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HomeMy WebLinkAboutMiscellaneous - 104 SHERWOOD DRIVE 4/30/2018w r� V� O Q �9 /� Location \04 PvZwy 9 No. a k -# Date 1251 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $3y Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ -� Water Connection Fee $ TOTAL $�'. Building Inspector 10/29/98 08:30 1,430-00 ppID Div. Public Works Location ! ts1 M No,,, `l Date r TOWN OFNORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL Building Inspector 10/3123 G3:33 t, 430. j PAID Div. Public Works Location ld�"'/LAUD/! I� /0� No. Date �o TOWN OF NORTH ANS VER Certificate of Occupancy $ Building/Frame Permit Fee $ FoundatiR ermit Fee $10 U d Other Permit WED ee$ Sewer Conn on Fe�AVIV,N�-- Wat Cod Vj d6ej $ �REq �7 �Iv -. g98 TOTAL URFR,CO� VtFJ $ SEC `Buil '/g Inspector Div. POic Works Location No., <y ,, Date F, NORTH TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ y Building/Frame /Frame Permit Fee $ g s�C ° 5 Foundation Permit Fee $ ! <' CEl 1E rpPgerrAmit Fee $ Sewer'"Cjmction Fee $ SEP 3 ov Connection Fee $ TREWS KTh Hlv) 8 $ 04 � 0 URER_��LL h �� OR Building Inspector Div. Public Works Zz A t ►i sm r co Z a A A m H � a - V a �v V 1 LA Z N Z V. D V Z � mrzr. ►i sm w co Z N D V Z � mrzr. z zz - = D m _rnyy N Y �r C = Z m 'S m Z C7 Z 7 m m D � mvo 5 �f l J Z tz, `r N {/ C V d N m K D LT �+ j 7 v i ? i V, }: LA >�> N z - N _ - - m z Z z � ;c X Z r) n - m .J A. L y n z — V. — w C T m. St D Z z z M1� n n 0 3 w ___ The Commonwealth of Massachusetts 1-72 Department of Industrial Accidents - _ — Office alloyeSaffigoas 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit name: location: city phone # (:] I am a homeowner performing all work myself. (] I am a sole proprietor and have no one working in any capacity "I am a -sole proprietQ the following worke general contractor or homeowner (circle one) and have hired the contractors listed below who have company: name: adtfress. city: phonesm- #• insarance>co. v.�..Yf Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do here certify nder the pain d enalties o erjury that the information provided above is trues and correct Sign= ign re - Date �— Gy Print name t hL, P Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # rlBuilding Department C]Licensing Board check if immediate response is required OSelectmen's Office C]Health Department contact person: phone #; r7Other Vevnetl JI95 PIA) �1 d v. y d C � 'v O a z CD O a� O o p a� CD CD O CD O. CDCD y. � O y to CD � v CA O 'v z CD a a o CD 0 CD 1 L C c?�o m Z ay C Cr Ic 0 ti Vol) momma o m Q Z o a s d o y O m a -1 0Sco -00 ri f� Q oZ H: C CA A C� Cri a a %== rb 3A o aos" ms •• as : S ` W CA y Cn m CD nICA y w er . O y d EL . • C e^T ^— . G,[ a CA aCO U2 ET 4c i 1„3E CD: NCD CD: to I_ CD O O*N O O O E 0 O z 3 . H o m r. o m o CD lot N ! _ M o i o m K aC n'i b 9cci, o 0 b rrl p oco 0 m o o ~ d z w w � � �. � tzCA Z S A.. 0. :$ CJ7 cn cn n 7d V 0 c 0 FORM U - LOT RE4EASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and 'Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION******* APPLICANT )ccylc(_ -To-Luer- LOCATION: oLuer- LOCATION: Assessor's Mai Number SUBDIVISION 6. STREET SherW 00 (- PHONE %&—'-�l PARCEL LOT (S) 9 ST. NUMBER10,4-' """O F F I C IAL USE ONLY**************'**** DATIONS OF,TOWN AGENTS: . r .G6RSERVATION ADMINISTRATOR DATE APPROVED _ aS DATE REJECTED i4COMMENTS, TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD IN ECTOR-HEALTH DATE APPROVED ' DATE REJECTED �.VtI NSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS \ Z� `I DRIVEWAY PERMITYQ FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE d Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant an Building Permit (below) Address of Property for Permit (below) u>,4 1 LORV, 1. r�-R Gln eru�oQ� �r Map and Parcel: Purpose of plication (check below) Phone Number of Applicant: • _✓ Single Family —Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or an from the requirements of obtaining other permits required prior to the issuance of the Building tothis Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is, issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. _ZThe lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. adjThis application represents a tract of land existing and not held by a Developer in common ownership with an acent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my kn n e or not, is/�oyhds for .. al by the Building Department to issue a Building Permit. _/V-4WL qX., I� / )`� � — e ^ w Authonzaka Ageni wno signed the Attached Budding Permit Date form must be attached to the Building Permit upon application for such permit. N2 832 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. �`"z/ 19 Application by the undersigned is hereby made to connect with the town water main in �/ v1 C�� 4�� !/� Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. 1t Street S or su j f - 455'¢ division lot no . _ �2 K� #4 5( 7e-,"tt Owner Address Contractor Address Nrpficant's Signature wr,�er � 4 52.00 PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to 1'51 to make a connection with the water main at _ zf/-U-) C9 subject to the rules and regulations of the Division of Public Works. Inspected by Date ? Street Board of Public Works• By, See back for rules and regulations NO 832 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. C `-v _ 19 16 Application by the undersigned is hereby made to connect with the town water main in � C�� Or� Street, subject to the rules and regulations of the Division of Public Works. `` f The premises are known as No. i/ 6¢ w t G'�GC�C3l�' Street or su division lot no. 1Te .� (I Owner Address V Contractor Address icant's Signature ,u,Jer C k 32-00 PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main at D L't zf subject to the rules and regulations of the Division of Public Works. Inspected by Date e( - Street Board of Public Works By 6t"JA�'t 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 V 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 4Y2 foot rod and brass plug type cover. GEORGE PERNA DIREC TOW.',, OF NOR- H .ANDOVER. MASSACHUSETTS DIVISiON OF PUBLIC WORKS 364 0SG00D S `BEET. 0'847 'ts �AC`HUS% DRIVEWAY PERMIT Telephone (508) 685-0950 Fax(508)688-957? ------- —I Date: eo( _ 2> . � Yio LOCATION: (a¢ '� er BUILDER: phone: OWNER: ephone: to �- S 315 l- 4�5�7 4 - 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: Lot 8, 104 Sherwood Drive 310 CMR 10.99 Form 2 DEP FIs Na. (to oe orcv,ded oy OEP) Commonwealth Ci,y,Town North Andover of Massachusetts Timberland Builders, Inc. Accilcant Aril 30, 1996 ' _ •• Oats ReCueii Fled p _Determination of Applicability Massachusetts Wetlands Protection Act, G.L. c.131, §40 From NORTH ANDOVER CONSERVATION COMMISSION Issuing Authority Robert Janusz To Timberland Builders, Inc. Robert Janusz (Name of person making request) (Name of property owner) 40 Sunset Rock Road 40 Sunset Rock Road Address Andover MA 01810 Address Andover MA 01810 Neve Associates, 447 Old Boston Rd., Topsfield, MA 01983 This determination is issued and delivered as follows: by hand delivery to person making request on date) xx�xby certified mail, return receipt requested on '�Co ` �� (date) Pursuant to the authority of G.L. c. 131, §40, the North Andover Conservation Commission has considered your request for a Determination of Aopilcability and its sucporting documentation, and has made the following determination (check whichever is applicable): Location: Street Address 104 Sherwood Drive Lot Number: St. Lot 8 1. p . The area described below, which includes all/part of the area described in your request, is an Area Subject to Protection Under the Act. Therefore, any removing, filling, dredging or altering of that area requires the filing of a Notice of Intent. 2. �2 The work cescribed below, which includes all: Dart of the work described in your request. is within an Area Subject to Protection Under the Act and will remove. 'ill, dredge or alter that area. There- fore. said work requires the filing of a Notice of Intent. Effective ttltOl89 2-t 3, 7 The work described below, which Includes all; oart of the work described to your request. is within the Buffer Zone as defined in the reaulatlons. and will alter an Area Subject to Protection Under the Act. Therefore. said work requires the filing of a Notice of Intent This Determination is negative: 1 . ❑ The area described In your reauest is not an Area Subject to Protection Under the Act. Z, ❑ The work described in your reauest 1s within an Area Subject to Protection Under the Act. but will not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing -of a Notice of Intent. 3. The work described in your reauest is within the Buffer Zone, as defined in the regulations. but will not alter an Area Subject to Protection Under the Act. Therefore. said work does not require the filino of a Notice of Intent. Install Erosion Control per plan. q, ❑ The area described in your request 1s Subject to Protection Under the Act. but since the work described therein meets the reouirements for the following exemptlon.as specified to the Act and the regulations, no Notice of Intent is reautred Issued by Signatur NORTH ANDOVER Conservation Commission This Determination must be signed by a majority of the Conservation Commission. On this 15th day of May g 96 , before me personally appeared George L. Reich to me known to be the _ -— person described in, and who executed. the foregoing instrument. and acknowledged that he. sfV-- executed the spfne as his/tfq'r free act and deed. Notary Public My commission expires Tnts Determination does not rel -eve the acoltcant tro^r corrtory-ng wrtn all oiner a_oltca7re teaeral. state o• loco! statutes. drarnances. by-laws or regulations Tnrs Determination snail ne vatic lot tnree years torm the date of Issuance Tho apohcant. the owner, any person aggrieved oy tnrs Determination,, any owner o! land aoumna the land upon wnrcn the or000sea Work .it to be cone. or any len residents of the city or town in wntcn sucn land is ldcateC. are netecy ndllftoo o! tnelr rrcnt to te_uest the Decartment of Environmental Protection to issue a Suoersedrnd Determrnauon of Apohcaoilny, orovrorng the request is mace ov certrlrec mart or nand delrvery to the Department, witn the appropriate Mina tae and Fee Transmittal Form as ordvrced in 310 CZAR 10.03(r wrtnrn len ceys tram I" date of asuanoe at tilts Determination. A cony of the request snali at Ine same time tie &ant oy certtlied marl or Mane Cauvery to trio Conservation Commission and the applicant. 7-ZA lip a'3" 1 ----------------------------------------------t---------- -nEw ; ---------------r---------------- „ „: — — — — — , . = - 1 i Ac r 1 1 X ' Drop top of foundation 2'9' 1 1 Q 1 •, ' 1 1 Q 1 L---------- -- .----F-------------------------------•---...T ' �•' i rt O D i" 1 I � "• i w °O A N r. ' a .. -I 1 1 a L v opa ° �..,� e 6 1 ' ' 1 ----� ' 1----------- --------------------------------- -----� r ---T— ul I �n I-� I N LYE i1.i66QQ' ' 1 to 1° I X�• IS X i I C Q w m E E 7r 1 p 0 1 _ •-'III- CA 3 N 1 .. 'i- —i- -0—✓'- - - �9 - A— 4 - A-1- 1 TI. ' 3'2"- - 6'0" - - 6,0■ - - G O" - f7'Ou - 3,2N ' 1 -nEw ; 1 ••• 1 x , N 1 i Ac r 1 1 X ' 1 1 1 Q 1 •, ' 1 1 Q 1 L---------- -- .----F-------------------------------•---...T 1 ---- 1 1 ------------------------------ T - 110° 2'6° 28' 16'10' 56" 6'O° '0" 320" J MIT 0 .�� O o� A C7 --� cn 0 DED P CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number o7% M4/ Date 1.2 % THIS CERTIFIE/S THAT THE BUILDING LOCATED ON A©4 �Sil sEn GAO acD :1�),e MAY BE OCCUPIED AS LS/N q lie l AM t 1y p7 5T,411 /��/jj� ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. MORT" CERTIFICATE ISSUED TO DAM%w ADDRESS 1/ 24 &4 (5/ r-6641117 IflF; C� -,A us us`Building Inspector R C3 'O C � CO) C") CD 0zCos CD O 06 a r c CL CO) CD CDCL o r� cr CD CD o D M t" 3 C CD y CD CL O_ y I CO CD B v COO) O 1 Z O O O CD O CD Orb - _ o G y o o O O y as m n y 0 Z ~ oil H O y T ._.► .dr m CL -p co Mn nro O -1 O H O -1 2 O m 0 C3 O �� ..f � : ro O C� O ZSe�s C r� 7Ri.— a CD F to a,�,,�: CDCD C/)m �= am m n c 03 z O o d r z y SCD• co G o �: CD: CA CA O C `1' � o � CD O i o � 3 'o o CD CD T y rn o C; CD C\ O a � -7 C'! m cn C= O O m ,anrrl x: '6 00 z � .01 n . �� O i�1 G _ o C y o o O y as m n y m ~ oil H � CD y T ._.► .dr m CL -p C Mn nro IN -1 O H O -1 2 O o y kA m 0 C3 O �� ..f � : ro O C� ZSe�s r O y:� 7Ri.— CD F a,�,,�: CDCD F �= am m� CD z ( CL r SCD• co �: CD: CA CA O CD C CS Cosm � o � O i o � 3 'o o CD CD T y rn o C; CD n� d : � O a � -7 C'! m C= O O m 0 _- - '6 z � o C/)- _ o o o o n p R' o o w � o d O ~ oil � w 0 C nro IN � G � OaJ L• � : ro O C� \ � Ste• _ *� z ( , r WN v. y — d CO) CO) CD SZ Z CO) U_ C ?C d S. CO) > to O n O v CD CDCL o cr r� CD O CD t" w = C CD W CD CL O CO) to I CD G c-Oo -01 =r -,O m _S Q n ao5a ti -� m CO C2o m o NCDdC = Z =r -C h _I m o CID n?d = m CD —Icm ti _ C042 o � cn ' m CD to O CD 4 _ n 0 o H' W a="O CD rb C Q r _m A c COL ... ,^ C m H Y C V J m n CD N . 0 y Q ►►ma�y.� (/� �N y CD tG CD Go cn y Q O i•- -� V J So -� CD Ca •�• 'toON .i O 0 C7 O O w CD 0 H` 'fl O �y W r► W .-► ? ' O m oq crrl d �► � CS a C1 o r?i aC CA 0 m ago Z o "Z po EZ o (/J (n Pi pi �^ � � `� a m OQ y w Cif b p? ooc ro °� aha °a' o w" COD It cn y 7C n ai O. M ON oNq 0 NORTN 0* ,,go s1�•p� O A t i x TOWN OF NORTH ANDOVER �9SSACFHUS���y APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: (o SG�(^ct9C� DATE REQUESTED FILED/READY FOR INSPECTION 3--26— 7 CLOSING DATE ON PROPERTY:__? FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND PERMIT SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY DOLLARD $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED ROUTING CONSERVATION PLANNINGv DPW - WATER METER p NOTE: DPW MUST INDICATE THAT WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW Sig ature f, Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director (978)688-9531 Dana Tower 5 So. Elizabeth St. Tewksbury St. 01876 RE: Certificate of Occupancy 104 Sherwood Dr. Dear Mr. Tower; April 6,1999 Please be advised that in order for an occupancy certificate to be issued a new home must be completed 100%. This means that all baths and kitchens must have non -porus floors, that all halls, bedrooms, and other living areas have the appropriate finish on the floors. Rect 1 �` GE vJA Michael MCGulre Local Building Inspector 'l0 , o Fax(978)688-9542 J BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 P 1 Date ...... ' ......... =a EE r r p: t�``o'•�',i�pp� TOWN OF NORTH ANDOVER C ` PERMIT FOR WIRING �SACNUSC' A This certifies that .................'. �Qt?w� P has permission to perform ....:,.... ............................Y. qA ..................... wiring in the building of.......�� . `..� .() ................................................................. at ............ t .q.... .�i.e iZ.k+JC��1 ..111! X=C�MRICAL ..North Andover. asst' ,3 F ls- l).. Lic. No.1........1.(......!..... /............... INSPECMR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r_ FC*i 14e e47 - m°n�e�rt a BpgAp ��kattutefrt A p pL �C OF pR� PgEyEy of rtbllc 444 to p AllT SON fi gyp" RFGUcgnpN a emit No•ff k• so On LEASE PRIM k i0 be Perfo� pEin r S $Z7 pMR �+v City or ' r IN INK pR !n a�v,I T / Q p � supe• Ch•�d 1 rhe uderei 7bwn of 7'1 ALL I a^cs with the ERFO � • �ank1 � fined NORM NFpRMATi Mti achwe �� Lo aPPq Owner !Street Nim for ;permit to ANDOgRR ON, � Z1 eC1` dds r�� A OW or Tenant bsr) 1 p4 S$ �rform the ,1 0,410 • S27 CMR 12: �OR�( ner•s '4ddreg MI RWpOD DRIB tries! yyork d Vo Is this s OCL CARO.LE NEL des the below• hs Inspector purpo.4e srmit in cAnl�ncti SON o! tiVires• Ex1sWn9 Se eul1dlAg o� W1th ft bundin. Per MAP N Nke fait• n env ge�ce `,fps vea �d i97 Ne,mbeill ll� r _� No of leder 'APs __�611s VtYAtrtiI(�R A�P r Location sand Mtpaclty _'bits Overhead Q �rlts ®p and Nature zwon lyo. ) of Prod Overhead Overhead Q Und�nb Q N No' °f t bhtt^F oou,y Ei wont Und9n)d Q °' O/ Meters No' °f t tohuna No' or Meters -1-i of A ��n• No. Of Hot n+b• � •opta,d• of gwftch Dut4� Ott• O• of ganoN NO• of 04 a 0 ,►s "a Q KV 1411111111 Of Ole posaa1111, eof NO• of Ni Of Altrod, tf,ghy a ^OY Clahy^p XVA N pta'"e•h•ra %.of f.•�N nes•�� to u . oof p�yrs N_ Of Do tYo. Of 20,x• ~. Afo• of Wats 8�~�•a fwl/ uat p•vrO, s ;,: Of No. Hearers H•au,111p..,.� KW No, offtuft% O 07-1 J0 "a• KW Al of -"'�•• or Seff �O^far • Rib, 81pn•• No, of kW oe�""+ndtna^W ' 84181• r NO• a "'°roa a Q Muoniti�py�• t Nt ; No 2 I59 Datel.?'., ? _F"P .... ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..... Z-Aollf—.Ze, has permission to perform wiring in the building of . Za... ............................................................ at i ...... . North Andover, Mass. Fee_ ?r.!...."...... L i c. N o P, 62f/ . ................. .................................... CAL INSPECMR 12/03/98 15:02 330-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts Office Use Only Permit No.� 1 Department of Public Safety /Occupancy & Fee Checked t BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (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 /44-98 City or Town of TEWKSBURY To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with ^ a1 building(permit: Yes 7 No ❑ (ChecVAppropriate Box) Purpose of Building /) .J P wk e— Utility Authorization No. �S S Existing Service Amps / Volts Overhead ❑ Undgrd ❑ o. of Meters New Service 2-0d>Amps /A0 / `a-40 Volts Overhead ElUndgrd I No. of Meters Number of Feeders and AmpacityS • f Location and Nature of Proposed Electrical Work 4 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool g nude 11md. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas burners FIRE ALARMS No. of Zones No. of Detection andtons Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal Local ❑ Connection ❑ Other No. of Ranges No. of Air Cond. Total No. of Disposals No. of Heat Total TotalPumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of ssachusetts General Laws I have a current Liability Insurance Policy including Comple Operations Coverage or its substantial equivalent. YES E(NO ❑ I have submitted vali proof of same to this office. YES NO ❑. If you have check YES, please indicate the type of coverage by h kin tthe appropriat �ox BOND ❑ OTHER ❑ (Please Specify)c�` c aS- viz - INSURANCE Estimated Value of Electrical Work $ (Expiration Date) Work to Start _ Signed under the FIRM NAME Licensee of perjury. ` 7 .. -. L- V .�G , / ,1 OT �I�✓ LIC. NO. A f 8S I LIC. NO. Address /d .tC� . C �C Its a pa u ,Bus. Tel No. % Alt4 . Tel. No. d�TiS OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. f,( Owner ❑ Agent ❑ (Please check one) /]N'y 3� Telephone No. PERMIT FEE $ 3�c�� (Signature of Owner or Agent) '4 4. 4-------------------------------- �o --— t4 i 1 Jz U U 1 I 4,1 F _ I I I I 1 � I ■ a- I Q 44 i I 4, I 4'4 L-------------------------------- - 4 _O II O,t II O, W JR x C—�o K. IL 4. d. 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IIIIIIIIIIIIII IIIIIIIIIIIIillllllll Rmm EE 5c E8 Q 0 0 Jqlly Permit No#: Date Iss BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received NORTFf q�" A LED �6'6•r� x " I ' IMPORTANT: Aimlicant must comblete all items on this base I LOCATION t0`A Sal U k)oir� d Oe-"" t Print PROPERTY OWNER YfSV�0.e-o-- Print 100 Year Structure yes no MAPt&g§—_PARCEL: ZONING DISTRICT: Historic District yes no /66' Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ A�ition ❑ Two or more family ❑ Industrial E?Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other i +Septic❑Well ❑ Floodplanf Wetlantls. El1Natershed� Distract L DESCRIPTION OF WORK TO BE PERFORMED: �� M i �.p I Lv l ok i [� �. ` \/ (� �� G-�1'O►'1 OWNER: Name: Jv Address: 1 b`4 SW trw Identification - Please Type or Print Clearly t -S1'\ kv-\a M Phone: a',8 U t,1 • u3 49 J Crtq C W. rkh .Jar( r M 14 bt V-A S Contractor Name: 16) r 4 -- Email: Email: ('hj Cr i r\J UL Address: P D fir X14 cw44-\i-cr- Phone \fin aV \ ubvv) cn4iA ml 3b Supervisor's Construction License: Home Improvement License: 3 1 ARCHITECT/ENGINEER Slq•--�'t83 Exp. Date: Exp. Date: O I ► , Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 3 ZO9 -`t o _FEE: $ 2),7 • M Check No.: V101 Receipt No.: b NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. c" CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on ature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter & Sewer Connection/signature & Date Driveway Permit ]DPW Town Engineer: Signature: Located 364 Usgood Street DUmpsfer On S te4,i,ypesus� g tT s:"�J�� no ." -yUUI dLUU dL IL�F�IVainmlreeL =- ' ,••. ' e' ,-' + 'i'•► {t +''+-r, Fiore �D ,a men ryry�g�nafure/date.* �y a ii♦k� a �ei'� �� t}� s � .*Y� ! v �• T rY-i. �3'tx rt6` ."'ri"., �a.—=�;.G+.� '�,t+. ..� s S'.0-.- �i se ''� ♦ �riC t'4ac ^ '��. �c .`_. l �.�� 'i` 'AY S rr � ";�... fs,�'t f �. xi �'�i_.: y � r. J_ i� - f3� COMM♦.1 da. ♦ - ♦ r�, t., + ..,,, rA'si 4.+�'a�'L,.�, Y �'•i t L`r'� � �'.. �i�1, , 7 �o .'r. ENTSt. l ! s,. sir .'r c.a. ,s r '.; , s•f4 4 ; it Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DAGGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ® Notified for pickup Call Emai Date Time Doc.Buildin; Permit Revised 2014 Contact Name We Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application 4. Certified Surveyed Plot Plan 4. Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4, Building Permit Application Certified Proposed Plot Plan 4, Photo of H.I.C. And C.S.L. Licenses 4. Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ,4. Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location ! 6 Date 617 Check #�? r'1 TOWN OF NORTH ANDOVEO d Certificate of Occupancy $ Building/Frame Permit Fee $ -'301 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ OV Building Inspector % tq—* 1 'a o ca Q ca n m cv +r c o v 0 O L 40 > � o N O 0 E 0 N Z O y 0 0 0 :�•� c :r C m 0_ .� c cc 0 am 0 = c Q L 0\: L m moo CL 0 H 0U)AW cc (D V m co W G "0 O O E 'y d y C ui0 LU L •E r - C) Q. O a CO G> 0 � N 2 o O .� . Q0U 2 Z 2 toZ W w CL w C� G W CL Z O U) J Z N gq rM7 L.: c CD m m 0 o � CL ai Q i_ r M J � O � Z 5 N x J Q LL D a O m u Y \ O O LL E T N U -Z - QJ Vl p W Z z Z_ c =' m C O 'O � O LL L : O 0' N C E L U (a C LL O W Z Z m J 4 t O O LL O C Z UQ _ R u W t 030 p d' N U O In C LL oc O w CL z 0 Q L M t O - ro LL z tJJ w ° W LL L N c m z y N v (% O) 0 Y {n 1 'a o ca Q ca n m cv +r c o v 0 O L 40 > � o N O 0 E 0 N Z O y 0 0 0 :�•� c :r C m 0_ .� c cc 0 am 0 = c Q L 0\: L m moo CL 0 H 0U)AW cc (D V m co W G "0 O O E 'y d y C ui0 LU L •E r - C) Q. O a CO G> 0 � N 2 o O .� . Q0U 2 Z 2 toZ W w CL w C� G W CL Z O U) J Z N gq rM7 L.: c CD m m 0 o � CL ai Q i_ r M J � O � Z 5 N The Commonwealth of Massachusetts DepaH ment of Industrial Accidents �--a' Office of Inv"tigations 1 Congress Street, Suite 100 �j Boston , MA 02114-2017 www.mass.gurldia Workers' Compensation Insurance Affidavit: Build ers!Contractors/ElectricianslPlumbers Aplalicant Information Please Print Lezibly Name 48usine»Org.tni stipt'lndisidual):_f Address: 80 O o x 314 U Phone #: Ss LO`34Its .5 Are you an employee! Check the appropriate hole: Type of project (required): 1. 1 am a cmpio�°cr with _ 4. [] 1 am a general contractor and i Vic" etrtploti-ces (,full and'or part-time 1. bane hired the sub -contractors t constrtertinn ,.'[ 1 am a soli proprietor or partner- listed on the attached sheet. %. Rcroodcling shin and have no cmplayce 7'hcsc subott Tactors have $. ®Detuolition woAin�.t for me to any capacity. employes and have workers* 9. [ Building addition [No workcr`' comp. insurance required.] rump insurance.', 5. corporation and its � We are a ' ME] Electrical repairs or additions 3. (� 1 am a homeowner doing all work otiicrrs ha, e exercised their I l.[] Plumbing repairs or additions rnywlf� [No workers comp. right of exemption 1x�r �iGl 1'.[] Roof repairs insurance required.] t c. 152, M4). and "e hate no 13.[] Other employees. [No workers' cornp. insurance required.] 'Am• appituant that check% box �d t tnu,t aI,o till out the tsectiun trekiu ih€w it:g :heti masker) cotr.-�xstfott policy in.i.1rtnanon Homeoulnerx N%ho submit this at?idas it tndica'ang the a:e doingall workard. 11 cr. hire migktc comnetnrc must ,uhmit a new- a ffida%it ifltlieatr.4t such. 'Coin:mctors thai check tt:ts box must a::a0cd an addsns. sheet shoutnr the nine of the ob-:tw-tactors attd st.t:e w heJur or nut tvse cn tttes have cntplo}m-. If the sub-contr.+cwcs have emp!.nre,, t'4er must pw, idc thrix winners' .tap. pall.', nunrtxr I am an emplgver that is providinsq workers' compensation inNurance for my eniplt treeN. ))elms• is the polo and job .site information. Insurance Company Name: Policy :� or Self -itis. Lic. -,: TI A P1 JZPjgg3 2,:1 Expiration Date:ko l - a l ikat . Job Site Address: t 04 Sh erwoa Ck On' VC City State•Zi I (j4 al 6K p= iv �� _._F Attach a coPy of the workers' compensation polies declaration page (showing the policy number and expiration date). Vailure to secure coverage as required under Section 25A of hIGZ c. 152 can lead to the imposition of crimiml penalties o`a fine up to $i,500.00 and or one-year ImprtsonTneitt, as well as 661 penalties its the form of S1 OF W'ORK 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 Investigptions of the 1x1.1 for insurance coxcrage %enfication. I do hereky certify under the /pains and penalties of perjury that the information pro aided above isl true and correct. SSjznaturc: V _���lJru"" '"~r Ible• c '1 I t YJ Phone f":'R Slt 34 Official use only. Do not write in this area. to be completed b -y city or town official. Citi- or Town: Permit[License # l", uing Authority ',circle one): 1. Board of health 2. Building Department J. Cih•tfow n Clerk d. Electrical Inspector 5. Plumbing Inspr.etor 6. Other Contact Person: Phone #: A 5'# 0 V -5 - Federal ID #05-04105629 RISE Eng,incc riilo Rf Contractor Registration No 8186 'A Contractor Registration No 120979 :>, division ot"Ibiclsch Fn��iaccrin RISE Company Address. City. AL1 00000 CONTRACT � � EidGINEERIVG- 401-123-1234 FAX 4111-123-123-t Page 1 PROGRAM 'Nis CONMACTIG ENTERED IIIA DE ,1EEn RISE �., 1:,-}11.5 Eh'�IIEERII7C i.KD tY.E CI>JTr,ER FG31:CfiK AS CESCRISM IMMU CU5MCIER PIICNE CAM CUEUT# CVCRK CRCER Suresh Ashara i978)651-0345 07/22f2016 437336 00003 SERVICE STwo 8104 S MEET �� i� - ,- '_'- ; ..' !0-! Sherwood Drive IO.1 Sltcn,00d Drit•e f L.-.✓ , t�r{,:,.'i1"'�IIJI SERVICE CITY. SIAM. DP OWNS CITY. SIAM. LP North Andover. MA 013-13� 1 '• North Andover. Ufa 015-1. �t Pi IASE ONE - Proposal for this calendar ve:lr IiAZARD BARRIER: We have identified that there are reeesscd lights present in your home. unless the rcccs ed tiles are certified as IC-raiet ( Insulation Contact Ratedi ue %:ill create a 3" clearance space around the fixture by u-;ing fil er0ass blanket insulation as a damning material. no insulation toll be installed across the iop and closed cavities c%hich contain recessed lieitts Hill not i -L insulated. so.w At R SEALING: Provide labor and materials to seal arca, of your hung amtinst wisiefid. excess air leakage- This turn; trill ty p normed in concert 4iih the ¢<c of special tools and dirtpostic tests to asctre that your Horne rill •rye tett ttith a healthful levet of air exchaiwe and indtlor air tittiliiv. Materials to be laud to seal your home can inclui caulks. li:ams and other products. Primary areas for sualim: include air leakage to :m ics. Ni cmenis. attached mora' es and other unhealed areas (%%iiidow; are not penerally atifresscd.) This lull rcguire 112 i wirklng hours. A redo tion in eultie feet per n11711Ee icfal 1 of air Infiltration %%ill occur. Pili tile WWI numF.r of chit is not auarantecd At the complet inn of the t%cathcri'ration pork. and at no additional cost to the hortcowler. a final blot%cr tt:w anti'or t:otnbtslion safely analysis till be conducted try the suircontractor to ensure the safety' of the indoor air quality. S 1.020.110 DAMN11NG: Protide labor and materials to install a 13" laver of R -3S unpaved fillerahse hits to (ii) suture feet for damning Plq poses. `_+I 12.75 ATTIC FLAT: Providc- laix)r and materials to install a 7" layer of R-2; Class I Ccllulostr ad'ed to 14201 sgt:::re fee: of open attic space.OVER NIASf IER BEAD ROOM AND GREAT 1,00M. K` 17EWALLS Provide Ialor and matcri'!Is it) ins_all 2" FSK faced semi-rigid fihr-ia s Maid insulation to ( f (r) suture feet of kneeuall arca.,'AAS-TER l3E OOM CLOSET :4;5.00 ATTIC ACCESS: Provide lahnr and materials to install ( I ) easily moved. insulatin-corer fiir the attic access folding stair. A small fiat stsface of ply%wod till ix created arutmd the opening %%;thin Elie attic. This pili allow the coveys irte(__:tl t:e alter -stripping to restrict air leakage. - 5237.6; ATTIC ACCESS: Provide labor and materials io make (2) temporary access u% an attic arca. 'File opcnirw trill be classed %%ith materials similar to those e::isin_. Finish sandin-_ and painting, is not includled.1MASM-It BEDROOM, C'LOSHT S170.110 VENTILATION: Provide L:Mr ;md materials to install (_') to atlatcd exhauE hose ttith roof mounted flapper vent io exhau t csisiim-, hathloum fall(s), VENTILATION Provide laity aad RtateriaN to instali ventilation chutes in (931 rafter laays w maintain air Holy. j I S6 n0 Federal 10 1105-0405629 RISE 1',n-ineelillty RI Contractor Registration No 8186 MAContractor Registration No 120979 A division of •Iltielsch Emuineering _ I S C:ompanc :Address. (Aly. MA 1101111(1 401-123-113.1 F:1\.1111-123-133.1 CONTRACT Page 2 PR0 6RAi11 THIS CCNIRACTIS EIIr=RED IU SET.'rEEN RISE ENQUEERNGAND TUE CLISIP.ERFCR VIORKAS DESCRIBED SELCOW CUS77.'ER PnOr7'a DA_ CUENT3 WMORDER Suresh Asham (978)681-0348 07/22/2016 137336 WDO SERVICE STREET BlttrlrG S BEET 101 Shmood Dine 101 Shemood Ddvc SERVICE CnY. S TT, ZI? BIWIM C17Y. SLIT-.-., ZIP North Andover. MA 01845 North Andover. NIA 01945 .JOB DESCRIFTION VENTILATiON: Provide latvr andnlaterials to install t 7)4" 'i ventsto increase ventilation in attic are; . `+i�ecif) color: \t: bite or (1',ttv,.MA5r ER BEDROOM C1,05t r �511.11n C{}.MMON WALLS 1'rovii c I:Ilalr and materials io install l" FSK faced s nd-rigid fiberglass hoard insulation to 13[11 square feet of common wall area SItr.I)n INCEN H VE: RIS£ Emgincering wll apply all appilc-Ne. eligible Incentives to this contract. You %%iil only rc billed the Net arlI01act. Carremiv. for Amble measure.. Columbia til: offers an incentiveof ;> a. not to escced 52.0010 ner calendar year, and an inccnt ive of tk)O% for tine Air F alien! measures up to the first %W and an additional 53.111 if savin s arc lu,tiiied by the auditor. PQ A LiMI T ED Tl;.1L. Colunbia Gas %:ill also offer an ad:inional 5100 incentive It, WLIs the v.vatherirotion %%Irk outlined in this proposal. This special Stnnmer Incentive is available to homeov'IM;:%170 hU%C had their C"ottanbia Lias home energy atziit t,ef re Jul% 31. 2016. A signed proposal for ::eathcrization needs to be submdtted by august 8. 1016 and mol-k Inuit be cinnplCWc b% S:ptcmicr 31), 20 If, For the safety and health of your homc"s in;! or air quality, me ulli N. con lactim, a Mmwr i.400r'Impostic of the available air flim in %ou home h)th ix:ti%re tine w,rk i; }yuan. and ttcr the neat lie,iration afire iscpmpletc. We ii! also :ordu..:t a Full Lssessrnem of the c:Imcustion safety ofvou heating syn:em and w%cr heater. Thishasa value of 396 and is at no cost to vont. The maximum allowable incentive for all nicasures. inc uding air scalinm- is S3.210 Fite Permit %:ill I,-.: rel b tilt !,(!)anon contractor. at no ad:1dl ionnl asst It is the ilomenuncr's rc,ponsibilit% to close: via this permit comaeling their mtinic,p Air. at the complcnon of tills aivk S<?t).tIG ,i r �. 4� t �- 16 Federal ID # 05-0405629 RISE Enoincering RI Contractor Registration No 8186 • , i.1AContractor Registration No 120979 .t division of'nlieisdl i-:ngineerin�:, RIS IR:G' Company :k ldress. City..NlA 0110110 CONTRACT 101-123-1234 FAX 401-123-1233 Page 3 PROCR: M T:aJS CCNZRACT15 EN =RED WO BETWEEN RISE CNIA-IlEs EJ7CINEERIHOAItD'u=CLY�.ER FOi IIWKAS OESCRISED SELc:1 CUST..MR PHCNE DAZ CUEJr0" MIM CRCER Suresh Ashara (97301-0313 07122/2016 437336 00003 SERVICE STREET BILLING SHEET 104 Shenvood Drive IN Sherwood Dri%e SERVICE Cm. S ; M, TTP SILLING CITY. ST—, T,P Nor:h Andover. MA 013.15 Noah Andover. MA 10184-5 .JOB DESCRIPTION Total: $3,209.90 Program Incentive: $2,784.93 Customer total: $424.98 Y! E AGRE_= HERESYTO FURNISH SERLRCEES - CO'SPLETE IN ACCORDANCE VIFTH ABOVE SPEytFICAMUS. FOR THE SUM OF "`Four Hundred Twenty-Four & 98/100 Dollars $424.98 UPON FINAL INSPEC NAND APPROVALGY MSE ENG;NEERING. CUSWER AGREES M REIATAR,'7UHTOUE PJ FULL INERESTOF I% WILLSECHARCcObT#MLYONANY UNPAID aALARCE .. R:0 DAYS. SEE REVERSE FCR IS?W&1{TDt. nbrLCtl ClJ GUi.AAJIEES, RICHu Cr REgSlgl, SCHEOUISHG, A+"D CONTRFCtCR REGIS :. wGN. DO NOT N THIS CONTRACT IF ERE ARE ANY BLANK SPICES � C •��c. r I� f AUTHOR D GNATURE-RISES In.- CUSTO,-RACCEMME ti I�K NOL-: WS CO:I ACTL::7GEVilTlDRAL•1110YUS IFN0TE%ECU`07AZ9II DAie OF ACCEPAHCE 30 ACCEP71ANCE CF CONTRACT-II{E ABOVE PRICES, SPECIFICAT.ONS AND CCVD17CnS ARE SATISFACTORY DAYS TD US AND ARE HEREBY ACCEP'ED. YOU ARE AUTHCPIMD 0DOTHE WORK AS SPECIFIED. PAYLEhTY ESE MADE AS WZMED ABOVE ,E �It JUL 2 D 2016 a i 16 SE ENGINEERING 60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com OWNER AUTHORIZATION FORM h Name) owner of the property located at: 10 (Property Address) -} JUL ti i I I( � (Property Address) - hereby authorize �r ��► C ►�SVI i v"- , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. O er's Signature t� Date ACORD CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDONYYY) 08/12/2016 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS . CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NOMEaCT Kaitlyn Da sh MARTIN MARTIN J. CLAYTON INSURANCE AGENCY INC PH°NE ,�; (413)536-0804 FAX E-MAIL kda sh m Cia tan com INSURER(S) AFFORDING COVERAGE NAICC # 1649 NORTHAMPTON ST., RTE 5 �y INSURER A. ACADIA INS CO� 31325 _HOLYOKE _ -� MA 01041 MV INSURED INSURERS: MED EXE one rson) S GAUTHIER INSULATION INC INSURERc: _ __ INSURER 0: I I NIA INSURER E, – ! PO BOX 344 INSURER F: GENERAL AGGREGATE S IPSWICH MA 01938 E`nVFRAf1F_9 r`FI7TI9Ir:ATC M11MRFA- 78701 13CY1I0Ir11d WII&ACCO. THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR_i TYPE OF INSURANCE–� S POLICY NUMBER 2 POLICY EFF !(MbIMONYYY), POLICY EXP (MM1DP=YIUMrrS COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR 1 EACH OCCURRENCES Air, A le' R'ENTE6_ PREMISESE( a occurrenc�j$_�_ MED EXE one rson) S ' I I NIA ! PERSONAL &ADV INJURY $ GENT, AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT LOC �I OTHER: GENERAL AGGREGATE S ' PRODUCTS • COMPIOP AGGI S is iA ;OMOBiLEL1ALITY i ( 91 ANY AUTO ALL OWNED ��! SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS � AUTOS ! N/A s i IMa ! c ( I_60IN LI I S N'dent) ' BODILY INJURY (Per parson) $ BODILY INJURY (Per accident) t $ PROPERTY DAMAGE $ $ I UMBRELLA LIAB IOCCUR I ii EACH OCCURRENCE $ EXCESS LIAR I CLAIMS -MADE j j N/A _ AGGREGATE $ DED RETENTION $ y—� ��� $ I 1 I A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN IANYPROPRIETORIPARTNERIEXECUTIVE I OFFICERNIEMBEREXCLUDED? wa [(Mandatory in NH) WE.L. �lf yes . describe under DESCRIPTION OF OPERATIONS below NIA NIA MAARP300327 i 10/30/20151 10/3012016 1 j : Iv P R TH- t_^ STATUTE ER i E.L, EACH ACCIDENT $ 500,000 i - DISEASE - EA EMPLOYEE S 500,000 Y----------- E.L. DISEASE -POLICY LIMIT $ 500,000 i i i 1 N/A 1 I DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H mon space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant t0 Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search toot at www.rnass.gov/iwd/workers-compensationrinvestigations/. Town of North Andover 1200 Osgood Street North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 01845 Daniel M. Crq' y, CPCU, Vice President - Residual Market - WCRIBMA ©1988.2014 ACORD CORPORATION. All rinhts racarvacl ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD V u � e U N � N u o CD ` t O ~ � E o _ O G 'O O n O m> = I e i H R a d a Q'� O x y'' __gym c w 20CIO 0 q o=_a tn IA M cn Q in ►. O , N � 'hO�A �x O UO v C,3U ;woo :� c� �% vNi +•., � a O — to cr Cl, O p � o a = a 100 o oda V \� WWLU ` �E>ro � O I— H m F.� o a o co U W y m W 01 2 CL CL 00 N K 0 W _ �..tLl✓" r w (Y of W CL Im 2 tu CL Im