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HomeMy WebLinkAboutMiscellaneous - 12 FOSS ROAD 4/30/2018 12 FOSS ROAD 1 2101047 000.0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGWORK CITY u e r MA DATE ( PERMIT# JOBSITE ADDRESS a55 OWNER'S NAME POWNER ADDRESS TEL i- � 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT �-�( CLEARLY NEW: [] RENOVATION:® REPLACEMENT: E PLANS SUBMITTED: YES NO 01 FIXTURES-1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM __I ___.) __,___. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _[ i DEDICATED WATER RECYCLE SYSTEM 1 [ ._ ..___i [ J �._._[ ._..___._[ DISHWASHER DRINKING FOUNTAIN _( ..--_--.-[ ._.-._ ..____►' _ _.__! [ _____1 _------ _ _[I_._._ FOOD DISPOSER FLOOR/AREA DRAIN _1 1 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I [ � _._.—.[ _ . URINAL WASHING MACHINE CONNECTION ! � W_( [ _ WATER HEATER ALL TYPES WATER PIPIN --..__- _ 6THERE_ o'L _ _ —� 1 ( I [ . ----! -------I _A= _77.1 ! ... -� f --[ _I I ..._._._.. ___._( ._._-_j INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY p 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: OWN _I AGENT I® SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are t ue and ac rate o b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in o p i ce wit all e -e provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ' ! �, (LICENSE# SIGNATURE IMP© JP D CORPORATION Fjl# a S PARTNERSHIP M# ;LLC COMPANY NAME Lam cA S ADDRESS CITY�— ASTATE ZIP FAX S A. IDELL _11 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY , ca'� MA DATE; PERMIT JOBSITE ADDRESS F 5 S _._ � OWNER'S NAME j OWNER ADDRESS TEL FAX i — TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL rr RESIDENTIAL CLEARLY NEW: ? RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 7, NO APPLIANCES-1 FLOORS BSM 1 2 3 4 5 fi 7 8 9 10 11 12 13 14 BOILER ----f BOOSTER �_ _. __.- _I CONVERSION BURNER COOK STOVE -- -` f. i - DIRECTVENT HEATER i =f F- - DRYER I FIREPLACE FRYOLATOR i FURNACE GENERATOR GRILLE _ ___ __ _. INFRARED HEATER — I LABORATORY COCKS _ MAKEUP AIR UNIT ' i i �_ 1 `� f° _ _ OVEN I :I. _ � � POOL HEATER , ( � , ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER - UNVENTED ROOM HEATER --= WATER HEATER t i OTHER — — _- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ N0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ? OTHER TYPE 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: 0 N 1' AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a th b st f my knowledge a true nd accur and that all plumbing work and installations performed under the permit issued for this application will be in complia ce with a ertin o pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. FLUMBER-GASFITTER NAME;William LeSage LICENSE# 9147 _! SIG( E MP% MGF i! JP i _ JGF LPGIL�jCORPORATIONi# 3256C f PARTNERSHIP #' LLC # 1 COMPANY NAME:'Lamco Systems,Inc. ADDRESS;4 Cur mmings Road CITY i Tyngsboro � Y _ STATE: MA lZIPI01879 ITELi978-649-6868 FAX'978-6494713 .a CELL;978-375-3363 ;EMAIL i r The Comniomvealth of Massachusetts a. 1 Coiigress Street, Suite 100 BOstgLi MA 02114--2017__=__—___-- __ __—._...___ _...._ __.._..:•__ -.—— -----��,.; _ _ _, _ . •.-:_ -= www niass.gov/iu[[. Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information )] Please Print Legiblv Nalrfe(Business/Organization/Individual): LC-Xn,)eo Sal Sfems, ZnG Address:- rnn,r"��yS 1�0 L V City/State/Zip: , r s prp Mpr 01 Fs_)9 Phone#:- 9'7�r-( Lj - 3 Fr J,1R Arc yo n employer?Check(lie appropriate box: Type of project(required): I. 1 am a employer with _employees(full and/or part-time).* 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in $, ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9• ❑Demolition 4. I am a homeownerand will be hiring contractors to conduct all work on m 10 Building addition ❑ g y property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.0 Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section belowshowing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compeirsatioii iirsitrance for my employees. Below is the.policy and job site information. Insurance Company Name: , !�+ Gr IC, ��t, t+t_,(— Policy#or Self-ins.Lic.#: �G j_, O(Dog loci L,3� Expiration Date: O I 3 Job Site Address: City/State/Zip: , 4-40 V ;/M Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage.as required under MGL c. 152,§25A is a criminal violation punishable by 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 tip to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerIA,corder the pains mid penalties of perjttry that the information provided above is trite and correct Signature: Date: lm Phone#: 91 11� 31R 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. ElectricalInspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• ACO® DATE(MNVDD/YYY1� CERTIFICATE OF LIABILITY INSURANCEF416/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN:THE ISSUING-INSURER(S), AUTHORIZED. REPRESPNTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does.not confer rights to the. certificate holder in lieu of such endorsemen s. CONT PRODUCER NAME: Eaton&Berube Insurance Agency, Inc. PHONE AfC No.Ert:603- 82-2766 afc No:603-886 30 11 Concord St EMAIL Nashua NH 03064 ADDRESS:C eaurega_rd@eatonberube.com INSURERS AFFORDING COVERAGE NAIC# INSURERAUtica National Ins Co INSURED LAMSY INSURER B Ian IC Charter Lamco Systems Inc INSURERC: 4 Cummings Road INSURER D: Tyngsboro MA 01879 INSURER E: INSURER F: CERTIFICATE NUMBER: 1 815 REVISION NUMBER: COVERAGES 13688 8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID-CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MM/DD LIMITS A GENERAL LIABILITY 287314 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 X DAMAGE O RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO- LOCSINULE $ A AUTOMOBILE LIABILITY 287321 411/2016 4/1/2017 Ea acadant $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per aaadent) $ AUTOS AUTOS X X NON-OWNED PP OPcEcR nDAMAGE $ HIRED AUTOS AUTOS $ A X UMBRELLA LIAB X OCCUR 287325 4/1/2016 4/1/2017 EACH OCCURRENCE $2,000,000 i EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$10,000 TH $ B WORKERS COMPENSATION WCI00096904 4/1/2016 4/1/2017 X WC STATU- PR AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE[N—] N/A E.L..E'ACHACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 if es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Workers Compensation Coverage for NH&MA. No Excluded officers.Additional insured status applies when required by written contract per Utica National Insurance form#8E3799(02/12)Contractors Liability Extension Plus Endorsement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. c/o Lamco Systems 4 Cummings Road AUTHORIZED REPRESENTATIVE Tyngsboro MA 01879 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i r ���OM11�fbNWEI�ITH'�� M� i��NC1S�FF;� :.; jssl1�S TW Fri l_OWIT1 11t tU LIGE MU-' STV A MAST 1;PL�IM ER t~ WILLIAM J LI=SAGIi AIiATT WANRi3 � 3 it LITjUE-TOO 1SifA t# 460 6Q4 rf 4 ti •Ger PemR 820245-Vbw x 13 75:9771 F 3r C htt�s:,I%nord)a-doverma.viewpointcloud.tom%#/reccrds/20245 q s -- .. _ __ --. .. _...... _.._.._. _._._.... . _... Town of North Andover,NAA 4 Se arch - 20245 -Gas Permit-Replacement of Existing Fixtures/Appliances(Commercial of Residentiall - - - TIMELINE V submission received Your request is in progress May 10,2016 at 11:20am We'll lee you know of any updates via email.Feel free to check the _ status at any time by coming back to this page. Gas Permit Review - Review by departmental staff j Permit Fee l Fosse ........ _ - _ (.� Pa;gnent v _ . let mlt issuance _ - r estD, r).,;.!fNV nc m ApPkant Locanan William LeSage 12 FOSS ROAD,NORTH ANDOVER,MA Owner BOWE,CHRISTOPHER T AAtttarhments Myj -OTOS3iJIOOIF Tue May 10-2016_15:31:.PDF Tuesday, May 10,2016 11:31 AM IM*K nbWv Pma 120297-V X r.. — ---_—_...--------------------._..__........__......_.._....._........ -- — —--- ------------------------------------------------ -----------_ ------------------- --- — hU:/ftvtw&verma.viewpointcloud.com/���#/records/20247 Town of North Andover,MA Q e ercn. �- 20247 *Plumbing Permit-Replacement of fixture/Appliance(Commercial or Residential) TIMELINE Submission received JYour request Is in progress May 10.2016 at 11:32am { `j We'll let you know of any updates via email.Feel free to check the status at any time by coming back,to this page. Plumbing Permit Review Review by departmental staff .. .. 0 Perniit Fee - Payment �! Permit issuance - .. .. . Dot.rrenc GO ¢°�. Appli— Loon William LeSage 12 FOSS ROAD,NORTH ANDOVER,MA - - - BOWE.CHRISTOPHER T Attachments t -OT2HU91001F Tue_May_102016-15:37:.PDF - - �,J i i Tuesday,May 10,2016 11:37 AM Date.....;.. ............ r10RTF/ 3r °oma TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 'SsgCHUS�S I This certifies that ....... .. w!Jl has permission to perform ......,. .:... .....i �G7...... ......"""" wiring in the building of..... {^'. ............................................................................. at ............', � 5............................................................... .North Andover,Mass. ........................ Fee......1�45.........Lic.0��.E..."' ELECTRICAL INSPECTOR Check# 12878 —/ � t THE COMMONWEALTH OF MASSACHUSETTS Official Use 0 ly No. Pertnit 0 -6 y Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy&Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12::00 (Please Print In ink or type all information) Daae /U 7,19 6 r/,I,— To STo the Inspector of Wines: Town of North Andover The undersigned applies for a permit to perform the electrical work d bed below. Location(Street&Number o2 O 'JR Owner or Tenant !'1� 0 Owner's Address1 ,2 D Is this permit in conjunction with a building permit Yes No • (Check Appropriate Box) Purpose of Building d UtilityAuthorization No. Existing Service gt Amps /ZQ J4 gVoits Overhead • Undgmd • No.of Meters 3 New Service Amps Volts Overhead • Undgmd • No.of Meters Number of Feeders and Ampacty, Location and Nature of Proposed Electrical Work JAGO aw J& _ If Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above In No.of Lighting Fixtures Swimming Pool and and Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di osal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices • Municipal • Other No.of D ere Heatin Devices KW Local Connection No.of No.of Low Voltage \ No.of Water Heaters KW Siuns Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND = OTHER = .(Please Specify) Estimated Value of le ce Work$ / 106n (Expiration Date) iWork to Start ,r¢�s*� Tpection Date Resquested Rough Final b Signed under the P alt of peQury; FIRM NAME , LIC.NO. i Lice W(� 1bCe� Signature LIC.NO. . D ; tolok "fl I Bus.Tel No. ? S j - 2.29- 8 410!r Address M dt AIt Tel.No. OWNER'S INSURANCE WAIVER: I am aidare that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that mysignatureon this permit application waives this requirement. Owner Agent (Please Check one) -A (Signature No. -PERMIT FEE $ (Signature of Owner or Agent) +. r ... � _ - - _.� 'r n _- ( � r 5 � � ' _ F , � • tP. r. 1 � 4..s. � � .rA 5 4 _ ' . . .� The Commonwealth of Massachusetts Department oflndusWWAceidents I Congress Street,Suite 100 Boston,MA 02114-20I7 www mass gov/dia Nklorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. To BE FILED WITH THE PERMITTING AUTHORITY. ApplicantInformAtion PIease Print Legibly Name(Business/Organization/Individual)' r 1 Address:_Rob LA.2rxyvxiirx - City/State/Zip:. !'k 1 , MA -D-1 901 Phone#: 1 ;79 -; $ 14 og Are you an employer?Check the appropriate box: of project(required):, � 1eCtr(• p moi ed)=. l$1--employ-with_, cmployccs(full aund/or part timcj x 7. New construction 2. proprietor❑1 am a sole PPn or partnership and.have no employers working for mein any capacity.[No workers'comp.insurance required_] 8. Remodeling: 3.E)I am a homeowner do` all work myself. 9. ❑Demolition mg ysel 1No workers'comp.insurance required.]t 4.[]l am a homeowner and.will be hiring contractors to conduct all wozk on my,property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or arc sole 11.❑Electrical repairs'or.additions victors with no employees-prof � y 12 • Plumbing ai❑ g rep is or additions. 5 i am a general contractor and T have .❑ gen hiredthe sub-contractors listed on the,attached sheet These sub-contractors Have employees and have workers'comp.insurance. 13.❑Roof rePairs b. We area corporation and its officers have exercised the right of exemption ❑Other ❑ gh ption per MGL c. 14. 152,§1(4),and we have no employees: No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t homeowners who submit this affidavit.indicating they arc doing all work and then Aire outside contractors must submit a now affidavit indicating such_ tConhactors that chock this box must attached an additional sheet showing the name of the sub-0ontractors and sista whether or not those entities have employees. If the subcontractors have employees;they must-provide their.wotkors'comp_.policy number. I am an employer that is providingworkersI compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name-1+ `�„� n`�rf t`�c-e - Policy#or Self-ins.Lic.#:_ t/V C. �'� ~] g(� Expiration Date: -1 ' � Job Site Address:. o_7� � ( City/StatelZip: n(�D�(Jl M01 gGl� Attach a copy of the workers'compensation policy declaration.page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c 152,.§25A is a criminal violationpunishable by 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$250.00a day against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage:verification. I do hereby under the pairs and penaMes of perjury lhat the dnformadon provided above istrue and correct Si attire: Date: Phone#: f�. D 90, mal rise on . Do OfJic ly not white in this area,_ to be completed by city town o fcrai City or Town: PermiVUcense# Issuing Authority(cirele one): 1-Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ELECTRICAL DESIGN PV MODULE RATINGS Ca)STC SOURCE COMBINER RATINGS INVERTER RATINGS 0 Tempgatures INVERTER MODEL:Enphase Microinverter m MODULE MANUFACTURER: Trina Average High:28°C MAX OCPD RATING(A):20 MODEL:M215-60-2LL-S22-IG MODULE MODEL#:TSM-260PA05.08 Record Low:-28.9'C OCPD AMPERAGE RATING(A):20 MAXMPOWER @ RATING(V): C W):)225 ' LUQ G OPEN-CIRCUIT V VOLTAGE(Voc): .6 OCPD VOLTAGE RATING(V):240 NOMINAL AC VOLTAGE(V):240 I. 0 2 40 OPERATING VOLTAGE(Vmp): 30.6 0 W OPERATING CURRENT(Imp): 8.50 NOMINAL AC CURRENT(A):0.9A Q,^ 2 X#10 THWN-2 Wire BLACK MAX BRANCH AC CURRENT(A):9.9A/6.3A SHORT-CIRCUIT CURRENT(Isc):9.00 2 x#10 THNN-2 Wire REO MAX BRANCH OCPD CURRENT(A):20A 0 j A MAXIMUM POWER(W):260 2 x#10 THNN-2 WHITE V LL 0 Voc TEMP COEFF(%/eC)=-0.32%/*C N p Isc TEMP COEFF(e/deC)=-0.05%/eC 1 x#6 THWN-2 EGC ^ 2 N PV LOA d Q 1"EMT INDOORS os 7 WIRE$ (PVLC) E m H c » 0t End-Fed Branch of 11-M215 Inverters 0 a z m AN leW el 11 wn.I•.enrm.a M we elrcu.nnu.n T8µ260 W.Imum.uyN hWt- .M0.6A"n.RIP-1 }6M-280 T8M•zeo MM-260 0 PA06.08 " PA06.08 PA06.06 0 PA06.08 l.� J-box / p6ee Enpleati En661He Enpes' 1SA �\ �� O L Z zll zu a lxu s LLca ,` End-Fed Branch of 7-M215 Inverters 0 TeW e6 TP.nW.e•rvi•M.GMAOeftUkbMen 7Hµ260 01..I,—11u1 W1 eun.n10.0Amu grp.nN 7Bµ200 1HM-260 TSM-260 /A PA06.08 0 PA06.08 0 PA06.08 PAU08 VI Enpiepe En E^��. En{fui. L08ID CL dt SB. 21 •2121 12D au*t. ML:., UTILITY AC DISCO NETER C J ICU C=D INSIDE 0 NOTE:A GEC(grounding electrode conductor)is AC DISCO O FUSIBLE required only for M215-60-2LL.It is not required ENVOY COMMUNICATIONS OUTSIDE 60A RATING Z Q for M215-60-2LL-IG NON-FUSIBLE 25A FUSES GATEWAY GF222N 30A RATING GNF321R L2 L N ETHERNE CONNECTION TO 1x#10 THWN-2 Wire BLACK BROADBAND ROUTER 120 VAC POWER 1 x#10 THWN-2 Wire RED CABLE 1 x#10 THWN-2 Wire WHITE Symbol Conventions: Y00 1 x#6 THAM-2 EGC 2-Pole Licensed Electrician Assumes All Responsibility For 1"EMT INDOORS ^— Circuit Breaker2110ADetermining Onsite Conditions and Executing 4.]ODBES T MSP , rs2 Installation In Accordance With NEC 2014 Codes ' 0 Fuse e/e Visible Break fir 1s e% Knife Switch AC DISCDNVI NECT RATINGS CANMJIT SIZING SERVICE PANEL RATINGS e% 1"PVC OUTDOOR MEP 6P ND_-GOULD DISCONNECT AMP RATING(A):60 1"EMT INDOOR BUS AMP RATING(A):200 DISOONNECT VOLT RATING(V):240 SERVICE VOLTAGE(V):240 oan Equipment NEMA3R MAIN AMP RATING(A):200 Grounding BREAKER RATING(A):25 Conductor 7- MODULE DATA DETAILS THE Universal' MODULE TSM-PA,D5.08 6MIViIEHSICdNSOPP9V'MIDiILE EL'ECTRICALDATA(STC) m � TTnIYmTTa Near<Pgv+er:YAr�tls-F'ws'aWpN ? � 3l5 l'. 250 . � 256 �'. 260 � sal WDo xkc+iny AM�>Li1aUm FOu`+rter'N1oltaige�J.,w(w1 ! 2519 80 3D 5 30.+6 d. 0 g r� O rAaxlTfxurlti Power�uTn�nr•i E^a� �;��° a s.�'. m �zs� �> s:, � '�� t 09 a.:.w.n F— CpenClrCiula Yglfgge A+x CtiI 37'�B ,- 36A 38.i 38.3 N W CI auwu 'Shafr r7 Ir C neK i 8 71i B'19' �areaawxoa' i V.., 0 tdodwte Er6cCency rI®d .. :rs.n r6 3 - p5.4 LL 0 SIC:J—dldnoa 10001W �.Cel:Tem ! v N parah+ra 23!C.AW raam Axil.sacflaudfng to EN 40904.3. IV ;l IeAflciancynxMrciian af4.15%ai2C4kWA-'=—ding�io EM 60404:1_ ELECTRICAL DATA(NOCT) = 4) +.k?sdmum Pgry.er Pw+�a Iw'+PM 9a2 4afa _ aa+o 193 � fel! 'O � p ),WldbnUM Pop.ti f'St�alrwd�� U Q Z d R.tcximum flowbri�U6aent-1.�ar({+y. fi u9 f6.sb !l 7+r G,�4 rbr nux c"°!e j:C1t j%-If If Mglrgge 5�'swc("vj 33 1 3S2 .. S 3 3-_d r. ""` 6!+ t^IrcluigC►ifrend-fix.(Fy} 7AF r0 ! ,5.99' T Y27 NOCF OnaaSwrree at 800 Wfmr,Arnbienl Tam6amaluro 20`C,Wl rd Spaod i mh_ 9�2 kill MECHANICAL'DATA T��� O ear-k ufwxw SG'lor per9s Mu�)llCryatarllna Y56x 956 InMj(�rnghagsM Vl At CbR gmYeTSfPtlgn 34 Cerls(81Oj ` IR \—V d sodWle ns*,It rarst9 r 932 35mm idm 4 3405it 37 6Tcheaj w •/ `QV �VC&rgh6 �a>�Aaag(ai.D�rK7 J //� ' 700f'�D00 rT>rh 7 Mm(4 r3lrvChesj+rlgnTransmiss8on hR•Cpaled TeM jar"Gfass ^ O i5nome Black Nngdked AIL"inrum A@qy, cn co VV w - j✓ a,+_ �'+. ff�i { ll >«4 t� 8�/iN4�"m +�k+,. 3� Iyi t..�: �,/� co Ca�4Jed PhgtoMgltcl)_reCrnglggy Cable.e..p�mm (8 Ob6 inches O rpQ110QDfs+m o �/► r-'.1'CN9RYEwk"?P'P`WM�QIDirI„E(2IVSW) G''x?nJ'leClgfx.-,.,.�...<.�, ..`.....� -.,. 4 VJ ii0.,.., ... Z TEMPE.RA'PUR:E RATINGS WARRANTY' &. 800Wfrw 7 Nom9nal fSpefgringGall 44 Cj32' j 9QYemr Prgduo <dm Tempercruua(NOCT} Wgrkmgnshlga tYcrraonty --. gg r= 9'^ T�yplXa�urp,�n71 SS a T6empera9ura C�aelilcdent qT V R..3256I°C � (waa Mfa toproduc =n far daata y° j !riPerfsr$9Cfe>�r4l�cr GpY1Gf .na,. ... a, ry C: C7 O..Qm pf74m :1f/.m 96.m J. f/v MAXIMUM RAn*GSd. �.y Operatlgndi8emparatuma 6d-!B5sK � y.Mcmds'nufn SysiprN :�QrYRrexCflUil" r YC19gge Mmic$er9es Plise karBTg�� YSA'i ... E 'CETiTI€MAT7. IO.N .PACKAGING CONFIGURATION 3 o roGn �,i,ocnulespevwbglc30u9n •� �Mgdulesper�a6 cgner896plecss ARRAY DESIGN / SITE DIAGRAM HEIGHT OF HOUSE PANEL ORIENTATION (TRUE) ROOF PITCH (DEGREES) 225" 2130 300 Quick Mount PV Solar Flashings FOSS ROAD 0 will be used on every roof penetration DRIVEWAY F-39.05"-4 ***ARRAY LAYOUT IS NOT TO SCALE*** a O Q io Oa, � o� UTILITY METER °' W PLACE PV LOAD CENTER OUTSIDE TO THE LEFT OF THE _ W c40 LGATE 120 UTILITY METER, THE CUSTOMER IS RESPONSIBLE FOR = N o AC DISCONNECT Z MOVING OBSTRUCTIONS 3' FROM LOAD CENTER d •• a LOCATION; PLACE ENVOY MONITORING EQUIPMENT TO c.� c 2 c THE RIGHT OF THE MAIN ELECTRICAL PANEL u� PROPOSED CONDUIT THROUGH = e Ix z a t ATTIC,DOWN EXTERIORTO PVLC;ELECTRICIAN WILL FIELD PIPE TO BE RELOCATED VERIFY E I � = � QUICKMOUNT PV ` '� 34'-8" (416") PORTRAIT/LANDSCAPE -> ca t Total's 12 TYP. t Total#of Panels: 18 .� Total#of Splice Bars: 8 C L t Total#of Bonding Jumpers: 8 (n 12"TYP. H Total# End Clamps: 14 - I Total#of Mid-Clamps: 36 X . — See Engineer's Structural Assessment O z ca c. 1-14 0 E Customer Signature: Date: "� TYPICAL ATTACHMENT DETAILS —THIS EDGE TOWARDS ROOF RIDGE RACKING COMPONENTS • ITEM NOT INCLUDED 2,25 NO. - DESCRIPTION QTY,/SOX — -- -- - - -- ---- -- 5 1 FLASHING,9"X 12"X,040",5052,Mill 1 =. --. 1,29 2 OBLOCK,CLASSIC,A360,1 CAST AL,MILL I '; M I"It 3 PLUG,$EALI'NG,5110 7/6',EfDM 10`8 SS 1 1 4 LAG SCREW,HEX HEAD,5/16"x 5.1/2",1$$SS 1 1.255_T WASHER,FENDER.,5116"ID X 1.1/4"OD,IN SS 1 3.00 2 4.50 . r pull-out lumber Lag Bolt Specifications Specific Gravity 5116'shaft per 3"thread depth 5116"shaft per 1"thread depth - Douglas Fir,Larch .50 798 266 Douglas Fir;South 46 705 235 Engelmann Spruce,Lodgepole Piste(MSR 1650 f&higher) .46 705 235 Hem,Fir .43 636 212 Hem,Fir(North) .46 705 235 Southern Pine .55 921 307 Spruce,Pine,Fir .42 615 205 Spruce,Pine,Fir(E of 2 million psi and higher grades of MSR and MEL) .50 798 268 Next Step Living Inc. Quick Mount PV REPORT FOR AITTACH ENT next step lIVI#1TM Module and Roof QMSE-LAG:QMPV E-MOUNT SPACING— home energy solutions Attachment Detail WITH LAG BOLT � III Q* Departm rit O �Ru retrctmffdtnCr r�,egcdti'Jf}s , Lice c ;�Superiis„- : - nse: CS-094414 ELW 240 C .RI,TSLE -BE-PP06 X4 6111-78 R- ell i _ 9 siorter E”piratien . ._ '98/04120?8 II Office of Consumer Affairs 8 Business Regulation � SOME IMPROVEMENT CONTRACTOR Aegistration: 178000 Type: -;Expiration: 6i012016 Corporacion STALKER ELECTRIC,INC. WILFRED STALKER. 400 W.CUMMINGS PARK S TE 17 � r_ W&ORN. NIIA 01801 t tidersecrecar}' Fold,Then Detach Along All Perforations COMMONWEALTH OF: MASSAOHU�E�`t'�. .sa 't a i3 _ C•. `gti HI.. a 1. r-_ XL-T BOARD OF . `elrii®NItV ,'fH ®!P ELECTRICIANS 121 1,$ e ISSUES THE FOLLOWING LICENSE AS A s -aF REGISTERED MASTER ELECTRICIAN : EL€Gi"RtCtANS . w ISSUES THE FOLLOWtNG" s :R. `JOURN.E L t CENSE. -STALKER ELECTRICAL CONTROLS INC YMAN ELECTRICIAN u WI LFRED;:;F::STALKERr Z Si.AWA1 A STALKER 6PER N T DR . X — 9 K I ERNAN'-AVE STRATHAM NH 03885-2222` , 14356': -A--` '07%3111-6 93540K X1.1 LM I NGTO�; 14A 01887-322. . _ 2. 7 32.2-9 a I _ a- 22S 1 Date........ .................. ............... TOWN OF NORTH ANDOVER . PERMIT FOR WIRING CHU5�� This certifies that .. � Res ..rn..P..c......................... has permission to perform ..... +.n. ,,, ,�/1... . ................................................... wiringin the building of......................W... -.............................................................................. 4 at ...:.. .........�'1`"l,) ......... .....................................North Andover,Mass. Fee..3(3.!7:77 .Lic.Not?.153... ...................................... .............:... ........................ ELECTRICAL.. INSPECTOR.. Check# � 2-1-,4 3138 �I M r � 1 � � � � ; � S }r' �m �G COmmonweahk o f Waaeachusetb Official Use Only c� Permit No. ��I �� y•' 2epartm.ent of-7ire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: o2Lo?S/l (o City or Town of: /V p f-(A A.-x doV-f-f- To the Inspector Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /a FOSS Y_a Owner or Tenant Ur C S e"Act LAU,-C, RD w-C Telephone No. Owner's Address a S Ki Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service aAE Amps 1 U / 7RO 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: 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 Emergency 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 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KWNo.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKN 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 of Electrical Work: 2?00- 6'0 (When required by municipal policy.) Work to Start: S Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VER GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove page is in force,and has exhibited proof of sa e to the permit issuing office. CHECK ONE: INSURANCE Q BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on t s applic ion is true and complete. FIRM NAME: N a d-et/t Ir1tc"4cG Jq • LIC.NO.: a )S$3A Licensee: DCAAv\,U yq„,4--,&I—S Signature LIC.NO.: (Ifapplicable,enter "exe pt"in the license number line.) Bus.Tel.No.•�79 I65 r 72 00 Address: 11 Mt td,(2S-0,X Avw. S+e• I D W 1IV"I -r)v\ WLA- a I V 3 7 Alt.Tel.No.:978 W Y 83 Yy *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 ❑own is agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �(7 �.., � I 9I-��-� � 9 � �N� v' The commonwealth ofmassalchasetts _ Department ofIfidustrialAccldents M 1 Congress street,,Suite 100 Boston,AM 02114 2017 www.rnass gov/dia Workers'CompensationlnsuranceAffidavit:7BuaXders/Con.$racLoxs/EXeciOcian8Nlumbexs. TO BE RMBD WITH THE)?FP HTTINC'.A UTROMTY' Please Print Le 'bl Applicant Information rr' Name(Stitsiness/organization&divid,,ui dQ OU —I•eC.t�iC 1rtC• - Address: I I At 16 S�- sc 6"v i [e I D City/State/Zip: (/�t'+nn�v� tv Are-you an employer?C&e kt&appropriate box: Type of project(required): employer with �p: employees(full and/or part tune).' 7. [�New construction 2. I am a sole proprietor or partnership and have no employees workurg for me in. 8. Remodalirig any capacity.[No workers'comp.insurance required.] 9, Demolition If]I am a homeowner doing an workmyself,[No workers'comp.insurance required.]t 10❑Building addition ¢. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 dElectrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole ; -l2:6;mumbiir�'xe airs or adchtiox�s .�..� 5.FJ I am a general contractor and I Kaye hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These snb-contractors have employees and have workers'comp.insurance. 14.❑Other 6,El We are a corporation and its ofCxqers have exercised their right of exemption per MGL c, 152,§1(¢),andwe$ave no.emplaYees.[Nrs'comp.insurance required.] o worke *Any applicant that checks Soap#J must also fill out section below showing their workers'compensation policy information. i Homeowners wfio submit#his affidavit indicating they are doing all work andthen hire outside contractors must submit a neer affidavit indicating such- -ug that check ties 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-conlraclors liave employees,ley const provide their workers'comp.policy number. worNTS'compensation insurance for my employees'Below is the policy andyoh site dam an erriployer that is providing information. � r Insurance CompauyName; ExpixationDao� 3 �7 Policy#or S elf-ins,Lic.#: -76 W i G G D (0 a te: ' 1 a rob Site Address: 'S IC cl City/State/Zip: fob Site a copy of flue Workers'compensation policy declaration page(showing tine policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation.punishable by 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.A opy of ibis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vexif�cation. lrclo leer eby certify uxa the res andpenalties®,�`pei7"l'�treat the inforn2ationpr ovicled above is t�`and correct. Date: !° sign . hone# 7 659 7 Z 00 Official use only. _d7o not write in this area,to be completed by city or town official.. City or Town: Permrit/License 9 Issuing Authority(circle one): BuildingDepartment 3.City TOwxx Clerk 4.Electrical Inspector 5.Plunnbinglnspector 1.Board of Mal& 2. 6.Other Rhone M Contact Person: . mORRI t�IWEALTH_ OF N9ASSACHUSfsTTS ErLEcwTRl C rAn1s, y 1551{ 5 A THS �OLGOW,I NG" L tENEr ASt " R>r S'I EI D Ma<STER EL CSR 14 b lMOIE .N ELECTRIC fNC N`DANNY R'ISDS 3 x" � ill R GRtIV ll{ vI ffi NqT- f �lA 01887 i11 X21583 A' '� ,- d /3`116x 50450 1�� .__ n:_;-"` _d":t?�,�`*w.)S,M...., •_.�.�,a.."_',¢ ...ter, ._.�moi._ r.. ', �=rs*�i I Date..�.�... .[ ................ OF r►OR711,� TOWN OF NORTH ANDOVER O 9 PERMIT FOR WIRING ,s3ACHU5�t This certifies that - � � •�� has permission to perform ...�... ... ��?........... �..�' I.......` A.....;�c,�................. K.W wiringin the building of........ .. ........................................................................ s at North Andover,Mass. ............................................... Fee..Q5 ..........Lic.N'?CIC) ELECTRICAL INSPECTOR Check# ►11 1.3072 -/ ( � : Docu5ign Envelope ID:OE9324AE-40F6-43SE-BBrC66-03AEDB��40122C s C cr» son sa a a Official Lase Only • I�o1�-I Permit No. 2'f 0/nv Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the 4iassachusetis Electrical Cotte(I1"EC),$27 C1%4RR 13:00 (PLEA-�E PRI_VT IV INK OR TYPE ALL INF OI�YL�TI�iV} Date: O\-O�q-�10 City or Town of N nc*n !P�n auy e- - To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)_ — OwnerorTenant bUW2 Telephone No.q-13,Lool-199Io Owner's Address Is this permit in conjunction with 2 building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building `16�,I X Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps I Volts Overhead© Undgrd❑ No.of Meters t Number of Feeders and Ampacity ` Location and Nature of P aposed Electrical Work: Lf1t r{'w i 1$ 3>V cAac VcAoe4�clon ,1 i com lesion&&e.jollawing tablema be waived ,the Ins for o 1!ices. NO.o lotal No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans `Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA A Yen_ o. mergency ng No,of Luminaires Swimming Poor d. rnd, ❑ Batte Units No.of Receptacle Obtlets No.of Oil Burners EIRE ALARMS No.of Zones and No.of Switches No,of Gas Burners o.Initiating Devices No.of Ranges No.of Air Conn. Toota No.of Alerting Devices eat ump .>... _::_ . ....ons. o.om h No,of waste Disposers Tots ls• Detection/AlLyfla Devices unicipal No.of Dishwashers Space/Area H1.ating KW Local E}Conne rs Other No.of dryers Heating Appliances KW urrty s: No.of ices arEquivallent ( No.of Water o,o o.o Data Wiring: ICS Heaters Signs Ballasts No.of Divices or§gjftalent No,Hydromassage Bathtubs No.of Motors Total HP ons W.11`109: No.of Devices or tr'rxa7ent OTHER: .4nach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work 41`600 (When required by municipal policy.) Work to Start: Inspections to he requested in accordance with MEC Rule 10,and upon completion.. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z, BOND ❑ OTHER ❑ (Specify:) I certify,under the Prins malt&of ty,that the information on this rrppticirttvn is true and corrgtlera FIRM NAME: r a LIC.NO,: 279' Licensee– ) `o- `Y 11 5 Signature LIC.NO.:e,06 ''' ,a r A, afappiicabiz,ewer..exempt„in the license n ber line.` Bus.`Cel.No.,J9?`!n 2.f.�.-y25-r Address: ra._. Alt Tet,No.- Address: 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)El owner,,.1 owner's agent. Owner/Agent orPERWT FES':$ Signature Telephone No. 1 - j .,.i �► ELECTRICAL DESIGN W PV MODULE RATINGS 0-STC SOURCE COMBINER RATINGS INVERTER RATINGS Q m TemMratureS INVERTER MODEL:Enphase Microinverter m � MODULE MANUFACTURER: Trina Average High:28' C MAX OCPD RATING(A):20 MODEL:M215-60-2LL-S22-IG T_ MODULE MODEL#:TSM-260PA05.08 Record Low:-28.9° C OCPD AMPERAGE RATING(A):20 MAX DC VOLT RATING(V):45 W Q O OPEN-CIRCUIT VOLTAGE Voc : 38.2 MAX POWER @ 40°C(W):225 ' Q ( ) OCPD VOLTAGE RATING(V):240 NOMINAL AC VOLTAGE(V):240 a O o, OPERATING VOLTAGE(Imp): .50 NOMINAL AC CURRENT(A):0.9A r 0 W ti OPERATING CURRENT(Imp): 8.50 N W SHORT-CIRCUIT CURRENT Isc :9.00 2 x#10 THWN-2 Wire BLACK MAX BRANCH AC CURRENT(A):9.9A/6.3A 9 d) MAXIMUM POWER(VV):260( ) 2 x#10 THWN-2 Wire RED MAX BRANCH OCPD CURRENT(A):20A W 0 O 0G 2 x#10 THWN-2 WHITE Voc TEMP COEFF(°/d°C)=-0.32°/D/°C U N 0 1 x#6 THWN-2 EGC �1 1 L2 Isc TEMP COEFF(°/D/°C)=-0.05%/°C 1"EMT INDOORS �� M ceHTER d a � Z r- 7 WIRES ----------------• --•---- ................... (ENTE) E IN /J 2 .. 0 a) I­ -------- C i ' d' r---------•---------------' O t End-Fed Branch of 11-M215 Inverters Q z a T°ni ai 11 panels ­--d m AC—cu e­­h �1 T8M-260 Mavimum ou pul foul t cu rreni D.9Arma p.r Panel TSM-2fi0 TSM-26D TSM-260 F_11\ PA05.08 D PA05.08 ° P—M D PA05.08 : •J-box — 15Acu 0 Enlhasa Enp\ase E.phasa -2156 -215-fi -21i-6 -21ST ....... ................ .............................................................. ...__..___.._.._..__ _..__.__..__..__. 2LL ILL 2LL - 2LL /U End-Fed Branch of 7-M215 Inverters •> •CU 11\ T-1.17Pan.l,c1.n t.dhACckcnh6ranch J TSM-260 Ma.imum ou pa—it carr.n10.9Arma p.rp-1 TS AL260 TSM-260 ° TSM-260 '^ D P"', D PA05.08 ° PA05.00 PA05.08 : ` (D Enp... Enpra Enpusa EnfApae LG�1C A■ \I`V -2158 ..... ................................................ '21 -------. •215.6 .__.. 2156 ILL �..... ... ILL 2LL 2LL UTILITY //� AC DISCO METER vJ ^, M ------ CD INSIDE O +r o NOTE:A GEC(grounding electrode conductor)is FUSIBLE X U) required only for M215-60-2LL.It is not required AC DISCO 60A RATING O for M215-60-2LL-IG ENVOY COMMUNICATIONS OUTSIDE 25A FUSES z GATEWAY NON-FUSIBLE GF222N 30A RATING GNF321R L2 L N ETHERNECONNECTION TO 1x#10 THWN-2 Wire BLACK BROADBAND ROUTER 120 VAC POWER , CABLE 1 x#10 THWN-2 Wire RED . Symbol conventions: 1 x#10 THWN-2 Wire WHITE zou 1 x#6 THWN-2 EGC 2-Pole Licensed Electrician Assumes All Responsibility For 1"EMT INDOORS Circuit Breaker Determinina Onsite Conditions and Executing 4 WIRES MSP Installation In Accordance with NEC 2014 Codes CU Fuse spa clr Visible Break CONDUIT SI SERVICE PANEL RATINGS Knife Switch AC DISCONNECT RATINGS 1"PVC OUTDOOR MEP BRAND_GOULD DISCONNECTAMP RATING(A):60 1"EMT INDOOR BUS AMP RATING(A):200 DISCONNECT VOLT RATING(V):240 SERVICE VOLTAGE(V):240 MAIN AMP RATING(A): _......---•------- Equipment NEMA 3R 200 Groundng BREAKER RATING(A):25 Conductor ` MODULE DATA DETAILS THE Universal MODULE '` -P 05. W �33aa4a€i4�.rCM9 iia rV MIC IS u m Go 947 €`euw5vaitn-E'wu+€�a } a, j ' 260 W ❑ O esRtDsr Pkcc:dt v v. v .,: $ 3 :vv A v �.:..aae i !Ha»t`��esus•n€�tso�:r 11k 4.^ E '�$� b' 'Wb co rg O \\\ a' rn pa c suis yaa v c v f d sB h id s , W U) W t eR�te s tac rcr.teat €l.� iv 1�. x €- O (� cV ❑ co t'ti-r,.a+n,n:.r.+��rc?wtiR+.�,.,o:ammi,a..rs.�, rsti-,as xeeasxaw.s.:eirrearr,rixp rn c�nrm'u>z r Z h ® +4?'Fr°,i:m.arGnrry...xmn-eivr,:.nrn .s:rxr:ai3'I wepn•ra-r.,.r,: pwv su a-nle.i L Q v f,ucrt€r.m as vx,=.No s+ p L ci finaHa\asur,€4rw'cF-k� 11r.o€ t&2 tssa 1", Y U) "C o Mz+33-dx,xl�tsa l'DWyli 4:w■cass-ica.�[a .c.SF .G.a? m Yes m.fi _i. _�"` wat!Csxite:ui,eviS +1 TQ.'t LHary T•n.vae rw—s lNpn+A, ,r a..gewx mr ysr.w.my xn,s.ra ' 8.12 .' 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Ct QS vvim 8 �sias. t�x nlima "trwc p: a } vckw sYf rafar ARRAY DESIGN / SITE DIAGRAM HEIGHT OF HOUSE PANEL ORIENTATION (TRUE) ROOF PITCH (DEGREES) 225" 213' 30* W Quick Mount PV Solar Flashings FOSS ROAD o Ln will be used on every roof penetration F-39.05°� 0° 00 DRIVEWAY \\� , = a o ."`ARRAY LAYOUT IS NOT TO SCALE"" Q , o w I TILITY METER \ \\� v ~ m W ti PLACE. PV LOAD CENTER OUTSIDE TO THE LEFT OF THE o > O0 LGATE120 \ \ _ � O �O \v _ �. UTILITY AFTER, THE CUSTOMER IS RESPONSIBLE FOR ��-� � � � N o MOVING OBSTRUCTIONS 3' FROM LOAD CENTER AC DISCONNECT E N a Ew = .. LOCATION; PLACE ENVOY MONITORING EQUIPMENT TO . THE RICHT OF THE MAIN ELECTRICAL PANEL PROPOSED CONDUIT THROUGH ' ° o r ATTIC.DO�VVN EXTERIORTO U Q z a PVLC;ELECTRICIAN WILL FIELD VERIFY E PIPE TO BE RELOCATED � � 14 CU O I QUICKMOUNT PV � CU 34'-8" (416") PORTRAIT/LANDSCAPE :> J r Totals Cl) TYP. Total'#of Panels: 18 C .� C t Total#of Splice Bars: 8 iL1) J El Total#of Bonding Jumpers: 8 U) (U \\;\ , \ \\ \\\ Total#End Clamps: 14 �. 12"TY P. ia> i �� 1 O 'a , Total#of Mid-Clamps: 36 ®®®—— See Engineer's Structural Assessment O O \\ \\ \\\\\\ 10IU 110"P\\\ c/ E .SW. Customer Signature: Date: TYPICAL ATTACHMENT DETAILS TM E--GE MWARDS EsW) RIDGE ;—RACKING COMPONENTS I11,.......__... .....v...................._...................._.................................. .. ._..._.._.._.. .. ._ `,r NOT hUJdD DELCN ��°,p��. ,/ ,-, X41i`,'L;T,5062,MILL 1 5 r�)6b 2 0E-Cf-K,CLASSIC.A3 6 A x. , 9 ......_............................ 3q t. � . 4 IV GH-RF NOW$(14� I0 K 1-1 P�t ) 1 M 51a 1 2 ,i Lag PLIII-OUt(withdrawal)capacities(lbs) in typical lumber: I Lag Balt Specifications V u Specific Gra4tyy 5116"shaft per 3"tFread depth 5116"shaft per 1"threac depth N Douglas Fir,Larch 5E1 796 266 Douglas Fir,South .46 705 2�5 , �Eegelnana Spruce Lodgepnle Pine(IVISR 16517 f&higher) .46 705 235 l H6rn,Fie .43 636 212 E _ ........ Here,Far(North) .46 705 235 Southern Pins .55 621 307 Spruce,Eine.Fir .42 615 2175 Spruce,Pine,Fu(E cf 2 million psi and higher er grades of I ISR and MEL) 50 738 _ 26`6 RING Next Step Living Inc. ri sRT OR ATTACHMENT [ ( Quick Mount PV lzEpa��r�oRA-r-�ACHr���rr Q:a, next t Uvin ,., Module and Roof QMSE-LAG:QMPV E-MOUNT SPACING— home ener PACING— ho eener ysotutions Attachment Detail WITH LAG BOLT DocuSign Envelope ID:7239A81C-709E-4CA5-8E9D-OFDC975083D8 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress street,Suite 100 Boston,.?t4A 02.114-2017 �✓` www.mass,govldia 'l orl:ers'Compensation Insurance Affidavit-]Builders;Contrac-tors/ElectricianslPlumbers. TO BE FILED WITH THE PIvT3MITTING AUTHORM. Aurilicant Information Please Print Legibly Name (Business/Org-aiizationIIndividual): ' �.. , ,, w Address: t ' �� CityiStatel7ipVk) C :tJ)P loner Are you an employer?Check the appropriate box: Type of project(required): 1.2 1 am a employer with__. _employees(full and/or part-time),'' 7. ❑New Construction 2.f_�1 am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity.[No workers'comp.,insurance required] jjj 9. ❑Demolition I 3.❑I am a homeowner doing all work myself.[No workers'comp..insurance required,]t j 10 Building addition �.�1 am a homeowner and will be hiring contractor;to conduct all won'.;on my property. Swill ensure that all contractors either have workers'compensation insurance or are sore l l.tR Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.(7 1 am a general contractor anis I have hired the suh-conk+,ors lined on the attached sheet. .[ These sub-�ht<-.�,"tors have employewe arra'have workers'-conte,ins•�zrance.t 13Roof repairs 6.❑Cie are a corporation and its officer,have exercised their right of exemption per PAGI_c. 14,7 Cattier 152,§1(4),and we have no employees.(No workers'comp.insurance required.] *Anv applicant'that checks box'!mus:also fill out the section below showing their workers'compensation policy information t iicmeowners who submit this affidavit indicating t hey are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Ciintractors 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 soh-contractors have empioyees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site in,formation, Insurance Company Name: Okg�,� Policy or S 1-ins.Lic, Expiration Date: j Joh Site Address:_ 1'1- Gass (L.0• City!StatetZip N.AC,42= (tl(�nti56H5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration/late). Failure to secure coverage as required under MGL,c. 152,§25A is a criminal violation punishable by a fine up to 51,500:00 andlor one-year imprisonment,as well as.civil penalties in the form of a STOP' O.RK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerV.1c�s 9 ea toy e paints and penalties of perjury that the information provided above is true and correct, Sitrnature: jnu VawS Date: ©i-oho" Vko Phone 4' 02 23A > Official use only. Do not write in this area,to be completed by city or town:crfflclal, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.C.;ityl,Town Clerk 4.Electrical.Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• '` 6 ® CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) 7/15/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Darlene Mulcahy y Malcolm & Parsons Insurance Agency acNNo Ext): (781)344-3200 FAACX No):(781)344-1425 713 Washington Street ADDRESS: P.O. BOX 527 INSURERS AFFORDING COVERAGE NAIC# Stoughton MA 02072 INSURER A Northland Insurance Company INSURED INSURERB:Sentinel Insurance Company Ltd 39098 Certified Safe Electric, Inc. INSURERCNautilus Insurance Company 50 Tower Avenue INSURERD:CNA Surety INSURER E: Marshfield MA 02050-5131 INSURER F COVERAGES CERTIFICATE NUMBER:CL157602635 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDYEFF PLICY EXP /YYYY MMIDDIYYYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO A CLAIMS-MADE ❑X OCCUR PREM SES a occu ante $ 100,000 7[ ISO Form CG0001 TBI 7/15/2015 7/15/2016 MED EXP(Any one person) $ 5,000 X Contractual Liab PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: General Aggregate $ 5,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 08UECZJ6251 3/7/2015 3/7/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ t X NON-OWNED HIRED AUTOS X AUTOS Per acciden X ISOCA0001 PIP-Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 C X EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTION$ TBI 7/15/2015 7/15/2016 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D FIDELITY- EE DISHONESTY 62447764 7/1/2015 7/1/2016 $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION certifiedsafeoffice@gmail. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Amne Parsons/DARL � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 I?m 4011 %A�o 01/14CERTIFICATE OF LIABILITY INSURANCE [__��E1/14/22016016 Y) / THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Darlene Mulcahy MALCOLM & PARSONS INSURANCE AGENCY INC PHONE WC,No,E,): (781)344-3200 a No: E-MAIL dm@malcolmandparsons.com dm macomand ADDRESS: @ P 6 FREEMAN ST. INSURER(S)AFFORDING COVERAGE NAIC# STOUGHTON MA 02072 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: CERTIFIED SAFE ELECTRIC INC INSURER C: INSURER D: 50 TOWER AVENUE INSURER E: MARSHFIELD MA 02050 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 24268 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DD/YYYY MPOLICY EF MIDDY LICY EXP LTR /YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JjECOT F�LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE OERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 7PJUBOG17773815 08/01/2015 08/01/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT J$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St Bldg 20 STE 2035 AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.CroWey,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 4 t s n s Beard of Building Regut Standards License' CS-104740 /yz�y� r!rr BRUCE A DAVIS so TOWER AVENUE, r �4.' `" MARSHFIELD MA ttZi# r 0111912018 . / r r N . f r r ,y 'jai 1� 7G��M�L✓ �Fj i� Vy J IfY.€. NY REM l•_ <tr ! ry x, 15 i � 6 x y y��/{e/C}£;� J (YURM ����1�f (r(>f9rylli".+TllI3t Y,(t�fT 3' i1{l�,(/fd4fl.+l�.�✓ ` Office of Consumer Affairs&Business Regulation License or registration valid for in$lvidul use only before the expiration date. If found return to: t . ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and.Business.Regulation gistration 1'6010410 10 Park Plana-Shite 5170 X; xpiration: Private Corporatio: Boston,SIA 02116 CERTIFIED SAFE ELECTR>C INC BRUCE DAVIS 50 TOWER AVE �✓',��--.-�� _�- -----�- MARSHFIELD,MA 02050 Undersecretary ��Not valid�vitltout signature Date.../y— .................................. r►ORTH TOWN OF NORTH ANDOVER o PERMIT FOR WIRING 3SACHUS� This certifies that ............. Jf/ (/1....... ./ �..7..{'.!.................................................... -:............................................. has permission to perform C ....... .......................................................................... wiring in tlw building of............... .. �............................................................................... atc' .......... ...................................:.. ..........,N`o Andover,Mass. Fee,d 5....`...........Lic. NdZ2 ........ .......................... ; ELECTRICAL INSPECTOR . Check# //9q , y � lek t� Commonwealth of Massachusetts Oficial Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFORMATION) Date: /'/a 3 /is City or Town of: NORTH ANDOVER To the InIpector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)�a Q-0 ,ed Al, ,1 ddy-Pr"� Owner or Tenant Ck r i S 6d v,4- Telephone No. Owner's Address Q o 15 lect Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature ofProposedElectricalWork: / 'Zi '. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Tr Total 1 Transformers KVA � No,of Luminaire Outlets No.of Hot Tubs Generators KVA Swimming Above ❑ In- E] o.o mergency fig ting No.of Luminaires Sw a g Pool rnd. grnd. Battery Units No.of Receptacle Outlets 2 No.of Oil Burners FIRE ALARMS I No, of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: " '' " """'"'' '"""'......"".."'" Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local ElConnection [I Other No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ��, d0(/• dy (When required by municipal policy.) Work to Start:—// 3 3/15 Inspections to be requested in accordance with MEC Rule 10,and upon completion. ^\ INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge ism force,and has exhibited proof of sam o the permit issuing office. CHECK ONE: INSURA=NCE [BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains rend penalties of perjury,that the information on Ili' pplica ' n is true and complete. FIRM NAME: . " t¢✓✓t & c,k vc l'K t• LIC.NO.: 2l S P3 4 Licensee: J0a f,,.H q,.t S Signature LIC.NO.: (If applicable,enter "e empt"in the license number line) Bus.Tel.No.: 258 12 e o Address: V I M i d�t/e It.,c /J,,c Sf< !G ,A&4- f f?c'7 Alt.Tel.No.:ql? &Y cY2 YY *Per M.G.L c. 147,s.57-61,security work requires Departmel 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 ERMIT FEE: $ Signature Telephone No. P � — � ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation 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 of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined 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 permit 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 of 2010 and extended by Sections 74 and 75 of Chapter 238 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 certain permits and licenses concerning the use or development of real 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. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass n Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re-Inspection Required($.)❑ G Inspectors Comments: . Inspectors Signature: Date: PARTIAL ngltGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: 4.,A- Date: " >� FINAL,INSPE ION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i T'� y The Commonwealth of Massachusetts z F Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIVIITTING AUTHORITY. Applicant Information ] Please Print Legibly Name(Business/Organization/Individual): M 6 d tm -0-eL�n`C kc, Address: It t4 t�j l-e tax liv-e.- SIC /0 City/State/Zip: �,! 1V, lav,,, vk cs LF2Phone#: q 7T 6 5 F ?Z00 Are you an employer?Check the appropriate box: Type of project(required): 1.Ef,am a employer with , employees(full and/or part-time).* 7. 0 New construction .2.❑I am a sole proprietor or partnership and have no employees working for me in 8. dRemodelirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor ansub-contractors on d I have hired the subtors listed the attached sheet. ❑ $ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.F1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no.employees.[No workers'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. 1Contractors 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. 'I Insurance Company Name: Policy#or Self-ins.Lic.#: 7 G 6-D G 2(e 3 Expiration Date: 02 3 ! tro Job Site Address: i,�j�y e 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 MGL c. 152,§25A is a criminal violation punishable by 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.A c y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e pain nd penalties of pefjuiy that the information provided above is true and correct. Signature: Date: / 23 bs Phone#: 9 7 52 72y 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#: r r 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 foi•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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i COMMONWEALTH OF ------ n 0 0 MASSACHUSETTS aoa�to of EL�ECTR I C`I ANS f;SSUES THE ,FOLLOWING L., ENS-,EAS A :..r 1:.. REG 'STERED MASTER ELECTRIC 1 r IN I R ,<:MODERN ELECTRIC I DANNY RESE S :END sy ' 111 1 11 R GROVE AVE 1� °WULM I NGTON MA 0 T887-372' J 21583 a 07/31/16004: 5 0 5 Location 162 /— e)5S -;�>J — Id No. Date _ d MORT1y TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $ S1�CHUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #14 ' ` `Building Inspector j i it N TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING :����' � Z��.� :". ,, ,,,a^�^,s•.� � ��. ."S�V�� , ,`1k � 'tom� �Y ti flt�'t z `z�^-. BUILDING PERMIT NUMBER: DATE ISSUED: �^ / d .j/z SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 42 e7? Map Number ParM Number 1.3. Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.1-C.40. 54) I.S. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record / Lj r r '{g amp r- „ o ur r Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: zI M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ a i Licensed GOnstruction Supervisor: License Number A re 7 / Expiration bateic gn-,0,aj dj TelepTione 3.2 Registered Home Improvement Contractor Not Applicable ❑ 2 Co pany Tame pig Registration Number �® r Address Q� D Expiration Da e Si nature Telephone SECTION 4-WORKERS COMPENSATION(NLG.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work(check all a h'cable New Construction 0 Existing Building 0 Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work: � _ I I SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicantINA, 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby au a to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 Y Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TPVMERS 1 2ND 3RD SPAN DEVIENSIONS OF SILLS D1IVIENSIONS OF POSTS DIMENSIONS 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 chusetts onWeeith Of Massa ents I Accid The Comm t of indust . e eons a,tmen �rnvestig 111 1 Dep Office ° ass' 02 rice A�davit Bosto enMtion insure i Come �. ' please Pint 9 � phone Narne` � r _ Work rnyseif. vocation'. aml capaem K �o�rttn9 ail a Worlcln9 to on thts job. Gi am a homee �etor and have no on emp1by�s Worlc�ng D �le Pr°pn nsat►on for 1 am an erNloger Prov idin9`No�ers oompe Phone i � narr►e: Com an poli # Address Insurance Co. Phone##� ,qon 0�000 on. $ r�fineup nae nstne• t� ► a ► Comn poi 01l$ 00)n i. ► Addressky teal to the o nER and foc,cage NAGL i 725P, ot a OP Ove0a . ns of the ptA d correct' l t Gt Go. reqaired andSecto K 6,A Pe d t o tpi{ice of►n bove is tie an l InstUr 0 sure a�etlac n m1 asal be focw urY fat the information Provided, Date a lre one leaTS .091 ot the ies of ped phone# enatt understand d—ify un pains and p Building Dept rd I do herby J Q Lice sin Board re Bele Departure g;gnatu n ottic'I 0 Health t pant name be completed bl C'm or town Building Dep p other ite in this area to phortedo # Ot{wia► use on�ll�miaoe response required OGheck if tact Persorl. . WORKMAN'SOOMPEkSfcT{OP! FORM NORTFj own ® E D / over p No. 9(a 011CCOCHIC dover, Mass., 8 /S! DRATED S H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System Icie /eBUILDING INSPECTOR THIS CERTIFIES THAT......0 A'"/5........ . I^ ...................le . ... Foundation .. ... ....... ... .. has permission to erect.... OO. ........... buildings on .... a...... m ss.................... .............................. Rough to be occupied as..................o.U � /Z / ....... L� IZ Chimney ................................................. ....... ...... ............................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By- ws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. V_ < Q cl aS PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMEXPIRES IN 6 MONTHS Final IT UNLESS CONSTRUCTIONS ARTS ELECTRICAL INSPECTOR � Rough .... ......................................................... Service BUILDING INSPECTOR 1, Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. 1[7�KEE REVERSE SIDE Smoke Det. a .J�W, l(>M/7/JY2lYI'illlP,lb�/tO�_i%��•lldNJ.C�•Cl6P.�.0 .. r BOARD OF BUILDING REGULATIONS I , License: CONSTRUCTION SUPERVISOR Number: CS 035867 z Birthdate: 12/15/1941 Expires: 12/15/2001 Tr.no: 11507 i Restricted To: 00 RAYMOND V BERUBE I 361 CHICKERING RD "�' N ANDOVER, MA 01845 Administrator HOME 1MPROVEMENi CONiRnCTOR Registration: 105523 Expiration: 01/11120.02 \ ! type: individual RAYMOND V. BERUBE Raysond Betube =`us 3bl Chickering Rd N podover MR O1B45 I� Date.... AoRTH ' 0*t"'°:•�"� TOWN OF NORTH ANDOVER .• 0- PERMIT FOR WIRING This certifies that . i �.. ...... has permission to perform ..../.. ....... • ....................:................. wiring in the building of....�� r-µe................................ .., ..................... at:.Ja..... �........ .. ..�...................... .North Andover,Mass. Fee`.... .. ........... Lic.No/• ?r� .................... ELECTRICAL INSPECTOR G Check # �� 81 94 4" --•--"•••''•• v •-•dssacnusetts Official Use Only �. Department of Fire Services Permit No. UV 7 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked.. [Rev. 1/073 (leave blank APPLICATION FOR PERMIT TO PERFORM AD work to be performed in accordance with the Massachusetts Electrical CELECTRICAL WORK (PLEASE PRINTWINKOR 7YPE14LI INF (MEC),527 CMR I2.00 O RM12T10 City or Town of: NORTH ANDOVER Date:— -" —08 BY this application the undersigned gives notice of his or her' To the Inspector of Wires Location(Street&Number) L•Z �d 55 .(Z intention to perform the electrical work described below. Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? � YesPurpose of Building i/ . 6 +tiR @ Nov No ❑ (C heck A PProP riat eBoz) Utility Authorization No. co Amps LZa d Wolts ------ NeOverhead ❑ Undgrd© No.of Meters w_ Service fps �__.Vlts � Namber of Feeders and Ampacity oOverhead❑ Undgrd ❑ No.of Meters Location and Nature of Proposed Electrical Work: bt eo r f No.of Recessed Lum �I No.of Cinaires Mable may be waived by the Inspector of Wires. ei1.-Snap.Co leYion of the ollowin(Paddle)Fans No.of Total No.of Luminaire Outlets No. of Hot Tubs Transformers gV�, No. of Luminaires Generators XVA I Swimming Pool Above In- o,o me en d ❑ cY ig No.of Receptacle Outlets d• ❑ Batte Unifs No.of 031 Burners . j No.of Switches EIRE�sIiARMS No. of Tones • No. of Gas Banners o.of etecon and a No.of Ranges No. of Air Coad, otni Devices No.of Waste Disposers Tons No. of Alerting Devices P. eat slumber Tons o. of elf: ontaine Deteciion/Alerfina No.of Dishwashers DevicesSpace/Area tEeating ' Local❑ Municipal ❑Other. No.of Dryers Heating g APP4aaces . Sec No.of Water ICW urzty Systems:* Heaters KW °. of °• of No.of Devices or Ea uivalent SiData W' ' No.Hydromassage Bathtubs Ballasts N°•of ev�c�or E Devices No. of Motors Total HP Telecommunications OTHER: No.of Devices : or E urvalenf Estimated Value of Electrical Work mach additional detail:(desired, or as required by the Inspector of Wires. Work to Start (When required by municipal�-��' �$ Inspections to b P PoIrcy) �P e requested in accordance with MEC Rale 10,and on.c INSURANCE COVERAGE: Unless waived by the own uP completion. n. er the � no mP he Provides proof of liability insurance includin •� Permit for the Performance of electrical work may issue mess undersigned certifies that such coverage is in force,and g completed operation"coverage or its substantial equivalent The Cl�CK ONE: INSURANCE has exhibited proof of same to the BOND ❑. O Permit issuing office.. I certify,under the pains and penalises o er« T ❑ (Specify;) FIRM NAME: fP ! r1',that the information on this applscation is true and cont 1�G$ �te4r� G plete Licensee: see: Vbvr+.��Pt_li`,Ae LIC.NO.:(If applicableenter license number line,) S $ e " -"`OLIC.NO: l,Z 3 M 2 Address: gox LZ(a A J.Z%to}oma, F 0,11 S N �{. Bus TeL No.:�C3•Qf f *Per M.G.L c. 147,s.57-61,security work re es D G3 Qq _ Alt TeL No.: OWNER'S INSURANCE WAIVER: I am aware ffi ��icitensepidoies notSafehavety ,the1jia se: required by law. B m si Lic.No. Owner/Agent Y Y gnature below,I hereby waive this requirement I am the(check one) owner coverage normally Signature ❑owner's agent. Telephone No. PERMIT FEE:$ <, i fi \ The Com ftwealfh of Massachuseft Department of Industrial Accidents Dfrice Of�ivgesta twlts 600 Washinton Sree t Bosrofi, MA 0211114 I Workers, Compensation Ins trance www"=Mgov1&a Ak Iicant Information �4.ffiriavit:$nilders/ContractorsMectricians/Plambers Please Print Legibly Name,(BysinesslOrganiration/Indviatmt); i c-e �1 '�`y ' Address: IP D ?>oX 1 Z..[�• • c�tyi�state/ziF: N om, �,- P4\1s ty L4 `�`� Phone Are you an employer?Cheek the appropriate•box: ' - I•❑ Fain a employer with 4. ❑ I am a Type.of project(required): employees.(full and/or ar�* . ►eraf contr s=tar and[. I. 2, p trate), have birGd the sub-cornsactor; 6 New construction .I am.asole proprietoror purer- Iisi�d on:the attached sheet 2 7. ❑Remodaiing ship and have no employees These st16-contractors have working for me.in any capacity, workers' comp.insuranceg' Q Demolidon' [No workers'comp,insurance 5. ❑ We area cc ns .n sad its ... 9. ❑Bw7ding addition 3•❑ required_] officers have exercised their !0•❑Electrical I am a homeowner da' ''cP�or additions mg all work right of exemption per MGL I I.❑Plumbing TeP�or additions myseIf..[Nonworkers'comp. :c..152:,.§1(4),'and we have no . Insurance required,]t -employees, [No workers` 12.[] f repairs wimp. mse we=required): I3.0.0the ;Any aPpl�than checks ben(#1 mum=iso fi[1 out the section below showing , t Homeowoeta who submit this afl-Wavit indiemting they ale doing an work their workers oompensation policy infonnstion ' (Contractors that rheak this box must attached an g end them hire•outside oenuaetoo must submit a new affidavit indecsd*such edditioasl sheer showing the name of the sub- contractnrs and their work=s'cones.poli I arsr an ersr,plover thr�.is;vrovrdirtg:workers'co errsatiotr ' �'iatorrnation. information. insrrrcnee,for my.=710yem Below is.the pofsci,audiob sit, " Insurance Company Name: Policy#orSelf--ins.I:ic.#: Expiration Date: Job Site Address.: Attach a copy of the.workers'coraCity/Statezip: peasation policy decl$ratiaa page(showing the policy number and expiratioa date] I?a1lure to secure coverage as required under Section 25A of MGL C. 152 can lead in fine up to S 1,500,00 and/or one- the im ositi ear imprisonment, P on of crani' Y prisonmen as mal penalties of up to$250.00 a t, well as civil penalties m the form of a STOP WORK ORDER of fine Investigationsthe violator. Be advised that a copy of flus ststecnenf ma be forty of the DIA for' Y arded to the Office of msurm�ce coverage ver}fication. I do hereby cerci render the pants and erraldes o P /Pel7�3'Ytlsar the u{formation pmyided ahvre is dare and coarct Si ,s:�. Phone#: D 3�. .R z p E orrl�. Do rrol wrrte tf1.1ItIS area,tm:he corrrpleted IV,O&Y or down.o rcra( . wn: PerwWLicease# thority(circle one): Health 2 Building Department 3.City/Town Clerk 4 'Eiectriesl Inspector 5.Plumbing I r nsp,,toson• Phone#: Information. and Instructions Massachusetts General Laws chapter 152 requires all emp.;oycrs 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 impiied,.oral or written." An employer is defined as"an individual,partnership,amim,62tian, corporation or other legal entity,or any two or more oftlhe'foreping engaged in&;joint erth.rprise,and includi"g the legal represcntatives of a deceased employer,or the receiver ortrustee-of an individual;partnership,association► or-other legal entity, employing empioyees.'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 orrepair win k on such dwell'snghouse or on the grounds or building appurtenant thereto shall not because of such employment.be deemed to be an employer." MGL chipter 152,525C(6)also states that"every state o„- local 6ednsing agency sha,n withhold the issuance or renewal of a license or permit to operate a business or 'to construct buildings in the cam moowealth for any applicant who has cot prodneed acceptable evidence.o'f compliance with the insurance coverage required." Additionally, MaL chapter 152,§25C(7)states"Neither the:commonweal#h nor any of its-political subdivisions shall enter into any contract far the pm* mance of public work until•acceptabit evidence of compliance with the insurance r•equiremertis of this chapter have been presented to the contracting authority.- Applicants uthority"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)amd phone number(s)along with.their certificate(s)'of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no.employees otherthm the members or partners,are not regrdr A to carry workers'compensation insurance. If an LLC.or LLP does have employees,a policy is required Be advised.that this afficlmv.it.rnay be submitted to the Depart amt of industrial Acciderris for confirmation of insurance coverage.. Also'be surge to sign and slate the affidavit The affidavit should be returned to the city.or town that the application for the permit or license is being requested, not1he Department of industrial Accidents. Should you have any questions regarding the law or if you-we requited to obtain a workers'• oompensation policy,:please-call the Dcpm-t cot at the arambcr.listed below. Self-insured companies shoulzi enterth= seif�irrsrnance".Iicensc number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. 7 a 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 appli= Pleases be sure to fill in the.permit/liocnae number which will be used as a refwcnce number.. in addition,an applicant that.must submit multiple permit/iicanse applications in arty given year,need only submit one affidavit indicating•cu:rent policy'information(if necessary)and under"Job Site Adtb-e;ss"the applicant should write"all locations in (city or town)."A copy ofibe affidavit that has been officially stamped or marked b the or town be. P y city may provided to the applicant as proof than a valid-afeidm&is an file for firtevc Perim 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 businew 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 Tice to:thank you in advance for your cooperation and should you have any questioM% please do not•hesitate to give us'a call. �. The Department's address,telephone and fax number: l. The Commonwealth of Massachusetts, DepMr nt of Industrial Accidents Office of Lnvetatisat#ons 600 Washington Street Boston, IIIA 6211-1 TeL# 617-727-49©0 ' _ . cxt 406 or 1 x.77-MASSAFE Revised 5-26-115 Fax#617-727-7749 www.inass.gov/dia � t i` /.:� G� I4 f I' 40 R T" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 49 ,SSACNUSE� 2 This certifies that X, Q. . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .S plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . .. at. . . . . . . . . —a. . . ., North Andover, Mass. Fee .."b . .Lic. No`�-7 ,, P--LU 412 LUM41 G INSPECTOR Check # 114S 7757 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location / Z S 2 Owners Name 1 (} w Pe lg S rrm't Amount Type of Occupancy 06, ell New Renovation rj Replacement "�� Plans Submitted YesNo El FIXTURES Z H ULC O O Ln U U O fi�i�71+1Z+I�II' 1S1:itiI1D(R M0 FLOOR 3M MOM 41H FLOOR SIH FIOCR 6IHFLOCIR 71HFLOCR - 91H FLOM (Print or type) Check one: Installing Company Name_ \f SG¢x -'M syy (0 Certificate Corp. Address S-D S 0 % A� `�� 11 Partner. Business Telephone 49 zr 2-rm/Co. Name of Licensed Plumber: t-10� 4e 'I'?, ,; Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ElF1 r F1 Insurance Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perforjped under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach etts otate Plu ing de and Chapter 142 of the General Laws. By: igna re 0-1 Muensf-Mer Titre Type of Plumbing License City/Town U kens um er Master Journeyman ❑ APPROVED(OFFICE USE ONLY i I� f 0 Ci Date.. . .. . . ... .. .��. ... . v S ? ��. pf NORTH 14 . 3= ti pc TOWN OF NO TH ANDOVER I; € PERMIT FOR GAS INSTALLATION This certifies that . . . ./.`. ���`1 - ^'�� . . . . . . . . . . has permission for gas installation . mac'. . . in the buildings of . r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .�a. . c`"�. . ��-? . . . . . . . . . , North Andover, Mass. Fee.`-. . . c-!. Lic. No..� 6. . GAS I P CTOR Check# 6346 MASSACHUSETTS UNIFORM APPLICATON FOR PMM TO DO GAS ff rn NG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations / z— r 2 Permit# Amount$ ' Owner's Name Be)- New a Renovation Replacement U Plans Submitted � x w V w < w [- 0 C w d rA GC7 H Z Q x W a W �as7 O W F' y. W > w a F, m z O z 9 O vFi x x O x E 3 0 5 .da 0 a > o a F o SUB -BASEM ENT BASEM ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOGR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR Name or type) �`f � �� Check one: Certificate Installing Company �l c, � 0 Corp. Address 'S� ��` l/� Partner. �-- Business Felephone �-t, g-� rFirm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance p icy or it's substantial equivalent. YesNoO If you have checked Les,please i icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 1 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: OwnerAgent 13 1 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 in p g stallatio performed under Permit Issued for is application ill be in compliance with all pertinent provisions of the Massachuse a Gas a and hapter 1 of the eneral --�.. By: Signature of Licensed Plumber Or Gas Fitter Title ©Plumber —2 City/Town, Gas Fitter icenseum er easter APPROVED(OFFICE USE ONLY) Journeyman I No 2704 NOR7M TOWN OF NORTH ANDOVER 3r •-.r - t p PERMIT FOR WIRING '6' ,SSACMUS� This certifies that .../.. .........�4 ~` .�v' ............J�J........................ has permission to perform .. ._ wiring in the building of..,.... .......` % -! .................................... at// ...... ? '.::- -f..........................................North Andover,Mass. Fee..�7—....... Lic. ? . .... .......1�................. / ..<- 'iLECfRICAL INSPECTOR Check #� U WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Official Use Only Permit No._ �JU DejrcvctrreeKt a��ut�(ca Sa�ery '�✓ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy&Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 C�M/R 12:00 (Please Print in ink or type all information) Date //` T `G To the Inspector of Wires: Town of North Andover The undersigned applies for aJ permit to perform the electrical work described below. or- Location(Street&Number 1 F0 5 t Owner or Tenant C 1 + it o,,- 3ovi C, Owner's Address 3C IM t° 6,15 o o V Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 20 d Amps 20 Voits Overhead ❑ Undgrnd ❑ No.of Meters New Service Amps Voits Overhead ❑ Undgrnd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work o C ' No.of Lighting Total Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets. No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di osal No. Pumps .Tons KW No.of Sounding Devices No./of Self Contained Mo.of Dishwashers S ace/Area Heatin KW Detection/Sounding Devices No.of Dryers ❑ Municipal ❑ Other Heating Devices KW Local Connection No.of Low Voltage 'No.of Water Heaters KW Signs Bailases Wirin No.Hydro Massage Tuds I No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = ILyou Pave checked YES please indicate the type of coverage by checking the appropriate box. BOND = OTHER Please Specify) t-�jC� f -/—,0 / '— _ ( P fY) A;r f G GUI Estimated Value of Electrical Work$ (Expiration Date) Work to Start /l,y—O C;> Inspection Date Resquested Rough Final Signed under th a alties of perjury p( C qp ^� FIRM NAME a hot,l�c>t IL-r e ec, l L LIC.NO.t�[ / Licensee d�E'r CC�� �. Signature � p�a L✓ / J LIC.NO.2_7 ave �cr l /nn "�`,. Bus.Tel No._ 6 - q5 / Y! Address_ Alt Tel.No._jQ&Crel �/y OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) No. (Signature of Owner or Agent) Telephone PERMITTEE $ i Location No. y o Date v U3 i TOWN OF NORTH ANDOVER F? • • L9 Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ �8 0— t sAcMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Z2 g 165 , 9 � Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BU3LDING PERMIT NUMBER: © -7 DATE ISSUED: �^ 62? _a O D X ic SIGNATURE: Building Commissioner/InSpeCtor of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number - Parcel Number O 1.3 Zoning Information: 1.4 Property Dimensions: �l Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R aired Provide Required Provided Required Provided Q 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 ZOne Outside Flood Zone ❑ Municipal ❑ On Site Disposal System. 0 �! SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT F M 2.1 Owner of Record /� Ctj C11Z R' y �►fL S t✓j�(}0. Name(Print) Address for Service: C . I Signature Telephone �OJ 2.2 Owner of Record: Name Print Address for Service: O z m Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 7� 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: O License Number wn i Address L/_ -9 77 ic g' -� ( Expiration Date re Telephone r' 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1CGE�) C'ntj a,0C0-o o �3 � 3 Company Name m 7,Z I�C&u /Y✓C Registration Number r' IAddress7 te!/ (� �j �' - l 7J0 Expiration at re Telephone w SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this.application. Failure to provide this affidavit will result in the denial of the issuance of the building.permit. -Signed affidavit Attached Yes....... No.......t] SECTION 5 Description of Proposed Work check all a Iicable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s), ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: JV Lo 2 X19 �4 �J �� A r�li4c� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be y Completed b permit applicant kt yet � s $a..,���� � « �,y• .x, a 1. Building c (a) Building Permit Fee O O Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) x (b) / 4 Mechanical HVAC 6 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ti�b SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, k C 1162 E I{n E CL ri as- 0Authorized 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 beli ef Prin e G - 3v - off Si re of er/A ent Date NO. OF STORIES SIZE t BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1' 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUIZ,.DING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with therovision of MGL c 40 S p 54, a condition of Building Permit Number 007 is-that..the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S.150 A.. The debris will be disposed of in: i se, (Location of Facil' ) r Signature of Pe plicant ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector I i The Commonwealth of Massachusetts �i Department of Industrial Accidents office of/nrresGgat/ops 600 Washington Street e, Boston,Mass. 02111 —" Workers' Compensation Insurance Affidavit A"Itcant'info matron -�-' '�'`� ��: y�� �.•< <lease'PR . � y name i� E� (� .9/�1 STIZ U C T;A � E �lJ Etk 1__? 41 �.J location J7 �E-Lk 1 ri L/F city Alp 2 �h tq N CI'O L n�i-k/ ✓ ,4 D 19q-5- phone#972 ' 9' ❑ I am'a homeowner performing all work myself. J;?-I am a sole proprietor and have no one working in any capacity .1 1I am an employer providing workers' compensation for my employees working on this job. company name: address: phone insurince co. policy# w•. ..,,... ,.,.....,k�...�.,,. �r�x�x lam a sole proprietor, general contractor,or ho� meowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: bhone'# insurance co. pohcy'# �ompanv name: address: city: phone`# Insurance co, ohcy Att tch add�honaC'she�f if neccss ire ' 'rkgg� ' .rmm.X:4x'sx.xi�a�. a`.rr,,x a .&.:�..;, ..,�l w- .,_.V,., -.':'"st;a,✓'; �'&" %' :i%..a? Failure to secure coverage as required under Section 25A of bIGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well:is civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DW for coverage verification. I do hereby cernfv under the in•a penalties o perjury that the information provided above is true and correct. Signature Date (( _._.. . l -Print name �'N/'�i- �h � • �tc a�Ni - Phone# T57 �,y'�oflicial use ondo not write in this area to be completed by city or town official ... . .-_ city or town: permit/license#CU] -Building Department OLiceiisingBoard' check if immediate response is required c3Selectmen's Office ❑Health Department contact person: phone#; -Other 1 (revised 3/95 PIA) .._,... ' _ ✓die �anvrnoou�seca� c y�/�/�aaaczc�ucaella t: ter. BOARD OF BUILDING REGULATIONS " License: CONSTRUCTION SUPERVISOR Number.-CS 058245-.` Birthtlate X03/24/1943 iExpires" 03/24/2004 Tr`.no: 20021 ` - Rn0tct _ d KENNETH B KEEN 21 HEWITT AVE N ANDOVER,:MA 0, 45 Admmistrator. jK ✓fie 7°a�vmo�uuea/,�C ``,�aaclucae�a . Board of Building Regulations and Standards HOME IMFRO,VEMENT CONTRACTOR fI Registration 108383 k I Expiration 8/102004 I Type DBA KEEN CONSTRUCTION GO: Kenneth Keen 21 Hewitt Ave �� p , No.Andover, MA 01845 I A;tl:miinistraE�r KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER,MA 01845 (978) 691-5201 Bowe, Chris &Laura 12 Foss Rd. N. Andover, MA 01845 (978) 689-7996 Contract#1570; Appendix A Date:06/27/03 Reside house: • Remove & dispose of existing siding on both gable ends and rear of house (not including garage or family room) & front only of garage and family room • Supply& install 1/2" x 6" primed finger jointed cedar clapboards in place of ones removed Price does not include replacement of trim boards which will be done, as needed, at an additional cost(time+materials). Price does not include painting of new siding. Total Price: $17,800.00 (seventeen thousand eight hundred dollars) Payment schedule:$1000.00 due upon signing contract $6000.00 due the first day of work $3000.00 due when one gable end is done $3000.00 due when the other gable is done $3000.00 due when the back is done (except where the new windows are going) $1000.00 due when the front of the garage and family room is done $800.00 due upon completion of contracted work Customer Kenneth B. Keen Date Date �OF?Tpy 0 ofAndover 0 :. ®C> _ � dover, Mass., 3 3 T � LA \J !� COCMICM WIC ADRATED S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System A.4 BUILDING INSPECTOR THIS CERTIFIES THAT.... ..V.P.4.... '... .�.�. ..........t3.......0.wC................................................... Foundation has permission to erect.... r p CC...... buildings on..... .Q........FO.=.S......�0 Rough to be occupied as.........{.r.. ...r...........CIA ALD P&I s I d I AA Chimney ..................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. a #4 it ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Fina' UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 11110040100.11.000'6400W .................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected -and Approved by the Building Inspector. Burner • Street No. SEE REVERSE SIDE Smoke Det. Location No. 16-3 Date MORToy TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /q Check # 7 Z 9 i 6 5 3 ) GAS Building Inspector = TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 'S c — SIGNATURE: A --I Building Commissioner/I ctor of Buildings Date z SECTION 1-SITE INFORMATION. + 0 1.1 Property Address: t � 1.2 Assessors Map and Parcel Number: Z ♦ o SS �2�+9 Q ! ? — -- Map Number i -Parcel Number' 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R aired Provide 'red Provided Required Provided 1.7 Water Supply M. .L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System. ' Public 0 Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System. ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record LAQAA 'Be) f2 � 2 Name(Print) Address for Service: � .. 4 99 - 6 Signature Telephone Qj 2.2 Owner of Record: aml Print Address for Service: O N M Si nat4e Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number 7, I Address Expiration Date re Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Co r-zl ,v Company Name rn ,/, ew ✓C + , ,^ Registration Number r Addresst1'r,41, X" t9 Expiration ate ` re Telephone s SECTION 4-WORKERS COMPENSATION(M G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this.application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes....... No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) Jew Alterations(s) ❑ Addition tT-- Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: l.ui 16 ec, 7- Z SECTION 6-ESTIMATED CONSTRUCTION COSTS Item ' Estimated Cost(Dollar)to bes ,US1 �} Com 1 ted by permit a licant � ���Ff ��. g `:�£r s .:,x 1. Building po (a) Building Permit Fee lc Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property Hereby authorize to act on My belialf,in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTI/O/N 7b OWNE R/ AUTHORIZED AGENT DECLARATION ,as- (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 Prin e Si ire of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1' 2 3Ku SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS r HE[GHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERLAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE M 0 R T 6 A 6 E INSPECTION PLAN City/Town:]\�oRTK_ S�R5�1� tate:__ A_ _ ----------- JOSEPH Date;__�LA L.Y_:Z1 y, \9`J Scile:---���--- ----- A. ESPOSITO, JR. V, Owner:_ �3E _r1�L_C .... Buyer:___r¢oE__-- t ,Ti Deed Rei. Z '-►3 S (o__-- Plan No. 'l_1-r►—Qa--- �'c• 4, --- -------/----- ------ - -- Drawn per City/Town of --------- Tax Assessors Map. L-C) 312> L-0-T3�`7 i Lo T 2� M ( 2,Ln 5 0o T S1F ,pEC.K N 1 r11 I N SOT 2 `E3 2 GT OR Sty wooer ' 1..0 i 3 / A I 15'± i i r To: Q �---aA - ------------------------------ I- hereby certify that the above Mortgage Inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , walls or bu'ild'ing lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown herein was in compliance with the local applicable zoning bylaws in effect when constructed, with respect to horizontal dimensional requirements, to lot lines or is exempt from violation enforcement action under Mass 6.L. Title VII, Chap. 40A, Sec. 7, unless otherwise shown herein. Subject building(s) lies in a flood zone designated Zon#t.__X............ and shorn on "FIRM map Community-Panel 6_�SOO &=_ 00071�j_L Dated: >4 _x,121 Job No. JCD, INCORPORATED, LAND USE DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, MA 01844 508-683-9931 The Commonwealth of Massachusetts Department of Industrial Accidents 7. _-- Office 81/0=021180s 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit A ltcant to ormatton name: I C c>J location: 44�11�- aft S S Cil city 1�' . i!T N if d V 5,., /7) >?hone# I am a homeowner performing all work myself. 5�-'am a sole proprietor and have no one working in any capacity � I am an employer providing workers' compensation foamy employees working on this job. company-arae. cityL phone`# msurince co - policy I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name• address: city: bhone insurance co. DO ICV company name: address:' city phone insurance co policy# `A"t tclr icfd�t�onat" heerin, Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a ;777= copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify d t/te p n a penalties of perjury that the information provided above is true and correct. Signature Date __._. — Print name c Phone#_"�7 O 6 9'r' � Z O 1 official use only do not write in this area to be completed by city or town official city or town: permit/license# p -Building Department ❑LicerisingBoard - -' " ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; -Other "'�;'ti • ..,mow _��_���.,��.�.�.�;�g._., � (revised 3/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity,P g 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 employsersons to do maintenance construction ion or repair work p on such dwelling house or on the grounds or buildingappurtenant thereto shall not because PP of such employment be deemed to be an em to er. P Y MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. brp N/ r F, ,, tirlr,7%t�h l 'lye- M/6 /✓xy/1 r�,Hr� .�'ri/,/..(m�', .✓i vy r/%!,% �%': r2'r' iI Srlel Applicants Please .fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address,and phone numbers as.all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. %„ w Mo Cityons 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 penniUlicense number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. .2 � ,,�'.-::w...,res r:+:,,��r,r-. � �� �qn»':,,///,,,.y✓fr�,.Wv,' `.U; w,.n ,�" ,� ,.� ' ',. ,v ..,,: ,� ,"�i, r3', The Department's address, telephone and fax number: � The Commonwealth ealt h Of Massachusetts - - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406,409 or 375 Town of North Andover FORTH o �' ;P F'• S Building Department 27 Charles Street _ North Andover Massachusetts 01845 x (978) 688-9545 Fax(978) 688-9542 � Ao��TD rP@•� y C}gU DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, s15Oa. The debris will be disposed of in/at: Facility location Si ature App `cant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. `- ✓1� Vanvm:ooarierz� c�'���aasuclu�ae� ;` ', Y•' BOARD OF BUILDING REGULATIONS License:.CONSTRUCTION SUPERVISOR Number: CS 058245 Birthdate ;03/24/1943 71 Expires,"03/24/2004 Tr�ho 20021 KENNETH B KEEN 21 HEWITT-AVE f N ANDOVER,.MA 01845 Administrator, x s - I Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR 1 _ Registrati.gn 108383 Expiration 8/18%2004 f Type DBA j KEEN CONSTRUCTION CO. 1 Kenneth Keen 21 Hewitt Ave �� p _. No.Andover, MA 01845" I\� Administrator 14 KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER,MA 01845 (978) 691-5201 Bowe, Laura& Chris 12 Foss Rd. N. Andover, MA 01845 (978) 689-7996 Contract#1579 ; Appendix A Date:7/8/03 Deck: • Remove & dispose of existing deck • Frame new deck with pressure treated lumber(@ 450 sq. ft.) • Frame double wile stairs to back yard with pressure treated lumber • Supply& install 5/4" x 6" Cambara Mahogany decking (using Deckmaster blind fasteners) • Supply& install cedar 4" x 4" posts, rail &2" x 2" balusters Price does not include drilling of posts (if possible), lighting, electrical, permits fees or rotten wood hidden behind existing deck. Total price:$18,657.00(eighteen thousand six hundred fifty seven dollars) Payment schedule:$6000.00 due upon signing contract $6000.00 due when framing is complete $3000.00 due when decked $3657.00 due upon completion of contracted work I C omer e B. Keen G Date Date 00, 1579 KEEN CONSTRUCTION CO. P"'ROPOSAL n 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax: (978) 682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with Submitted J c i the Commonwealth of Massachusetts. Inquiries about To t.-� �.1 ".� --1-�� ---- C�t -- - registration and status should be made to the Director, (^--- Home Improvement Contract Registration,One Ashburton Place, Room 1301,Boston, MA 02108 (61 7) 727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. HONE DATE REGISTRATION NO. F.I.D.N0. 72 ) -799(-) -7t _ MA. H.I.C. 108383 04-325-8052 > C/S = Customer Supplied S + I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: ._��____....._..,...__....,_,_____._._.....,._. ....___. ,...,.,�.....__.._.._...... ... ... ... ........ ............... .........................__.. ...,..,..._....__._.....,......._..,._..._.. _.,........ .... ...___-......_.......__.__.__-__.._......_,.._____... Construction related permits. ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,-......................................................................................................................................... ............................... WORK SCHEDULE Contractor will of begin he work or order the materials before the third day following the signing of this Agreement,unless specified here i ntin ontracto will begin the work on or about �f.°� (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed,by �� `rte Gate). The Owner hereby acknowledgeg and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY __ ; PA f--'_followina completion and shall i i k NORTH Town E ®ver R N6. 033 O dower, Mass., AORATED P -\C2 S H BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT......, ,./o.v/'`a.... . ���.5 � w . . . . .................................................................................................... Foundation has permission to erect....... .�� ....:...... buildings on ....... .a......�/. ..............�.................. .......... Rough �� Plo P& c /C �� ob r 0 S fir ht Chimney tobe occupied as....................................................................................................................................................................... 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-Lawsr lating to the Ins action, Alteration and Construction of Buildings in the Town of North Andover. Al /�/ 9, '�Q PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough eC .40 .. ........ ....... .............. ..... ........... ..... ..... Service ...... BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. Location No. re-)�:3 Date NORTIy TOWN OF NORTH ANDOVER y t Certificate of Occupancy $ ♦ i a SAc.+us t Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� Check #14322 l� Building Inspec,�r C/ ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING SIS SectioH;foi ofticiat Use BUILDING PERMIT NUMBER: DATE ISSIIM- ff000 • X SIGNATURE: BuildingCommissioner/I for of Buildings Date Zr SECTION 1-SITE INFORMATION 1 O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: i z mss Rel , Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided v 1.7 Water Supply M.G.L.C.40.t 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of RecordNZ wn, Name—(Print) Address for Service Signatur / Telephone ? g 2.2 Ow of ecor . I � O Name Print Address for Service: M Signature Telephone S1Q SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ L-L/6 PNt_j-� gIAC Etj Licensed Construction Supervisor: 0. 17 IV- dXj License Number Addressj' Z® � Expiration Date ure Telephone- r 3.2 Registered Home Improvement Contractor Not Applicable 0 CQ V,E E N L n t�T rty c-+ d .� 2 3 TC Company Name l0 1 „ Registration Number r w i R lV v c � Addr r � �/9 a -2., Z 69/ . -- Z ® Expiration Date L irc Telephone SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) it must be completed and submitted with this application. Failure to provide this affidavit will result Worker Compensation Insurance affidav in the denial of the issuance of the building rmit. Signed atfidavit Attached Yes.......11 No.......❑ SECTION 5 Descri tion of Proposed Work check all a licable ❑ Alterations(s) p8 Addition ❑ New Construction ❑ Existing Building ❑ Repair(s) Accessory Bldg. ❑ Demolition ❑ Oth&`' ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS OFFICIAI.USE ONLY Item Estimated Cost(Dollar)to be Completed by permit applicant ' 1. Building � E(a) Building Permit FeeUD O ulti lier2 Electrical timated Total Cost of onstruction 3 Plumbing Building Permit fee(a) x(b) 4 Mechanical(If 5 Fire Protection Check Number ir 6 Total (1+2+3+4+5) SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT s ,as Owner/Authorized Agent of subject property I, to act or► tr Hereby authorize to work authorized by this building permit application. My behalf. in all matters relative Date Signature of Oxvner SECTION 7b OW NER/AUTHORIZED AGENT DECLARA/T�ION ,as Owner/Authorized Agent of subject property Hereby declare that the statements and in on the-foregoing application are true and accurate,to the best of mV knowledge and belief fi -S N lJ C e pJ I'r•in e 5i of ti er/A.ent Date SIZE NO. OF STORIES BASEMEN"f OR SLAB 1 2 3 SI7.E OF FLOOR TIMBERS SPAN DIMENSIONS OF SILLS IM DENSIONS OF POSTS DIMENSIONS OF GIRDERS 11[ICKN1iSS llla(ilfl Ul 1OIJNllA'1'lON X SIZE 01,I-'OOTING MA'FERIAL OF CI EVINEY IS 11U11.DIN(l ON 501.11)OR FILLED LAND 15 I11111,DING Co D TO NA"13.JRAL GAS LIM: F NORTH Town of-- `�C - over o n . �,. .r.: No. & o3 �. �o �== LA dower, Mass., ��• • moa COCHICHEWICK V ADRATED pP�,`�5 S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES ..........& ............. Foundation has permission to ere .. ....... buildings on�Z..... '�!� ...•.. ... ................................... Rough to be occupied a& /1►... ... .......... , ............................................................. Chimney . . . .. . . .... .............................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 7�6 000 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STAAdVj ELECTRICAL INSPECTOR Rough Abaw ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. ,;�*w'sJi?` �IZP loomvrrto�nureacua o�✓IiladJfi.�,�,udeCZ6 . BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 058245 Birthdate: 03/24/1943 Expires:03/24/2002 Tr.no: 18312 Restricted To: 00 KENNETH B KEEN _ 21 HEWITT AVE Z2"— zf.-- N ANDOVER, MA 01845 Administrator ✓dee i�om�nmarue¢��o�.�uiaac�uu5ell HONE IMPROVEMENT CONTRACTOR a Registration: s 106383 Expiration: 8/18/02 Type: 08A KEEN CONSTRUCTION CO. Kenneth Keen 21 Hewitt Ave ADMINISTRATOR No. Andover MA 01845 r The Commonwealth of Massachusetts Department of Industrial Accidents -E �- office 01imres992tieffs 1 � 600 Washington Street Boston,Mass. 02111 -- Workers' Compensation Insurance Affidavit lease A M l hcant•in ormatton=`�°.� pz; ,w' at name: 001'JSTa1JCtio1r l /LE"NN Cf6 kms_, Location: 77—/ •/7 6-tu r Ir o�a6- city_ A L02 N d U f n Rhone# ! 7 a " G !1'S ZO) ❑ I am a homeowner performing all work myself. �1 am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. x company name address city: Rhone!t• Durance co policy# n ❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'.compensation polices: company name- address: cit': Rhone# insurance co policy# �.,,.e, -•,� , ..,�.nz-• •� ��... .,. Thi .. _YrA._..a_. �;y..\.+it..�!•+ .. ...+r.¢s,�...O,nx.:'L$(d�'���M.II{�CIfRCi';tL.Y'���• company name: Ud ress itv phone# Y i u e li' ns r�nc co •Ati'ach Hcfilit�grrnl.she_,ef'if�necessery��� �� '"'`�` �r ���r" ��i - ,� Ro cY# Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of of penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the ins and penalties of perjury that the information provided above is true and correct. Signature Date Print name _ k,5 A)kj E t� • K EE' _. .__. . phone# 9"71'6 2/`Szo official use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department pLicensingBoard " check if immediate response is required C]Selectmen's Office C]Health Department contact person: phone#; nOther (revised 3/95 PJA)