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HomeMy WebLinkAboutMiscellaneous - 104 FOXWOOD DRIVE 4/30/2018 (2)Location - No. Soro Date 22 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ O '' Building Inspector �V 411./23/95 1/23/ M04 1,110.00 PAID Div. Public Works r (kt 4G Location __I o4C No. " ' Date o , ,t NO;T:,ti TOWN OF NORTH ANDOVER 3? �•� ' •• OCG Certificate of Occupancy $ 1 4L 1 Building/Frame Permit Fee $ �ssAt Foundation Permit Fee $ oo Other Permit Fee $ g- Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �0 Building Inspector 4c 9 := 9303 Div. Public Works 46 Location /�Lf l ©"'� !' C,xa 1( //rr J2 /V No. Date U� NO"T" TOWN OF NORTH ANDOVE19 Oft«ae �ti0 Certificate of Occupancy $ Building/Frame Permit Fee $ -rte Foundation Permit Fee $ o Other Permit Fee $ t 969 Sewer Connection Fee $ /�Dno. m Water Connection Fee $ /n77 • `� TOTAL $ Zob } �' �[� Q ilding Inspector 74- -' 8 9 H Divi Pini is Works Location �a-Xcao2 No. gin - C- Date is 9392 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Per 't Fee $ Other Permit 43M $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 7S^ 25.04 PAID Building Inspector Div. 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O m Hqa z O i/ O N t'7 m X CL, „y ... . m m y cc G CD pt y CL m H � CO) m m : r .Ort CO .rt O O m O C43h mrn o H W� m n� 00 c n L� ' `J cn by�+-�t cd -,IS ? O ?O n C O b O 0�►�y "r(r' T;* ° a a r)cp� wo 'CD ti i 7d � )Mi 0 9 0 c 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: X too � C'. PP o r rO Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) 116 Street W o d D_ly e_ St. Number j 0 tN ************************Official Use Only************************ RECOMMENDATIONS FTO7S: A/W*_ 1 %�� Date Approved Av W *S Conservation Administrator Date Rejected Comments IR JkLu i &Q Date Approved C� Town Planner Date Rejected Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections/r.ZL) zo- l(v -9S - driveway permit-' 42 te�-I6�j ved by Bu Inspector Date 'r A"66Y Ta Tile riTZEiwv�As•aeo.�,vc/o f G or RG.41v IIV Tf/E ffAIVW Tis/igT Ti/EG�'ELG/.W /S GKI+TEG O.c/ Ti/E -ddr 4.S Sifbll✓N ANO 7-1.4fr17'OAFS L'aw"WaPAf /N ,v. Auo a vice zolllwG eE6vG4r..VAS I � , ,4L�6rI.e0/.V� SETB.IC.CS FZI W GOT L/.✓ES. " �!/,c/po,�E �o� ASS, LOLATEO Al/ �ETFE� AL. ,IiAwlo H 2A O APE oT OiP�i%!�/V fOiP syQlvN O/V FfM•?'=�OMMt/N/Ty /D.LtIGL '� 257409g �Ar�n 6/2/93 OF A. i••-¢o ���� it zz /vdY, ZZ, i 99 HOFMANN Z #36381 9o��sg`0��. AIE.P.P/itl.4Gr E"•f/6�.�/EE.P/•l/6 SE.Pf�/lES suav�� 6G i'-4•P,E� .ST.rEET A.VODYE.� �1.4S.S,4L•iYl/SE7TS o/8/D ,o pL r 7.9t �MM � \ W O.SO7AcCr �a2 O OS e, Ile ebb n ' ao 'r A"66Y Ta Tile riTZEiwv�As•aeo.�,vc/o f G or RG.41v IIV Tf/E ffAIVW Tis/igT Ti/EG�'ELG/.W /S GKI+TEG O.c/ Ti/E -ddr 4.S Sifbll✓N ANO 7-1.4fr17'OAFS L'aw"WaPAf /N ,v. Auo a vice zolllwG eE6vG4r..VAS I � , ,4L�6rI.e0/.V� SETB.IC.CS FZI W GOT L/.✓ES. " �!/,c/po,�E �o� ASS, LOLATEO Al/ �ETFE� AL. ,IiAwlo H 2A O APE oT OiP�i%!�/V fOiP syQlvN O/V FfM•?'=�OMMt/N/Ty /D.LtIGL '� 257409g �Ar�n 6/2/93 OF A. i••-¢o ���� it zz /vdY, ZZ, i 99 HOFMANN Z #36381 9o��sg`0��. AIE.P.P/itl.4Gr E"•f/6�.�/EE.P/•l/6 SE.Pf�/lES suav�� 6G i'-4•P,E� .ST.rEET A.VODYE.� �1.4S.S,4L•iYl/SE7TS o/8/D ,o pL r 7.9t �MM � \ W O.SO7AcCr �a2 O OS e, Ile ' ao OC - 'r A"66Y Ta Tile riTZEiwv�As•aeo.�,vc/o f G or RG.41v IIV Tf/E ffAIVW Tis/igT Ti/EG�'ELG/.W /S GKI+TEG O.c/ Ti/E -ddr 4.S Sifbll✓N ANO 7-1.4fr17'OAFS L'aw"WaPAf /N ,v. Auo a vice zolllwG eE6vG4r..VAS I � , ,4L�6rI.e0/.V� SETB.IC.CS FZI W GOT L/.✓ES. " �!/,c/po,�E �o� ASS, LOLATEO Al/ �ETFE� AL. ,IiAwlo H 2A O APE oT OiP�i%!�/V fOiP syQlvN O/V FfM•?'=�OMMt/N/Ty /D.LtIGL '� 257409g �Ar�n 6/2/93 OF A. i••-¢o ���� it zz /vdY, ZZ, i 99 HOFMANN Z #36381 9o��sg`0��. AIE.P.P/itl.4Gr E"•f/6�.�/EE.P/•l/6 SE.Pf�/lES suav�� 6G i'-4•P,E� .ST.rEET A.VODYE.� �1.4S.S,4L•iYl/SE7TS o/8/D KAREN H.P. NELSON did •,o•••,� - — ti °TOWIl of °'mro' !'�'�! . _NORTH ANDOVER BCILDt 'G nmsio i of 7.tw.► CONSERVATION HEALTH PLANNINGPLANNING & CONI MUNI M DEVELOPMENT CHIMNEY APPLICATION AND PERMIT DATE 0 LOCATION 1-io1 11 L/. r()XwaGrz OWNER'S NAME 1 bV , ,4 BUILDER'S NAME // MASON'S NAME /J kAT (,(p- J."W -%Cly► t w MASONS ADDRESS �F [� 1y �l l / f : Ze&VV-, YKASON' S TELEPHONEp �� Dec/ MATERIAL OF CHIMNE'_ / J"I jr C INTERIOR CHIMNEY 1311'l L' L EXTERIOR CHIMNEY Nj,~;$E:t e�lD SIZE Cr rTrTrc THIC_CIESS OF HEARTH. %b 120 Main Street, 01845 (508) 682-6483 PERMIT # ` C w i__cit"c 11 chi;^nev or faCa ccn= reuirements of the code and have rules and recu'_aticns been received: DATE 7 SIGIIATURE OF MASON -A�,--�/A44aiz i3TR . LIC. EST. CONSTRUCTION COS T f CONTR�C-PR ICE PERiIJT GRANTED Z rrz ROBERT NICETTA, Bi:ILDI::G =::S= EC':OR INSPECTED REMARKS cr- -n ,RTC_{ REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREi1ISES C7 C O d CO) C) CD n Z y CD o -v ar O ? 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V1 0 y 0 9 0 c i 77 xx d z a O�to z � � o C4 0 m > `o z C� � z C r� > z Q zy z >> rn y i 77 d z z � � o C4 0 m > `o z � C r� i 77 0lllce Ute, Only The Commonwealth of Massachusetts G DePar'tment of Public rermlt \O'— n V � c Safety , DOARD OF nnE PREVENTION REGULATIONS occupancy a Fee Checked— 527 CMA 1 200 3 /90 (leave Elan- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORW. , NI work to be petformed In accordance with the Massachusetts Electrical Code, $27 CMR 12:00 Lr (PLEASE PRINT IN INK OR TYPE ALL INEORtid.TJON) Date City or Town of py To the •Inspector of Wrest The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)_ /119 Z �Ox ���Ssl �j�/v-e Owner or Tenant_ __=© © rye 4s G 4 Owner's Address_ Is this permit in conjunction with a.building permit:. Yes LTJ No ❑ (Check /lppropriate >iox):~. r Purpose of Building ,oP�s j c��h� Utility Authorization N0. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Haters_ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Haters____„ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Tota No. of Lighting Fixtures Swimming Pool Above❑ In- KVA grnd. grnd. El Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners — FlR$ ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals No. of Pump ts Tions otalToKWI No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local ❑ Municipal ❑Other Connection No. of Water Heaters KW No, of o. o Low Voltage s Si ns Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a currentLility Insurance Policy including Completed Operations Coverage or i substantial equivalent. YES(;?NO [_JI have submitted valid proof of same to this office. YES[ NO ❑ If you have checked YES: please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ �0� 4 (Expiration/ate) Work to Start Z—/O� Inspection Date Requestedt Rough_1—/-Y— 7 Final GU/I/ G110 ` Signed under the penalti of perjury: FIRM rlAiU: L �L�G C LIC. NO,6-.4453 Licensee ��q`rT' L Signature LIC. NO Address �j hy., �j��R��fi Bus. Tel. it. Tel. No. 014NERIS INSURANCE WAIVER: I aro aware that the Licensee does not have the insurance coverage or is su - stantial equivalent as required by Massachusetts General awsZ , and that my signature on this permit e application waives this requirement. Owner Agent (Please check one) � No. Telephone Signature of Owner or Agent p PERMIT FEES !rt/ ,• ..�i� k iT2 686 Date............ �.d......7. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. ........ `......�....1 ... ....... has permission to perform ...............ft,...1��� .....""�-^ ����� ............. wiring in the building of . �.. U. �� ..:.....! �i ,rl 1,2 1 at.. .. %............ . North Andover, Mass. F .�.-Vv Lic. No.. _........................................................... ELECTRICAL INSPECTOR 01/10/97 09.05 ildiryg tPA C� WHITE: Applicant CANAR : 8 �C" .- reasurer Location f d � Y) No., 640 Date MpRrM TOWN OF NORTH ANDOVER ft Aamadp Certificate of Occupancy $ ° Building/Frame Permit Fee $ A Foundation Permit Fee $ �°' scMuse Other Perm!t-Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Atl,Au P,,2 --n Building InsplectYr 10506 Div. 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CA 0. cnb° � � 7� 5 w T a ro 5 W T 0 Z M � e :� ,r-. m w O c w � � d 'O � cnX CL \ O PTI .y a CA M 0 c 0 OfNce use only u &MMOnMM" of use �tft No =� ' 7777- - aC E>�t IIJf tthl[t _ O=pancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 peeve blank) - APPLICATION FOR PERMIT TO- PERFORM ELECTRICAL" WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00OL . (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date or Town of NORTH ANDOVER To the Ins ector of Wires: _. The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Yr,�lue`xry Owner or Tenant �0)( w000 /�v Owner's Address �L �t �ti Is this permit in- conjunction with a building permit: Yes No Q (Check Appropriate Box) Purpose of Building Cnvi/"�V.- t di, nnUtility Authorization No. 090'3 Existing Service Amps Volts Overhead a Undgrnd a No. of Meters ` New Service jk_ Amps 3,r) / Iy0 Volts Overhead a Undgrnd No. of Meters 1� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work _ 4 No. of Lighting Outlets I OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Mass _usetts general Laws I have a current liability Insurance Policy including Comoie Operations Coverage or its substantial equivalent. YES Z NO = I have submitted valid pr f of same to the Office. YES NO _ If you have checked YES, please indicate the type of coverage by checking the appTprlate box. INSURANCE BOND -- OTHER = (Please Specity) (Expiration Datel Estimated Value of Flectrical York S Work to Start e Signed under the Penalties of perjurry: / FIRM NAME fl�vgl� Aloz::7 Licensee Insoection Date Requested: Rough c� l� Final Address % gcfg t if /-eTNtl— /=' — Alt. Tel. No. LIC. NO. // Tq'7W OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re ouired by Massachusetts General Laws, and that my signature on anis permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEES �( (Signature of Owner or Agent) x-6565 No. of Hot Tubs Total No. of Transformers No. of Lighting Fixtures ISwimming Pool Above grnd. — In- I grnd. Generators KVA No. of Receptacle Outlets I No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local Municipal n Other i_; Connection t No. of Ranges 9 I No. of Air Cond. Total tons No. of Disoosals I No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW Heating Devices KW No. of Dryers I 9 No. of Water Heaters KW No. of No. of �ll Signs Bailasts Low Voltage Wiring Nn Hvrirn Massane Tubs I NO. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Mass _usetts general Laws I have a current liability Insurance Policy including Comoie Operations Coverage or its substantial equivalent. YES Z NO = I have submitted valid pr f of same to the Office. YES NO _ If you have checked YES, please indicate the type of coverage by checking the appTprlate box. INSURANCE BOND -- OTHER = (Please Specity) (Expiration Datel Estimated Value of Flectrical York S Work to Start e Signed under the Penalties of perjurry: / FIRM NAME fl�vgl� Aloz::7 Licensee Insoection Date Requested: Rough c� l� Final Address % gcfg t if /-eTNtl— /=' — Alt. Tel. No. LIC. NO. // Tq'7W OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re ouired by Massachusetts General Laws, and that my signature on anis permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEES �( (Signature of Owner or Agent) x-6565 C V -1 ( i( WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 2774 r10R7M TOWN OF NORTH ANDOVER A a o PERMIT FOR WIRING o �,SSACMus� This certifies that .......� 1 !......�..�I.6C.......... d M has permission to perform ............ J(A—(.............1. f v�Y1.�......i wiring in the building of ' at ... �r? t... .....lo.. ...... F,►.� trc� .......... fid....... , North Andover, Mass. .. o" %. Fe ........ Lic. No..�.f.7� .............................. .............. ................. ELECTRICAL INSPECTOR C V -1 ( i( WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 4 9 7►2 Date ...... r"t.7'. ' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. 6 .......... .......................... has permission to perform ..... ... /i, 44t�.v ........ wiring in the building of ....... L'...V.IQI� ....................................................... /0L t -6 - at ............... / eq North Andover, Mass. .......... .... .. e7 c:> Fee ... 6 Lic. No....a7P. .... ... . . .......... rELECTRICAL INSPE CpTOR Check # y m m m /XYI/� m m v. H d 3 d Cos CM) 'O O CD 0 Z .y r � � o CZ = y O o p CD CD O CLQ "C d CD CD 0 CD C CD -, EO y CC CD � v CO) O CD Z O o CD C CD M O O am 0 O fD r 0 0r�,a GO \y NNJ O �• N O CS N SoECDm ®!09 CO) m m a = m C! C) N Z =•Cp N N _I 7 .d► m fa?a T m = m O y CO) r0 C _ O = C U2 �. o X o Zc•IN O h• C2 . W ;& C" O::Er/— a m ao o a� m I=O ? CD O N :4 C")= c Co.. O CS) N 01 N CCA, O. � C `c o CL CCD y .N.► t 0 N Ca O 3 d N COD co o 5 J ocli �C2 ®o: r N CD K o Ca CD a3 N Cg o d : r. rh O �• O Ca d O � -a a'o C-) w 0 0; � N -1. -2 o am 0 O fD r 0 0r�,a GO \y NNJ byy •G �OO / yW�y � a x by\Y\yr ti V �(A� 17 b1 �J m W v I )Mq 0 0 c l.ominonweaLth o� /i/a�basiu�e Official Use Only aCJeParimenE o� ire �ervice� Permit No. c BOARD OF FIRE PREVENTION REGULATIONS [ROevcupancy and Fee Checked . 1/07] (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 IN INK OR TYPE ALL INFORMATION) Date: I o� I I 1E) City or Town of. Nor4k A n vV e R To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ' 04 FA A L000 D DIME Owner or Tenant -TOM LUKAS Telephone No. Q }$- 55--- 5b26 Owner's Address 1(')1--V �=( Vl Ii l? 1 \ 1F Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Bog) ERI'1'1 11- Purpose of Building k)F t -I nG - 51 n(ai r- FA(1111- tility Authorization No — 285 -2011 Existing Service 2L -XD Amps 120 / 240 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: Re -RR Sun Rocs M re)Mnletion nfthe fe n,+ina tnhlo ,,...., h., ,.. ,l b., +a,. r ------- .- ..run --- No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of aft Transformers KVA No. of Luminaire Outlets - No. of Hot Tubs Generators KVA No. of Luminaires + Swimming Pool Above ❑ In- Elo. o Emergency Lighting rnd. rnd Batte Units No. of Receptacle Outlets 0 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 3 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number TonsKW ............ No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipa [:1 Other Connection No. of Dryers Heating Appliances KW Security Systems:" No. Devices No. of Water KW Heaters No. of o. of of or Equivalent Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommumcattonsWiring: No. of Devices or E uivalent OTHER: Sub Anel Attach admonat detail iJ desirect or as reyufred by the Inspector of Wires. Estimated Value of Electrical Work: I Soo, Op (When required by municipal policy.) Work to Start: 10 22 ([) 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 D4 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this app&cation is true and complete. FIRM NAME: -U,14D Keuj (og�j LIC. NO.: 2-0439 Licensee: I I ( r4 Signature � ��LIC. NO.: (If applicable enter "exem t" in the license number line.) Bus. TeL No.: �$' -(� Address: OD � - 1� l ry) 014 03C�� Alt. Tei. No.: *Per M.G.L. c. 147, s. 57-G1, security worg 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. PERMIT FEE. $ (zi-CA, (7K l0 -as -cam The Commonwealth of Massachusetts Department of Industrial Accidents 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 Legibly Name (Business/Organization/Individual):__ Q,� j� he-LL_owng Address: q S i LVEF, l?'D140 City/State/Zip: sotj�Y)1 n4 03Q-Jq Phone #: CI lb - -4 lo -1 - QJq Ej Are you an employer? Check the appropriate boy: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): G. ❑ New construction 7. ❑ Remodeling ❑ Demolition 9. Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other r�ny appucam inat cnecxs box » I must also 1111 out the section below showing their workers' compensation policy information. t 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 their workers' comp. policy information. I am an emplgver that is providing workers' compensation insurance for in empGiyees. Below is the policy and job site information. Insurance Company Name:_ URRT(S Policy # or Self -ins. Lie. #: ().�(' �j � 3 (6, 5 Expiration Date:- -415111 Job Site Address: ((JL4 FQX CK=Q �� ��� _ City/State/Zip: : D1$ q.5 Attach a copy of the workers' compensation policy declaration page (showingthe 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature:. Date: 10/,)i 1 In Phone #: q 45 - --(Di' - D-+9 b Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/Ucense # 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 #: 7 4 '06 Date. NORTH pf ao ,e,'1'O o? ' TOWN OF NORTH ANDOVER a PERMIT FOR GAS INSTALLATION This certifies that.. � .. ' ./... .......... y has permission for gas installation in the buildings of' . FI. �. ....................... at,,rr�� .. ` .. r O. /r,/�1...-� , North Andove� as F Lic. No. ?() ,/ GAS INSPECTOR Check # y 6 MASSACHUSETTS LTMRVlAPPLICATONFOR PERTNUTO DO GAS FITTING (Type or print) Date O C/ a /O NORTH ANDOVER, -VIASSACHUSETTS 91 Building Locations Owner's Name Vew ❑ Renovation Q- Replacement ❑ Permit # Amount $ Plans Submitted ❑ phi mac_ Address 10 4-5 A -44- W14 02&1 ness weDnone O„ "i —) --, --wn Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner.. Firm/Co: ]I 1SURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M[ No If you have checked yes, please indicate the type coverage by checking the appropriate. box. Liability insurance policy Ea- 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 El Agent .--j "luty Ll uL au vi uic ucLaus uuu Iuunuauon 1 nave SLID nil (or entered) m above application are true and accurate to the, heat of mN knowledge and that all plumbing work and installations performed unrler Permit issued for this application will be in compliance with all pertinent provisions of the Massachusel State Gaye dej�ul'Chapter 142 of the General Laws. By: Title Ci tyiTovvn IAPPROVED lOFFICF USE ONLY) Signaturt�Licensed Plumber Or Gas Fitter P1Umbcr 30?3 Gas Fitter License A umber Master Journeyman y W x a Q q rn H C4 p 0 O '6 x z o '� � 6 E-4 cil E- � a 4 CAp°p�� z o , a H En O W Q a U x y O SUB -BASEMENT U` A H BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR . 4T II. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 1 STH. FLOOR -91 Address 10 4-5 A -44- W14 02&1 ness weDnone O„ "i —) --, --wn Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner.. Firm/Co: ]I 1SURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M[ No If you have checked yes, please indicate the type coverage by checking the appropriate. box. Liability insurance policy Ea- 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 El Agent .--j "luty Ll uL au vi uic ucLaus uuu Iuunuauon 1 nave SLID nil (or entered) m above application are true and accurate to the, heat of mN knowledge and that all plumbing work and installations performed unrler Permit issued for this application will be in compliance with all pertinent provisions of the Massachusel State Gaye dej�ul'Chapter 142 of the General Laws. By: Title Ci tyiTovvn IAPPROVED lOFFICF USE ONLY) Signaturt�Licensed Plumber Or Gas Fitter P1Umbcr 30?3 Gas Fitter License A umber Master Journeyman I COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS ER LICENSED AS:A_JOURNEYMAN. PLUMB E�I ,I ISSUES THE ABOVE LICENSE TO JOSEPH +A, ASHFORD ro;! I '10 ASHFORD LN ATKINSON NH 03811-5118 39 30373 05/01/12 8128, , Fold, Then Detach Along All Perforations SA H ss 03ADJ76281 �.EYe. eRc 3.DOB: 03128/1976 H*: BRO 4b, Exp: 03128/2014 j %saw 1,2. JOSEPH A ASHFORD (� C J0 ASHFORD LANE t`�f -,ATKINSON NH 03811