telephone�{C'�
Name of Licensed Plumber:��
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy ❑ Other type of indemnity O Bond El
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 'E1 Agent 0
1 hereby ecttiry that all or the details and in(otnutiort 1 lu.c snboniticd (or entered► in aho•c appticalion are tine and 3mcm2tc to flit lr.it of tr.y
• knowledge acid tttat alt rlumbinr work 2nd installations l+er(ormcd undet rcrmit i<nrcd for this applicslion will be to cornpllarice with all pwillent pro• r
visionit or the Man3citusetts Stitt rlumwng Code and Cluptcr 142 or flit Ccnetat laws.
By
TitleMAY I % 1997
City/Town:
APPROVED iorr-tcr use ot(LY)
`Lt%
siclnature of Licensed Pllu bei
Type of Plumbing License
t..:i_cense. tJurnber Master 0 Journeyman
Date..
NTI- 3,334
SACMUS /
This certifies that ... �:...... ,•,
has permission to perform .....�i ,4 ..... o
plumbing in the buildings
at.. 3 ` ..
��� .. ..��...�. jti: ,North Andover, Mass. �
qq
Fee c? . Lic. No... C3. .Q............... ...............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept.
PINK: Treasurer
o�"`°T.14,o
.....•a
TOWN OF NORTH ANDOVER a
3? a ,,
�`
p
PERMIT FOR PLUMBING S
Cd
CU
S
SACMUS /
This certifies that ... �:...... ,•,
has permission to perform .....�i ,4 ..... o
plumbing in the buildings
at.. 3 ` ..
��� .. ..��...�. jti: ,North Andover, Mass. �
qq
Fee c? . Lic. No... C3. .Q............... ...............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept.
PINK: Treasurer
U, P &MMUnwalo of Mttoottt uotg
Eevartment of Public 21%afetg
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Office Use Only
Permit No. 7
Occupancy & Fee Checked
3190 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date - S-- �-Z
or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform/ the electrical work described below.
Location (Street & Number) /o 3 GDS7 pn.
Owner or Tenant �//NTG
Owner's Address
Is this permit in conjunction with abuilding permit: Yes � No ❑ (Check Appropriate Box)
�.. /
Purpose of Building ` A Utility Authorization No.
Existing Service mps Volts verhead ❑ Undgrnd ❑ No. of Meters
New Service Amps lc�b 1(volts Overhead ❑ Undgrnd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
1 have a current Liability Insurance Policy including Complet peraticns Coverage or its substantial equivalent. YES L—Ne
have submitted valid proof of same to the Office. YES NO If you have checked YES, please indicate the type of coverage by
checking the appropn ox.
INSURANCE OND OTHER G (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S
Work to Start $ — /STY' 2
Signed under the Penalties of perj_r)
FIRM NAME CAE
Licensee a
Inspection Date Requested:
Rough W144- e � Final C-0141- C5Wu
us. Tel. No.
Address - `-' • _.V—. - - - Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I 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. Ow er Agent
(Please check one)
Telephone No. PERMIT FESIV
(Signature of Owner or Agent) x-6565
Total
No. of Lighting Outlets �(�
No. of Hot Tubs
No. of Transformers KVA
No. of Lighting
g 9 Fixtures Imm
Swimming Pool Above In
oogrnd. ❑ grnd. ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets
f
No. of Oil Burners ( a
Battery Units
Zones %
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of
No. of Detection and
/
Total
No. of Ranges (
No. of Air Cond. tons
Initiating Devices
Heat Total Total
f
No. of Disposals
No.o
Pumps Tons KW
No. of Sounding Devices
No. of Self Contained
No. of Dishwashers
Space/Area Heating KW
Detection/Sounding Devices
Local 11Municipal Connection [I Other
I
No. of Dryers (
Heating Devices KW
No. of No. of
Low Voltage
No. of Water Heaters KW
I Signs Ballasts
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
i I
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
1 have a current Liability Insurance Policy including Complet peraticns Coverage or its substantial equivalent. YES L—Ne
have submitted valid proof of same to the Office. YES NO If you have checked YES, please indicate the type of coverage by
checking the appropn ox.
INSURANCE OND OTHER G (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S
Work to Start $ — /STY' 2
Signed under the Penalties of perj_r)
FIRM NAME CAE
Licensee a
Inspection Date Requested:
Rough W144- e � Final C-0141- C5Wu
us. Tel. No.
Address - `-' • _.V—. - - - Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I 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. Ow er Agent
(Please check one)
Telephone No. PERMIT FESIV
(Signature of Owner or Agent) x-6565
y Date.......... �.' /....
,o
s- 939
NQRTM
Qt �.ao ,a 1tiQ
Q p
SAcmus��
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......• c. . ......... . ...........................
has permission to perform .......Q
wiring in the building of ....................................
at ....�U r v<2 ..... U�AJ.�..... tAV............. , North Andover, Mass.
Lic. No. / .'�.R ..............
..................:.........................
ELECTRICAL INSPECTOR
05/16/97 09:03 203.00 pRID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
A
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is
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?F-'eW1oue Flr,(A - t aX i a o pgn,
FORM - U - LCT $,, .LEASE FORM 1 fits �w( 6 $
rmo1w, EY-(pRivSiot—, ,
INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT A v% -%.e --s V -N PHONE 5 0 B - 5 0ck - -7-5-CS-
ASSESSORS
7uS-
ASSESSORS MAP NUMBER 104 B LOT NUMBER & . I
SUBDIVISION,,,,nn LOT NUMBER
STREET Lc)st POA4 STREET NUMBER I �%
OFFICIAL USE ONLY
............... .
RECONpvlENDATIONS OF TOWN AGENTS
It ■/0000.■■ ■.■ ■0608■8.........■■.tt.t■0000.. tt.....-0000.. ■..............■
�f� S DATE APPROVED
■
CONSERVATIONADIVRMTRATOR
DATE REJECTEDCOMvtITS AJ e( -P C CIA) (� M
TOWN PLANNER
CON&& -NTS
FOOD INSP, TOR - TH
SEPPG IN tCTOR - HEALTH r
F'
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED� Q
DATE REJECTED
//-in a) tkht i, T -, y
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR
MO]R..r
�� JI 1—' Ox .G INSPECTIOYPLAN
NOFIYHERN ASSOCIATES, lid.
342 N. MAIN ,STP£:E-T ANDOVER MA 01810 TEL: (508)4,74-4410 FAX.- (508)474-5067
MWTSABOfi CARLOS O 8USAN BYBLICKT
LOCATIL'JY►+C' LOT 7 LOST ~ LANE
?ITY, BTAM N4RTH ANDOVER MA
�„C, i•c
A
P]
1.
CEiRUMSP M,, ANDOVER BANK
NOTE: this morigoga inLpac:t+oi. wai` ;.t ,:1 •i[•cd
specifically for mortgage purpo,oi• ur•:p and
SB nOt t0 1,U rallied upon dt, a land or 1.!ope:rty
lino survey, usad tut lecra•d1nq, pr1.1•,,t,nq Ovid �.1N Of MAsr
descriptloha, vY CGnGt ructson. the ;•c; t.,•, :, wrrc $: •ie�+
set. uullding 11", T..iGn „n<f Gtt-�[_. CARMEN
dpproximatt:ly JUGotv4 Gn Lh, grt,tl;I
are shown P.veciflu.IJy tOr Ycr:tnt;
u u,;orrtt,nlfun o
only end orbut to be ui,ua to vl-tuhl !.t. p ol),xty
lines, Tile mBt tvl16 bbe,wn Leri- d10 Al
ur,
client -t,.11710946 lntormati:,r, errs roup!•Al Ik.Ct
to further oit-culet, tal,ti,slt, [:vs;rm[i,u• curl rights
of way, end otter n1[itturt; ut rac:c:ra t t,l prescripti.[itl ��Jd` �F STFf yaw
or outer rights.. Hortttal•n (;;yuPl:iil, Ilia. dssumas no Nq� LANpS�
responsibility helcin tv C+n! lo„o o.tr,=.t ,n• ocuupant,
t,¢epts no respuusiuility 14)t e,w.otty, vI;ultjnq from said r
relianer by n
arlyne othur User. tbe. Loi,: r,:irtq&gau and itc aesl,1nd 7 l
in connection with its wu;,;,!.r..1 t..•:!.:..... ttj,ancir,gto sold mortpago ,
D*W fes'. 4272 / 30
PLAN RAD7. PL.PtPQld ✓
SCAM =r 80 •
j” * 07103153
This mortgage inspeccti(n was; pJetparotf In uaaotdnn,:c
With the Technica) Stnndortll; fol* M01'ty4gd I.uon
inspections 8S 9tloitte(l Uy t.hr tlAsaet:hualttlF puartl c11
Ite!git:tration of Vrofernion:,l f:nQia,lt,Ir, nhtl r.,n,tI
Surveyorer 250 CHR 6115.
I further state, that it, my pn,ice:vtnutl upinitset that
the structures SheJwn runthl'n, wtttt tilt! 1,+,•,tl zttnln,J lint izos.tt,t
., dimansiona] re7tl,,,e;k requiremeutt.• al thu lima of conatrt,[a1,r�,
4 ara ox(!Mit UUSiOY IfYo�i Hloue of M.t:. l.. C9t. AU -A $.:.:. 7.
J M.1.Property/House is not ill a Flood Hazetrd.
l-12.1,roperty/house is ill a V16011 llal4erd Area.
r:13,lnformation is instlfticient to dctLrmin[:
Flood Hazard.
Flood MaZard determined irom let4 t lItIOMt'aI hlQu•i,i
Insurance Rate Map panel ��'�a 6C-. , r'
I
i -
I
d
CA-
/*
R,
I
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265 00'
5
1
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/
239.24
,
,
,
,
,
,
,
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r � �
ry
7Z o
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Lot
66,574 S F.
7. 5J A Cres
Up/and = 42, 483 S.F.
C -48.4'
� Sep tic Tank
I N
o D—Box _
K J
cn L H
I C
0
� ZD
iZ
O Leach *amber
System
,J I
1
I
I
Utlll ty �asern en t _,
'00
h'jde
Aron—AIotori ed
f j i ___ __-____ Recreat1Ona1 Ease
Top Of Foundation
Elevation = 133.82'
/*
265 00'
5
1
I
I
I
/
239.24
,
,
,
,
,
,
,
,
r � �
ry
7Z o
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Lot
66,574 S F.
7. 5J A Cres
Up/and = 42, 483 S.F.
C -48.4'
� Sep tic Tank
I N
o D—Box _
K J
cn L H
I C
0
� ZD
iZ
O Leach *amber
System
,J I
1
I
I
Utlll ty �asern en t _,
'00
h'jde
Aron—AIotori ed
f j i ___ __-____ Recreat1Ona1 Ease
Top Of Foundation
Elevation = 133.82'
24 Hour Emergency Service
Commercial, Residential, Industrial
GON MCWC, INC.
Licensed and Insured
Post Box 285076
Boston, MA 02228
1-978-532-3400 JAMES GREEN
Tnu Fran 1 -R77 -79G-3400 President
��v/o3
at. .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
(- Pe �
This certifies that ....... �, � _. IK ...... o.0 ...... . /.�.7/** C
.... .... .. ... ....... ...... ........
has permission to perform .... ........................
wi;Ang in the building of ....... ................................................
5 Z— . .. ...... , North �Andover 4 -ass. P ...........
Lic. NoA6ef ......
Fee.... . .........
ELECTRICAL INSPECTOR
Check #
4 3 6
Ilk
or
OF FIRE PRE VEiNT10i`,! REGULAITIONS
Pern-ut Nlo. U1nCWl U5,,2 Only
Occupancy and I'ec Clicked
bLmk)
-`IPPLICATION FOP, PERMIT TO PERFORM ELECTRICAL WORK
o i I I 0I llicd III c urJanrc v, ilh the INILl (, IEC), 5-27 CkIl", I ?,(I()
W
To the hispecrol- of, J:Vin?s:
C Ills or her Intention 10 perforin the decli ical l,Jof k described b,Iow.
"Telephone No.
q
H!
poo Init, YesNo
L j (cjlcclApproprinte 13,)--()
tau l:....;—_-Litility AuHioriz:11jull No.
S11 A I t S ON-CrIleAd❑ El
b No. of Meters
:int )sEl U11dard ❑ No. of Meters
.\u-1'„\.�!- Ji-1'Cc'�cr� ailL .1-tllpa�t[1'-.
it :.Ild �N t ti j— Pi-ciposed f Iccl 1-ic.11 Work:
--------
c! 1-
NO. Of CCIL-SUSI).
12,14
mute 111a), Ve 11,01veft bi'. I'lle Illsoc.ctl of V:1
o
NU. of Total
ui Lich(ill- otithms
No. uf Ho(Tulis
Generators KV A
ot
S�)-ilmuillgo Pool Abw❑
ElBattery
1 0. 0 e —n c—v ri-21 -It—,l 17--
—TIN
rJINO�
Units
FIRE A LAM ql)� 01 hones
of Zones
u"Rccqtactu outlets
—00f Oil -Burners
"N 3.
o 1, S l� c 1, "S
Of Cas Burners
lNo. of DeLectioll and
L,
0.
0 1 l') e 5
I FNI —.1 f Air Cond.
Initjatiri2 Devices
S:
No.
Tons
cf.Ajorjjjj,x Devices
At
of W21it,� Dispos%aj S
I lent pul! ------------
`Totals: 11Iu I
- 0. Of Self-contained
its-------
Del[Oction/Alertillo Devices
�Spact/.Area Hcaiino J�W
:appliances
'Local Municipal0 El Alter
conliec , ii011
L
0CLIFAY Systems:
C,
N
NO. Of Devices or Equiyalelic
Dain wirili6-
W
s
Ballasts
d
FN -1,0.
L
NO, of Devices Or Equivalent
I.Llec
Telecollimulliefitions
•
-H:, 1- 0111:1 S S -Bathtubs
of Mo I ors TWA lip
t 211
Tota]
L t, Or, NN'll-illo.
N
, 1 0
No- of Devi
Ot �L L -filij),11i'(1i
r—� k V-- j 0-c vL
��6 r
Aunch additioilal detail ifdoirecy, ol* as eqjlil-ed bl, I!le jllsluectol
V%l-li�A-NCE COVI,i) "CL: Uni -ss llv�lived b): the ol,, nef, no perm[ for the performance()[ejecfl-,c2I I ;I -e
1 s
I Work fllaykStle L111ICSS
Le 1
icability )Ilcumllcc including, "completed operation" coveva,,c of its substantial ifquival6a. The
iicl] 1: CEN i �-S til. -t til.-tSLIJ-1 cove f.10 - is in force, and has c.\hibj icd proof of same to the permit issuil) office.
ft e
1 N S U R- C. 6-1 D ON 1) ❑ OTHER EP, (Specify:)
C I C. c `,fork: required by municipal policy.)
(E.�piratlon
Inspections to be ic-)uestcd M accordance with MEC Rule 10, and upon completion.
:hies tha., the iilfu I'll., a lioll On This applicafiull is 11-12e and complefe,
I \_=__',11_:-C.a- - ------ LTC. No.: j,5c??17 fl.,
----
Ll NO.:
13 us. Tel. No.:
'5 4-ce- M00
o.: cc, t -7 n I o
Alt. Tel, i N
I ;11I1 2warctI121 [lie Liccl-Iset- does polhave [h7(-Imbihiy "IsIl"J [Ice covemo�! normnik,
S; I-, t, I; c b c, w, I lic rcb I c this is teqLl
tromclit, I am [lie //check one)
Telephone No. PERMIT 1711 J 35-o
PLEASE FILL OUT BACK SIDE
01/17/2003 09:19 6173897554
. 1
i i...:COJ
.���TM :,i i�l .. 2 r 111 :Il i•1
J
.. .,,..i;.•. ilii r
-ROOMER
Qiganti Insurance Agency
787 Broadway
Everett, WA 02144
GIGANTI INS AGENCY
V
PAGE 07
•.:;:, a �� :::. ,.. „ :...,,,�;. ' oil tMMroorrri ' '
1/17/03
Nq RIGHTS UPON THE CERTIFICATE
,ATE DOES NOT AMEND, EXTEND OR
AFFORDED BY THE POLICIES BELOW.
COMPANY
AWESTERN WORLD
N8URE0 COMPANY
Green Electric Inc B SAFETY INSURANCE CO
193 Arnold St COM`PANY GRANITE STATE INSURANCE
Revere, NA 02151
COMPANY
D
,.•:' ; •'�r,..t i .P!11.: ••il, r..... p,.r.r ,. , .. ..li. .. i''N:ff•` '';! ... �, 7. ., s'l;iv1E.
THIS IS TO CERTIFY THAT THE POLICIES �I RINSURANCE
„. INSURED NAMED ABOVE FOR THE POLICY PERIOD
LISTED BELOW HAVE BEEN ISSUED O THE I r. I •,. ,r ;•.,:,D
INDICATED, NOTWITHSTANDING ANY REQUIREME T. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT H
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. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE�POLICY NUMBER y- POLICY EFFECTIVE POLICY EXPIRATION LIMIT6
LTR DATE (MM/DD/YY) DATE (MMIDDIM
OPNERAL LIABILITY GENERAL AOGKGA M & 2 000 00
A X COMMERCIALGENERAL LIABILITY NPP725476 8/19/02 6/18/03 PRODMTS-coMP1oPAG0 s 2 000 OC
CLAIMS MADE F7 OCCUR PERSONAL & ADV INJURY S_ 1,00040
C
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE - 5 1 C10O , OC
FIRE DAMAGE (AMv one 1111) S
kX48Z•j
S
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
3138624
4/21/02
4/21/03
COMBINED SINGLE LIMIT $
BODILY INJURY = 20,000
(Per w”)
BODILY INJURY 5 40,000
(Pel 8000m)
PROPERTY DAMAGE S • 100, 000
AUTO ONLY • EA ACCIDENT 6_
tiARAOE
LIA9ILIT Y
ANY AUTO
OTHER THAN AUTO ONLY;
EACH ACCIDENT S
AGGREGATE S
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE i
AGGREGATE f
=
C
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THEI'ROPRIEY4R!r� INCL
PARTNERSIEXECUTNE I II
OFFICERS ARE: EXCL
Wc2152543
6/12/02
6/12/03
T Y COMFITS
EL EACH ACCIDENT S 100 000 _
ELDISEASE • POLICY LIMIT EJCiC♦ OC)Q
EL019EASE-EA EMPLOYEE & 100,000
OTHER
2E3CRIPTION OF ()PER
ELECTRICIAN
SHOULD ANY OF TH ABOVE SCRI940 POLICIES Be CAN4"D BEFORE fHE
TOWN OS NO . ANDOVE1R E PIRATION DA13THERIENW, , P ISSLIINO PiPPANY WILL ENDEAVOR TO MAIL
ELECTRICAL DEPT. 14 Fulo
N NO91GE To THE C ICAYE HOLDER NAMED TO TH! LEFT',
37 CHARLIRS OTREET
NO.ANDOVXR, NA 01545 BUT FAIM I_SUCH NOTICE S IMPOSE NO OBLIGATION OR LIABILITY
OF ANWOON THE COMP I S AGENTS fl RBPRESENTATIVE3,
e r �urerniC _ _.
COMMONWEALTH OF MASSACHUSETTS
� Id�
OF ELECTRICIANS,
AS A REG JOURNEYMAN ELECTPIA;
ISSUES THIS LICENSE TO \ \ Y
JAMES E GREEN JR
('J1.
193 ARNOLD ST
L,
REVERE MA 02151-334
35845 E 07/31/04 342875
Fold, Then Detach Along All Perforations
COMMONWEAL OF MASSACHUSETTS a.
•iNO• ,
,OF ELECTRICIANS
MASTER ELECT
RI —
REGISTERED
ISSUES T06 LICENSE TO
1.
JAMES E GREEN JR
193 ARNOLD STREETn
MA 02151-334
REVERE 342874
15987 A 07/31/04
• I,
Then DetacFold,
h Along All Perforations
Nam ♦. „ �fp��7 :�i Zr'�fii e1�R�
�r f
i
NUMBER DRIVER S LICENSE
ee f
a3: Q6342S a i
DATE OF BIRTH CLASS REST HEIGHT SEX
5 -pg M
DM
C
EXPIRES
Ei
JAMES JR
193 ARNOLD STt 9
oT-xa•toss � ,�
REVERE, MA
02151-3342
C `�
n
rn
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:
Q3j c2l, DATE ISSUED:
SIGNATURE:
G/ `tel/
Building CommissionerflnsO&or of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
Ls4
1.2 1.2 Assessors Map and Parcel Number:
/03 /" nIDC/L—
// _ _/d VM IJ
/[�
C
o/ p-IS7
Map Number Parcel Number
-4,
/� -4 `
, (
1.3 Zoning Information:
1.4 Property Dimensions:
A ? 2
(� ��3 Acty-
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
R red Provided
R red Provided
(:90
a0
1.7 Water Supply M.GLC.40. 54)
Public ❑ Private 0
1.5. Flood Zone Information:
Zone Outside Flood Zane 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
-us�1 �- /0-S
�, cK� /A) ZDS� Pond i�
Na a (Print)
Address for Service
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
"
JC6 #lV
e.,e-S
Not Applicable ❑
Licensed Construction Supervisor:/
C-)
1�� � e S7 ,
� 5 D��'��
License Number
Address '
p /� �Lp /
7a '(IC (J ! 36
/�117Loaa
Expiration Date
gna reI
elephone
3.2 Registered Home Improvement Contractor /
Not Applicable ❑
130 Q (
Company Name
//
11.2
jgtJe-S /c9. 0 r d'7
Registration Number
`/
/
Addre s/
�f Q /
' 7� . i /Q 7 6
aU�
Expiration Date �
Sig lure
Tele hone
n
rn
J
l
SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building rmit.
Signed affidavit Attached Yes ....... No ....... 0
SECTION 5 Descri tion of Pr6posed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑ TAddition
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work: . % ,,
& iC / �yoM 1,J/ -1k d'Lck /d Ou.;� C),j
6012sZe1 a'Aa`I
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant'
T3FFTCIALyUSEClNL
u
1. Building
v(a)
LID 0 . v 0
Building Permit Fee
Multiplier
2 Electrical
!1
zoo 40
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (b)
C)
4 Mechanical (HVAC)
,go
5 Fire Protection
vp
6 Total 1+2+3+4+5
-R/ '7.2,6, QD
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building pennit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Pr -int -Name
Signature of Owner/Aent Date a
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TI1VIBERS 1 ST2ND 3KD
SPAN
D[WNSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
TERIAL OF CHIMNEY
IS DING ON SOLID OR FILLED LAND
IS BUILD CONNECTED TO NATURAL GAS LINE
Location 1,23
No. 3/a Date o
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
{ Foundation Permit Fee $
''. *►� Other Permit Fee $
TOTAL $ Z 2
Check #
Building Inspector
)�4 j `-�(d"j � �) cC
..... ...,r owl CAcc cnORA
M u - Lv ncLc.,.�... •,•,•••
FOR
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION******'*****************
✓ S Y% C 71 U HP ONE � "qJ�2�
A��LICANT
vCOCATION: Assessor's Map Number
L-�RCEL o2/S
SUBDIVISION LOT (S)
✓STREET o Lost ?Oab 1-4T. NUMBER
*****►***,*******************OFFICIAL USE ONLY**,►,.,t*****,►*,****�**,�***
RECOMMENDATIONS OF TOWN AGENTS:
DATE
CONSERVATION ADMINISTRATOR DATE REJECTED APPROVED - i
-IIS"`I -- �e.�� �ia'e•C,p�s�'ruc.%ioh /1��'��aaq — �'�f ��7. �a S�r�
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FO, INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED 'L Z`
DATE REJECTED
S d(, F6"_A
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
Le. ► c•V
IRE DEPARTMENT 'i^)/1 �C�-i'T7?l�l tl�(�i h"✓/�,i
✓Fiya`�'�-C�{�!f
►r�
DATE
RECEIVED BY BUILDING INSPECTOR
Revised 9N97 im
�0 e % i
.kAZO"
�o .i
0f
y
r
To
00
O'
Won // N
Bch 3
tem i �WF206
Proposed a
Deck
Deck i
1 &�ppport,
Existing --
Deck WF;
(To Be x i i
Razed)
;Concrete
' Pad
:24'
i Elev. = .124'
slap Community
'.8 0007 C,
'3)
Lot B
Proposed
Addition
(18' x 16'
0
WF207
3
204-
Proposed
Erosion
Contro/ ��
WF201
WF202
WF203
Ale Va�nnto�zurect o�✓I/Gaaoaciu�aet#d : -
�\ Board of Building ftpiations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 130867
Expiration: 5/1104
Type:.. Individual
James S. Peters
James Peters
112 Vale St ,
Tewksbury, MA 01876
Adpa-Istraior
O
71w e.
BOARD OFpM T
CONSTRWTIOW r RMOR
Nuww: CS 061185 i
Vis: 12/171t962
Ex
pk": 12/17/2002 Tr. r+e': 5716
sl
Restricted To: 00 j
JAMES S PETERS
112 VALE ST
TEWSBURY. MA 01876
1 �l
r r
VA
El
1
3
$, G,Ascnwcn+
Cgs`r,cn+ 61, S/1,4cir
T-
43
C
tv
Massachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form 5 - Order of Conditions 242-1154
Provided by DEP
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:
When filling
out forms on
From:
North Andover Conservation -Commission
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Conservation Commission
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®Order of Conditions
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E] Amended Order of Conditions
To: Applicant: Property Owner (if different from applicant):
IL 10
Susan & Carlos Bielicki
Name Name
103 Lost Pond Lane
Mailing Address Mailing Address
North Andover MA 01845
Cityrrown State Zip Code Cityrrown State Zip Code
1. Project Location:
103 Lost Pond Lane North Andover
Street Address City/Town
Map 104B Parcel 215
Assessors Map/Plat Number Parcel/Lot Number
2. Property recorded at the Registry of Deeds for: .
Northern Essex 4790 32
County Book Page
Certificate (if registered land)
3. Dates:
6/13/02 7/24/02 7/25/02
Date Notice of Intent Filed Date Public Hearing Closed Date of Issuance
4. Final Approved Plans and Other Documents (attach additional plan references as needed):,,
Plan of Land in North Andover, Mass Showing Proposed Addition & Deck Lot 7, 6/10/02
103 Lost Pond Lane Date
Notice of Intent 6/13/02
Date
Title
Date
Title
Signed and Stamped by:
and Documents Si
5. Final Plans 9
John M. Morin, P.E. & Thomas Neve, P.L.S. of Thomas E. Neve Associates, Inc.
Name
6. Total Fee:
$127.50
(from Appendix B: Wetland Fee Transmittal Form)
Page 1 of 7
Wpaform5.doc • iev. 12/15/00
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A%,oVffc vL-i� 1 11-ivr% I c yr L.IM1 I I I INSUR BICE 11/05/2002
PRODUCER (800)333-7234 FAX __
ALLIED AMERICAN INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Carlin Insurance ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
233 West Central Street
Natick, MA 01760 INSURERS AFFORDING COVERAGE
INSURED James Scott Peters INSURER A: Acadia Insurance Company
DBA: Peters Construction INSURER B: Travelers Indemnity Co
112 Vale Street INSURER C:
Tewksbury, MA 01876 INSURER D:
I INSURER E:
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.
LTR
TYPE OF INSURANCE
POLICY NUMBER
DATE (MM/DD/YY)
DATE (MM/DDNY) ra
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE a OCCUR
SCA007851910
05/28/2002
05/28/2003
EACH OCCURRENCE $ 500,000
FIRE DAMAGE (Any one Fre) $ 12S,000
MED EXP (Any one person) $ 5 / 000
PERSONAL 8 ADV INJURY $
$00,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOC
PRODUCTS - COMP/OP AGG $ 1, 000, 000
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person) $
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY
OCCUR ❑ CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
7PJU8679X361A02
10/12/2002
10/12/2003
TORY LIMITS ER
E.L. EACH ACCIDENT $ 100,000
B
E.L. DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500-,00
OTHER
_
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
.ocation - 103 Lost Pond Rd. North Andover, MA
CFRTIFIrATF unl n=D I I---- ------ ----- --- -- .....,.�..._._..
. nGV, IRJVRGR {.CI ICR:
Town of North Andover
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KINDhIPON THE CQMPANY, ITS AGENTS OR REPRESENTATIVES.
PETERS CONSTRUCTION
SUPERVISOR'S LfCENCF 4 CS 061185
GENERAL CONTRACTOR
112 VALE STPFFT
TEWKSBURY, MA 01876
P14ONF: 979-640-9361
PROPOSAL
CI TFNT WFORMATION
I
Name. mf sort Date:
Contact:
�OnS LSC V" (j
Address: Title- L4 awb a,
Phone:
JOB DESCRIPTION
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PROJECT INFORWATIOIV:
PRIOR TO START OF JOB:
DUE UPON COMPLETION:
Client Acceptance
Signature:
Contractor Acceptance
Signature:
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