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HomeMy WebLinkAboutMiscellaneous - 114 BEVERLY STREET 4/30/2018 114 SEVERLYSTREET 210/=0-0050-p 000.0 i 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: in accordance-with theprovisions of M.G.L.c.143,§,3L,the I\ permit application form to provide notice of instaflation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed- " on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application.Such entity shall be responsible for the notification of completion ofthe work as required in M.G.L.c.143,§3L. " Permits shallbe limited as to the time of ongoing construction-activity,and may be.deemed_by-the-Inspector-of-Wires abandoned_aad.imvalid.ifbe—. or she has detennined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A pemmit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of2010 and extended b Sect' ns y to .74 and 75 of Chapter 23 8 of the Acts of 2012.The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certaispermits-and licenses concerning the use or development ofreal property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence'during the qualifying period beginning on August 15,2008.and extending through August 15,2012. L —Permit/Date Closed: �/ Z _% **Note:Reapply for new permit Extension Act—Permit/Date Closed; i r..z FDate....? ".Z. ... NORTH 0L TOWN OF NORTH ANDOVER • '° PERMIT FOR WIRING ,SSACHUS� This certifies that ............ ....... �.D11/rJ�j (� ..... .... .............. ..................................... has permission to perform .........©.�......:4�!"w.��� ....... ....................................... wiring in the building of �.�� Oat �� Ur�Y i............................ North Andover Mass 1 .................... ... r� . . LFee.. 5 " Lic.No. . 5? 7 ........ INSP.-C.Check � S'2 Z EL �.; 7 rlv C'omm.onwealth o f Mam w4wetb Official Use Only Apartment o f Jiro Seruicea Permit No. 2fe� 7Y BOARD OF FIRE PREVENTION REGULATIONS [ Occ l any/07] 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 IN INK OR TYPE ALL INFORMAT Ol9 Date: �• Z y-6 q City or Town of: �0/- f h l7�°ij To the Inspector of Wires: I.By this application the undersigned gives notjc of his or her intention to perform the electrical work described below. Location(Street&Number) e tie Owner or Tenant Telephone No. Owner's Address -.570S lOylQ . �'©�72 g 4!5�3P f Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 0,11A 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: 1491reP Completion of 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 mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. ons TotaNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW....... No.o Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KWecuritySystems:* No.of Devices or Equivalent No.of Water No.of No.of Heaters KW Data Wiring: r 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 of Electrical Work: � (When required by municipal policy.) Work to Start: COinspections 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 ov a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER E] (Specify:) lZ t( Y�C�? _Tm 5 Cl�i'�C(� I certify,under the pains a PenoWdes of perjury,that the information on t ' application is true and complete. FIRM NAME: LIC.NO.:- g/ Licensee: Signature OrC LIC.NO.: (Ifapplicable,enter "exempt"in tiKlicense}� er line. p L Bus.Tel.No.: .S Address: t o X'f�'L '7 �4 -7 L11 10 �O �� Alt.TeL No.• S *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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. $ i Date..- `_�./-9 .o . ... . NORTH 3� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACNUSEtt This certifies that . . .... . . .. . . . ....." `. .. . .�. . .. .. . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of '?''.`...... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .�? . .'�-^ .-'d . . .�. , North Andover, Mass. Fee. . . . . . . . . Lic. No.�%�.i . . ,� . . . . . . . . . . q� GAS IN Check4V � 7 6b6U MASSAGIUSEIM UNIFORM APPUCA'PON FOR PERMIT TO DO GABS (Type or print) FMNG NORTH ANDOVER, MASSACHUSETTS Date Building Loqations / Permit# �6p 60 Owner's Name Amou $ aD or, New Renovation Replacement Plans Submitted ❑ y w w e a o a a w 660 U. 19 m x w q y, L d w d x C y�3 c F w z o SU SM AS BASEEMEE M ENT o c O w F NT U ; 1ST. FLOOR 2ND . FLOOR 3R D . FLOOR 4TH . FLOOR TH . FLOOR 6TH . FLOOR i 7TH . FLOOR STH . FLOOR. (P:int or type Name dm - a � S Check one: Certificate Installing Com an Address � �„ Q Corp. p Y usmess 'e ep one Name ofLicensed Plumber'or Gas Fitter Frrm/Co. f 1 INSURANCE COVERAGE I have a current liability insurance policy or it's substantial equivalent Check If have checked yes,please indicate the type coverage by checking the appropriate box e. Yes No� Liability insurance policy Other type of indemnity n Bond Owner's Insurance Waiver I am aware that the licensee does n-$fie the insurance coy Mass. General Law13 s,and that my signature on this permit application waives this coverage required b requirement Y Chapter 142 of the Signature of Owner or Owner's Agent Check one: hereby Certify.tha'all of the details and information I have submitted(or en d)in application best of my knowledge and that all plumbing work and installations perto��under Permit lapped for thiare s compliance with all pertinent provisions of the Massachusetts State G true and will to the Gas ode and Ch 14 application will be in General Laws. By. Signature f Lice ed Piu er Or Gas Fitter Title ® Plumber City/Town, Gas Fitter wise I�u �er Master APPROVED(OFFICE USE ONL), Journeyman ••-- &LRffLrVJ=a[¢n of Massachusett j• �',; �l 6 Departrnent of Industrial Accidents t. ' i;I Dice of fizvestigatio2r % 600 W _ ¢shin,0ton Street Bostosz, �4 U2111 c , Workers' Com ensation �.nsurance fEid mi g,ov�dia P davit; i.}ders/Contractors/Eiectricians/Piumbe A Iica.nt Information Bn res r��� Pease IJame (Business/prganizationMdividuai):1—�- - Print Leib}v- City/State/Zip: Phone#: — Are you an employer?Check thea appropriate _ 10I am a employer with PP prelate box: —�--- empioyees(full and/or part-time).* 4. ❑ a�° hire eral con 6YPe of project.(regained); Factor and I 2. 1 am a sole proprietor or partner- Iisted nni a sub-contractors ❑ New construction ship and have no employees These st cb- ached sheet; ?' ❑ Re:nodeIinc'. working for mein any capacity. work contraCtors have 8. Demolition [No workers'comp. insw-ance 5 We ens' comp. insurance. required.] are a corporation and its 9' ❑ Building addifim 3•❑ [an a horrn9owner doing all work right of X�r ex A 10:[] Electrical r, ercised.their apairs or additions Myself [No.workers' ption per MGL T 1 Plumbing re insurance required] t cAmp. C. 1S2, §l(¢)�and we have no repairs or additions 'employees. , workers' 12,❑ Roof repairs comp. insurance required] 13•❑Other *Any appli�nt.that checks box#1.must also�iil out the section below sho +iiomcowuets who submil Ibis aiudavh indieatin� Win=tieeir workers' p.n 2Conuasmta that ehc4.this bin.must brei'etc i uing ,.=re:rlt;; coin saiion policy inionnation. sitached an additional sheet showi ru LhM hire outside eontrec{urs aiusi xubmii a nc„ .the name.offhe sub c atnriavit ineicsitrgs ch. f aJtt P11 employeriii is Providing �„ orazctots and their work..-rs'comp.poliCT Information. Providing wOrfi�$ � �Je� �i i., . arformQtcort once for�'er'rP1oYe�r. Below is the o ' Insurance Company Name: P 'job site Policy#or Self-.ins. Lid,.#: Job-Site Address: Expiration Date: Attach 2 copy of the workers' compertsafaon Policy decla Cry'/Stat~/Zip: .Failure to secure coverage as required under Section 25A o�tEioa Forge(showiQb the Policy cy number and expiration date) fine up to 31,500.00 and/or one-year imprisonment as well MGL c. 152 can lmd to the imposition of Of up to.5250.00 a da against as civil p criminal penalties of a y a=aor i the violator. Be advised that a co P-naldes m the form of a STOP WORK 0 PeroDER and a fine Investigations of the DIA for insurance coverage verification, °f this statetnert ma be forwarded d to the Office of I do herekp cer&fy under the airzc and P °•fpe rJ' at the information Provided f eabove Si�r►aivre: � Lan correct Phone Dat : t v Dffccial use onlp. Do hat write in this ares to be completed b3,Chj,or town ofricia( City or Towa: Issuing Autho Permit/License 4 rity(circle one): 1. Board of F'eatth 2. Building Department 3. C' / 6. Other n Torr clerk 4. Electrical Inspector 5. Plumbing b Inspector Contact Person: . Pbone#: 1111V1111QLIVU mnu tust ucrionS Massachusetts Ci neral.Laws chapter 152 requires all employers to provide workers' compensation for their employees. ` Pursuant to this statute,an employee is defined.as"... very person in the service of another under any contract of hire, express or implied;oral or written." An employer is donned as`pan individual,partnership;association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and includ_irr.g the legal representatives of a deceased employer,orthe receiver or trustee of an individual,partnership,associati on or other , entity,employing employees. However the owner of a dwelling house.having not more than.three ap arfinents and who resides therein, or the occupant of tie dwelling house of another who employs persons to do maitrtenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be d„-timed to be an employer." MGL chapter 152, §25C(6)also states that"every state tim►r focal licensing agency shall withhold the issuance or renewal of a license or permitlo operate a businrss or- to construct building in the commonwealth for.Roy applicant who has not produced acceptable evidence to`f compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states"Neither *he commonv,ealffi nor any of its political subdivisionsshall enter into any contract for the performance of public wort{ until acceptable evidence of compliance with the insurance requir=cn s of this chapter have been presented to the contracting authority.". Applicants Please fill out the workers'compensafion affidavit compl-etely,by checking the boxes that apply to yotr situatim.and,if necessary,supply sub-contractors)name(s), address(es) d phone nwnber(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limitd Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry.workers'compensabon insurance. If an LLC or LLP does have.. employees, a policy is required. Be advisedthat this afficlvit maybe submitted to the Department of. Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the.affidavit. Theaffidavitshould be returned to fire city or town that the application for the permit or license is being requested,trot the Department of Industrial Accidents. Should you.have any questions regi-fig the-law or.if you arc required to obtain a workers' compensation policy,please call the Department at the mzzmbcr.Iis+.ed below. Self-insured corpanies should enter their self-irsurance iicerrsw neunber on the arspropr is - line. City or Town Officials Please be sure mat the affidavit.is complete and printed legibly. The Department has provided a space at the bottom of the.affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appiimnL Please be sure to fill in the permit/license number which wig be used as a reference number. In addition, an applicant -that must submit multiple permit/ii=rse applications in arty given year,need.only submit one affidavit indicating current poiicy information(if necessary)and under"Job Site Ad tress"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 fut:Lm permits or Iicenses. A new affidavit must be filled out each year. lhrlre.re a home owner or citizen is obtaining a Iicems or Permit not related to any business or commercial venture (i.e. a.dog license or permit to burn leaves etc.)said pt-norn 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,teiephone and fay,number. The Commonw-taltb of Massachusetts Department of Lmdustrial Accidents. Office of Ezvesfi'vatilons 640 Washirngton Street Boston; MA (12111 Tel. 4 617-727-4900=7t 406 or 1-877 MASSAFE Revised 5-26=05 Ear,�617-7-7-7749 WWWJn3Ss.Dov/dia �A The Commonwealth of Massachusetts k1f1 Department of Industrial Accidents 1 ,r ! Office of Investigatiotu All 600 TYvshington Street ti° Boston, MA p2111 � wwlw nmsgov/dia . Workers, Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plambers 012ficant Information Picric Print Leaiib Naini (Business/prganiza for individual): Address: Citystate/Zip; �� d l el�� Phone#: . � S� Are you an employer?Cheek.the appropriate box: 1.❑ I am a e plover wi#h 4. ❑ I am a general contractor and I Type of project(required). em Mull and/or part-time),* have fired the mb-contsactots 6' ❑New construction 2• am.a.sole proprietor or partner_ fisted on the attached sheet x 7• ❑Remodeling ship and have a employees These sub-contractors have working for in arty capacity. 8• ❑Demolition g act workers' comp.insurance. [No workers'comp.insurance 5. 9. ❑ Building addition ❑ We are a corporation and its required. officers have exercised their !0.Q£iectrical repairs oradditions 3.❑ I am a homeowner doing ail work right of exemption per MGL i!. umbing repairs or additions myself[No-workers'comp. c. l52, §1(4),and we have no irtsutance rt uired. .t 12•❑ Roof repairs q ]. employees. [No workers' comp. insurance required.j I3.❑.Other 'Any applicant that checks bob!{1 must also fill out the section heloW sbovving their workers'compensation poi icy information t Homeowners who submit this affidavit indicating they art doing ail work and then him outside connctots must submit a new affidavit indicating such ;Contractors that check this box mustattwc an additional shaetshowirrg i;he name of the sub.contractvn;and their worksrs'cam. i..' r . i infomatior.. arc an employer that isPm g:warkers'compensation infornratinm irzsurmce for ray.employees: Below i17he,P0lley adj.6 sit, . Insurance Company Name- Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/statrzip: Attach a copy of the workers' compensation policy deciaration page(showing the poli cy number and expiration darae� . 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. Ido hereby certify under the pa' a peri ofPedury that the information provided 7725 Si tures and correct Date: Phone#: t —�S, 7 7 091cial use only. Do not write in this area,m be conrplet�d by city or town o rra( City or Town: Permit/License# Fssuing Authorify(circle one): 1. Board of Health Z Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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 enberprise,and includirkg the legal representatives of a deceased employer,or the receiver ortvstee 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 m such dweiUng house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,525C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insumuce'coverage required." Additionally, MGG chapter 152, §25C(7)states`Neither t1he 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 cor&acting authority." Applicants Please fill out the workers'compensation•affidavit comp14--tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)acid 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 mem'oers or partners,are not required!to carry workers'co rnpensation 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 arc required to obtain a workers' compensation policy,please call the Department at the nurnber.listed below. Self mrnud chanpaniPs sh��sid en+�d+eir ,: self-insurane'e-license number on the'appropriate tine. 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 applicmt Please be sure to fill in the permit/license number which A-iII be used as a reference number. In addition,an appiicant that must submit multiple permitnicense 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.officiaily 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 Indnstriai Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL#617-727-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date. . . . . . . . . . . pf HpRTM,�p ` TOWN.OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that . . . . . . . . . . . . . . . . . . has permission to perform-:�a.-� . . . . . . . . . . .•. . . . . . . . . . . . plumbing in the buildings of . .'. . . . . . . . . . . . . . . . . . . . at.//y . . . North Andover, Mass. ti Fee_7� . . .Lic. No.. . . . . . . . . .— //` .�/ . . . . . . . . . . . . . . PlUM81NG INSPECTOR Check !t `j 8*14 9 ray r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS L Date Building Location Owners Name �(�� � P Permit# l 17'9 Amount �Z Type of Occupancy New Renovation Replacement El--� Plans Submitted Yes No ❑ FIXTURES Ln ° Cn a z A a s � � w w A a a s�asly� M>LOCIR M ELOCIR 41H HfM SM>D 6M HiOCIR - M HDM- 91H R" (Print or type) Check one: Certificate Installing Company NamedZ� / Corp. Address �� artner. Business Telephone g'(_ — 11 Firm/Co. Name of Licensed Plumber: Gtc lat S Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy rM Other type of indemnity ❑ Bond Insurance Waiver: the gned,have been made aware that the licensee of this application does not have any one of the above three insur ignatu 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By: Signature oi License(Ium er Type of PI ing License Title i L� 7 City/Town APPROVED(OFFICE USE orn,r icense um er Master Journeyman 0 APPR 100 North Parkway PO Box 15089 Premium Financing Specialists, Inc. ' Worcester,MA 01615-0089 A MISSOURI CORPORATION,HOME OFFICE,KANSAS CITY,MISSOURI (508)757-1628 FAX:(508)852-1245 PREMIUM FINANCE AGREEMENT CASH PRICE $2,066.00 AGENT INSURED A (TOTAL PREMIUMS) (Name&Place of business) ;Name and residence or business DUFFY INSURANCE AGENCY ALL AMERICAN PLUMBING AND DRAINS CASH DOWN j $723.10'. B ; PAYMENT 317 BROADWAY P 0 BOX 14 PRINCIPAL BALANCE j mm _. $1,342.901 LYNN MA 01904 PEABODY MA 01960 C ' (A MINUS B) (781)593-1200 (781)858-7725 LOAN DISCLOSURE Quote Number:1969881 ANNUAL PERCENTAGE RATE FINANCE CHARGE Amount Financed i Total of Payments The cost of your credit as a yearly The dollar amount the credit will The amount of credit provided to i The amount you will have paid after you i rate. cost you. you or on your behalf. i have made all payments as scheduled. 15.5 % $70.26 $1,342.90 $1,413.16 YOUR PAYMENT SCHEDULE WILL BE ITEMIZATION OF THE AMOUNT FINANCED: Number of Payments JAmount of Payments When Payments Are Due MONTHLY THE FULL AMOUNT FINANCED WAS PAID 7 1 $201.88 Beginning: 7/15/2009 TO THE INSURANCE COMPANY. Security:You are giving a security interest in the unearned premiums and,on commercial policies, loss payments which will reduce the unearned premium of the policies. Late Charges: A late charge will be imposed on any installment in default 10 days or more. This late charge will be 5%of the installment due. Prepayment: If you pay your account off early,you may be entitled to a refund of a portion of the finance charge computed by the actuarial method on a 360 day basis. The finance charge includes a predetermined interest rate plus a non-refundable service/origination fee of$16. �OLIC1`PREFJXt FECTIVE DATE ___ Et}L3LEF PpI tGIES `K COI7ERAF F'OL. F?REIJIIUM fi [,AND AMD NUMBEROF POLICY,,' >' •INSURRANQ-5 COMPANY AND Gt=NERAL,AGENT TRIMS PENDING 16/15/2009 MASS WORKERS COMP ARP ' ARWC 12 $2,066.00 f I I t I ._...............................__..............._ .................. 1 1 CHECK CORRECT BOX PERSONAL ✓ COMMERCIAL TOTAL$ $2,066.00 The undersigned insured directs Premium Financing Specialists,Inc. 4. Agrees to all provisions set out on pages 1 and 2 of this (herein,"Lender")to pay the premiums on the policies described above. agreement. In consideration of such premium payments the insured agrees to pay NOTICE: Lender at the branch office address shown above,or as otherwise directed A. Do not sign this agreement before you read it or if it by Lender the amount stated as Total of Payments in accordance with the contains any blank space. Payment Schedule,both as shown in Loan Disclosure,subject to the B. You are entitled to a completely filled in copy of this Provisions herein set forth. agreement. The named insured: C. Under the law,you have the right to pay in advance the 1. Assigns to Lender as security for the total amount payable hereunder full amount due and under certain conditions to obtain a all unearned premiums and,on commercial policies,loss payments partial refund of the finance charge. which will reduce the unearned premium which become payable under the policies listed above,as to all of which insured gives to Lender a D. Keep your copy of this agreement to protect your legal security interest. rights. 2. Irrevocably appoints Lender attorney-in-fact of the insured with full power of substitution and full authority upon default to cancel all Signature of Insured or Authorized Agent DATE policies above identified, receive all sums assigned to Lender or in which it has granted Lender a security interest and to execute and deliver on The undersigned hereby warrants and agrees to Agent's behalf of the insured documents,instruments,forms and notices Representations set forth herein. relating to the listed insurance policies in furtherence of this agreement. 3. Understands that the finance charge begins to accrue as of the SIGNATURE OF AGENT DATE earliest policy effective date. Page 1 of 2 (10107)Copyright 1988 Premium Financing Specialists,Inc. 9 06/12/09 EQUOTE-MAC X 7815937260 DUFFY INS AGCY PAS 01 _`CERTIFICATE OF LIABILITY INSURANCE >�TI:� 593.1200 FAX 781.593.7260 THIS CERTIFICATE IS ISSUED AS A MATTER OF IN 05/08/ O� urance-Agency,, Inc. C1NLY AND CONFER3 NO RIGHTS UPON THE CERTIFICATE uare ALTER THTHIS ME AAF�FOa ED gY THE POl�pW, e' Square An, NIA 01904-2602 INSURERS AFFORDING COVERAGE DIED A American U 'Ing and Drains HAIC S C/o Neill Ross nNsuaeRA Safety Insurance Company 39454 S Charles Streat INSUWR& Peabody, RA 01960 INSURER e: INSURER D: COVERAGES INSUAn E: THE POLICIES OF INSURANCE LISTED BELOW HAvE BEEN ISSUED TO THE INSURED NAMED ABOVE ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCl3MENIPFOR THE POLICY PERIOD INDICATED.NOTWITH,�TkNCiryG MAY I ES.AG THE TE LIMITS SHOWNAFPDRA BY THE I"ULICIES DESCRIBED HE 13 SUBJE RESPECT llT EITERMSTEXCLU ONS AND CONDITIONS OF SELF! HIS CErM POut~IES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIED OR LTR TYPE OF INSURANCE POLICY NUMBER ESE POLICY TION G6NERALLIABILfTY BP00011456 1z/15/2008 12 I5 z009 EACH I.nxlra X COMMERCIAL GENERAL LIABtLm / CH OCCURRENCE s 1 . CLAIMS MADE aocctua PRE c=man& $ 104 A MED EXP(Any am person) $ 10. PERSONAL&ADV INJURY S 1 0o0, G'tnrt,AVUREGATE LMR APPUES PER: 00C RAL AGGREGATE i 2 Onn, X POLICY jE� ! PRODUCTS-COMPJOPAOG $ 2 000,0 AUTONgIRLE UAMUTT ANY AUTO IAMBSINGLE LIMIT $ ALL AWNED AUTOS 6CHEDUL.00AVM BODILY INJURY HIRED AUTOS NON.OWNGD AUTOS AOD GARACC UAQIUTr ANYAUTO EXCEM1 UMBRELLA LIABILITY— OCCUR CLAIMS MADE Commonwealth of Massachusetts DEDUCTIBLE Division of Registration--_. RETENTION S Board of Plumbing.Exdirrzr`�.__._. WORKCRc OONP@f1AT(pN AND RUPL0YER8'LIABILITY �-- ANY P3tOP� RIPEARTUDEDD? t NEIL B Rte; fOFFIC U T I-� ' Ry bo 6 CHARLI=S�=E:t--i_ SPECIAL.PROVISIONS below OTHER PEABOOY;-]l ff 3 Master Plumber `= EBQRIPTFDN OF OPERATIONS!LOOATIONS/VEAICIE$f EXCLUSION8 ADDED BY END PROyr$IDN �f 0031: MWj3pECUCLPL15475-M 10 License No. Expiration date. Serial ,I`RTIFICATE HOLDER CANCELLATION DAOD,NiY OF THE ABOVE Ri>eD DESQRPOL K=BE CANCELLED BEFORE THE IMMUTION DATE TNEMp,THE al ER WLL,L ENDEAVOR TO MAIL 10 DAYS INWTEN RGTME.Ia THF NAMED TO THE LEFT,BUT FAILURE TO DO 80 BNALL IMPOSE 11110 08Lt6 City Of LOwel 1 r OF ANY'a PON THE INSURER,ITS ACENTS OR Attn! Sandy Ames P NTA Lowell MA A ° CORD 25(x009101) FAX! 97$ "6.7103 ` ®9 Z00 CORD COR ORATION. All righia r 11.d, The ACORD name and logo a reg- markLs of ACORD Date. . . . . . . . f NORTH 1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SSCHUsf� This certifies that,.,, has permission to perform plumbin in,Che buildings oft', ��� ��. : . . '. . . . . . . • at.// ".�/`fJ �—.�. , . .`. .... . . . . . . . . . North Andover, Mass. Fee/'...i,.-. Lic. No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # J t� 6307 Sg - g El 17 WATER CLOSETS KITCHEN 81 • !� � _ � NK8 � C ' LAVATORIES .Z BATHTUB � O -a Rt r SHOWER STALLS DISHWASHERS �r $ DISPOSERS a $ —A LAUNDRY TRAYS -p WASH. MACH. CONN. �• HOT WATER TANKS 4. '�ANKLES8 SLOP SINKS O FLOOR DRAINS C'Z 33 0 x OAS TRAPS E 1'1 O 0 URINALS r; DRINKING FOUNTAIN AREA DRAIN WATER PIPING N ROOF DRAINS BACKFLOW PREV, t O OTHER FIXTURES: 0 BOILER MATE GREASE TRAP r SCULLERY .SINK . I'.' a K3. SHOWER VALVE O, � G) BELOW Poll OFFICE 081 ONLY I FINAL 1N8PECTidNB 8KE_ T_ FEE PROOREBS INSPE0T10N8 NO. lAPPLICATION FOR PERMIT TO DD PLUMSINO UNDERGROUND ROUGH COMPLETE ROUGH FINAL INGPECTION PERMIT GRANTED DATE PLUMAINQ INSPECTOR M_ ASSACHUSETMUiNiFORM-APPUCATiF01 T TO DO GA FITTING (Print a Type)- _ �A44 W4��, Dat . P 4 dt '' y —�S 8u1dkV l� ��\ Owner".s Name-:: y/�V , Type a OcaVancy_ �'l46 New 0 Rte° Plans.Submitted:. Yelp a a- a: z h.• C. h C C. W J. 'Inc i .V Fv _. F" IC Z H Z C E o �f H < C C O= Z: Z Q 'IC C W C 16 sue,asw. :s�s'EMs14T- I _17F .1 ST FLOOR 2140 FLOOR SRO-,FLOOR. 4.TH FLOOR O- _ STH-FLOOR aTH'FLOOR TTH FLOOR- aTH'FLOOR_ Instaait oomlmny:Nww AdAc_, afs _ Address_5 5 k Q�,��c �'F Corporation � Zt M✓L D n.. n �... �.. O Party FkWCa Date. . . .. . .. . .. .. ... . Q WORTH pf o '"o <:.xhe requicerne A&d-,MGL-,CiL 142.• 3� 6 TOWN OF NORTH ANDOVER p 9 _ opdat..b • . PERMIT FOR GAS INSTALLATION �- Bond_ O . 9 SACHU5IrmuanoeEt•( ' .coverage required-by. This certifies that ,� . . . . . . . . (�j....c . . Peron walves this requirement. Gxck one: has permission for gas installation���1� � �• • •� 7 Agerco in the buildings of, at��l f . . 'r !•-f. -t...-. . . . , North Andover, Mass. �n wa tw and��to.dw bea`t.oi /.,; �� �will be incomprance wittrail�. Fee. .,- Lic. No. , �/ . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR S�� 14 Check# - or �tterG% 1 5002 31aCo. MLOW FOR OFFICE 2t ONLY FINAL INSPECTION 8KETCMEB PROORE88 tNSPECTION • FEE NO. APPLICATION FOR PERMITTO 00 OAOFITTiNO NAmit l TY.Pl.OF.B.UILDINO.. .. t LOCATION OF dLiLDINQ • PLUMSEA Oh OAIZFI'tTER �... _ • MOW ORAMD OATS 20,,,,_� QAS INswiECT61i Location No. Date NaRTM TOWN OF NORTH ANDOVER 3? � . 00 F 9 + Certificate of Occupancy $ �'�s'••°''t�' Building/Frame Permit Fee $ sA04 Foundation Permit Fee $ Other Permit Fee $ ti TOTAL $ Check # 5 (7/454-- 6 4 Building Inspector 4 V r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUII,DING PERMIT NUMBER: DATE ISSUED: //74� XX SIGNATURE: Building Commissionerffp§=tor of Buildings Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �© F Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(st Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record pp Name(Print) Address for Service ?b—,G!9- q;-3, ' Sr tdr—e Telephone 2.2 Owner of Record: e Name Print Address for Service: Y01 Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable E?' Licensed Construction Supervisor: License Number Address l Expiration Date ic Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 9 — Company Company Name Registration Number M Address r Expiration Date ppzy Signature Telephone , i f SECTION 4-WORKERS COMPENSATION(N.G.L. C 152 § 25c(6) , Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building 0 Repair(s) ❑ Aherations(s) 0 Addition 0 Accessory Bldg. R-- Demolition 0 Other ❑ Specify Brief Description of Proposed Work: X8' u+,I'rig iI.e.� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant I. Building (a) Building Permit Fee 6-M Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection .0 6 Total 1+2+3+4+5 6-1 o Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Owner/A orized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name -Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3 RD SPAN DIIvfENSIONS OF SILLS DIMENSIONS OF POSTS MANSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE f, 9 S k ,�, CQ_ FORM U - LOT RELEASE FORM Z"2-` 't C� , Q- 1�- o l INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT A� t/1/� �d-e PHONE LOCATION: Assessor's Map Number PARCEL—Q5 D SUBDIVISION LOT(S) STREET :B-e r S4- ST. NUMBER *****************************************OFFICIAL USE R 19N OF TOWNVENTS: NATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm � N-NI- S STREET t2 3 ,] X71 >✓`. 9.500 f F. 4S_e8 ddd0 ii. 5013 S.FI ! � S9 � I I •n_oo,i l.i I S� II e 160 f F I I I w I I ---------------------- 10,000 S.F. 15 000 S.F. Is ]5 IS e 105E 5+ ❑ _.. r 'cl 7,0OO S.F.I 7000 S FI 8250$.F. 8:.SJ S.F. III��__ 1111 - �.$`�OiFI 9.500 IFI 10000 S.F. 10.000 S.f. e t BEAD STREET C: ---------- A4 __—_— ,a4 I (so ❑ 62 46 LG J7 _49SSiF a?61 IF dl ---'d2 LLJ i 4000 S.t. —•. lJ I sT se 47 X ( I I i •- `_-J 10.000 f.F. I -�a , 655x_ 9,$00 IF 5 SOO 1 FI �.i.J 1475) S.f, 4750 5.F ❑� ._. (S aeo T.F. 0�:. L�7- 1 4 aj 75 Gz 'J ss 77 ---= S� 7c9x S.F 9.020 S.F. �—----� 70 G7 5Z 5730 SF I 9,000 S.F. 9000 SF,73 � r- i 6a 23 400 S.F. 23 40O S.F. 4000:.F i i I70 5 F 5000 S.F 4JOU T/ STREET SEE PLAT If 0 Ell -