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HomeMy WebLinkAboutMiscellaneous - 11 EMERSON COURT 4/30/2018 �� �' {'; ��y ��p,V � . 'J �: { i 3i� �, 4 +li Date.�d !,=!U.77..... .. Of.NORTH 1 , o? �` TOWN OF NOR+H ANDOVER ti p ( • f PERMIT FOR GA5 INSTALLATION r �• -- `� qq•10•.��Sy �9SSACHUSEt This certifies that . . . . . . . . . . . . . . . . . . . has permission for gas installation . . .Djl . 1;.4?. . . . . . . . . . . . . . . in the buildings of . .T.�. �1�. ?`?. . . . . . . . . . . . . . . . . . . . . . . . . . . at . ./l . . E �• •`a•`•'• • •� • • • • • North Andover, Mass. Fee. Lic. No.,y"d 3.�. . . . y. . . . . . . . iASINSPECTOR Check# ? ?C3 6173 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date _A�/G"7 NORTH ANDOVER,MASSACHUSETTS Building Locations f �itir XPi; tT� C/'r Permit# Amount$ Owner's Name ►l f beg / Ll 14/ New Renovation D Replacement Plans Submitted y V � CG vi C7 W O O F" z m w c c � c z y y, V U w x z F 9 o. C > d w w � � oc w x o Q w z Fd W z F F w O > W F W �� W 0 z o x o Ov a > o a F o SUB -BASEMENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR Y' 7TH . FLOOR 8TH . FLOOR (Print or type) NameChe k one: Certificate Installing Company _ /� � � 5 � I-��-'k--mak. �d— � Address - C b k,�r! Corp.12. y T Partner. Business eep one 1 7 0- to R 6 _D IC �`irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. YesNoO If you have checked yes,please indicate the type coverage by checking the appropriate box. 13- Liability insurance policy [a Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: 1 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 13 Agent 1 I hereby certify that all of the details and information I have submitted(or entered)in above application are true an best of m knowledge and that all plumbing d accurate to the � Y g p g work and installationserformed under Permit P t Issued for this application will be In compliance with all pertinent provisions of the Massachusett tate as Code and Chapter 42 of th General Laws. By: Signature of Licens Plumber Or Gas Fitter Title Plumber k�J3 City/Town 0Gas Fitter License NumDer I1. Master APPROVED(OFFICE USE ONLY) Journeyman If Date.....l.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU -C— V) This certifies that ................(................... ............................ has permission to perform ......te..f wiring in the building of..... ... . ....... ...................... at.............. 7. ......e.4.,-iiorth Andover,M.S. FeeV�......*........... Lie.No............ .............. ... ..... ............ .... Check # -ti-71 � ELECTRICAL INSPECTOR 4 1� 56 Office Use OnI14%:T, idle &MH181=8101 Of 14UH00 IJUS 6 permit No. 1epnttment of flublil: *afetg Occupancy b Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 3190 (leave blank) APPLICATION FOR PERMIT TO PERFO. M ELECTRICAL WORK All work to be performed in accordance with the Malsachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date QGw or Town of ANDOVER f To the Inspector of Wires: The udersigned applies for a permit to perform the electrical -yw�ork described below. Location (Street & Number) /f/ Owner or Tenant Owner's Address A16 , Is this permit in conjunction with St building permit: Yes 1a No ❑ (Check Appropriate Box) Purpose of Building W�� Utility Authorization No. Existing Service Amps _/ Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _1 Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and NatQre of proposed(Electrical WorkG`'X/t'/r'A No. of Lighting Outlets Total 9 9 No. of Hot Tubs No. of Ttanslormers KVA No. of Lighting Fixtures Above In 9 Swimming Pool grad. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. o1 Ranges Total No. of Detection and 9` No. o}Air Cond. tons Initiating Devices No. of Disposals No.of Heal Total Total Pumps Tons KW No. of Sounding Devices No. of Sell Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal ❑ ❑Other Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to tho requirements of Massachusetts general Laws 1 have a current Liability Insurance Policy Including Completed Operations Coverage or Its substantial equivalent. YES C NO C I have submitted valid proof of same to the Office. YES NO checking the appropriate box. C II y ve checked YES, please Indicate the type of c erage by `�� / � INSURANCE X BOND 1= OTHER G (Please Specify) / �//(Expiration Oate Estimated Value of Electrical Work S L/f-- Work to Start /"'/2-' ©Y Inspection Date Requested: �� �� Final � � tel Signed under 1 Rough Penalties of p FIRM NAME !, LIC. NO./ 7 LicenseeSignature UC.NQj!� ao / I�c Bus. Tel.No. Address r Alt. Tel. No. OWNER' INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or Its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agsnt (Please check one) Telephone No. PERMIT FEE (Signature of Owner or Agent) x-6565 d Lo cation No. t j 17e Date `�r TOWN OF NORTH ANDOVER a Certificate of Occupancy $ �'�s'•"°'t<�' Building/Frame Permit Fee $ t ncMus Foundation,P.ermit Fee $ Other Permit Fee $ TOTAL $ s 1 Check # Building Inspect&/ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVA OR DEMOLISH A ONE OR TWO FAMILY DWELLING 101 See"* BUII.DING PERMIT NUMBER: DATE ISSUED: rn SIGNATURE: / Building Commissioner/InEpedor of Buildings Date Z SECTION i-SITE INFORMATION 1.1 Property Address: 1.2 Assessm Map and Parcel Number: O Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area F 8 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard uired Provide Required Provided 'red Provided1.7 Water uppNLG.LC. s4) 13. Food Zone Ifnnua1.8 Sewerage Disposal System- Pob6c ❑ Private a Zoe Outside Mood Zane ❑ Mmcl v Oa Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIHNAUTHORIZED AGENT [' i str!Ct: Y,?; NO m 2.1 Owner of Record Uq Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: 0 Name Print Address for Service: M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES PC 3.1 Licensed Construction S",,,r. Not Applicable ❑ v 6,,) Licensed Construction upervisor: License Number _t Address /c/D ), "), c — Expiration Date Signature Telephone a a 3.2 Registered Home Improvement Contractor Not Applicable ❑ V Company Name / M l_-�- Registration Number �z Address Expiration Date z Signature— Telephone 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 unit. Si ed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work checkd• bk New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: 6Ze I � SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be 0MCL4L USK ONLY Completed by permit applicant 1. Building ^t 0 Q Qa 66, (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumb' Building Permit fee (b) 4 Mechanical HVAC 6NJ 5 Fire Protection �v 6 Total 1+2+3+4+5 O & Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ` I, `)a as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in allma lative to work authorized by this building permit application. a O Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TllvlBF.RS 1 h7 2"D 3 SPAN DM ENSIONS OF SILLS DINIENSIONS OF POSTS DUVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH ANEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH Town o 4 � . Andover No. 7za 4K 0, l A E a dover, Mass., COCMIC MEWICK yt 0 C A D 2 BOARD OF HEALTH Food/Kitchen Septic PERMIT T D Septic System Aw THIS CERTIFIES THAT is BUILDING INSPECTOR ............................................................ Foundation has permission to erect........................................ buildings on ................W......................... Rough to be occupied as Chimney provided that the person accepting this permit shall ln'every"res'perA'confor'm"to't*h*e"`terms'ofthe*application''o'n"file,in Final this office, and to the provisions 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 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION T S ELECTRICAL INSPECTOR Rough ............................................................. Service BUILDING i6fok Fin. Occupancy Permit Required to Occupy Building GAS INSPECMR Display in a Conspicuous Place on the Premises — Do Not Remove Rou hnal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE __Jj Smoke Det. ` q c. lalecf +r r ' f+ rc 'Licena C(1N T'RUC,pti1 LIi' F VI t3>t `+ DAVOGA F �. 42$F�� � c a... �x " board of Hkiliding Tte oiationa and Standards, ' ' `HCilAt'IMPIiOA Nt CONT!RACTOR r ROO strm"Oni 120199 # 1 Typr Individual. E . DAVID GULE21AF4 *# DAVID GULE21Aht e 428 PLEASANT-S' , i -NORTH ADOVER,'MAglAg, „ Ad ministrafor E f 04/27/2005 08:25 19783276517 WILLOWS FAfjL 01 DATE(MNUDDIYYY'r) • 04/27/2005 A�w/'Spl1TM CERTIFICATE OF LIABILITY INSURANCE SED AS A MATTER OF INFORMATION ATION ACV 1t V 978"975-4344 ATE ONLY AND CONFERS NO RIGHTS UPON THE EXTEND OR PROOt10ER WILLOWS(INTERNET INSURANCE:AG- HOLDER. THIS CERTIFICATE DOES NOT AMEND, 522 CNICKERING ROAD At THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER,MA 01845 NAIL#_ INSURERS AFFORDING COVERAGE _ _ _.(._. _ ._ —._. -- — — TINsuR±RA: NQRFOLK — INsuRED INSURER e: NORFOLK&DED - D.G.CONTRACTING,INC. �. — OAVID GULEZIAN I It1suRERc: AR86LLA PROTECTION&NORFOLK&0 it 428 PLEASANT STREET INSURERD: AIG INSURANCE NORTH ANDOVER,MA 01'345 INsuRERE I COVERAGESABOVE FOR THE POLICY ICY THE POLICIES OFN STERMCOR ICONDITION QF ANY CONTRACT OR OTHER DOCUMENT EVY�TK R SPECT TO WH CH THRiS COERTOIF CA ITIASTANDING WITHSTANDING TE MAY IC SSU , H ANY PEQUIREM — MAY PERTAIN, EN INSURANCE AfNBY THE pQLIC17n5 DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CpNbiTIflNS OF Su POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.EFFEG I FOLD EXpgRAndN _ — LIMIT8 _ — IN8WTA0�I'l - -- _ -- --_..�i-- pOLtCYNUM6ER ' EACH OCCURRENCE S 1,000,000 i GENERALLUI6ILITY I 07/01/2004 I 07/01/2005 C°Re°�pMR-M� A X j COMMERCJALGENERALLUIBILITY .RO401723A 5,000 _ MED EXP(Any One person) _CLAIMS MADE 1 x OCCUR — 1 000,000 PERSO_NALaADVINJU_RY 8 i. I OENERALA00_REGATE _ E — Z 000.fl00 I PR000CTS>CCMPIOPAGO 19 _INCLUDED GEN'LAI30REGATELIMITAPPLIES PER: POLICY PR + I LOC I(Es aM,B�NEDSINGLELIMIT iS 1,000,000 AUTOMOBILE LIABRITY 90151692 I 0$/1212004 f 06!12/2005 :. E3 I I ANY AVTO I I BODILY INJURY i ALLOWNEDAUTOS I I(Perparsan) E rX(SCHEDULED AUTOS I I I I g001LVINJURY I MIRED AUTO$ (Psatdtl6rtt)^ _— NON+OWNEO AUTOS I I I - - PROPERTY DAMAGE E ---.-- — (Peramident) I AUT_b ONLY+EA ACCIDENT GARAGE LIABILITY .._.._ I OTHERTHAN ��AACC IS .,_. _— I ANY AUTO AUTOONLY: AGG S — ! EACH OCCURRENCE S _ 1,OQO,000 EXCESSWMBRELLALWKITY 0001370 ( 12/1012004 6/1012005 AGGREGATE — C I X�OCCUR I CU+IMS MADE I DEDUCTIBLE 1E NTI H S STATU0 y� TH, RETENTION ETE 0 WORKERS COMPENSATION AND ?QRY,LI�zS. ER D ON-LOYBRS'LIA6IUTY WC333-27-74 03/3112004 I 03!31/2005 E.L.EACH ACCIDENT �S — 100,000 ——"' — ANY PRpPRtETORIpARTNERfEXECUTtVE; IRENEWAL 3/31/2005 31312006 I E.L.DISEASE,EA EMPLOYEE_# 1 OQiODO OFFICERIMEMSEREXCLUDED? ___.. — li yy9e�e tlRsaibe under Ek DISEASE,POLICY LIMIT 'b 5OO OOO SPEL'IAL PROVISIONS be :oTMER Dr4cRtPTIDN OF OPERATION91 LOCATIONS f VEHIDLES I EXCLUSIONS ADDED BY ENDORSEb1ENT 19PECIAL PROVISJON$ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 86 CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE 135UFNO II$URER WILL ENDFAVOR TO MAIL 1 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TME INSURER,ITS AGENTS OR REPREVENTATIV AUTMOR¢8D ENTIF RATION AA ACORD 26(2001108) CORPO 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 c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant VIVI-L 0 5 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts a d Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 . Workers'Compensation Insurance Affidavit Name Please Print Name: Q.U J \0 -C&1, Location: q," e-0 9. v- Af)e)r CV 4411e, _ Phone I am a homeowner performing all.work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Com n name: (/ �4 ` Address City' N,I �' Phone* W('((o uJ ,Q lWC X33 -�7-7 y Insurance Co. a / ---- - -_ -_ Policy# Company name: Address Citi Phone# Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or orae years'imprisonment.as.w4.as_dv.1i.Renakiasin mfmndA.STOP.WDRK.ORDER..and..a.fins d_(;100.OD)-aj*agaime. I understand that a copy of this statement rp be forwarded to the Office of Investigations of the DIA for coverage verification. t I do hereby certify under the pains naldes of penury that the information provided above is true and correct. SignatureDate '-f Print name (� P.hone# 4'�� Official use only do not write in this area to be completed by city or town official* City or Town Permit/Ucensinq Building Dept []Check if immediate response is required I] Licensing Board p Selectman's Office Contact person: Phone#: Health Department Other Location No. 7f 7 " Date ".. , ,a NORTry TOWN OF NORTH ANDOVER f 9 � Certificate of Occupancy $ Q- ,sACMUs t� Building/Frame Permit Fee $ Foundation Permit Fee $ c Other Permit Fee $ TOTAL $ tt L Check # i5� 59 '�, Building Inspector/ 1 • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING . : MIrn BUELDING PERMIT NUMBER: / DATE ISSUED; 01 A ! 3 SIGNATURE: Building Commissioner/Inspector of Buildings Date -- Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zo nin Dislrid Proposed Use Lot Area Fronlaw 8 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred Provide Rapfired Provided ReqWred Provided v 1.7 water Supply M.G.L.C.4o.§54) I.S. Flood zone Informadoa: 1.6 Sewmp Disposal system D Public ❑ Private ❑ zoic oalside Flood nose ❑ Mooicipal ❑ on site Disposal system ❑ "1 SECTION 2-PROPERTYOWNERSE"/AUTHORIZEDAGENT un3 NO M 2.1';Owner of Record UV6960 4t Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: C z M Sistnature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 L' need Construction Su icor: Not Applicable ❑ Licens Con structi Supervnsor: /Col 1 License Number ff "n Address ��� l� � �. Q ?� Expiration Date Signature Telephone r// 'i 3.2 Registered Home Improvementntractor Not Applicable ❑ Q D 1(6 Gjka-t(wil aui Company n Name Registnatioli Rumber r � Address r_ Cly ( Expiration Date Signature 17 Telephone �1I 1 SECTION 4-WORKERS COMPENSATION(KG-L C 152 f 25c(6) Workers Compensation Insurance affidavit roust 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.......0 No.......0 SECTION 5 Description of Proposed Work check at a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alteraticros(s) Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: UYo �l Codes SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building0 a) Building Q.� ( Permit Fee B l Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumb' D Building Permit fee (b) 4 Mechanical HVAC 5 Fire Protection /S 6 Total 1+2+3+4+5) J 5"/' 106000 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L 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. Si uture of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject. property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 6d Print Name Signature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 3Ku SPAN DINIENSIONS OF SILLS DINIENSIONS OF POSTS DINMNSIONS 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 NORTH Town of over - O 1 arM.x. •1.• 0 9 - A dover, Mass., l4o!7- /40-46-67— I� COCMICMEWICK V 7 RATED PPS` 5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... ................................. . ............. Foundation has permission to erect........................................ bui IMS on ...c2h. ........ ........... ......... Rough to be occupied as ....... .... ... ...0.............................. Chimney provided that the person accepting this permit shall in every respect n rm to the terms of the application on file in Final this office, and to the provisions 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 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough s )4r Service ..................................... B0LDING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. 130ARq 6E Bti{LDIOG REGULATIONS Ucetlae: CONSTRUCTION SUPE tV#SOW NumtserS _ 001821 . �*. Bftthdate,•10fQ21�I�6$ ' a Exp'tir�s: 10Ib tS^5 T!, ., �testrfcist3 �, S t[4 5 DAVID P Gt.1 .0 A 428 PLt~ASANT $T,,' N q }VEi2 MA 01�Y46 Admir�fstr2tor,' i$oard of Building Regulations and Standards r° •'i HOME IMPROVEMENT CONTRACTOR h# Registration 120199 < ; Expirafion: 'I 1/1/2006 Type: 1rldM uai DAVID G'ULEZIAM�,'• ` ' aw, DAVID GULEZIAN 428 PLEASANT ST• " .NORTH ANDOVER,M d 'Administrator x a: 04/27/2005 08:25 19783276517 WILLOWS PAGE 01 ' DATE(MMIDDRTn 04 I�SU /27/2005 DANCE nO RDTM CERTIFICI�4T� OF LiAB�L1YY RIGHTS UPON THE CERYIFIGATE 87$-975-434a THIS CERTIFICATE IS 13SUED AS A MATTER OF INFORMATION pRovuCER ONLY AND CONFERS NO R EXTEND Oa WII.IOWS/INTERNET lP1SURANCE3 AG, HOLDER. THIS CERTIFICATE DOES NOT AMEND, 522 CNICKERI E ROAD i At THE COVERAGE AFFORDED BY THE POLICIES BELOW NORTH ANDOVER,MA 01845 NAIC#M _ INSURERS AFFORDING COVERAGE - �._ NQFDEDNAMOLKAiN5UR INSURED _ __ - - - —D.G.CONTRACTING,INC.€ I INsuRERe:N{�RFOI-K&DEDHAM . _ ....._._ DAVID GULEZ{A1V INSURE ac_ARB irLEA PROTECTION&NO_RFQLK&�..II - — _ EDD: AIG lIUSURANCE _� uR — INS 428 PLEASANT STREET -_. .-- ----. NORTH ANDOVER,MA 0105 I iNSURERE: COVERAGES NDITIOW OF ANY CONTRACT OR OTHER DOCUMENT WITH TOALL,THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH THE POLICIES OF INSURANCE LISTtrD BEl�?w HAVE BEEN iRACTD R THE INSURED NAMED AH RF FOR THE POLICY PERIOD CERTIFICATE INDICATED,MAY BE ISSUED S UEDI ANY REQUIREMENT.TERM OR GOMAY PERTAIN,THE INSURANCE AFFORDE(3 BY THE POLICIEB DESCRIBED EIN I5 SUBJECT - — - - POLICIES.AGIaREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,EFFEGi�E pO�Icr ExPiRAnoN LIMITS INSUPOUGYNUMBER EACHOCCVRRENCE_., 1,000'000 TR pAtG1AGETOTREI.7TECf '-' i- 1001000 GENERAL LIABILITY 07101!2004 07/01/2005 I PREMI58S(Eeaxv-n�xl_, A X ommERGL►LGENERALLUIBILITY ROA01723A I I _- _ 5 000 MED EXP{AAy One person) 8 _._ 1 000.000 ' CLAIMS MADE I X_-OCCUR I I PERSONAl6ADVINJURY 8 f, I I OENERALAGGREGATE 2000,000 PROdUCTS>GOMPIOPAGG I s 11VCLUDED OWL AGGREGATE LIMIT APPLIES PER: — I ^POLICY ... P I LOC I.(Eq &�NEO$INGLE LIMIT i$ 1,000,000 AUTOMOBREIJA9RJTY 190151692 I 06/1212004 I 06/12/2005 ..). — - - B I ANY AUTO I I BODILY INJURY i ALLOWNEDAUTOS I J LPetDelsQ+) I _ _. ...-. S X I SOHEDULBDALrrc* ( I (ar a0*19 ) I g N -I HIREDAUTOS I I - --• — _._..I __ .-.. -- -- NO"WNEDAU?OS ;I I PROPERTY DAMAGE g I -I —•--- ---•--- — I ( (Perecclaanq iI AUT_OONLY,EAACCIDENT. ... 1- i I GXA�RI AOGCECLIABILITY gI i I OTHERTHAN E! ACC AC.G_ I SgANY AUTO AUTOONLY EACHOGCURRENCE_. s 1.._',.0O0_Q-0',000�ESAMIAILXCEBRELI.AL12/10/2004 6110/2005 AGGREGATE 1 I CLAIMS MADE 0001370 C0- -.. :77— - _ .--- -- --1 S — DEDUCTIALE RETENTION S yy��;STATU. OTHI T¢RY lIM1T$. ER WORKERS COMPENSATION AND 03/31/2004 I 03/31/2005 _— 100 000 f - D EMPLOYERS'LIABILTTY j I WC333-27-74 I E.L.EACHACCIDENT ANY PROPRIETORMARTNER/EXECUTIVE : RENEWAL 3/3112005 313112006 E.L.DISEASE,EA EMPLOYEE 5 100go pFFICERlMEMSER EXClU0F t OFFI ERNA LMBER F t E.I..DISEASE,POLICY LIMIT 'S - 500,000 SPECIAL PROVISIONS hebw OTHER i I DESCRtPTH)N OF OPERATIONS S t LOCATIONS I VEHIILES I EXCLUSIONS ADDED BY ENDORSEMENT I WECIAL PROVISIONS CERTWIG TE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Bt:CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE I95UINQ M$UREFR MILL ENDEAVOR TO MAIL 10-DAYS WRtMN i NOTICE TO THE CERTIFICATE HOLDER HAYED TO THE LEFT,BUT FAILURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATWESO AUTN0R4EO ENT ACORO Z6(20Q1/08) 'ACORD CORPORATION 1983 .� 7 I L+ 1 `�I �� . :w .. � ./ ry _ _ � E i ��I �,. ' . 1 ,r + 1 � i � j o ,� i #, E� ti � i y. � �' Y �� �� `�I � � � {s. e� i �_ � ... /; v _/ �11 -_.._ __ ��� � - 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 c11, S150A. The debris will be disposed of in: _ (Location of Facility) Signature of Permit Applicant VIV--L 0 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations w� Boston, Mass. 02111 ' Workers'Compensation Insurance Affidavit Name 'IPlease Print Name: Q ( u "o KIK Location: Wo Ci rn�� Phone 0 I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: a U 64 Address City: dv-e A2_ Phone#: W V;7 Insurance Co. < / POUGY# Company name: Address Ch: Phone# Insurance Co. Policy# Failure to secure coverage as required under Section 25A or 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_ciml..penaftlesin the form nfe.ST.OP WORK_ORDER.and..a.fine of.($100.00)atfay.against me. I understand that a copy of this statement y be forwarded to the Office of investigations of the DIA for coverage verification. I do hereby certify under the pains nalties of perjury that the information provided above is true and correct. Signature date Print name U t� Phone# �� Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensi ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone k ❑ Health Department ❑ Other