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Miscellaneous - 11 OXFORD STREET 4/30/2018
/ 11 OXFORD STREET 210/056.0-0025-0000.0 i i PROPOSAL NO. too is �! 031013 SHEET N0. Sol e , 'V DIVE PRpMMIStRi I'IMM. WORKTOBEPERFOWiiif-DAT: Ma ��l ot01 1I riGtGc 00 /brner- ADDRESS b dor ADDRESS I 0 Abrd&er, 01 DATE OF PLANS No"thoYe r M ofg�S PHONE N0. �^� �O ^ , � ( ARCHITECT We hereby propose to furnish Ore materials and perform the labor necessary for Um completion of 0,10 laeA C.x U Pre 1-2 f If u!M , AU material is wranteed to be as specified,and the above wA be performed in accordance With and specifications submitted for above work 67 completed In a substantial workmanlike manner for the sum of Dollars ($ )wri8r payments to be made as fdovv& twyarteraBo+rorde�nn tram afore apadrinLarsinwMg edracosts wMbeamaitedodlnpo writ orfte YQbem=@nwftdwW Respectl* mer end abm to estw mh Al a cpm strbs, submitted aaWerds,or delays De�nM aur amimi. Per Nota—this propose!may be wlh mvm by its B not acaipted w1h'n days. ACCEPTANCE OF PROPOSAL. The above FLM specifications,aid conditions are saiisfactay and are hereby accepted.You are authorized to do the work as specified. Payments will be made as outiinedabove. Daniel Tumer �"'� • Date June 19,2017 S�gnantre Patricia Tumer iadnrrsrDM18 s-t? PROPOSAL NO. SHEET NO. PROPOSAL.St1BFffM To. / DATE NAME WORK TO BE P�ORNIEO A1T/ �--- �. ADDRESS /I �ji f�JIC�( C ADDRESS c� )YP r WoFPLA,<s PHONE NO. a- We hereby propose to furnish the materials and perform fie labor necessary for the completlon of t � y 00 m io ' P 1�, All material is gu=nteed 10 be as specified,and fie above work to be performed in accordance wl'ih the drat^d s MWCompleted � pleted in a strttlai worlmtanmanner for manfor tie sum of � Specifications submr�ed for above work and Dollars ($ )with payments to be made as follows. �Y al�era5at«dadaLon 6acn atsove a qua costs OW°d.bm ft � ra, bxemesnmctRcr�s Respectfully acC M, Crdd3W ►McuftL `0�°Daantuponstc es, submMed Per 'O--f11iS propria!may be wiith kmm by us N nom e=pmed vrWn may, ACCEPTANCE OF PROPOSAL fie above prices,specit�tfons,end condttiorts are satisfactory and are hereby accepted.You are auiharized to do thework as specified. Payments wtR be made as outiined above. g;gr Daniel Turner DatE Siire Patricia Turner (7 ' ��arfaos natta 3.12 r The Commonwealth of Massachusetts Department of Industrial Accidents �- Office of Investigations ton Street 600 Washington- g Boston, MA 02111 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): Cl�/V�51��L[/W E�$ 'LL C Address: L,/U &WG-u UAP'T'49�5~ JZIO C I��� , �!�� IV ff City/State/Zip: lbw Phone #: 60Y-..31-666? 03074 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2;<1 am a sole proprietor or partner- listed on the attached sheet. 7. JX Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.x 9. ❑ Building addition [No workers comp.insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify up4er the pains and pen hies ofper'ury that the information provided above is true and correct. Signa re: Date: Phone#: 603-,9.31 -M209 Official use only. Do not write in this area, to be completed by city or town offieiaL 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 6.Other Contact Person: Phone#• CJ/ie�ommanweal�a,�Cac/uael�i iOfnce of Consumer Affalrs&Business Regulation Ilug HOME IMPROVEMENT CONTRACTOR TYPE:individual 03104/2019 THOMAS A.G}�1 ._ THOMAS G106: 40 Lowell Rd UnV� a_: Salem,NH 03073. Undersecretary Massachusetts Department of Public Safety i Board of Building Regulations and Standards I License: CS-077258 Construction Supervisor i .. THOMAS AGIOSEFFI ! P.O.BOX#9016 SALEM NH 03079 Expiration I Commissioner 03/13/2018 I -r PJr o=•=`��i-aF ---,MOON GENES-4 OP 10' ACORD' DATE(MWDDIYYY1� CERTIFICATE OF LIABILITY INSURANCE F06/28/2017 THIS CERTIFICATE IS 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 have ADDITIONAL INSURED provisions or 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 11eu of such endorsement(s). PRODUCER 603-890-6439 NgW,Cr James A_Santo Planright insurance-Salem PHONE 603-890-6439 FAX -8 -6521 224 Main Street Suite 2A Na .INS N01 _ _ _ 'Salem,NH 03079 D : amTeefsanfoolnsurance.com- James A Santo —' - INSURER S�AFFORDING COVEIUGE r MAIC 0 IN3URERA-Tudor Insurance Company INSURED Genesis Builders LLC,GIO INSUMB. Realty LLC,GIO MO Properties -"'-- 40 Lowell Road INSURER c.: Salem,NH 03079 INSURERD: _ INSURER E• INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 1NSR DL U8R POLICY EFP POLICY EXP _ TYPE OF INSURANCE !!SD POLICY NUMBER _ LIMITS A r X f COMMERCIAL GENERAL LIABRIIY EACH OCCURRENCE I, 1,000,000, r�CLAIMS-MADE �OCCUR NPP8361012 01/08/20111 01108/20181 DAMAGE M`cE c0(a oc= n�1 t 100,000 MED EXP(Any one oerton) i __ 5,000 _ _� PERSONAL3ADVINJURY i S 1,000,000 AGGREGATE pURMpiT APPLIES PER I I I GENERAL AGGREGATE _ ¢ 2,000,0 POLICY t �JECT C LOC PRODUCTS-COMPIOPA03G 2,000,000 ,GEM OTHER. `AUTOMOBILE LIABILITY I COMBINED SINGLE IIMFr { ANY AUTO I BODILY INJURY er on OWNED SCHEDULED (AUTOS ONLY AUTOS BROW RDILY INJUR(jPer aodde AUrO.S ONLY NAUTO , PoOaaiden _AGE _.. i! UMBRELLA LIAR F—a OCCUR EACH OCCURRENCE ¢ EXCE33 LIAR y CL VM34WE AGGREGATE ' DRETENTIONS _ r-1 ....... PER � �$ WORKERS COMPENSATION pTM, AND EMPLOYERS'LIABILITY Y/N , S7AIIlM 1 .FA ANY PROPMETOR/PARTNERIEXECUTIVE NIA A EL EACH ACCIDENT ¢ OfF CERIMEn EXCLUDED/ `J i E.L DISEASE-EA EMPLOYE S (l(Myyaee+ss,�does YalEel under - - - DESCRIPTION OF OPERATIONS below r r _ __ —_ EL DISEASE-POLICY LI_Mn I¢ - ------ ' -- -- - -1 AE 7 UPOF L.Ire®L S 1 LOCATIONS I VEHICLES(ACORD 101,Addftlonal Romano 3cheduN,nay be atlxhod If mon opm It rpuked) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover,MA 01845 AUTHORIZED REPRESENTATIVE �.-*�! ACORD 25(2016103) !/ ©1988 2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I I -179" - —— -- — 3n t 24"�- 30"�18" - - 44" - - - 2036" ` -- ---76'! — - 36" 7" cm irl 71 � t W361224 1 WPR2430R W3030 W1 013E W 13 , iN pp M � 'M^ to ILI W1r i PLG2 5-341 PLG2585-34 I HU LO M I It BRD3634 B3D1634 BSC363424 B1 D1834L3424R c+j L11 I 36 -164— 2f,"�_3$.. 18.,x.. .. 3 " 1' a Z 4-30-11'- 0;" -- --244 I I I I All dimensions-size designations DEIRDRE DESROSIERS This.s an original design and must Designed 4J28I20171 given aro subject to verification on not be released or copied unless Printed 4/28/_2_017 II i !job site and adjustment to fit job JACKSON KITCHEN applicable fee has been paid or job ,I conditions DESIGNS order placed. �I ' I -- _ TURNER-BROOKHAVEN-KTTCHEN-FINAL JEI 1 Drawing W 1 No Scale) i 148'' - - - —-- - -- --�f' „ - 24"- --49" —�j�-24"- 24" 25" 34 e„_ _ -38Z -- - I 75' ------- N �ia W361224 T -f_ I W2430 W,'430 0o T LO PLG2585-34,534 TIC248521 M I UF 84 LO B1 D243418 B1 D243418 ' M I t I ;I 254' ' -49" - - 24„ 24"---7-24'. - 4 -16"- - 132"-- - I i All dimensions size designations DEIRDRE DESROSIERS This is an original design and must Designed•4/28/2017 given are subject to verification on not be released or copied unless Printed.4/28/2017 job site and adjustment to fit job JACKSON IOTCHEN applicable fee has been paid or job conditions DESIGNS order placed. TURNER-BROOKHAVEN-KITCHEN-FINAL EI I Drawing is 11 No eScale. --- 107 3it ----- I 3 it 4 25"-- -- - -30'�--- - -25"-- ----24"- I An N W 012 r W253013 - - W253013 WPR2430R LO „ W�HOOD o Elm - IIII 1N /0/� V/ ' LO ' a^ LO - B3©253424RANGE, AS 30-l-)133424 BRD3634 M - -- - ------------------I LJ l --3 ,� 13”- -36"-- ' 2511 i 4 43.41 _ __ - - 64" ' All dimensions Rize designations DEI RDRE DESROSIERS This is an original design and must Designed 4282017 given are subject to verification on not be released or copied unless Printed:4!282017 job site and adjustment to fit job JACKSON KUCHEN applicable fee has been paid or job -- — conditions. DESIGNS order placed TURNER-BROOKHAVEN-KITCHEN-MAL Ell DratvinYl► 1 NoScsle. 179" 24"— 4" 20" 36" 76" 36' 7" 4" -607" 24- " 36" 9 2 ' 3 " 18'—�fi' " 3 s I W3030 W18301 2 1 N N a� c��l - ¢ I W�61224 _ w- A BROOKHAVEN CABINETS M 3 i Di DISH-106 B C 24 iD1 FRAMELESS ALL PLYWOOD CONSTRUCTION I - - - - DOOR:BRIDGEPORT m 5 PLG2685-34 DRAWER:5 PIECE WITH OFH N FINISH:MAPLE PAINTED JASMINE B063424R PLGF CEILING HEIGHT:90 1/2" i QSS34 a HANGIN HEIGHT:85 112"ABOVE FINISHED FLOOR w CROWN:MCR803 TOF0684 m FACIA:MTTB806 N rn LIGHT:MTV8 BASE:MSU605 c1 t7 5 6 Z Q _ 7 N 1-SILVERWARE - v a to a 2-(5)ROLL OUTS 21"DEEP CABINET in v in a ���000 - N 3-CUTLERY O Q7 A 4-KNIFE BLOCK 5-SPICE RACK RIGHT DOOR 6-DECORATIVE DOOR PANELS o II 7-BASE CABINETS 18"DEEP i 8-DOUBLE TRASH - y N ' APPLIANCES DISHWASHER:BOSCH SHP65TLSUC 1201-" ig MICROWAVE:FRIGIDAIRE FGMV1750 z }• REFRIGERATOR:FRIGIDAIRE FGHF2366P 141 RANGE:FRIGIDAIRE FGGF304DPF 30 t/8' All dimensions-size designations DEII2DRE DESROSIERS This is an original design and must Designed:4/28/2017 given are subject to verification on not be released or copied unless Printed:4/28/2017 job site and adjustment to fit job JACKSON KITCHEN applicable fee has been paid or job conditions- DESIGNS order placed. TURNER-BROOKHAVEN-KITCHEN-FINAL All Drawing#: 1 No Scale. Date. .P/o NORTM °E �.ao ,s'11'O TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION h SACMUSE' 236 �..,,_, This certifies that . . . . . . . . . . . . . . . . . . . . . . . . J r J �� has permission for gas .Oq�. .Vit. . . . . . . . . . . . . . . . . . in�he builldiings`bbV.t f. .vt '?.N.4tl. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . A.4 . af'�. . . . . . . . .. North Andover, Mass. Fee d�y0 f" . Lic. No4� .3 fC?. . MQ. . . . . . . . . . . . . . . . . . . . . V GAS INSPECTOR Check# / 3 1.2, 8305 Date. A/-' 9554 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I`SSACAUS� R+- This certifies that 6.�. . �^/�.PY7 . . . . . . has permission to perform . !.�" �14 ld..-!. . plumbing in the buildings of . . .K!` eA. . . . . . . . . . . . . . . . . . . . at . . . . �`. . �h�. e —.— .. . . . . . . . . . . . N h dover, ss. Fee?� . . . . .Lic. No. �. �?. j i� •. . PLUMBING INSPEC OR Check ., .A' y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY `Zi c9 _ ✓�- _ ! MA DATE PERMIT# JOBSITE ADDRESS P /L OWNER'S NAME �--U/L'Is e AIL- OWNER ADDRESS . TEL — FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL O EDUCATIONAL 01 RESIDENTIAL !' PRINT CLEARLY NEW: fl RENOVATION:0 REPLACEMENT:O PLANS SUBMITTED: YES NOF —f 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM ___..__) DEDICATED GRAY WATER SYSTEM -! DEDICATED WATER RECYCLE SYSTEM ______..,.I DISHWASHER ( ........._{ _._.__.! w_ DRINKING FOUNTAIN 1 -- FOOD DISPOSER r FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ! ..._.._...._( ___._... i i ....-.._...__f __I .__..__I -------.1 KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL ........... :-..___.f ....._...._.l ._.._._..... WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[�J'NO EI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b t of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be' c plia with al ertine pro ton of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME !LICENSE# �� SIGNATURE MP Ell JP 0 CORPORATION f# 3 3 Y j PARTNERSHIP i# LLC COMPANY NAME CITY L-". �DSTATE ZIP D C�7� TEL FAXL ( CEL .__ _ /�?3s. _ EMAIL --- --- ----- - - _._.._... . - - - -- ------ --- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL,INSPECTION NOTES a Yes eNo THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV. 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): �� t ��q�(�j,,L( Aq Address: AD t5 o y S--5 Y City/State/Zip:-z O . GCS�!j c1 �'�-`� Phone*: `7 P F—& 6 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with z 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.❑Other comp.insurance required.] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. / �^ A�- v nsurance Company Name: 7`0- ",�,'�c{ 'olicy#or Self-ins.Lic.#: ff Expiration Date: ob Site Address: 1( K r�A Jc City/State/Zip:_71 D , ! c✓ � GLL%� attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ,f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the DIA for insurance coverage verification. do hereby cer un r thepa and per ties of perjury that the information provided above is true and correct. i ature: Date: hone#: 7 �' Q X- Official use only. Do not write in this area,to be completed by city or town 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 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,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, §25C(6)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,MGL chapter 152,§25C(7)states"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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 021.11 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE .evised 5-26-05 Fax#617-727-7749 www,mass.gov/dia ,r 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY +�`1'`-'- MA DATE A 0C PERMIT# JOBSITE ADDRESS G, Fd21 _ OWNER'S NAME j/ GOWNER ADDRESS __j TEL , _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION: REPLACEMENT:14 PLANS SUBMITTED: YES Q NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER LQI C .. .=1 -J 1 . _ I f r I f BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER -► _� __ I - - 1 I J I DRYER FIREPLACEl- FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS f I? .. _.I MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT - _ ( -- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 _----- - -- -- --- - =--_- ;---J==_� - L-311-41--j E:711 ! __I INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 13M IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [0- OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Ei AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application ar ru d accurate to thelbest of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ompl' ce ith aMPertin t prov' i n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME /JJ v1't L° LICENSE# SIG ATURE MP El MGF- JP 0� JGF�n_-(-LP—G] _�CO_RPORATION[` 3 3 PARTNERSHIP DI# LLC . I# COMPANY NAME: 0'4. ADDRESS CITY '� (� .�- _ STATE aAZIP 4 .Fy, - TEL FAX CELT_�15. SEMAIL - -- -- -- - -_ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ f'❑ FEE: $ PERMIT# PLAN REVIEW NOTES y i� N The Commonwealth of Massachusetts Department oflndustrialAccidents 07 Office of Investigations 600 Washington Street Boston,MA 02111 IV www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n / e Please Print Le0bly Name(Business/OrganizatiorAndividual): Address: !�� /S;� X City/State/Zip:-IL U, c- Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.FJ I am a employer with 'l— 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# �• [-Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. ` n V Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:_ 1 ©5C <J/L� City/State/Zip:W lJ Gj — lGG 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 fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c rte r the pains nd pena ies perjury that the information provided ov^e iis,7(re and correct.Si afore: Date: Phone#: cl 29 ( i 11 Z-,cD Official use only. Do not write in this area,to he completed by city or town 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 6.Other - - - Contact Person: Phone#: v - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- 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,§25C(6)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,MGL chapter 152, §25C(7)states"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." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth,of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,IMA 02111 Tel,#617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax 4 617-727-7749 __WWW-mass,govfdxa if.. . . . -�.� ...... TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION h SACMUSEtt �Jhis certifies that ? . . . . . has permission for gasinstallation . - `,7"� ' *�'�'. . . . . . . . . . in the buildings of . ..�/. �- :.- �.. . . . . . . . . . . . . . . . . . . . . . . . . . . . f� at . . . .� '. . .. . . . . . . . . . . . ., North Andover, Mass. Fee: `... . . Lic. / GAS INSPE&TOR✓ Check# k,:5 P 7U ,:)0 t P MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GASnTnNG (Type or print) Date 1LIAPI NORTH ANDOVER, MASSACHUSETTS �J Building Locations I I Dk FAW I Permit# /U3v 7U2NAmount$ Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ x W a U F„ z � F a v F c�z1 O 0 O O z F W W � � U W a W G7 F z F d F C7 p > W W U a W > w z d a a > °o w `� o x W o m >G o a H o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print o;t�'Pe p Check one: Certificate Installing Company Name ❑ Corp. Address �-� �� 11 Partner. usmess lelephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter +`��U(►-t/ks �. DUG�fit/cr'r INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes F1 eamNo❑ If you have checked,yes,pldicate the type coverage by checking the appropriate box. 13Liability 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 an i stallations perf ed under Permit Issued for this application will be in compliance with all pertinent provisions of the M ac usetts State s ode112-4t— By: d Chapter 142 of the General Laws. t — B ignature of Licensed Plumber Or Gas Fitter yl 11 -7, Title ❑ Plumber City/TownR Gas Fitter kens" um er Master APPROVED(OFFICE USE ONLY) ❑ Journeyman ! The Commonwealth of Massachusetts Department ofIndustrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): OU l/(r/[—' J7(JG9'r7_jJ/C- Address: OSS P fL City/State/Zip: 1_v PY2o A)Ptm f f Phone#: 605 S 6 �(7/f - Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.[ I am a sole proprietor or partner- listed on the attached sheet. 1 ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. g. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.[:] Other t".,:y r:Ypli ant that checks box 9;r..tra`also Ell out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job 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 fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to $250..00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ert' under the pa' nd penalfies of perjury that the information provided ab v�&Irue and correct Si ature: �._� Date: Phone#: Official use only. Do not write in this area,to be completed by city or town 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 6. Other Contact Person: Phone#: Information and Instructions `. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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, §25C(6)also states that"every state or Iocal 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, MGL chapter 152, §25C(7)states"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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 bei_*:g 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc..) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us�a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Fax # 617-727-7749 Revised 5-26-Q5 ,A-A,w.mass.erov/dia Date.....9:r-v..(J..4..... 40RT11 "° TOWN OF NORTH ANDOVER A PERMIT FOR WIRING SS C"usEt T/ This certifies that _A......`cT.�.r..�............................................................. has permission to perform ..................... wiring in the building of .................................................... at ................... .North Andover,Mass. r Fee lk-1S'............ Lic.N8,..7mu ..................... ELECCRIC%L INSPyBC'TOR Check # e 6961 N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /17 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked '�� [Rev. 11/991 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: 9-28-2006 City or Town of: North Andover 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) 11 Oxford St. Owner or Tenant Pat& Leo Turner Telephone No. 682-7194 Owner's Address same Is this permit in conjunction with a building permit? Yes X No ❑ Servo # Purpose of Building nes bath 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: wire bath Completion o the following table may be waived by the Inspector of Wires. of No.of Recessed Fixtures No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- 1:1o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection `~ No.of Dryers KW Heating Appliances Security Systems: Q' No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 X BOND ❑ OTHER ❑ (Specify:) On File Feb/2007 i+ (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) r y Work to Start: 9-28-2006 Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Kelly M.Casey Signature LIC.NO.: 37200 (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 978-697-4453 Address: 700 Robbins Ave Unit 3 Dracut Mass 01826 Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the leability 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: $35.00 �,. Date.................................. Of Ha°TM,$ 32 .t`:�`` -.•_�.°oma TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACNUSE� This certifies that ^ ................................... ........... .................................... has permission to perform ✓ T'� ....................................... wiring in the building of.................�v.......... ....................................... at........5.. ...................... o .. ,North Andover,Mass. Fee.. ..... Lic.No. ..t Z � M� i= b" . .................... - ....................... ` . ELECTRICAL INSPECTOR Check # • — 7952 Commonwealth of Massachusetts Officiia172- Official Use Only Department of Fire Services Permit No. / BOARD OF FIRE PREVENTION REGULATIONS Rev 1//07cy and Fee Checked � ] 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 W INK OR TYPE ALL INFORMATION) Date: (! P,I b a City or Town of: NORTH ANDOVER 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) I 1 b Y. Fc r p fi- Owner or Tenant Po,+ T. r N I-, +^ Telephone No. Owner's Address % % O&F e r 1) S T, Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building (3144-K 12 yrs ov►4 t �,.. Utility Authorization No. Existing Service I o o Amps 1 Z o / agc-Volts Overhead 0 Undgrd❑ No.of Meters i New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 Sfi F(oo r ! Completion o the ollowin table maybe waived b the Inspector of Wires. 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 Z Swimming Pool Above ❑ In- ❑ o,of Emergency Lighting rnd. rnd. Batteg Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.ofZones No.of Switches , No.of Gas Burners No.of Detection and Toi- Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "' ' Detection/Alertina Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: r Heaters g: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent 4 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: % I S I o$ 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 ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties o perjury, that the information on this application is true and complete. FIRM NAME: ►L e r e` .c S-e r 1 c-L LIC.NO.: 1 7,3 a Licensee: L*i r y R c..e Signature �a LIC.NO.: 12 3 t'Ll ✓L (Ifapplicable, enter" empt"in the license number h e.) Bus.Tel.No.: 403 9 Z�m' n'�1 Address: (mob e51< l Z q►v, o v I=A- S N t} 6 3 9 1414 Alt.Tel.No.: 1-63-'R 19• la 647 *Per M.G.L c. 147,s.57-61,security work 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:$ -Sr� a The Commonwealth of Massachusetts >^i ! Department of Industrial Accidents Office of Investigations 600 Washington Street tis; i Boston, MA 02111 c; www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): L..t4wM trees 2it..#— ID r3-1A G. 1��y 1, Address: Qb t3ox t Z 0 City/State/Zip: -1>4�P��" g ( (S N N Phone#: . Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.x 7• E] Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me.in any capacity, workers' comp. insurance. 9, Q Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10 Q Electrical repairs or additions required.] officers have exercised their i. 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 1317 Other Any applicaritthat checks bo) #I must also fill out the section below showing their workers'compensation policy informatiom t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 4 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert" nder the pains an emit' of perjury that lite information provided above is true and correct Signature: "�-�' Date: 6 Phone#: (0 — Of j`icial use only. Do not write in this area to be completed by city or town 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 6.Other Contact Person: Phone#: b Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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,§25C(6)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, MGL chapter 152,§25C(7)states"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." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their Self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in {city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. j The Office of lnvestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date. Av . RT:�� TOWN OF NORTH ANDOVER PERMIT F R PLUMBING 41 ACHUS� r_ �} This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .'. . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . T U{Q NJ �� . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . .. . .. f'. . .. . . . . . . 5 . . . . .R. . North Andover;Mass. J Fee No.. .F0 .(. ?I*NN . . .PLUMINS ECTOR Check � /L/07 -2 7623 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS I f l Building Location r0�?. Owners Name Date '�(/12✓V�-/L— Permit# �G L 3 Amount Zr Type of Occupancy � ic�.� �),c�• New Renovation Replacement 13— Plans Submitted Yes No E] FIXTURES w Cr En w o aLnx ;T� w SLB-BSNE >aASEVErr >sT Hbm s -IM ILOCR 41H lIDM SII3 ROM 6M FIIOQt 7M R OCR M ROCK --f-H (Print or type) r Check one: Certificate Installing Company Name `1 I S'l /Q Gyi��� ❑ Corp. Address S SC rd fZ- � ❑ Partner. usmess Telephone 7 /�p Q 1 w Firm/Co, Name of Licensed Plumber: , 1 j '< "� ", Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ri 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 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 under Pe •t Issued f r this application will be in compliance with all pertinent provisions of the Massa s is tate lumbi Code Chapte 2 of the General Laws. i By: igna ure o icense u er Title Type of Plumbing License City/Town LicerisuNumoer Master Journeyman ❑ APPROVED(OFFICE USE ONLY 14 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,:MASSACHUSETTS � Date L� l Building Location /r/ 'i� Owners Name j evv -Z— Permit# Amount Type of Occupancy New Renovation rl ReplacementPlans Submittedes ❑ No ❑ FIXTURES F > H > r Z Cf a. > st�as�i>c >aaSnvEvr ISr FIDM M MOOR f ,c 3MMOM 41H R>M 5M HffR 61H)FLOOR 71H MOOR 9M)FLOCK (Print or type) Check one: Installing Company Name /� -!/Ltr6 Certificate _ Corp. Address G ❑ Partner. Business Telephone 13—Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate'the 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 ignattire Owner ❑ Agent hereby certify that:ill of the details and information 1 have submitted((-,r entered) in above app 'cation are true and accurate to the )est of my knowledge and that all plumbing work and ins llation,' )erfornied un er Permit Iss �d Lor this• lication will he in _ompli:urce v,ith all pertinent pmvi;ion;ofthe vTri,s etts S e ' rnbing C. de and Ch er 142 e General Laws. By: I a IX(it LICCIISCLIuni Title , Type Of Plumbing License City Town ice urn �r�� Master � Ioum� man kPP ROVED(OFFACE USE ONLY LJ Location X =�• No. Date • , N°"r" TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ J�CMUS Other Permit Fee $ /� • o c2 Sewer Connection Fee $ Water Connection Fee $ TOTAL44 ® J Yr Building Inspector" 1 Ott v Div. Public Works PE&at> vo. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE i MAP K40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK '.PAGE 4 - ZONE SUB DIV. LOT NO. LOCAT OvF n � PURPOSE OF BUILDING OWN NAME �_^�� NO. OF STORIES SIZE OW R'S ADDRESS 1 I p n�y{� BASEMENT OR SLAB ARCHITECT'S NAME ` ��tt r��l'^V SIZE OF FLOOR TIMBERS IST BUILDER'S NAME T�,mag G�/C, nr,�.� -SPAN DISTANCE TO NEAREST BUILDING t,2_0/ice/ DIMENSIONS OF SILLS DISTANCE FROM STREET �V POSTS DISTANCE FROM LOT LINES-SIDES �-- REARL `'7 . ' GIRDERS AREA OF LOT FRONTAGE -r ��_ HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW !"t� o SIZE OF FOOTING �^ f 'i- IS BUILDING ADDITION * MATERIAL OF CHIMNEY 7(~+IS BUILDING ALTERATION\�v�S ` �-_, (�a IS BUILDING ON SOLID OR FILLED LAND 'r WILL BUILDING CONFORM TO REQUIREMENTS OF CODE y IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION ,J LAND COST SEE BOTH SIDES '+ U P -6q-- -1A Z-?(('�"1 EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 . EST. BLDG. COST PER SQ. FT. C EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS i - 12 CC)N(K. 1L. V�J SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 9-13 - BOARD OF HEALTH SIGNA WNER OR HORIZED ENT FEE zoGF� -�- PLANNING BOARD PERMIT GRANT 19 BOARD OF SELECTMEN OU1LD1 NBP OR BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILYs�ORIEs THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS, WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH Neu.) go CONCRETE 2 I ¢!�e� G1:� IQ� ✓\ „s CONCRETE BL'K. —I PINE Nosc- ^.� l} ,J BRICK OR STONEARD.D _ �•`�" ��` ` `N+}`,. 1.�5 � ( 1�t d' s.oTt r PIERS PLASTER JJJ��� DRY WALL VV-.1/�.�� , �'V S �Gs 1�Ci� Q VBG. G7�{SZU•\5(�O(/� UNFIN. J` 3 BASEMENT AREA FULL I FIN. B'M'T' AREA _ y, 1/1 3/1 FIN. ATTIC AREA _ NO B MT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS OORS CLAPBOARDS N B 1 —2 3 DROP SIDING CONC —I_ WOOD SHINGLES EftkTH ASPHALT SIDIN —D _ ASBESTOS SID G C N VERT. SIDI S H.TILE _ STUCCO ON SO Y STUCC R DAME BRICK N SONRY ATTIC R & FLOOR I_ BRICK O R E _ CONC. 0 "S_%, "DEt STONE ON ASO WIRING STONE ON E ��� SUPERIOR POOR _ AD TE NONE 5 ROOF 10 '%4ILbfABING GABLE 3 FIX. GAMBREL MA ARD T LET RM. )2 FIX.) _ FLAT WATER CLOSET _ ASPHALT SHIN ES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING I MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING To: Building Inspector Town/City of Iy6 From: As owner of the residence at I hereby authorize the town building officials to issue a building permit to: Thomas D. Zahoruiko 24 Woodland Park Drive Haverhill, MA (Mass. Construction Supervisor License #055417) for specific work to be completed at the aforementionad residence. ZI homeowners Signa ure DEPARTMENT OF PUBLIC SAFETY COMMONWEALTH 1010 COMMONWEALTH AVE. OF BOSTON,MASS.022151 MASSACHUSETTS LICENSE EXPIRATION DATE CONSTR. SUPERVISOR 01 /31 /1994 6 EFFECTIVE DATE LIC-NO. 6 RESTRICTIONS , NONE 02/01 /1991 055417 mTHOMAS D ZANORUIKO 24 WOODLAND PARK CR SS h U32-46-0456 HAVERHILL MA C183C PHOTO(BLASTING OPR ONLY) FEE: 0. 00 HEIGHT: NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY STAMPED -OR-SIGNATURE OF THE COMMISSIONER DOB: 04/05/1960 ��' llC THIS DOCUMENT MUST BE IGI�ATUV OF LICENSEE CARRIED ON THE PERSON OF THE HOLDER WHEN ENGAG- OTHERS -RIGHT THUMB PRINT ED IN THIS OCCUPATION. OMMISSIONER j 20OM-2-87-81429 I I w _r_FINA1. PLANNING FINAL "9 ';C_, N WERMATERNORT1y o � ® 6 ndover VIA No. 387 AIV5 �A -K er, Mass 9? / C N HEWICK SS BOARD OF HEALTH THIS CERTIFIES THAT . . ..... ........ R T 0 .. ....... ... ....................................... BUILDING INSPECTOR haspermission to erect ........................ 'lding ..�.... .............. Rough Chimney tobe occupied as... ... .... ...... .............................................. Final provided that the per on acce ti is permit shall in every r pe conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit PERMIT EXPIRES I MO HS ELECTRICAL INSPECTOR UNLESS CONS UCTIO T RTS Rough service Final ..... .. ... . ... . .. . .. ... ... ....... B I PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buil ing Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. et. Building Inspector 4. 1 PER-lift NO. 0 / 0 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE i MAP NO. LOT NO. 12 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE I SUB DIV. LOT NO. LI LOCATION PU RPOSE ARG 5-7,\J� OWNER'S NAME1 Cn �,`7L�Y �J NO. OF STORIES SIZE -OWNER'S ADDRESS t! C��T�1,\� ��t�\L` BASEMENT OR SLAB ARCHITECT'S NAME V SIZE OF FLOOR TIMBERS IST 2ND 3RD -BUILDER'S NAME ��� �/ o 14C SPAN DISTANCE TO NEAREST BUILDING 1 DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS !! DISTANCE FROM LOT LINES-SIDES REAR GIRDERS 1V ;\ AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS � 1 -,\t IS BUILDING NEW SIZE OF FOOTING X •� ` IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER -ARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 ST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 1/DATE FILED BOARD OF HEALTH SIG RE OF WNER AU RIZ AGENT FEE 70 (� PLANNING BOARD PERMIT GRANTED 19 BOARD OF SELECTMEN BUILDING 81SPE O BUILDING RECORD I OCCUPANCY 12 SINGLE FAMILY S-ORIEs THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ B 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ y, 1/1 1/1 FIN. ATTIC AREA _ N_O BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD11✓'D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF IT 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS L OI B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING P WOOD STOVE INSTALLATION CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove .-_ A. New �><= Used 4 B. Type/radiant Circulating C. Manufacturer T")f �R Lab.No. Name/Model No. 4 E(RL-bOl A .306 N Collar size Dimensions/Height id1@4011110W ZS HIWI Length Width f Chimney A. New ' Existing B. Size(flue area) X(Z- C. Other appliances attached to flue(Number and flue size) D. Prefab(Manufacturer—name and type) E. Masonry/Lined Flue liner (type b manufacturer) Unlined F. Height(refer to diagrams) -----;—cap. OVER,lo` 4"r- t IZ 12n MIN. 2, Mlty IT Ig IS o' o' 3 Ml N. 12't ,MIN. 5f � a 18 it MIN. HEARTH L J CHIMNEY HEIGHT Hearth(non-co le) A. Materials /—V-1 B. Sub-floor construction- SIV( zT' C. Minimum dimensions(refer to diagram) Clearances and Wall Protection(see stove installation c)e rances chart) A. Type of wall protection provided B. Clearances(refer to diagrams) -7 j FIREPLACE CORNER WALL/CENTER 13 cap factory-built chimney C roof support c support bracket B connector pipe non-combustible wall protection A _ connector overlap A i/ woodburning 1" / stove q �non-combustible 12 floor protection y 11/2 18" 12". Figure 2109.4 Figure 2109.4 STOVE INSTALLATION CLEARANCES Combustible 1/2"Asbestos Millboar Concrete,Masonry Spaced Out 1 " Stove Components Material Spaced Out 1 't21 Foundation Wall 4" Brick Veneer Radiant Stove(l. 36" — - -Front Circulating Stove6i.) 24" - — - -Front A. Radiant Stove 3. —Sidei BackiTop 36" 18" 6" t8" A. Circulating Stove 12" 6" 6" 6" —Side.,Back/Too B. Single Wall �/�. 18" 12" 6" 8" Connector Pipe B. Insulated 2" 2„ 2„ 2„ Connector Pipe C. Chimney Height Three(3)feet above adjacent roof and (Metal or Masonry) two(2)feet above any roof ridge within 10 feet.. 0. Damper If a damper is not included in the stove construction. it must_be installed.in the connector pipe. 1. Front:Fuel or ash access side. 2. Non-combustible spacers required. '3. Clearances on each side of a radiant stove with a heat shield shall be measured as if a circulating type. Note:Clearances shall be measured perpendicular to stove body. Laboratory verified test clearances permitted. 4. Thimble required for passage through combustible construction. 12