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Miscellaneous - 111 PEMBROOK ROAD 4/30/2018 (2)
BUILDING FILE Date.... .'..2 .12— F O, vtORTH,� a? ,•t�`'� �o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHUsf . This certifies that has permission to perform ........ ..................................................... wiring in the building of.........L....l,.:.:/, . ......L- :. ................................ ... �,vt�i�c39 . .... ,North Andover,Mass. .�. r Fee.. ..Z.0..."'"�Lic.No........C�,d �1 ...... . .. . . . ...... ... ....... ....... / ELECTRICAL INSP dOR Check ;t 10791 -Commonwealth of MassachusettsFI/07] Official Use Only Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ' nd Fee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ( All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 'V (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City , 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) ;(�,� Owner or Tenant`�L �, ( �� Telephone No. Owner's AdI cS dress { C-,4n 't � zo, tpk 144A Is this permit in conjunction with a building permit? yes ❑ No ` ❑ (Check Appropriate Box)) Purpose of Building 2S 1 t �� ,C _ Utility Authorization No. 31 �9 1 Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service, ZOO Amps /,�o, / ayo Volts Overhead ER111,_ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the ollowing table may be waived by the Inspector of Wires. a 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 (, jj Swimming Pool Above ❑ In- o. mergency ig ting rnd. rnd. ElBatteo Ky Units No.of Receptacle Outlets 7. No.of Oil Burners FIRE ALARMS No.of Zones s No.of Switches S No.of Gas Burners 1 No.of Detection and Intiatin Devices No.of Ranges No.of Air Co d. TotaTons l No.of Alerting Devices No.of Waste Disposers ,!1 Heat Pump Number. Tons KW No.of Self-Contained Totals: Detection/Alertm Devices IIN No.of Dishwashers ` Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers r Heating Appliances KW Security Systems: No.of WaterNoof No.of Devices or Equivalent . • ' Heaters Bal Si ns . Ballasas ts Data Wiring: No.of Devices or E uivalent .1 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Estimated Value of Electrical Work: A41:2010- Attach additional detail if desired,or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: 1 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 c,o�v,ers is in force,and has exhibited proof of same to the permit issuing office. PINE:NE: INSURANCE [9` BOND ❑ OTHER ❑ (Specify:) I certjo,'irnder 7the ains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: �,, Licensee: LIC.NO.: � Signature LIC.NO.: (If applicable enter "exempt"in the license number line) Address: Bus.Tel.No.: — y Alt.Tel.No.: d-3 -(�� *Per M.G.L c. 147,s.57-61,secikitywork 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 ance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) Owner/Agent ❑owner El owner's agent. Signature Telephone No. [PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL tfbmvectorsl CTI ON: Failed—ailed—comments: [ j ` Re-i�n..s. pection requirecT($50.00)-[ ------------------ pectors' j a Signature-no initials) k s Date 2.FINAL lNS TION; Passed—[ Failed—[ .] Inspectors comments: q ($50.00)Re-inspection required - ---------------- (Inspectors'Signature-no initials) c.v 5 ate.--t,, Date — y/Z 3•UNDERGROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-.no initials) Date 4.INSPECTION—SERVICE: - DATE CALLED NATIONAL GRID: NAME: Passed—[ Re-inspection required($50.00) Inspectors'comments: -------------- -z �2 (Inspectors'Signature-no initials) Date .• 5.INSPECTION-OTHER: Passed—j ] Failed—( 'j Re-inspection required($50.00) Inspectors' comments: . , (Inspectors'Signature--no initials) Date D OOR TAGS ARE TO BEFYL,LED OUT.AND LEFT ON SITE II+'TEEE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE.-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address:. P&Lcs B City/State/Zip:_���g i A" QJ Phone #:-- q7 -3 7s'-t>" Are yo n 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. Eg 1''°w construction 2.❑ I am a sole proprietor or partner- listed on the attached shget.1 7. ❑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.❑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. I 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 the policy and job site information. Insurance Company Name: R A,y QQ� t✓&)', Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: l L f e"'t City/State/Zip: ,�_ . -4 t 4lLe S 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 cert'y under the pains and penalties ofperjury that the information provided above is true and correct. Si nature: Date: Phone#: 7S -O Y(o Official use only. Do not write in this area,to be completed by city or town official. City or Town: Per # 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 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-OS Fax#617-727-7749 www.mass.gov/dia 9393 Date. . . "oRTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSES This certifies that . . f. . . . _ ��� !/. . has permission to perform ,r. . . . .. ,�. . . . . . . . . . plumbing in the uildings/of . . .!� ail� lC at. . ��� P!'' '�. . A. . . . . . . . , N rth ?ndovei, Mass. j - 1 Fee. Lic. No. /S,lS�. �� ` . . . . '. . . . . . . PLUMBING INSPECTOR Check # Zr �j zo, l a MASSACNUSETI S UNIFORM APPLICATION FOR A PERMIT"TO PERIFORM PLUMBING WORK f CITY MA DATE ��5 PERMIT It JOBSITEADDRESS Pe"6 rcic j OWNER`S NAME) OWNERADDRESS IIS (44 ��'�`C: I"� TELT IFAXI I TYPE-OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL } RESIDENTIAL PRINT CLEARLY NEVV..I V RENOVAT19N ( ( R I-ACEMENT:( ( PLANS SUBMITTED: YES 1 ( NOI I FIXTURE9-1 FLOOR-' ' esM t 2 3 4 . 5 6 7 a s 110- 11t2 13 14 BATHTUB_ _I ... . -t 1` _ -----I GROSS CONNECTION DEVICE •' ..'; —' DEDICATED SPECIAL WASTE'SY$TEb1 _ _ :a.. __ .; ...._; ,_. , . .__.. .._. :1 • -- DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM j DEDICATED WATER RECYCLE SYSTEM DISHWASHER i :i4 DRINKING FOUNTAIN FOOD DISPOSER i 1. I i I ! j FLOORIAREADRAiN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY IED ROOF DRAIN SHOWER STALL - •$ERVIOEIMOP SINK TOILET URINAL - WASRING MACHINE CONNECTION WATER.HEATER ALL TYPES, WATER PIPING _ .OTHER L . . —�-- ...... .. _ _. _ ... 1 a: -- INSURANCE COVERAGE: — - — have a ctirrent.liabilit tiis>lrallce policy.br its sulistantfal equivalent which meets the fequirenients of MGL h.142. YES(r,�NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY C14ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IV( OTHER TYPE OF INDEMNITY I 1 BOND I• I OWNER'S INSURANCE;WAIVER-f am aware that the licensee..rloes not have ihe•i[tsurance coverage required by CfiaptetI42 of the Massachusetts General Laws,and that ltfy sir�nature on this pentiit application vaaives this recfuiteittent. CHECK-ONEONLY: OWNER I I AGENT-1 -1 - SIONATURE OF OWNER OR AGENT I Hereby certify lliat all of[he details and irifonnation I liavesubditted of enlered regardingahis appiicalion are true and accurate to the best of my knowledge and that all plumbing Mork and tns[ailations performed under the permit issued for this application toil[be in compliance e'h all Pe ' rovision of the Massachusetts Stale-Plumbing Code and Chapter 142 of the General Lags. PLUMBER'S NAME M(C k4f- �� LICENSE It t/S/Sr I ' SIGNATURE MPI- JPI ( ,'CORPORATION] -Iltl IPARTNERSRIPI' (Ifs LLC 1' 110) COMPANY NAME I iYK V kdtt, �q"n 1 ADDRESS I CITY ] (STATE I K) ZIP 1 D !EL 1 6 6 3 d � '��� / I FAX t CELL I�'7b qd . J EMAIL t i i 1H J[LU1VS.W. G u4V ux' ' TIO 1 OTE,1'9 J�J LCM t Qr,:o4 , 'M Ugr':ONLSL ���Ll�S1cx:�Ca2ON N�u'TrIs y6s No ThIPS APPLICATl0NSERI ES AS THE PERlVIB3 FEE::$ PEMOT PLAT-,RX,VM4 W..No=s ! - J Date.. . ./ . .. .... . Hp RTN 3� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION s oe ,' • ` - �,SS�IC MUSEt t This certifies that . . //_j< . . . . . . . . has permission for gas installation . 1✓ 1/'�?' ? . .t" in the buildings of �°�`!'� `!?� . . .zz. . . . . . . . . . . . . rn / at . . ��� / . . . .l�. . . . . . . . . , North Andover, ass. Fee. Lic. No.1. . . . .?. . ` GASINSPECTO• Check# 2 7 8,1130 /00-00 v p,0. r 1, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: r ('l�/q� MA. Date:-- Permit# Building Location: !�/ J-� Owners Name: Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional❑ Residential New: []Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES - - - - - - - - - - - W Q to U) U Z O F- m 2 0O (Wu W U co H O = co W O Z g a 0 W W = Lu IR O F— FFO-- W 0 W m 0 F- Wa. O a x W F- to U W W ~ _ (n 0O FW- 0 = u. > V W Z O J H h O Z J U' LL co = Z W W Z IY v7 J Q Q m w O z O F- > Z I- _ O 5 >r Q W W a > O O W Z Z W Q F- U 0 O u_ 0 0 = = J O a WI.—M > > O SUB BSMT. BASEMENT 151 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: Check One Only Certificate# _ � � �,��t�t ¢y ❑Corporation Address: oZU k&.n1A4I ✓ City/Town: State: ❑ LU -8f Partnership Business Tel:_ LU —8('_ -13211 Fax: / ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 9"No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent El By checking this box❑,-I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑Plumber Title ❑was Fitter Sig ature of Licensed Plumber/Gas Fitter V Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorsAElectricians/Plumbers A licant Information Please Print Legib Name(Business/Organization/Individual): Address: City/State/Zip: /Ze � 1w e?d'7,C Phone#: (Do ,? _ V3 /_5N1 ' 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 ❑ �• E]Remodeling 2.C] I am a sole proprietor or partner- listed on the attached sheet. 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.E1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1111 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' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy anXjob 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 requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert under the pains andpenaldes ofperjury that the information provided above is true an correct. - Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License ff 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#: t Information and Instruction 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"ever state or local P �§ O y 1 1 hcensing agency a shall withhold the issuance or y 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 maybe 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 Gommonmalth of Massarhv..sPtts Department ofIndustdal A,ccideots Office of11westigations 600 Wasbia&a Street Boston}IIIA.02111 Tel,#617-727-4900 eat 406 or 1-877;MASSAFB Revised 5-26-05 Fax##617727-7749 wWW.Mass.gov/dia Date....... ,— f�_ !Z p�MC oTH �,- TOWN OF NORTH ANDOVER p PERMIT FOR WIRING '••,,.o �,SSACMUSE� } This certifies that ............... ...../L /d9c...... %.......................... has permission to perform ..... .........................../1t ..............:..................... R wiring in the wilding of --{�^ ............................................................ North Andover Mass. Fee. S Lic.No.. s�'1 � �'1 ..S.�h........... ................ f" G ELECTRICAL I1SPE ,R Check , t( 7 / v "� 1 0654 � J i \ - - Commonwealth of Massachusetts Official Use only Permit No. Department of Fire Services �— BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),P27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2, - t I City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to Rerfarm the electrical work described below. Location(Street&Number) Owner or Tenant (_ t7, ( _ Telephone No. ]— fc,3S' Owner's Address Is this permit in conjun ion with a building permit? Yes ❑—No ❑ (Check Appropriate Box) ' Purpose of Building 5 P g t �E•v(fit -- Utility Authorization No. L L Existing Service Amps / Volts Overhead ❑ Und rd �— � g ❑ No.of Meters ' New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the ollowin table may be waived by 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 Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. E] Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of No.of Detection and Switches No.of Gas Burners Initiating Devices i� No.of Ranges No.of Air Cond. TotaTonal No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals: ..........................I•"".•"'••'..... ' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters ' Data Wiring: Si ns 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. Estimated Value o Electrical Work: &7t'2 d (When required by municipal policy.) Work to Start: 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 cover is in force,and has exhibited proof of•same to the permit issuing office. CHECK ONE: INSURANCE [y BOND ❑ OTHER ❑ (Specify:) - I certify,under the ains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: "4 Licensee: - Al ignature LIC.NO. 2 7� (If applicable ente "exempt"' the license ber line. °� Bus. 1. No.• 3 Z.-2_o l Address: -`� 0 - 4 5�►1C� K c f�.t i ts.S j st i/ Alt.TeI.No.: �6 *Per M.G.L c. 147,s.57-61,securit 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 a ent. Owner/Agent Signature . Telephone No. PERMIT FEE. S � ELECTRICAL PEST NO. INSPECTxONR +PORT.' - _ ELECTMAL INSPECTOR- Passed—[ Failed--[ ] Re-Snspectzon regozxecT($50.00) [ ] ` Inspectors'commeits: C 1 •.•1 w S. (Inspectors'Signature-no fufttials) Date Z.SINAL INSPECTION; - Passed-[ ] Failed—[ ) � Re-nspection required($50.00)--[ � Inspectors'comments: (Inspectors'Signature-•no initials) Jute 3.UNDER GROUND INSPECITIOW: Passed—[ ] Sailed—I ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-•no initials) Date 4.INSPECTION—SERVICE:DN.—kr',COY nD NATIONAL G t t� ; NAM:. Passed— Failed—[ ] Re-inspection required($4.00)-[ ] Inspectors' omm.enls: I Ion^L (Inspectors'Signature-ito itials) Date S.INSPECTION-OTHER:" Passed—[ ] Failed—[ ]_ Re-inspection required($50.00)•-[ ] Inspectors'coxhMents: Okspectors'Signature-no Wtials) Date DOOR TAGS AM TO BE FILLED OUT AND LEFT ON SITE IF THE AREA.TO BE INSPECTED IS NOT ACCESSIBLE AND A RE INSPECTION OF X50.00 IS TO BE CHARGED. S J -CA The Commonwealth of MassachusettsIn D7 Department-of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �t nti rJ Address:--a- VA-5 6 o, •�, ,�� City/State/Zip: zj)tJ 6�cy��-Phone#: 7 ?j 7 S-p Sf(& -L-- Are>eu an employer?Check the appropriate box: Type of project(required): 1. I am a employer with P 4. ❑ I am a general contractor and 1 6. ❑Zod onstruction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t eling 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 1011 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 *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 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:_ 14 IA-A)-"tom, LAA, Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: V� PeA46L4,0City/State/Zip: J,)0, ,q' b 1 �r e 5 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 hereb cert'y under the pains and penalties ofperjury that the information provided above is true and correct. Signature: ,_J Date: Z- (a l -L-,_ Phone#: 3?S-c>cr(D 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#: n- 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 ,t 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 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#61.7-727-7749 www.mass.gov/dia I 6 Date jY"l6---�.��.. .. H°RTM TOWN OF NORTH ANDOVER pF4„to ,e,h0 ° p PERMIT FOR MECHANICAL INSTALLATION s a y �9SSACHUSEtA ' This certifies that . . ? . . . . . . . . . . . . . . . . . has permission for mechanical installation . . . . in the buildings of-' , ���., .,ft? . ! f.t.. . . ^ . . . . . . . . . . at .,���.��P'��?. ' P.y r"" . . . . . . ., North Andover, Mass. Fee. ” Lic. No.. . . . . . . . . . . . . . . . . . . .�,, : . . v GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of'Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: $ Y AW Permit Fee: $ ` _ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 196 Applicant License# 161 Business Information: Property Owner/Job Location Information: Name: J&J Heating. & Air Conditioning Name:Tura Leigh Development LLC Street: 17 Arlington St.<. Street: I fiery, broo S T City/Town: Dracut, MA 01826 City/Town: North Andover, MA 01845 Telephone: .97.8-454-8197 Telephone: 978-687-2635 Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 /M-1-unrestricted license J-2 /M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential-f'T--2-fd1ftil7y `MWti-family Condo/Tbwnhouses- Other Commercial: ' Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. ✓` over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: ✓ Renovation: HVAC ✓ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: to 14 04 e,7a / d4,ecu o r Gr �,F®� y u,¢c s y r Te„-., d-u FrE COVERAGE: ent liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes R�No❑ hecked Yes,indicate the type of coverage by checking the appropriate box below: surance policy Other type of indemnity ❑ BondSURANCE WAIVER: I am aware that the licensee doesnot have the insurance coverage required by Chapter 112 of the assactts General Laws,and that my ilignature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By. ❑Master Title ❑ Master-Restricted Cityrrown ❑Journeyperson SIa ure of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval COMMONWEALTH OF.MASSA CHUSETTS A A. BUSINESS ISSUES THE ABOVE LICENSE YO ' ED:4iARI1 -T ,A,YOTTE. J J W,EATING "=A`: Ct C>OONIN 17; ARLINGTON STREET{ �:. bRACUI MA f0°1826 I315. i r LICENSENO. EXPIRATION DATE SERIAL�O. 1:96: 0119/14 49:5273 The Commonwealth of Massachusetts Department of Industrial.Accidents. Office of Investigations 1 Congress Street,Suite 100. Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name.(Business/Organization/Individual): JW Heating.&Air Conditioning,Inc. Address:17 Arlington St City/State/Zip:Dracut, MA 01826 Phone#:978-454-8197 Are you an employer?Check the appropriate'box: Type of project(required): 1.0 I am a employer with 4. ❑ 1 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. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition ees to and have workers working for me in any capacity. employees y ; 9. Building addition [No workers' comp.insurance comp.insurance. 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.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t e. 152, §1(4),and we have no 13.❑ Other employees.[No workers' comp.insurance required.] *My 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. tContractors 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:Great American Policy#or Self-ins.Lic.#:WC 6418907 04 Expiration Date:06/02/2012 Job Site Address:All locations in 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. 1.52 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, IA for insurance coverage verification. I do hereby c d r na ie 'uqj that the information provided above is true and correct. Si na al Phone#•978-454-8197 Official use only. Do.not write in this area,to be completed by city or town oJrciaL 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#: U-4I00vI -v�+ to�oi�4ics 'U/tf UKIhINHL uurr 0503031 GREAT AMERICAN •ALLIANCE INS CO Administrative Offices WC 00 00 01A ( Ed . 01 /97) ;u 301 E 4th Street Cincinnati OH 45202-4201 l.. 513 369 5000 ph PolicyNo . IW I C I 1 1 6 14 1 1 1 8 19 10 17 I 1 0 1 4 :�"'•'' INSURANCE GROUP Prior Policy No . IW161 1 161411 .18_1910171 I I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE nsurance is afforded by the Company named below, a Capital Stock Corporation : GREAT AMERICAN ALLIANCE INSURANCE COMPANY NCCI Company No . 14028 j ....;...::::.........::.::::..... .. ......... •. •: ..v•r.:h:?r.. r. n•Y/.} .{{. .r.{rr:..r 4}F.i'£:}/ii£:•£::�}::•:•'%ff:f i:•'}::i....... �' :v: � � ::w:::;:•.. .: ..::r:::..} :.::•: v.;••.v:;v• .r r :r/.. {• hrfr: ur'?....r:.... •:r}rw:f.:::{.:,rx::.4.vr::::{v}}:4': :� r.:: ....:�.i. ..... .... ..... ...�:... {lf::J'....f.fr.�. ::rr..v•...�.+.•;•l.. ..�•.. f..t.........l......... ..v..... : .r... ..n.h.x..,}.r.:..vf r. ....r.. ......... ....:::::::4fv::::::::::.v. ...................v. 'he Insured : J&J HEATING & AIR CONDITIONING Legal Entity : j INC . Corporation lailing Address : 17 ARLINGTON STREET FEIN No . : 042488433 !' DRACUT, MA 01826 i Ith.er Identification Number : See Extension of Information Page . j ether workplaces not shown above : See Extension of Information Page . !! .nM v... .JY,r.h.v r},;{?x,rr ; •:.f ;ruff•/rr•.rvv••f.: vx/.:...f.... i:.•,f,.;::::..;:.....::::.:::.:}.. ff. ..r... .�:.•..•f?•.:::L. r•.a.•r:fr:r}£}}}•n:{.,.r...{}}}:{•:;}}:{.}}r•}:{{:...:..::.:::.}•:.}...;..... :}££:;r • :r.:.:: ..:::::: ...{•>: .: .;,.,.,. •:: •,::.:.:........•H r:f.. .:. Y:.:r.... .:.rr;. ..l.fr.:.f:{.?r............/.....o.r........ :....: ......:. .......K....... ... ..... .. .... ::::.+..::...r...f,...hff£.. r.....r../rh}.r..�. .. r.•Y.'.......r..{.:::v:::•v., .}:-'F.?h:4:4::•}S}:'•:.}::::;:•::•}}.{^}}:•£:•£:•£:C�:£ii:R:.::.::££} 'he policy period is from 06 /02 /2011 to 06/02/2012 12 :01 A.M. Standard Time at (" he Insured ' s mailing address . ;i .��yt� #}y� �r�• lr•7,;.�:r.: ?. .r£rf :r.. r.::r.. ::•i'•;;}?::::% i ;i. ,�. 7'I:::.�.R'i�.;T..II:::.?.::::r:.d�I. .Y i3 ......... ............ ... ..r:...rfr�..'...r ..f.: .•r. .:.... r..r:::•::::.r>£}:::f..}}::.}•?.£.::.}:•£S•r.{•::.r•r}}.'•.r•}.{}s:•}:?.:::::•:£:}:.�::.:;.: 1. Workers Compensation Insurance.: Part One of the policy applies to the Workers Compensation Law of the states listed here : MA, NH (. 1 . Employers Liability Insurance : i I Part Two of the policy applies to work in each state listed in Item 3 .A. The Limits of our Liability under Part Two are : Bodily Injury by Accident $ 1,000 ,000. each accident l Bodily Injury by Disease $ 1 ,000 ,000 policy limit i Bodily Injury by Disease $ 1 ,000 ,000 each employee it Other States Insurance : ?' Part Three of the policy applies to the states , if any , listed here : All states except ND , OH , WA, WY states designated in Item 3 .A. r- I. This policy includes these endorsements and schedules : See FORMS AND !'s ENDORSEMENTS Schedule , WC 99 06 22A 101/971 . � a ....... ........ ...;.;...::•::•::r:x.:v v:: �•r::v ::::::.v::r::::::::: ..v.}Y{•}}}••}}'i.{:r.'F^}y••i%i}}i}:•}:•}}i}}}}}}:}}}v:::.:Si}iF:l}{r,:!::•£::Yri£££:}:%::££££££n{::v i££ .....................................:...........:..:.:..;.. .........................::.........::::•::.wnvrf.::ir,.::.n.vr..rl...:......r.. :1.,. .r1 dt•v :•}W..r ^.r•Xv: rr1. ..v.v w:;. Ff/"r•:•. �. rte••' :..r::f+ :r:r.r ::::.:v:{.... v..::........ .. ....n.... .h{.h.. n•.... ::. r:.r•..... •}::....:.. r/•vr£{£££::.v;.:v::(:£;v:..:r:w:::::::•::::.}:r.;:•:::•}:{££££: ...,....... ?::{w;•.......r......n.......:..v,£. .+rr,.,f.?:n•:•£:v:r£.`.. ...:.).... .... .. :..E:}.::•{{.:x!.•r:.:r:?• M•::::x::.},:•:;:}i;.}:. :0. :R:<{:{.�:?:;:::��: . . he premium for this policy will be determined by our Manuals of Rules , : lassifications , Rates - and Rating Plans . All information required below is 1' ubject to verification and change by audit . See E.xtension of Information Page A I'..�......}..�....} ..•.:.{.yyF�:.:.. .... . ........... .. ..:.v.:.:::.:.:.r::?:::..:..:..:..:.r:..:...?..v..:..vr� i :f?i:r.»..•..:...v..r.:r.£r....rr.::.r o.r.f.....f...>.........r.:r:}rr>.:.......•.....,.....h?{..../{J.r:>.+.f...n....r{.h.f..ry}vr./....r...r. f:.r..'••f+l:.nrr...:.:r''?r.r.:.?...;.r..{..•.}..r....?..{..{..•.}..rr,.. :{:.}::.:.•.>:}:£.}F•.•.£..••.}.}:;.: fi �. r it .. r.r£r.. ....... r ....::r::w::v:;•.:::.v::,v.}::}:.:..::::::x::::...:::.v. 'OTAL ESTIMATED ANNUAL COST : S 46 ,014 Minimum Premium: S 750 'r a, leposit Premium: S 46 ,014 Date of lssu.e : 06/22 /2011 ' i .......... ...... .. a., .......... ..:• :• .. ...................... .:..:. :r.:rr:;r� .nr ..:r...:...r: :.rr...rr..r.:r..r.....:r..?.:.:::.::.....r..,£':{£}::.:{•}::::.v:.{•.}•.;•:.{•:.,..:::.�:::::. .... .... .. �. .: ........... ..rrr....t..r...d.....uf.r:..1..3. .r..:r:f'•.k:.:,•.:£::;;••:rF::/•::r:::.{•:r:::{.:{.xr:•.:::.?:.r...r...........::..:................. tame of Producer : EDWARD F . SENNOTT INSURANCE A Servicing Office : PO BOX 457 SPECIALIZED MARKETS TOPSFIELD 01983 657 :ountersigned by : Copyright 198.7 National Council on Compensation Insurance ;72Q39011i00 01A ( Ed . 01 /97 ) PRO (Page 1 of 4 ) DATE(MMIDDIYY1 �acvRnM CERTIFICATE OF LIABILITY IN 06/06/Zoll RODUCER 97$,$87.4900 FAX 978.887.2404 THiB CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION P ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Edward F. Sennott Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1th Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P6. SSoouBox 4S7NAIC# Topsfiel d, MA 01983 INSURERS AFFORDING COVERAGE INSURED ]&7 Heating & Air Con Ttiomng, Inc. INSURERA Great American 17 Arlington Street INSURER B: Dracut, MA 01826 INSURER C: INSURER D: INSURER E: COVERAGES BEEN ISSUE LISTED BELOW HAVE D TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING THE POLICIES OF INSURANCE ANY REQUIREMENT,TERM CONDITION OF ANY CONTRACTOR 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LIMITS INSR DD' TYPE OF INSURANCE POLICY NUMBER D ATE MMIDD LTR NSR GENERAL LIABILITY PAC6418906-04 06/01/2011 06/01/2012 EACH OCCURRENCE E 1,000,00 $ 300,00 COMMERCIAL GENERAL LIABILITY - PREMISES Ea occurrence CLAIMS MADE a OCCUR MED EXP(Any one person) E 10,000 PERSONAL&ADV INJURY E 1,000,nn ri A X GENERAL AGGREGATE E 2-,WWW, OO PRODUCTS-COMPIOPAGG b 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY M jECT LOC AUTOMOBILE LIABILITY CAP64189S7-02 06/01/2011 06/01/2012 COMBINED SINGLE LIMIT E (Ea accident) 1,000"00 EE ANY AUTO ALL OWNED AUTOS BODILY INJURY E (Per person) X SCHEDULED AUTOS A X HIRED AUTOS BODILY INJURY b (Per accident) X NON-OWNED AUTOS PROPERTY DAMAGE E (Per accident) AUTO ONLY-EA ACCIDENT E GARAGE LIABILITY' OTHER THAN EA ACC E ANY AUTO AUTO ONLY: AGG E EACH OCCURRENCE E EXCESS I UMBRELLA LIABILITY AGGREGATE E OCCUR CLAIMS MADE b E DEDUCTIBLE E RETENTION b WORKERS COMPENSATION WC6419907-04 06/02/2011 06/02/2012 X TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT S 1,000,00C A OFFICERIMEM ER EXCLUDED?ECUTIVE❑ E.L.DISEASE-EA EMPLOYE b 1,000,00C (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT E 1,000,00( SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR nvEs. AUTHORIZED REPRESENTATIVE /J Evidence of.Insurance Peter Sennott LA ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009101) The ACORD name and logo are registered marks of ACORD Load Short Form Job: 11 Pembrook St.North... wrightsoft® Date: Mar 30,2012 Entire House By: AJ Heating and A/C 17 Arlington St.,,Dracut,,Me 01826 Phone:978-454-8197 Email:Jeff@ffheatac.com Web:www.kheatac.com • - e • For: Tom Zahoriko,Tara Leigh Development 115 Carterfield Rd., North Andover, Ma 01845 D - • e • Htg Clg Infiltration Outside db(°F) 12 88 Method Simplified Inside db(°F) 68 75 Construction quality Average Design TD (°F) 56 13 Fireplaces 1 (Average) Daily range - L Inside humidity (%) 50 50 Moisture difference(gr/Ib) 43 28 HEATING EQUIPMENT COOLING EQUIPMENT Make Amana Make Amana Trade Amana Trade ASX13 SERIES Model AMH950904CX Cond ASX130601B* GAMA ID 2012267 Coil CA*F4860*6B*+G*VC951155DXA*+TXV ARI ref no. 3695779 Efficiency 95AFUE Efficiency 11.0 EER, 13.1 SEER Heating input 92000 Btuh Sensible cooling 38500 Btuh Heating output 89000 Btuh Latent cooling 16500 Btuh Temperature rise 44 OF Total cooling 55000 Btuh Actual air flow 1833 cfm Actual air flow 1833 cfm Air flow factor 0.028 cfm/Btuh. Air flow factor QA46 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.80 ROOM NAME Area Htg load Clg load HtgAVF CIgAVF (ft2) (Btuh) (Btuh) (cfm) (cfm) Laundry 64 1644 1156 45 53 Powder 40 5511 301 152 14 Family/Kitchen 448 9125 8843 251 406 Living 168 6102 5850 168 269 Dining 180 3343 3246 92 149 Foyer 105 1321 590 36 27 stairs 166 1426 699 39 32 Bed#1 168 3673 2079 101 95 Bed#2 168 7036 2854 194 131 WIC 50 5024 1159 138 53 Mast Bath 90 7108 2333 196 107 Master 210 4678 4190 129 192 Bed#3 168 2343 2635 64 121 Bath 84 6434 2860 177 131 Hallway 183 1875 1128 52 52 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. ^- -+- wrightsoft- Right-Suite®Universal 8.0.04 RSU05790 2012-Apr-1815:40:13 ...J\Desktop\Wrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 1 Entire House 2292 66642 39923 1833 1833 Other equip loads 0 0 Equip. @ 0.93 RSM 36969 Latent cooling 9892 TOTALS 2292. 66642. 46861. 1833 1,833 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. .Q 411- wrightsoft^ Right-Suite®Universal 8.0.04 RSU05790 2012-Apr-18 15:40:13 ...J\DesktopMrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 2 Building Analysis Job: 11PembrookSt.North ... -�+ wrightsoft® 9 y Date: Mar 30,2012 Entire House By: J&J Heating and A/C 17 Arlington St.,Dracut,Me 01826 Phone:978-454-8197 Email:Jeff@kj eatac.com Web:www.gheatac.com e e e For: Tom Zahoriko,Tara Leigh Development 115 Carterfield Rd., North Andover, Ma 01845 MOM• e • e Location: Indoor: Heating Cooling Boston Logan Int'IAP, MA, US Indoor temperature(°F) 68 75 Elevation: 30 ft Design TD (°F) 56 13 Latitude: 42°N Relative humidity (%) 50 50 Outdoor: Heating Cooling Moisture difference(gr/Ib) 42.7 27.8 Dry bulb(°F) 12 88 Infiltration: Wety ranje6F) _ 72( L ) Method Simplified Construction quality Average Wind speed-(mph) 15.0 7.5 Fireplaces 1 (Average) • Component Btuh/ft2 Btuh % of load Walls 3.6 7548 11.3 Glazing 50.0 16413 24.6 Doors 16.1 677 1.0 Ceilings 5.2 8235 12.4 Floors 2.2 2918 4.4 Infiltration 3.2 7942 11.9 Ducts 0 0 Piping 0 0 Humidification 0 0 Ventilation 22910 34.4 Adjustments 0 Total 1 66642 1 100.0 cqkillilli:q • Component Btuh/ft' Btuh % of load Walls 1.0 2077 5.2 Glazing 30.1 9861 24.7 Doors 7.7 323 0.8 Ceilings 4.7 7406 18.5 Floors 0.5 661 1.7 Infiltration 0.3 761 1.9 �. Ducts 0 0 Ventilation 4153 10.4 r"r Internal gains 14680 36.8 Blower 0 0 Adjustments 0 Total 39923 100.0 Latent Cooling Load = 9892 Btuh Overall U-value= 0.127 Btuh/ft2-°F Data.entries_checked. -f14- wrightsoft:- Right-Su@e®Universal 8.0.04 RSU05790 2012-Apr-1815:40:13 ACCK ...J\Desktop\Wrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 1 Component Constructions Job: 11 Pembrook St.North... wrightsoft® Component Date: Mar 30,2012 Entire House By: AJ Heating and A/C 17 Arlington St.,Dracut,Ma 01826 Phone:978-454-8197 Email:Jeff Qheatac.com Web:www.9heatac.com For: Tom Zahoriko,Tara Leigh Development 115 Carterfield Rd., North Andover, Ma 01845 D - • e • e Location: Indoor: Heating Cooling Boston Logan Int'I AP, MA, US Indoor temperature(°F) 68 75 Elevation: 30 ft Design TD (°F) 56 13 Latitude: 42°N Relative humidity (%) 50 50 Outdoor: Heating Cooling Moisture difference(gr/Ib) 42.7 27.8 Dry bulb(°F) 12 88 Infiltration: Daily range(°F) - 15 ( L ) Method Simplified Wet bulb( F) - 72 Construction quality Average Wind speed (mph) 15.0 7.5 Fireplaces 1 (Average) Construction descriptions Or Area U-value Insul R Htg HTM Loss Clg HTM Gain fF Btuhff--°F tY-"F/Btuh Btuh/11' Btuh Btuh/fi' Btuh Walls 12F-Osw:Frm wall,wd ext,3/8"wood shth,r-21 cav ins, 1/2" n 228 0.065 21.0 3.61 824 0.99 227 gypsum board int fnsh,2"x6"wood frm a 237 0.065 21.0 3.61 857 0.99 236 s 289 0.065 21.0 3.61 1044 0.99 287 w 9 0.065 21.0 3.61 33 0.99 9 all 763_ 0.065. 21.0 3.61- 2757 0.99 759 12F-Osw:Frm wall,wd ext,1/2"wood shth,r-21 cav ins,1/2" n 399 0.065 21.0 3.61 1442 0.99 397 gypsum board int fnsh,2"x6"wood frm a 265 0.065 21.0 3.61 959 0.99 264 s 315 0.065 21.0 3.61 1138 0.99 313 w 346. .0.065. 21.0 3.61. 1250 0,99 344 all 1325 0.065 21.0 3.61 4790 0.99 1318 Partitions (none). Windows 1 glazing,clr glz,wd frm mat,1/8"thk:1 glazing,cir giz,wd frm mat, n 36 0.900 0 50.0 1801 20.3 731 1/8"thk n 24 0.900 0 50.0 1201 23.6 565 n. 96 0.900. U 50.0. 4804 20.3- 1950 e 24 0.900 0 50.0 1201 55.4 1331' e 24 0.900 0 50.0 1201 55.4 1331 S 52 0.900 0 50.0 2602 31.9 1658 s 72. 0.900 0. 50.0 3603,_ 31.9 2296,. all 328 0.900 0 50.0 16413 30.1 9861 Doors 11 P0:Door,mtl pur core type s 28 0.290 10.5 16.1 451 7.68 215 w 14 0.290 10.5 16.1 226 7.68 108 all 42 0.290 10.5 16.1 677 7.68 323 Ceilings 16B-38ad:Attic ceiling,asphalt shingles roof mat,r-38 ceil ins,1/2" 1121 0.026 38.0 1.45 1620 1.30 1457 gypsum board int fnsh C part ceiling,:C part ceiling,hrd wd fir fnsh,frm fir,10"thkns,1/2" 468 0.255 1.0 14.2 6615 12.7 5949 gypsum board int fnsh ,At�_ wrightsoft` Right-Suite®Universal 8.0.04 RSU05790 2012-Apr-18 15:40:13 /TCCA ...J\Desktop\wrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 1 Floors 19A-Obswp:Part floor,hrd wd flr fnsh,frm fir,10"thkns 172 0.295 0 6.16 1060 1.40 240 19A-30bswp:Part floor,hrd wd flr fnsh,r-30 ins,frm flr, 10"thkns 1171 0.034 30.0 1.59 1858 0.36 421 1, -Fid- wrigtitsoft- Right-Suite®Universal 8.0.04 RSU05790 2012-Apr-18 15:40:13 'Izb ...J\Desktop\Wrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 2 Project Summa Job: 11 Pernbrook St.North... - wrightsoft, Date: Mar 30,2012 Entire House By: J&J Heating and A/C 17 Arlington St.,Dracut,Me 01826 Phone:978-454-8197 Email:Jeff@j heatac.com Web:www.flheatac.com 0 - 0 0 For: Tom Zahoriko,Tara Leigh Development 115 Carterfield Rd., North Andover, Ma 01845 Notes: D - • e • Weather: Boston Logan Int'IAP, MA, US Winter Design Conditions Summer Design Conditions Outside db 12 OF Outside db 88 OF Inside db 68 OF Inside db 75 OF Design TD 56 OF Design TD 13 OF Daily range L Relative humidity 50 % Moisture difference 28 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 66642 Btuh Structure 39923 Btuh Ducts 0 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 66642 Btuh Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 36969 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 1 (Average) Structure 9892 Btuh Ducts 0 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area(ft') 2292 2292 Equipment latent load 9892 Btuh , Volume(ft3) 20624 20624 Air changes/hour 0.38 0.16 Equipment total load 46861 Btuh Equiv.AVF(cfm) 130 55 Req. total capacity at 0.70 SHR 4.4 ton Heating Equipment Summary Cooling Equipment Summary Make Amana Make Amana Trade Amana Trade ASX13 SERIES Model AMH950904CX Cond ASX130601B* GAMA ID 2012267 Coil CA*F4860*6B*+G*VC951155DXA*+TXV ARI ref no. 3695779 Efficiency 95AFUE Efficiency 11.0 EER, 13.1 SEER Heating input 92000 Btuh Sensible cooling 38500 Btuh Heating output 89000. Btuh Latent cooling 16500 Btuh Temperature rise 44 OF Total cooling 55000 Btuh Actual air flow 1833 cfm Actual air flow 1833 cfm Air flow factor 0.028 cfm/Btuh Air flow factor 0.046 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.80 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. SCA -Pp- wrightsoft` Right-Suite®Universal 8.0.04 RSU05790 2012-Apr-18 15:40:13 ...J\Desktop\Wrightsoft HVAC\11 Pembrook St.North Andover Ma.rup Calc=MJ8 Front Door faces: Page 1 :K Date. 4.0 RT +o TOWN OF NORTH ANDOYERa pL p PERMIT FOR PLUMBIX w , _ •+ SSACMuZS� 1' This certifies that . .�� � F. . . . . .:.�'"' ���°. has permission to perform . . . .P e.i,- " `:' .`. : . . . . . . plumbing in the buildings of `. . . . . . . . . . . . . . . . . . . . . . . . . . l 2 at . . . �'.�. I. . .E c t--: . .1) b . {. . . . . . . . Andover, Mass. Fee S ,7. . . . .Lic. No_ 73 3 ?. . . . . . . J��`.y.,,N-orth UMBING INSPEC�rOR Check # J O � � MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO Do PLUMBING � yzlo� - pat 20 Per it # IIII, Buil Ing Loc ion -OwnerIsAAam Type of Occupancy New U Renovation p Replacement 2.1, Plans Submitted:" ubmitted: Yes D No D by FIXTURES t3.N. SEWER # SEPTIC # z U) 0 , UJ � u-' to z in Q � E- z O C12 Ln CL Z M of W Of Ln LU Of C) :3 ¢ lYg ¢ to Z n O u }— U ¢ = a z ire � 0 z z w L w LL Of > }- O m. cn Uj 0 � In ii t7 Q � m I O SUB-BSMT BASEMENT r 1ST FLOOR 2ND FLOOR 3RD FLOOR =� 4TH FLOOR STH FLOOR 6TH FLOOR �. 7TH FLOOR STH FLOOR I I nstalling Company Name " azoc c_ Check one: Certificate kddress a Corporation 1 YI CL W .. A 2y 3usiness Telephone_ (} 0 Partnership Jame of Licensed Plumber or Gas Fitter iTmIco. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 1-42.-. Yes � . No - 0 If you have checked yes, please indicate the type' of coverage by checking the appropriate 'box. A liability insurance policy Other type of indemnity D Bond 0 OWNER'S INSURNACE WAIVER: I am aware that the licensee sloes 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. Signature of Owner or Owner's Agent Check one: Owner D Agent D hereby certify that all of the details and information I have submittedentered}En above applicatk'on are true and accurate to the best of y knowledge and that all Plumbing work and installatior_s per€ormed nd r the permif iss €ar this application will be in compliance with l pertinent provisions of the Massachusetts State Plumbing Code a t 142 of the feral Laws. By Title S1 na ure of Licensed lumber f CiryfTow•n � APPROVED(OFFICE-USE ONLY) Type of License: IfYMMaster DJourneyman License Number Date...... :.��'....�. .�'.. f NORTH x 0 TOWN OF NORTH ANDOVER :k p PERMIT FOR WIRING r This certifies that ....................�.. le!}" ............... d has permission to perform ......... 4� /... .�/ . '�,,,1�1�. wiring in the building of............. .................................`............. 111/ Q at......f.(.. ..... . /t��l?/L l.. ..... <�.......QL41C North Adover,Mass. .a op / Fee..., ......... Lic.No. a �i�SAC'M� { Check # 8350 ;r Commonwealth of Massachusetts Official Use Only 1 Department of Fire Services Permit N°. 'z�,-5` f Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank r; ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeEC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � l City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives no ' of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ,e ,QU 4ze- Telephone No. Owner's Address Is this permit in conjunction with a building permit? YeAC No ❑ (Check Appropriate Box) G� Purpose of Buildin N/ I� << Utility Authorization No. Existing Service Amps f2 f tilts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity L tion and Nature of Proposed Electrical Work: � L � -� Com letion of the ollowin table maybe waived by the Ins ector 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 Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Batte Units No.of Receptacle OutletsNo.of Oil Burners rNo. E ALARMS No.of Zones No.of Switches /'� ` No.of.Gas Burners of Detection and es No.of Ranges No.of Air Cond. Tons of AlertingDevices No.of Waste Disposers Heat Pump Number .Tons._. . KW . of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating AppliancesKW Security Systems:* No.of Devices or Equivalent No.of Water , 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. Estimated Value f lec 'cal Wo (When required by municipal policy.) Work to S � � _ 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 licenseerovides roof of liability p p insurance including"completed operation coverage or its substantial equivalent. The undersigned certifies that such c 'erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANC -J BOND ❑ OTHER ❑ (Specify:) I certify,under the ains a d penalties of perjury, that the information on this application csi�^^ue nd complete. FIRM NAME: ��v�� �� 1P?&LIC.NO.: ��" Licensee: / ® � t�? Signatur LIC.NO.: (If applicable, "exempt"in the lic e b line.) us.Tel.No.: t J Address: n Alt.Tel.No.: *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: $ 7 f i 4 • 9 Ok « ©,8 B 1 I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street �s Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):,- / Address: ' City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: - Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6 E]New construction employees(full and/or part-time).* have hired the sub-contractors am a sole proprietor or partner listed on the attached sheet. $ 7. ❑ 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.❑ 1 am a homeowner doing all work right of exemption per'MGL 11.E] 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' . 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. 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: c 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 cerfi nder pain es of perjury that the information provided abo a is tru 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#: xw Location I t t'a 2cx��� �1-0►4� No. �Ii. Date v �� < °R,M, TOWN OF NORTH ANDOVER c? °;, Certificate of Occupancy. $ + ; • Building/Frame Permit Fee $ cHusFoundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector �sy y :0111/34 09:04 91.00 PAID Q" 7550 Div.°Public Works' PFIMIT'NO. 44-Z APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. LOCATION va p�--. _� 7�._— \ PURPOSE OF BUILDING , /� �''�"�( C� EO(ISI Cl OWNER'S NA4E ,j;,V,,7e 4 NO. OF STORIES v SIZE OWNER'S ADDJJR,f?S/ Pre fl? koyU �� l� BASEMENT OR SLAB ARCHITECT'S NA/ME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME { / A �iG�( M/4/tV sr A�.�. SPAN -- DISTANCE TO NEAREST BUILDING '/ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES -SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING K 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 BOARD 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 ST. BLDG. COST /lelpo: PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 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 `' ®UILDINO INOPKCTOR �SI GNATU R64:��fiEF&ISROUYIHORIZED AGENT / F E E 7 '� OWNER TEL.k PERMIT GRANTED CONTR.TEL.# X36 D I is CONTR.LIC.a. H.I.C.# 116 Z3 BUILDING RECORD I� 1 OCCUPANCY 12 1 SINGLE FAMILY I 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 RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION I 2 FOUNDATION —I 8 INTERIOR FINISH { CONCRETE d 1 2 13 h` I CONCRETE BL K. PINE _ BRICK OR STONE HARDW D —_ —— PIERS -PLASTER DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN, B'M'T AREA _ lh 1/1 '/. FIN. ATTIC AREA _ NO 8 M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS - CLAPBOARDS 8 1 2 3 DROP SIDING CONCRETE ��_ f WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE I _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME - CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT I 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 7 ( 6 FRAMING II 11 HEATING f 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 II RADIANT H'T'G - + UNIT HEATERS 1 7 NO. OF ROOMS GAS OIL B-M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING Town of0 Andover No. 44 ` ,<NOrt6,Andover, Mass., 0dreficD91-199+ r E[70- 'S t, BOARD OF HEALTH T B' ILD Food/Kitchen Septic System PERMI T . T BUILDING INSPECTOR THIS CERTIFIES THAT.............. 744 . ...�..1..P..a.A'. ../..!.!.. . ! '.....!��w... .� ............... Foundation has permission to 0Xt....40va ..............�buildings on ..,.J.j�... �- �1e!*� ...��D Rough h to be occupied as............�II/V ......... /..��� ... /S�.. /N .......0"Ur� INi�......................... Chimney e provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final hI.L.�.'���: L ELECTRICAL INSPECTOR „ ,., Rough • .... Service ............................................................................................................. BUILDING INSPECTOR Final Occupancy Pet-Yillr R(.,q bl cCd to GAS INSPECTOR gh Display in a Conspicuous Place on the Premises - Do Not Remove F nal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT PLANNING FINAL CONSERVATION FINAL Stre`'t No. tin�f fl:�• I��•i. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT______ Yo 1-- Q C W W G J 3 OCO Q Q /— O O O m N LO W y ..-. H W S OC W E <J> aGl S J � Q OQ Y 1 I ' \v } i ; t \. • i � t t 1 a+\j .a i <� - t D L`. t -t� �+ yti �+ a I �:i+ '\`�y�( 1 t' .\ 5>,t 1. ..� 1\t-� '��t ..�4\1f�: \`�1 .l:i♦ , ll� it r:tt ♦ j{(i^a t f . y a' ',�tifro 4-..i.} � .;�1 I - ) , ," 9 1 .11 , < r. .. f y xr �t 1 x ro y`'��, :Ca -Af ..t•. 'f Uk �t {; �-1. t: -� .- � 1 - L � � .�- :ii° h ...�a:��?. 'w .. 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( � 3wy, :`µ 'ti<_'-v _ '.'°y,, S( q�x.`t:- ° yxr .X��w *� <��k�. c Y,�Zr.y� .y,4:14,`i>�y��� '�;.il� � il};, '�. �`l}t, { u .^4 'v.•- �,t n y ` -te'�41� t>�4'I'�Y r'`Stt. t`�`•.{,:�. . s 4.,.:ix, ``.�+, F.;:."�” t ti .,`'!r • ,.^t •,. `� 't �� "r`t' V{° `r` � 1 �'S'' �`-.- -4 ` . y.. 'iak t ;; ` • }`.{'S- `, .. �•°i"�rh�„�`.t�) � ?t' a trv� `��''4�`�'l.'^'"S�•.� .L{i,Y c�'Z�.3� "``a',�.'��•'y�t .�`�'�?`h''�++{\,'tY +; �,`���Ap�c ,�'S�'a�'4, f � Page No. of Pages MAIN STREET BUILDERS 733 Turnpike Street,-Suite 206 Remodeling Proposal' N. ANDOVER, MASSACHUSETTS 01845 CONTRACTOR LICENSE NO. JOB PHONE NO. �/V �. $00-37�-5064 _ ' JOB NAME/NO. . , Submitted Io: t /.4........................................._.......................................� �..........:......... JOB LOCATION /1.------------_------------............. ..., ..................................... ........ ..'. ......... ......... ...... ARCHITECT DATE OF PLANS PHONE DATE APPROXIMATE STARTING DATE APPROXIMATE COMPLETION DATE > 4 7N . We hereby submit specifications and estimates fore {r7S^� - C � e � ..........................................r........................._....._......_..._..... _... ...._ . _. .- ....V.........................................._..................__ _..... R _, . i7 Z_ 00, - - , .. _ ....... r _ - .._...._......._............_ ._t:._d ..._G.._��.............. _....��. "._.._ f` .__._...........:..... ...__ _. � eti ,� --------- I-L'.12..... ......................................................C._��................. `................... ... >_ .''...._77.............. T e This Proposal does not include: �- _ ---.. _. All aterial is.guaranteed to be as specified.All work to be Gom- m We Propose hereby to furnish material and labor-complete in accordance with plem a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications involving / above specifications,for the sum of: extra costs will>be done only upon a written change order.The costs will become an'extra charge over and above the estimate.This is to include,but is not limited to,hidden damages that are uncovered during the course of the job and additional work required by local j building inspebtors.` d011arS($. I All.elements of this agreement are contingent upon strikes,accidents Pa ent to bemaas follows: va or delays beyond our control.The estimate does not include material price increases,or additional labor and materials which may be required should unforeseen problems arise after the work has started. You,the buyer, may cancel this transaction e / at any time prior to midnight of the third ' ' f - r '..business day after the date of this trans- action. Cancellation must be done in writing. 5 � L� 1 Note:This proposal jam' may be withdrawn 41 tom-' by us if not accepted within ays:.y Authorized Signature r. Acceptance of Proposal: The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined above. ,Signature..J`y It -'" Date GI ��+ ' � Signatures !!� a: -'�'`'� 'T a�,7 t�e' ` Date "�. PRODUCT 5524 Inc.,Groton,Mass.01471.To Order PHONE TOLL FREE 1-800-225-M z4c71 RECYCLED PAPER �P Contents:40%Pre Consumer•10%Post-Consumer f NORT,y OFFICES OF: o °m Town of 120 Main Street M0019APhEALs :off;:; NORTH ANDOVER North Andover, BUILDING ;' ~gig Massachusetts 01845 CONSERVATION ,Ss4CNU5ES DIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR x In accordance with a provisions of MGL e 40, S 54, a condition of Building Permit Number — is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: / II (Location of Facility) Signatu�f nadt Applicant /i-(v �O D to NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.