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Miscellaneous - 109 LYMAN ROAD 4/30/2018
109 LYMAN ROAD 210/020.0-0065-0000.0 I Date.. /A.../K1. TOWN OF NORTH ANDOVER PERMIT FOR WIRING P SS CHU r ........LD 61W..... .nl--. 7:;�; This certifies that .. .. ...... ...... ....................................... has permission to perform ........./ ...................................................... wiring in the building of........... ....................................... at.4D9. 0.0-0/1...�I)........... orth Andover,Mass. Fee..5 Lic.No/L1113,�*4* ............... ... ELECTRICAL INSPECT!)k Check 0 r) 7 7 Commonwealth o� a»ac�ivaQ(ta Official Use Only .LJaPari!manf o�,tieo �arvita� Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS / 7 e 10 (Rey, 1 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: 101.a.fa g City or Town of: lVaa72f ,► �p�� 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) 1Y 21X:: Owner or Tenant Y&4+,4/ /ZO Telephone No.,o Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lf2,9�-.-� .�► r Com letion of the following table ma be waived by the Ins ecior of Wires. No. of Recessed Luminaires No,of Cell.-Susp,(Paddle) Fans o.o Total t Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LumiAaires Swimming Pool ova ❑ °' ❑ o. a Units Emergency Lighting rnd. grnd. Batte Units No, of Receptacle Outlets No,of Oil Burners FIRE ALARMS No, of Zones No.of Switches No,of Gas Burners o. of Detection an Initiating Devices Total No, of Ranges No.of Air Cond, Tons No.of Alerting Devices No.of Waste Disposers eat Pump „,...um,,.,er .,.ons .,.....,._. o,o e - onta ne Totals: Detection/Alerting Devices No, of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No.of Devices or Equivalent No.of NVa(er KH, o. o o. o Data Wiring: Heaters Signs Ballasts No,of Devices or Ec uivalent t gg No. Hydromassage Bathtubs No, of Motors Total HP c ecommunicnhons taNo.of Devices or Equi valn : en( 4 O"rHER: Attach additional detail if desired, or as required by the Inspectui o/Wires Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1,9114 1,9,5 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 cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penaltieso perjury,that the Information on this application is true and complete,'' II FIRM NAME: DAV I D E(,E'J'rt4I C14L, Cot rtQgCT LIC. NO.: I`79�,3A Licensee: DAV Ip I+ACaci&Q, Signature LIC, NO,: (If applicable, engr "exgg��mpt"in the license number line.) Bus, Tel. No.: `f V 6*74 4 2 Address: �'7 ►::PeLmOAJ r ST t bORIW ANb6VfR 5 Alt,Tel. No.:q7t 3�SS'7�y Per M.G,L. c. 147, s. 57-61,security hwork 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, $ Date./ NORTH °`'"`° . TOWN OF NORTH ANDOVER PERMIT FOR WIRING 43ACHUS This certifies that .... . ...... .......................................................... . ....... ....... has permission to perform,.A.---- . . ............... wiring in the building of ............................. ............................. at ...... North Andover,Mass. !.r.......... Lic Fee. N04..F?.;.If............. Check # --1-1440-- 7701 �. Commonwealth of Massachusetts Official Use Only 42) Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS IItev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance wiib the Massachusetts I?IecU.ical Code(N1 'C),527 CM If 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inq)eclor ofWires: By this application the undersigned gives notice olrhis or her intention to perform the electrical work described below. Location (Street& Number) I t'� Owner or Tenant N-N V Telephone No. Owner's Address Is this permit in conjunction with a building permit? Ves No ❑ (Check Appropriate Box) Purpose of Building ( Fn\ I� �4 Utility Authorization No. lu 6 d 1 1�— Existing Service AmpsjVolts Overhead, Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and Antpacity Location and Nature of 1'rpo d EleMric:►I Worl:: Z Completion of the.iVlowing table mai,be waived)by the Inspector of ll'b•es. { No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle) Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swinunin Pool Above [IIn- ❑ o. o Emergency tg tng g irnd. grnd. flattery Units ..� No. of Receptacle Ontlets No.of Oil Burners FIRE ALARMS No. of Zones No,of Switches No. of Gas BuNo.of Detection and Burners No. Initiating Devices Total No. of Ranges No. of Air Cond. .rolls No. of Alerting Devices i Heat Pump Number Tons KW No.of Self-Contained No. of Waste Disposers 1 Totals: Detection/Alerting Devices No. of Dishwashers S ace/Arca Heatin► Municipal p• I, KW Local❑ Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterIOW No.of No. of Data Wiring: Floaters Si,its Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total 1I1, Telecommunications Wiring: No.of Devices or Equivalent O"TIIFR: t ltaclr additional detail if desired, or as required(btu the Inspector of(Vires. , r Estimated Value of Electrical Work: coo (When required by numicipal policy.) Work to Start: lh 3 'CJ? 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 BOND ❑ OTIIF'R ❑ (Specify:) I certify,under the pains and penaNies o/'perjurt,, that the infornwtion on this application is true and complete. FIRM NAME: TG- LeoLs ffjec4ocTG-Leo Cc, n c LIC. NO.: G IT I Licensee: a� e i\ (T- L.e U es signature \LIC. NO.: (ll'opphcahle, enter r.�chn N"in the lic•crt.rr nanrher linr.) Bus. TCI. No.: ,Address: �U f�C SCI i( At- 0 i l d ff G SL5'_ Alt. Tel. No.: 7 7,0- *Per M.G.I-c. 147, s. 57-61, security wort: requires Department of I'll blic Saltily "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the I.iccnsee 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 aoent. Owner/Agent PERMIT FEE. $ Signature Telephone No. dh 1 sr r .F r The Commonwealth of Massachusetts Department of Industrial Accident~ r __-. . __......... Office of Investigations – ' - 600 111ashington Street Boston, MA 02111 www.ntass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // PleasePrint Legibly Name (Bus iness/Organization/InllVl(laal): Address:��Q / /� C City/State/Zip: r"0441 ./iva� t®1 Phone #: q-7 6(9 0 7 2793 Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ I am a employer with 4. ❑ 1 ant a general contractor and 1 6. ❑ New construction wployees(full and/or part-tine).'" have hired the sub-contractors 2eWl am a sole proprietor or partner- listed on the allached sheet. .j: 7. remodeling ship and have no employees 'these sub-contractors have Q. ❑ Demolition working for me in any capacity. orkers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself [No workers' comp. c. 152, 171(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other required.]COMP. insurance ired. P 1 ] *Any applicant that checks box#1 must also till out the section bel0\v showing their workers'compensation policy inibrmation. 1 Homeowners who submit this atlidavit indicating they are doing all work and then hire outside contractors must submit a new allidavit indicating such. tContractors that check this box must atlochad an additional shed showing the name ol'the sub-contractors and their workers'comp.policy inlormalion. 1 tun an employer that is providing worhers'compensation insnranc•e.firr nw employees. Beloit,is the policy and.job site in f on-mrtion. Insurance Company Name: Policy#or Self-ins. Lie.1#: _ _ Expiration Date: .lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a Fine j of up to$250.00 a clay 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. 1 do hereby certify under the pains and penalties of ei joy that the ni f n-mation provided above is true and Correct. Signature: Date: O— Phone -7 Official irse only. Do not write in this area, to be completed by city or towit official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector F 6.Other Contact Person: Phone#: Date ORT o',"•5° TOWN OF NORTH,ANDOVER oa .�.� --•.'•°off17 � PERMIT FOR PLUMBING ;,SSACH This certifies that . .i�.�f n . . . . .�,� . . . . . . . . . . . . . • • . . . . has permission to perform { plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at . . . . . . . . North Andover, Mass. Fee.3 6 Lic. No.IAY.`!. . . . . . . . . \.. . . . . . . . .PLUMBING INSPECTOR Check # {� 8258 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS i Oq� ) � � I�i Building Location Vj54 e- Date 0 Owners Name W � Permit# j,�- Amount-- Type mountT e of Occupancy New ❑ Renovation Replacement ❑ Plans Submitted Yes ❑ No ❑ FIXTURES 0 a o W U o � cq �FiSIVIC &191YII r M I+IM M HDM i 4M MOOR SIH ILOOR 6M K—aR 9(- 7M FLOOR SIH I+IDCRt (Print or type) e-^� " ifCheck one: Certificate Installing Company Name i V 1 �G► N,J ElCorp. Address F �� Partner. MA usmess Telephone . p Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicatetype of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ 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 Signature Owner ❑ Agent I hereby certify that all of the details and informat' I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing wor d stallations perf under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass h setts State Plu bi Code and ter 142 of the General Laws. By: igna ure o7 Z-17-en-s-eff rjurnoer Title Type of Plumbing License � P ' City/Town License um et'� Master Journeyman APPROVED(OFFICE USE ONLY ❑ t 1, c.umPnonweaft of Maysachuselts 1 ' DePamirerzt OffRdustrial Accidents 'F"•k i ,, //i Q07e of Im►estigations' . 640 ffashington Sheet B&SfO t, AN 02111 t7 Workers' Compensation Insetrsace A iiicant Information At�itiEavi Sabers/ContractorsoectriciRus/Pimmbers Please Print Lee'bi Name(easiness/brgao:zaEion/tndividuat): UM Address..* � �� � —� .Crit'/,�IZip: {� � ff • Phone#: . �,`� •-' I;�'' �� Are you as em*YerT Cheok.the appropriate-box: 2.Lam a emPIOYar,with 4. ❑ I am a Type of project(t•egairw):. emPloyees(full and/or parttime.* have g°d the contractor end I 6. , I am.a sole ) e d the srrb-� ❑ ow coristruLbon . PrapnetAr or Pffi�cr- listed on the attached sheet 2 7. (Remodeling ship and heave no emp}oyees 'I'h,. A working for meat _s_sul3-eontrac�rs have 8. [�Drmolrtion' any capacity. workers' comp.insurance. [No workers'comP,insraance 5. [] We are a aorposatiom and its 9. ❑Building addition �u"d.] oft'icers have exercised their IO•❑Electrical 3.❑ I sin s homeowner doing all work light repairs or additions myseI£'[No•works' of exemption per MGL 1 I.❑munrbi insurance ' .c � g 1(4),and we have no TePairs or additions regnired'];t .on3Ploy�s.[No worms' 12.[]Roof repairs `Avy eppt►cent gw �P. insurance required.] I3.0.pt}� checirs butt€l must also fiU out the seabon below BhowiQB theirworhart'cotupensefion poi�y mfnrmetion t tiomtowndt�who submit this affidavit indicatmi [hey ars �j ;Coatracmrs that check this box must 6vtng was'tc and[hm him Dmaide contractors rrmgr an ad cit. d.�tiasal she ar dwwrcrg.the rmrrre of the sub-coefta*rs and tt anew afirdnvit ind' sre l cr:. e+ sioyer fha7 ia,onomryz2o:wQrt. a w°nl=•' e �Y'�fE�6�ZFtptTfam>a610n. irrfnrn nr hzsarcnee for my=F*e=. B,Iw ir tfic r"o&, rasa job s ite Insurance Company Name: Posy#or self-ins. Lir. #: Job Site Addross; cpirafiom Rafe; . Attach a copy of the workers'�com esadou 'Crty/statcolp: Faihrre t4 p° declsr�atioa page showing secure covers a as req lab (Showing the policy number and e g aired under Section 25A of'MGL e. 152 can I�to the imposition of criarinal u�tton date, fine up to$1.SD0 DO and/or one-year irnnprisonm of up to$2 0. a �as well es civil Penalfies in the form of a is of a �3 aesinst the violator. Be advised that a c S'7�P W0�ORDER Md a fine fnvesiigati0 s o e DIA for ins opt'of this staters may be forwarded to the Office of coverage verity"cation• !do h mbyMn c nder the Ppendulia of add y J*&the ucfnnr>ation Provided above ' Si tta•e:.. " � trice and caned Dat~: la Phone offAci&use ofily. do not write is tfris asoma,to be cors tete! or tow ' n QfI�aL City or Town # Issuing Authority(circle one): Permit/Licause 1. Board of Fiesitb 2_ Saelc#ing Department 3.City/Town CSerSt 4 ESectr;ca(Inspector 5. PSumbin4 E Other Inspector Contact Person: Phone#: Information a ind In§tructions Massachusetts General Laws,chapter I S2 requires all emp 3oyers to provide worked' compensation for their employees. Pursuant to this statute,an entpinyee is defined as"..:every person in the service of another under any contract of hire, exprtss or implied,oral or wren." An employer is defined as"an individual partnership,association,emparation or other legal entity,or arry two otmom of the'famping engaged in a joint erittiprise,and incyudiiszg the Iegal represcritativm of a deceased employer,orlht receiver ortnrstee-of an individual,partnership,associa6oi n or other legal•entity,employing empioyem'liowemthe owns•of a dwelling house having not more than thix apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or ' wcirk on such dwelfthouse or on the grounds or building appurtenarst thereto shall not bccaus:of such employment be doomed to be an employer." MGL chapter 152,§25C(6)also states that"every state o•nr local licensing agency SW withhoW the iumnoceor renewal of a license or permit do operate a busmem or tz construct buildings in the commonwealth for any appri at who has cot produced acceptable evidence-Of compliance with the.insurance coverage wired." Additionally, MOL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contact fur the p=*m====of public wm ie until•acceptable evidenx of compliance with#fie insia = requirements..of this chapter have been preseatted to the canrrt-acting aulhority." Appiicauts Please fill out the workers'compensation•affidavit completely,by checking the boxes that appy to your situation and,if necessary,supply sub-cordzactor(s)rrame(sl addo ess(es).gild phone nimnber(s)along with their cratifimte(s)of insurance. Limited•Liability Companies (LLC)or Lmnited Liability Partnerships(LLP)with no eanpioy=s otherthan the members or.psrtners,are not retluired,to=yworkeirs'eaTnpe nsafim insurance. Ifan LLC or-LLP does have employees,a policy is required. Be advised that oris afUavit may be submitted to the Depwimant of Industrial Amidexnts fforr confirmation of f=rM=coveasge. Also lige sure to sign and date the affidavit The affidavit should be,returned to the city or town that the APPH afion for the peimft.ar license is being requested,nott he Depaftei t of Industrial Accidents Should you have any questions regarding the law or if you at required to obtain a worlcers' oorrepensation policy,please-call the Depar'tnm t sit the nurnber.liisted below, Self insured Menpaaios should enter their self-insiunne'ficcnsc mucor on dte•approlsiistz u�. City or Town Offic.imis Please be sure that the affidavit is compiete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in.the event the.Office of invmstig ons has to contact you regarding fisc applicant Please be sure to fill in the permi0icense number which w ll be used as a reference number. In addition, an appiicant that must submit multiple pmmWhcm=applications in any given year,need only submit one.affrdavit indicding-cnarent policy'iriformafion(if necessary)and under"Job Site Address"the applicant should write:"all locations in (cityor tman)."A copy of-the affidavit that has born.officially stamped or marked by titre city or town may be provided to the applicant as proof that a valid affidavit is on file for futwe permits or licenses. A new aftndavif must be ziilled out each year.Where a home owner or citizen is obtaining a Tic== or Permit not related to any business or commercial vulture (i.e. a dog license or permit to bum leaves etz.)said person is NOT,mcluired to.complete this mTl&viL Tim Office of investigations would duce to thank you in advw=for your.caoperadon and should you have any questions, please do not.hesitate to give us a call. The Department's address,telephone and fax number. The Commona1t13 of Nfassaci�tzsetts Department of Industiial Accidents Office of Lnv�sfigions 600 wadiington Stiect Boston, MA 62111 TeL #617-7274900 czt 406 or 1-11.77-MASSA Fax 4 61 7-727-7741 dLvise 5-26-(15 wvvw.mass.govidia " Date. ..., /.G.7 Oe PORT.i4, TOWN OF NORTH ANDOVER .� PERMIT FOR PLUMBING sSACMUS� This certifies that . . .�✓.'� . . .-1�.c_. ��!!H-.,h. . . . . . . . . . . . . . has permission to perform . . . 1�'. o.� -� .c./��. ...... . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . at. ./O.cr. . . .t�y. .t-- .& .... . . . . . . . . . . . . . .. North Andover, Mass. Fee.44.3. . . . .Lic. No..2.1 t ?:u. . . . . . . . . . . . . . . . . . . PLUMBING INS EP CTOR Check # 7522 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location/0 O�yr►?19 it/ Pd Owners Name i l Ige( jffCLj[P i Permit#��- T Amount C 7 i Type of Occupancy P—(n r New 0 Renovation 0 Replacement Plans Submitted Yes No FIXTURES En w �Bava R4SE X _ 2hD IHIaIt M KOR 5I RnR 6MROIR 7IH R M 9]HBD i (Print or type) r~ Check one: Certificate Installing Company NamIca, r-I DQ vin PO( Corp. Address _ Partner. Business Telephone Finn/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver. L the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing w and atio ed under Permit Issued for this application will be in compliance with all pertinent provisions of the assac usetts Plumbing Code and Chapter 142 of the General Laws. r By: igna o r Type of Plumbing License Title O / City/Town License Number Master Journeyman APPROVED(OFFICE USE ONLY Jk, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING z�4 (Print or Type) . Mass. Date 199 Permit # ].O G p BuildingLocation 01 Owner's Nam A Type of Occu n pa cy_ 1� _ t New p Renovation p Replacement Plans Submitted: Yesp No p N N W N Y Z ¢ N N N U y rC N Q O N = �Z.. W J N W 0 V m S A z c u a ¢ cc o 0 0 = W a m 0 F- y W O a e � r W Q H N a tu N W 2 V W N W a C H O FS W W y W a r cc Q: W {L W W Vcc a }- 2 J 4 Z F. t. �W N m Z O 2 W O N = Z a W Q: W Z, < Q a a O O W O rl F- ¢ '= O tl Y W O 3 G tl U y Q a F- O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name T A jZ T A 30M MAT 0180 Check one: Certificate Address 30 OoA C N i>1 A ry i-N[. ❑ Corporation Me r H v E r 011-1 . 01 k qq ❑ Partnership Business Telephone Z —9 S"7 2--Arm/Co. Name of Licensed Plumber or Gas Fitter 2 0 13E P T A- 5 A M M 11 TAP INSURANCE COVERAGE: I have a current H bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes hd' No ❑ If you have checked Ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed underthe pe " i ued for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. BY T of License: G� Plumber n ure of LicensedPlu or Gas Fitter Title fitter 8333 ter License Number City/Town Journeyman APPROVED OFFIC S ONL BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE GAS INSPECTOR t' f Location h 9 Za No. 4 6 Date NORTh TOWN OF NORTH ANDOVER 0 N? � .. t � • + Certificate of Occupancy $ s'' Building/Frame/Frame Permit Fee $ sscMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 44 Zy 18183 Building Inspecto A TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT BEtMj RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: �� � asr X SIGNATURE: Building Commissioner/12% for of Buildings Date SECTION 1-SITE INFORMATION 1 O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: t o 0► L-�VVNAt j �j ©6&S Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage A 1.6 BUILDING SETBACKS R Front Yazd Side Yard Rear Yard Recmired Provide ReqWred Provided ReqWmd Provided v 1.7 Water Supply M.G L.C.40.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Nm to 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ _J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT lj ti!Ct: Ys r,10 M 2.1 Owner of Record M lkr- Name(Print) Address for Service: 1., Cor,,sT c— - (�85 53�`i Signature Telephone r' 2.2 Owner of Record: BUNROEUN €;HHOUY _ 0 Name Print HOMF DEPOT Address for Service: Z 4 COBURN RD. M TYNGSBORO,MA.01879 Signature 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0 License Number �1 III Address A Expiration Date Signature Telephone faaa' 3.2 Registered Home Improvement Contractor Not Applicable 0 v Horn hq o-r Company Name l M �j 1 c Registration Number-f�,�f t�st�oo� �i V�7r�2C�'iE'tZ Address I&L �2 E xpiration Date Signature Tele hone g SECTION 4-WORKERS COMPENSATION(M.G.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 permit. Signed affidavit Attached Yes.......K No.......0 SECTIONS Description of Prosed Work check a8 a bile New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) Addition ❑ Accessory Bldg. 0 Demolition 0 Other ❑ Specify :�' .l . >, .�1i\ Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee b Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x bbl 4 Mechanical HVAC c 5 Fire Protections 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN t OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION hH k oL/,t--( as Owner/Authorized Agent of subject B l Property Hereby declare that the statements and information on the foregoing application are trate and accurate,to the best of my knowledge and belief Print Nameh/\,— LWc) Si ture of Ownerh6rgent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS Pi 2 ND 3RD SPAN DMIENSIONS OF SILLS DIMENSIONS OF POSTS Da ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS. . SIZE OF FOOTING X MATERIAL OF CHIIIAINEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH Town of i. GNo. ! — o .. :. .. -Y.M 0 C% __. - dover, Mass., �� O LAKE COCMIC EWICK 7�S RATED P`Q �y BOARD OF HEALTH Food/Kitchen . PERMIT T D Septic System 6Z� BUILDING INSPECTOR THIS CERTIFIES THAT. f.. ...................... .. ... . ............................ Foundation ............. ... .. ..... .. ................................ has permission to erect........................................ buildings on.. . ................... Rough .... to be occupied as . . . . . Chimney . . . . . .. ..... ..... ............... ...... ................................................................ provided that the person cepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the pro isions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIONS TS ELECTRICAL INSPECTOR .......................s!..'.1...................... �� •••••••••••• Rough . ................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. w AT-HOME installed Siding and Windows Board of DwMag ReBalatlons and Standards HOME IMPROVEMENT CONTRACTOR Uccnse or registration valid for Individul use only Rwy! .,_ Ig8893 before the expiration date. If found return to: Board or Building Regulations and Standards One Ashburton Place Rm 1301 "_ ( $ element Card Boston Ata.02108 *',. THE Home Oepol 13rviC BUNROEUN CHFtOl3 =.: 3200 COBS OALLE"RK"—#20 ALTANTA,GA 30339 Adsidnistrator Not valid wititout signatur Maty 04 05 11 : 38a Michael Bedard 1-401-246-2868 p. 5 HONE TNIPROVCMFNT CONTRACT A� Sold,Furnished and lnstalltd by. �.,,t' Tk1D At-Horne Services,'no' 13rrinch Name: S 1� Dater^ �$ d,'bla The borne Depot Ar-Home Se,-ViceS 345A Grconwocd SLsrol,Woroester,MA D1607 /?,� Toll FTCC(800)657-5t82;Fax:508.756.2859 Branch Number: .—_Job itt --p+�,iy. pede+oi.Ua 7!-1696460?.M I.ic a C ou39 u Cum.Lica I6427 I jA 56s5I2; MA 110AV If prove halt Lnwwor Rag•0126991 Installation Address: --+1-- City Starr. zip 1 CVI, H e P6uac: ,le'erlcyhonr, Yarch t; l DrhtcsttVLiwc.t�ie&,Etc Dew �. -_ �b aQ�. X[omCity e Address: State P (if dirfcrcnt from 1-tallatioa Address) rma : I/NVtrYou r`Purchestf'),the owntm of the property located tit the above instahaian sudress,offer w r to famish,deliver and arrange for the instailation of all materials as contract w oma put Li.S,A.,tina("Horne Depot') iraotporated hsYeh:by refereaec end made a psi hcrvof. described on the attached Spee Sheet t!: rne rPot thfit it tic"l of the il' ""not peirforin its bliliaticntstto COMM dug to a Oruls mAtrelet if,uPun cturat problem with he tlntue or hcutt sooworf�reyu�d to completoSthe job was not included in the contract. Uk.!'ClSiT FAYMy,NT OPTIONS r.,. (SumJtx"to fund v�ltiettvn end!or credis eppry+.�. V t Check.Ceshic�Chtck vi US 1>aou+7 sarvin hloncy Ord[ CONTRACT AMOUNT S — (lladevs atk a TheHnMeDepot). r Credit Cardr ondlot eller yayLMnt optlara.Circle Qne aelew "I,RAS DEPOSIT S_..__ 1lawK.,ud D;3Covcr ArttericanEspr<ac Vire BA!ANCE DliR i l `� 71t:Hmvc Doyul Honu I pnwcmend fAan Tru Nemo rkpn:C editC ttd ON Co?4PLETIO 1 S 1 A..•allsble Crad[t:s_ r ulL fs NnC,(On Y) Aiiairaum 2S of Contract Amount due upas c"cudoa g D Fxp,Dyte; 03 0 _ I thea contract. Metria u it 1p7eats oq'pgrQ: ——���� wee 6etow.fAve aL c<to at nv x eD chupp the ata• ImdlcatePrymme hiethodPor 'faerno d%1, urd rtlw Ind A. BALANCE PUP,ON COWLETION: [/ �� _ Date IAtatutc HSL or HDCC AuthoriaA ore Codes Dr c• @'Inst Pnyrantt H _ 1 ll purchaser agrees that,immediately upon s ��to bo jD ntiy end sevcompictioil erally y obligated and I arhle hereunder.omplttion C.crtificate and pay any bulancc due. Purchaser ai30 a8 the winPP .n t reem at:This agreemcnl and its altschments,including any financing to A fe��dn�gnill d by bo:Vl1rdiccs- erween t a partlea and can not be amended Or modified unless u:tATnmg to a scparn g NOTICE TO PURCHASEIt ou Do trot sign thismatrect before uu feedyyit.Ynu are entitled to a tompietety fitted-in co of the eontraal at rbwIIV tht eotiFnp njert y rNsibrb home repair conte ttoro from re ucstin or aceeptinp a C umpleteon Ccrrlficate rl>!rectl it to protevd year rights. llo cot at$n na ompfedon Ccrtlecate or agreement stating t at you are salts r before this prol 't;v complete Law p by the atrncrpriar to the aetualcemplrtdea efthenorp Lo ba per�arrasd under i�a cos ahertde dace ofthia coutrac;. Sce Nat to of You tray eancc!this tranacNoo g!any time prior t0 mtdRiy{Ttt of rho third businat day, ensallitdrM'PurohatertAlrrL+R rhe C6lYtlbuttnasz�i�.wdl he�urvlct ehorlte e4uat td IS/e of the atntrtct amount If the jot,is t BY)fY�00JR A1C6p OF TF►b CONTFACT°ND TWO CONI'LETf�J COPI[SRJt TIdI TOTICT UANCELLA110N. wL T RFCEIP TO VERITY AND Rf,Vww MY ouft HY M4'(UUR St(iNA9'(1RT:ygI,OW,Vw'E tlNDtg$TAND 'l'EiAT 1'Hfi AGREEMENT 1S g1713IECT TO FtEV1F.W of rAY... CREDIT F115'CORY ANi!L'tHli AUTFTORxE ROME DEPOT AUT14ORLZBD CONTRACT Oft IONS E ORS, DO NO`r SIGN•,HIS C0NTRA(7f IF THERE ARF.aAY BLANK CREDIT IIS ORri AND AN� TU 1`10 DRNT CTIF.DI'r REPORTING A.(iB,NCY ,IND RfLL'1SF• fl'Th�T 1Ri)UI ALA.i.lA LA NCiJRItED FRt1WNADV ERT T O 0� SPACES. fr ,(J`J Dse:- sUB�iITTED Ill': 58tte l a I _ Date:�...� ACCI..PTED D Y: •-- • �ilolttenv,ntf.—r. .,rvu AaE 9Arr nR T'tJ1a t::f\TRACT ;WJ'*'l(:}'.:AttG{'fIl1AA1.Th1eMS.CU�III'rIARS ANU WARI2A1T1Ky ARIE STATRU ON TUd IS6�"RRXG SIDF 1,\hire-drlr:h l•i:c Y<tlow C�nM++�+l5ne-5nte•Cm:9Attm 1 G•YAa C-SC •.td oZH6Z9i:Ed9 -C1N }Rjd 1.1H4i1?1 t4fJeiH Od Wd W:01 Sox Ee d Date.... ............ pt 'AORTAI TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAC14 This certifies that .......vl-"�)"—' "-' .................................................... .............................. ti has permission to .................................................. wiring in the building of. ................... ............... .North Andover,Mass. Fee .............. Lic.Nod ELECTRICAL INSPEfM Check # 5 7 4 I=I.UIVILYIULV Vvr AI"n Ur I L3 �••w � � DF.PARTAIWOMBIlCS MY Permit No. BOARDOFFMPREVEMONRBgJM ONS5ra&12:1X1 Occupancy&Fees Checked APPLICA77ONFOR PERMUTO PERFORMELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASS ACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da Town of North Andover o the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) �'q jp�y 57'-- Owner f—Owner or Tenant c-T(/ r^ �`IGrr7 !�CA.114 Owner's Address Is this permit in conjunction with a building permit: Yes ElNo (Check Appropriate Box) Purpose of Building Utility Authorization Na. Existing Service .� Amps /�/dam )Volts Overhead 0"Underground No.of Meters New Service AmpsVolts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round El ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local a Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHERS n D -Can i �� ��fi hmaanoeCcm a Runintothe tegtriranall dM=xhBt G=2alLaws Iha%eaamailiabrTdykmr&=Po ymciul gCotnpl Q Come pertsmbstmalegr mAm t YES NO Iharesubrrimdvafidptoofofsamebthe0ffim YES lf)ouhawdr elodYEi plea mdrc*detypeofamWby INSURANCE BOND M OIIiFR (PleaseSpec�y) EstirrrabdValreofEbcb al Waic$ WoticbStart Da Rath Firm 9igrtedurrder�iePt�albesofpew. �/� FIRMNAME LioenseNa i r (•✓ /t Licerrsee ��r/ �.f � Sigrrm ` Lx msTo G� D I, f-/ /�"tel Busk=TdNo, .� A- -22L �- (��Jk' ✓ r� 1 1 CP�K�et f24 d ���o ALTe1Na -57 ref JoZ`l 3,< (, OWNER'SINSURANCEWAIVER;IamawarethattheLineaedoesmthawtheir>sumncerougesitssl>l>swtialetliWaltasret}iWbyM Ga>etalLaws andthatrrrysigrramcn thispeen[ffhabmwm%es driSragtl¢errratt (Please c . ne) er Agent �^ Telephone No. PERMIT FEE$1 signature or Uwner Or Agent Location No. b Date �oRT►, TOWN OF NORTH ANDOVER f F i - y Certificate of Occupancy $ . ; 4 "••ea't<� Building/Frame Permit Fee $ sACHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # l `� �a 17260 U Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER / DATE ISSUED: ic SIGNATURE: ic Building CommissionerA for of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O / 07 2A-1 Z 4 j /J av L, S Map Number Parcel Number p� 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record NamePrint � ) Address for Service: � Signature Telephone 0 2.2 Owner of Record: Name Print Address for Service: o m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ T6\,,,, . f�� ?-A p,- C-: � Licensed Construction Supervisor: C 2 0 3 n Al-IMS License Number Address / Q u 9�s 7 '�5 �( xpia on Da n S ture Telephone Er re 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Ae (company Name m Registration Number r Address r Expiration Date _ w � `^ Si na a Telephone V �. A. SECTION 4-WORKERS COMPENSATION(M.G.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 permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE: NLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of 4J Construction 3 Plumbing Building Permit fee(a)X(b) 0 J 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf;in all matters relative to work authorized by this building permit application. Signature of Owner Date t` SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION r a 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 Print Name Signature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB ST RD SIZE OF FLOOR TRABERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS �- DMIENSIONS OF GIRDERS —HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE tj 0 1a /ND n n �31 2�j t �� ZIL IL IM)L5 IJCS � � MI ��lp Chimneys `Residential & Commercial Roofing Siding CHIMNEYS POINTAlED-REBUILT-GAPPED 1 Types Of Mass Toll Free >f Roof Leaks Experts Expert Mason Work 1-800-WAIT-4-US ®• . Locally Own''Ad&Operated Sirce 1976 i!---- . Licensed& Insured License#034200 (924-8487) IKO C?aeB WOZW cc ,�?Vh-v °•°��= Wi& Work Year Round Proposal Submitted To Pho e Date 0' L ULL614 3 21S X Street Job Name _--e- City,State&Zip Code Job Location Job Phone /l, /-h�iJ/o Lji✓q 144 ss olj- � f We Propose hereby to furnish and labor in accordance with specifications below, for the sum of- -- f:__ ELk tai -co T X30_ 6,k C -) Dollars ($_ il'o Q � All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Signature: low involving extra costs will be executed only upon written orders, and will become an — extra charge over and above the estimate.All agreements contingent upon strikes,accidents NOTE:This proposal may be or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within 9° days. We hereby submit specifications and estimates for: S17"C fi ❑ Install 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley.4 roof is stripped, we will apply conventional ice and water shield ( ) ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at ( z,E'C� ) per linear ft. or ( — ) per sheet of plywood. d install heavy gauge aluminum drip edges along every edge surface of each roofline. 3"" ❑ Cover entire roof(s) with IKO 25 year all asphalt, non-fiberglass, premium grade shingles (Color of choice). 1'C� � CIReplace all pipe boots where possible. d-Seal all flashings with clear Geo-Cel sealant. No black tar unless previously applied. Remove all work-related debris. &(Contractor warrants.roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. U'Local current references androof of workman's p a s compensation Insurance gladly given. EfRemarks `,. -r-C-f -f sr-+'C L�? W&_6C- N v �<-' v ,�.✓i rC/f-i /?�,t, W ,L L ns�c' y/S//S Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Signature: will be made as outlined above. , �I 1 Date of Acceptance: 4 -7 f` - Signature: � � The Commonwealth of Massachusetts _= Department of Industrial Accidents - Office ellnuestigadefis 600 Washington Street, 7t'Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors sApplcarififti n , 4T'IeaseP' 1`esnbly. ': - name: address: city 0'Wt stt�ate: .��?/GJ zip.�(d'`� phone# work site location(full address): /O� 1 J/h",A-,? /?�—, ❑ I am a homeowner performing all work myself. Project Type: []New Construction❑Remodel I am a sole proprietor and have no one working in an ca acity. E]Building Addition y—r I am an employer providing workers' compensation for my employees working on this fob comuanyFname: f �?t t�' C5 #L t r3f , AM -11��- S • address go city. + phoney#. j (} t` d. msurarice co. ohc " 11 17 71# w 3 ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices 5 � � : J. A i ddresS. #„ x x Y :I ,city, 44, S unsurance co "' ollc # F yY COmAanV address. phone t P � l s i °lllSutB.`nCe.CO. pOhCY�# ' P'U(Lich-additionaltslltEet if i ecessar �'„ ` "� 4' ry Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 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 hereby certify der a pains nd penalties of perjury that the information provided above is true and correct. Signature G ~ Date Print name U ��`� 0\A� 2�� �"" �� Phone# // Ij '��?5�'�S 3/ FLco.tae only do not write in this area to be completed by city or town official : permit/license# ❑Building Department ❑Licensing Board immediate response is required ❑Selectmen's Office ❑Health Department N person: phone#; ❑Other 003) F. .y Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual,partnership,association, corporation or other legal entity, or any two or more of .the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. :rig L c' t a .fiij a„s' r-. ~.. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. 77 ' •t# �, ..� -..z3F�.t�-. .. «b a.. -=# ."E, City or Towns. Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be.sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. � �s .�'::, ,•fit-.^r, ...:.s�,:�, :" _r, w'r, ,,.. x w^ 3s9 -" ".a -. 4,7 al- The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street,7th Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S_150 A.. The debris will be disposed of in: r 14 (Location of Facility) Signa re of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector NORTH TOMM Of 6Andover 0 :. 0 No. to = _ o , lover, Mass., T O LAK 11 COCMICMEWICK V ADRATED p`P �5 . 7`s U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System � � ! � � '� BUILDING INSPECTOR THIS CERTIFIES THAT...... ................................ 40 .. . ........................................................................................................ .... Foundation has permission to erect.... ................................ buildings on ....... .. ......r.........�...`�...�.4.4........ ........ ....... Rough to be occupied as...... ......e A a ..~�O Chimney ......................... ................................................................................................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to theIns ction, Alteration and Construction of Buildings in the Town of North Andover. C9 dZA a d 00000 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough CService BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected andApproved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location `3 yo 3 No. 5105-- Date NORTH TOWN OF NORTH ANDOVER F P " Certificate of Occupancy $ sib+ ; 70 ,SSACNUStt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ca 14/0 — { Check # X010 17258 `Q -- Building Inspector CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. 5 6SCALE,1"=40' DATE 5/3/2002 Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. THE ZONING IS R-4. 50 Deer Meadow Road SEE ASSESSORS MAP 85 North Andover, Mass. PARCELS 35 AND 52. PRINCETON (UNDEVELOPED) STREET 150.00' LOTS 18-23 AND 44-49 m PLAN#195 N.E.R.D. 24,864 SF, C7 0 O y C) �¢ O^� 4 9ULKHI�AD r O a 24' 10 54'+1- EX/ST FND. EX/ST ySE PND. � kn 24' �1,Po•Ny u � `m v *14R � M cd � M 11 I 1 t t 140.47' m OSGOOD -� ST BEET I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BYLAWS OF CONFORMITY OR NON-CONFORMITY t NORTHANDOVER WHEN BUILT WHEN CONSTRUCTED. 1 LA ate r 2060 Date.!,11 �9.... ...... .. c, I Q a 0* TAO oT,1ti TOWN OF NORTH ANDOVER . g O 0 `p PERMIT FOR GAS INSTALLATION� { 49 �9SSACHUSEt O Cr% O This certifies that . . . . . . . . . . . . . .. . .. . . .o+ has permission for gas installation . . tll : . . . . . . . . . . . . . . . . . . . .Q in the buildings of Ai!: . Le.e.( .7k . . . . . . . . . . . . . . . . . . . .. . . . . i at N th Andover, Mass. Fee.: :©,.'". . Lic. No.l:3`�.3. . . . . . . . . . . GAS INSPECT WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File