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HomeMy WebLinkAboutMiscellaneous - 12 HOLBROOK ROAD 4/30/2018 12 HOLBROOK ROAD 210/016.0-0037-0000.0 1 Massachusetts Department of Environmental Protection 100273647 BWP AQ 04 (ANF-001) -- - - Asbestos Project# . Asbestos Notification Form Project Revision Project Cancellation A. Asbestos Abatement Description ' .:,6111 1.Facility Location: CYNTHIA CASSILLE `12 HOLBROOK ROAD R(N Instructions 1.All a.Name of Facility b.Street Address �0 �0 sections of this form Yl`= must be completed in NORTH ANDOVER MA 01845 0000000000 N order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification SAMUEL J.NIGRO III SUPERVISOR requirements of 310 CMR 7.15 and g•Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: ATTIC Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. IS the facility occupied? rF,a.Yes r b.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? r a.Yes r b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 DUDLEY SERVICES INC 1504-NEW BOSTON STREET a.Name b.Address WOBURN MA 01801 7812702650 c.Cityrrown d.State e.Zip Code f.Telephone AC000112 h.Contract Type: r 1.Written r-2.Verbal g.DLS License# 7. SAMUEL NIGRO III AS032802 a.Name of Contractors On-Site Supervisor/Foreman b.DLS Certification# 8 ENVIROSAFE ENGINEERING DBA AA000131 a.Name of Project Monitor b.DLS Certification# 9 ENVIROSAFE ENGINEERING AA000131 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 11/6/2017 11/9/2017 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8AM5PM 8AM5PM c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? 17 a.Demolition r b.Renovation r— c.Repair r d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection 00273647 BWP AQ 04 (ANF-001) .- - � � Asbestos Project# Asbestos Notification Form p' Project Revision r Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation r c.Enclosure ri d.Disposal Only r e.Cleanup r f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: ri a. Indoors rj b. Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 500 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement VERMICULITE 500 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: POLY CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA VACUUM i 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): ADEQUATELY WET ASBESTOS PROPERLY SEALED IN DOUBLE SIX MIL POLY BAGS PLACARDED FOR ASBESTOS IDENTIFICATION I .17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A-F apply to this r a.Yes ri b.No project? Revised: 11/13/2013 Page 2 of 4 A4. Massachusetts Department of Environmental Protection P 100273647 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision r7. Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENTIAL PROPERTY 2.Is the facility owner-occupied residential with 4 units or less? r— a.Yes r b.No 3 CYNTHIA CASSILLE 12 HOLBROOK ROAD a.Facility Owner Name b.Address NORTH ANDOVER MA 01845 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4 N/A N/A a.Name of Facility Owner's On-Site Manager b.Address N/A MA 00000 0000000000 c.City/Town d.State e.Zip Code f.Telephone 5•N/A N/A a.Name of General Contractor b.Address N/A MA 00000 0000000000 c.City/Town d.State e.Zip Code f.Telephone AIM MUTUAL g.Contractor's Worker's Compensation Insurer 7026686 7/9/2018 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1788 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: ri a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station DUDLEY SERVICES INC 1504-NEW BOSTON STREET c.Name of Transporter d.Address Note:Temporary storage of Asbestos WOBURN MA 01801 6179814280 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestos l f waste material temporary storage location/transfer station to final disposal site: contractor or a transfer p �' g p station that is permitted by J.O.B.ROLLOFF PO BOX 6037 MassDEP and a.Name of Transporter b.Address operated in compliance with Solid CHELSEA MA 02150 6173871495 Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 tt Massachusetts Department of Environmental Protection 100273647 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r- Project Revision Project Cancellation L r- C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: N/A N/A a.Temporary Storage Location Name b.Address N/A MA 00000 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): TURNKEY LANDFILL WASTE MANAGEMENT a.Final Disposal Site Name b.Final Disposal Site Owner Name 97 ROCHESTER NECK ROAD c.Address ROCHESTER NH 03869 8008475303 d.City/Town e.State f.Zip Code g.Telephone A Certification SAMUEL NIGRO SAMUEL NIGRO "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 9/29/2017 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) Note:Contractor must 6179814280 DUDLEY SERVICES sign this form for DLS all attachments and that, based notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 150iL NEW BOSTON STREET WOBURN responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 01801 information is true,accurate,and complete. I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement h (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 d�gt„CD/b�ffO NORTH ANDOVER BULVyyrDEPARTMENT , �`'RaTecF •t� ,1600 Osgood Street . ��SACf9lF5�G Nol'thAIidover 'Pel: 978-•688-•954 . , . Fax: 978-688•-9542 .BOEM&FOM FOR TOIL'CLERK D.ATP-- hO ADDRESS; 4�1 tYa/1 OrdChrPY ONINGI)ISTRiC: TYPE OF13USINBS MILDI G LAYOUT PROVIDED: YES NO mvAmASLEP.RMG S-VAMS ZONINGBYLAW USAGE: S . NO /4 ING INECTOR SIGNATDPX BUSINESS FORM POP,TOWN CLERK 2.40 Roane Occupation(1939/32) .An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use..of the building for living ptiuposes. Home occupations shall 'iiiclhde,"bu`t tot'limited to the following uses; personal services such as finnished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kannels, or-the, conduct of retail business,or the manufacturing of goods,whi&impacts fhe residential nature of thoileighborhood. 4. For use of a dwelliiag in any residential district or,multi-family district for a home occupation,tho following conditions shall apply: a. Not more than a total of flue-, (3) people may be employed•in-t a,home occupation, one of whom shall befhe�Mier ofthdMmo c ccdpatiort and residing in said divelliug; b. The use is carried on strictly withinthe principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; - d. Not more than-twmn ,fve(25) percent of the'existing gross floor area of Ile,dwelling unit. so used, not to acted one thousand (1000) square feet, is devoted to'such use. fn connection with such use,there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display ofgoods or wares visible from the street; f The building or premises occupied shalt not be rendered objectionable ordetrimental to the residential character of the neighborhood due to the exrterior appearance, emissiozi of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shalt include no features of design.not custdmary in buildings for residential 611ro An ignafure ate 5 l Date .(PA�� �?-- TOWN OF NORTH ANDOVER ti PERMIT FOR WIRING This certifies that . . .�� {2 c_. .!_.�. . . . . . . . . . . . . . . . . . . . . has permission to perform . <J ' wiring in the building of �- ! �e-. . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . .,.r7?. . .c.. . . . . . . . ,No h Andover, Mass. Fey . . . . . Lic. No. 205 �,. . . HQ. . . . . rP�E �ELECTRICAL INR Check# 10912 Au"inassacnusettsElectricalCodeAmendments527 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 throughoutthe Commonwealth,and applications shall be filed- on the prescribed form.Atter 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,fire 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 shallbe limited as to the time of ongoing construction.activity,and may be,deemed_by-the,Insp.ector of_Wires abandoned_and.invalidaf he—.. or she has determined that the authorized worlG has not commenced or has not progressed during the preceding 12-month period.Upon written e permitted for reasonable cause.A permit shalj be terminated upon the written application,an extension of time for completion of work shall b 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 promot6 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 contemning 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 beginningn August 15 008-and extending'through August 15,2012. 19 ule 8—Permit/IDate Closed: � ***Note:Reapply for new per ❑Permit Extension Act—Permit/Date Closed: 1 Ofriciai Use Only cornmart:vea��rz o�IT(cz8sattu�e`t� Permit No._- 3i ! fff " oL eRa.4m.ent o --ire--Jervicev 4 `:•:.:,, ( . l ` Occupancy aridt ee checked_ r (time t r r irr r^ Ct EN TI I C 111%E30A D- O R C r'R (_l!i GN R�G'vLh'c!CN„ 1�[Rev. 1 (leave bland Ali-Nor::to be pe.iormed in accordance wish the?Vfassachasetts=fectrcal Code(IMEC ,_7 Ct�LR??.f}9 (FLE.?SEPRI_�zrT' i Pji�OR i. ELL /T OR-4,1-1 70N) Bate: , A6"�� City or To��ti of: 41 IPA !77 YXe)V e r_ To the Inspector of Wires: By this aoph LLtiar.the undersigned gives ratice of his or tier intention o Pero, e electrical work descraed below. Location (Street&Number) O vner or Tenant Telephone N�g18 9—�� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No r�heck Appropriate Box) Purpose of Building SE'.ryl (Q G�1CLo'l1 Utility Authorization No. E:tistingService /0() � Amps l /a'{4olts Overhead LUndgrd❑ No.of Meters New Service o�C7� Amps lap / c{C�Valts Overlied�Undgrd❑ No.of Meters J Number of Feeders and Ampacify n 5 iJ �� ®�a 0. 1 12S Location and Nature of Proposed Electrical Work: p` �y� Completion Lf thefollowing table may be waived by the Inspector of Wires, No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA ` Na.of Luminaire Outlets No.of Hot Tubs Generators KVA Swimmin Pool Above r In o.or mer,ency i ignting l No.of Luminaires g arnd. arnd.° Battery Units i No.°of Receptacle Outlets ° INo.of Oil Burners FIRE ALARMS No.of Zones ° o.of Detection and No.of Switches No.of Gas Burners Initiatine Devices No,of Ranges No.of Air Cond. Toni No.of Alerting Devices eat Pump{{Yumber Tons o,o Self-Contained ! No,of Waste Disposers Totals:I I I .ll)etertionf4lertins Devices i S acelAres Hestina Municipal F,No:.::6o:fDishwvashers p s Local Q Connection ' Heating Appflanc� .... KW Security Systems:'. ` No.of Driers ri of Devices or Equivalent No.of Water KW NO.of Ballasts Data Wiring: Heaters Signs . No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs JNo.of Motors Total BF No.of Devices or Equivalent OTHER: Attach additional derail if desired or as required ov the Inspector oj'Wires. Estimated Value of Elec tical Worit: _v� ' ® (GVhea required 6y municipal Policy.) Work to Start: Inspections to be rmuested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE. Unless waived by the owner,no permit for the performance of electrical work ma_v issue Ltniess the licensee provides proof of liabili utsurance including"compterwd operation''coverage or its substantial equivalent. The undersigned cer limes that such cov .age is in ioree,and has exhibited proof of same to the pe mit issuing ofnce. C�rIEciC ONE: IivSC .i�ICE. la C� OTHERC (specify:) I certifi,under rhe pains and penalties of erjury,that the information:on his application s true and complete FIRM NAME: l\�� � C— LIC.NO.: IC.NO.: Licensee: 5 (If applicaole,ewer "e empt"in rhe iicens2 n rmber:ine.; m Bas.Tel.No a7��''fab-75oa Address: 'f Alt.Tel. ?er�LG.L,c. l"7;S. 5 -dl,security worlcrequires Department of?nblic Safety"S"License: Lic.No. OWNER'S IN8URANKE WAIVER: I am aware that the Licenses does not have the liabi'dry insurance coverage normally required by law.'By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's went. ' Owner/Agent Telephone No �'EII? FEE: Signature Date: 7/ _ Commonwealth of Ma setts Division of Registratio Board of Electri ' KIRK AtJ 1 R 26 TALM-f 1 HAVERHI� Master Elecfr; iai m� 21431-A 07/31/2013 �e 007464 Always Electric 26 Talmuth Avenue License No. Expiration Date. Serial No. Haverhill, Ma 01830 (978)420-7501 phone (978) 377-0709 fax Please allow to pull a permit in my name, with my license number. If you have any questions,please do not hesitate to contact me directly to verify any of this information. Thank you, Kirk Murray Master Electrician Date.:5�2.....1.14........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU P41 Lk�Zn4o(o , This certifies that"_.-J................................(A i2_4 r-OD................ ..................... -has permission for gas insta Ila ion Y60 . .... .......................7....... in the buildings of, 'z ,r(ov ... ............................................................................. at....... ........................................................................................ North Andover, Mass.. Fee.-3 D........ Lic. NA1..5.t,+.o.......... ..................................................................... GAS INSPECTOR Check# 9318 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 512212014 PERMIT#V A JOBSITE ADDRESS 12 Holbrook St OWNER'S NAME GOWNER ADDRESS Same TE JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT:® PLANS.SUBMITTED: YES® N0[3 APPLIANCES-1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT +TEST ,UNIT HEATER NVENTED ROOM HEATER WATER HEATER OTHER _ Re lace 1 Gas Meter x Ir INSURANCE COVERAGE I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E]NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED 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: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be inpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 11414 PLUMBER-GASFITTER NAME I Joseph Marino LICENSE# 8736 SI NATURE MP[D MGF® JP® JGF LPGI® CORPORATION Ej#I 3285C PARTNE SHIP E]# LLC®# COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE MA ZIP 01501 TEL (508)832-3295 FAX 508-926 4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com . 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# GZ�4 PLAN REVIEW NOTES t • tlll liOiVilVEAL.'TH OF MAS Mu I' - - .;; — l l?1 U111tI:3Ef�5 ='f GCI ;-S ANa �ASF�TTR &EJ AS Wk-ASTER ' t ' 8" •`�`'s -_ fSUE5 T11 `4HQV.E'Lit 6NSE l -- 5=-= ''JtiSE-H '3J:F AR R,I1N6 61N 8T - jR MA 0'a ��j` .f/// �`,,:Y:'• ^g.l-'7'J'.'V 4T / 'a— /14 :. Cba0M_ON,lNEAi Tib OF NBASSACti�S.l�1�i 5• � L-:- U] ER fJ(BS AND GASFIY,'ERS:,' E"D AS A JQU.RNr=ym. � fSSUES THE ABpV 'L10EfV5E `�°�TXRRR:T=IGTON WURe STERA 016�Q4=3•ZCt9_ T i ACV�® ��--- CERTIFICATE OF LIABILITYINSURANCE page 1 of 1 08/29/2031 THIS-CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAN13CONFERS 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)muct be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certaln Policies may require an endorsement.A statement on this cartiftcate does notconferrights to the certificate holder In Ileu of such endorsament(s). PRODUCER CONTACT Wi11iQ p>: Maeaaehusetts, Ins. NWRPHONC PAX C/o 26 cexitury Blvd. ,.Nq,KXrr. 877-945--7378 _No) 886-467-2378 P. 0. Box 305191 DARE&,&cQJ;tificatp _.Wi1jis.GOm NaAhville, TN 37230-5191 INSURFR(8)AFFORDING COVERAGENAICrt, INSURED INSURERA: The chartor Oak r•'ixe Inauranco Company 25615-001 R. H. White Conatruction Company, rnc. INSURERS:TravoXgr9 property Casualty COlWany of Am 25674-002 41 Cmntraz street INSURERC:NaEiOnAl Union Firg Snsurancm Ccmpauy o£ 79445-001 P. 0. Box 257 Auburn, MA 01501 INSURERD;Travelers Indm=i.ty Company 25699-DO1 INSURER F; INSURF,R F; COVERAGE$ CERTIFICATE NUMBER:20287680 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 TYPEOPINSVRANCE 6D' SUB yam POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY VTC20tD 977A9998-13 9/3/2013 .11/1/2014 EA�I`I� COURRENCE $ 2,000,000 X CQMMFRCIALGENERAL LIABILITY TOR�CLAIMS-MADETOCCUR MEEP(Anyone ereon F 10 000 J PERSONAL&ADV INJURY S 2 QDO,000 OENERALAGGREGATE 8 000 000 GF1d'LAGGREGAT] I;R PPLIESPER; PRODUCTS-COMPIOPAGG $ &()0 000 POLICY LOC B AUTOMOBILE LIABILITY VTJCAP 9778955.716-13 9/1/2013 9/1/2014 OM61EDSINGLFLIMIT X ANYAUTO accNent S 2,000,00(1 AO LI.OWNED AUT08ULED BODILY INJURY(Perpemon) $ AUTBODILY INJURY(Peraccidont) X HIRFOAUTOS X NON-OWNED AUT03 ^� X Com Dad Coli Ded ereccident S C UMBRELLALIA86 X OCCUR BES766140 9/1/2013 9/1/2014 EACHOCCURRENCF $ S�000,000 EXCESS LIA6 CLAIMS-MADE AGGREGATE $ S,040,000 DED I X IRETENTIONS =0,000 $ D WORKERS COMPENSATION vxR$UB 6205A185-13 9/1/ZC73 9/1/203 X O AND EMPLOYERa'LIABILITY yYYY/JJJINNN� TAI�YLI, D ANY PROPRIETORIPARTNFR)FXECUTIVE� N(A VTC2xuB 820g•A71A-13 9/3,/2018 9/1/2014 E.L.FACHACCIDENT .2i 1.000.00o OPFICERIMEMBFREXCLUDED7 LJ Mryo dee eo 11 NN) E.L.DI8EA6L-EAEMPI,OYFE S 1,000,000 UE�VKeIIeUN u1d-vNFRAnorls nalow F1,DI8EASE-PMICYLIMIT 1,000,000 )ESC RIPTION OF OPERATIONS)L,OCATIONS I VEWICL MG(Attach Acord 107,Addlionpl Rema►kC 3thadutn,11 more epeeo la rsequlrgd) :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZIID REPRESENTATIVEEvidence of Inmuxance CoXI44297604 TPI!1694012 Cert:20267680 ©9988®2010ACORD CORPORATION.All rights reserved. ,CORD 25(2090/05) The ACORD name and logo are registered marks of ACORD Date.//., .... . .. . AORTk OF .... ,° 3r °` TOWN OF NORTH ANDOV O 9 PERMIT FOR GAS INSTAL TION h �9SSACNUSESS This certifies that . . . . . . . . . . . . . . . . . . .r has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . `1,?. 4: . . . . . . . . . . , North Andover, Mass. Fee. . �_.C.. Lic. No.t:.V. .?... ;��.,._ . . . . . . . . . . AS It; Check# J 9 �, LI MASSACHUSETTS UNIFORM APPLICATON FOR PERNVIPT TO DO GAS FrrrING (Type or print) Date NORTH ANDOVER,,MASSACHUSETTS Building Locations 1.2 aea 0 A n�0 Permit# Amount$ Owner's Name New❑ Renovation ❑ Replacement ® Plans Submitted ❑ W � q O E. c7 w w E» vi W r� 0 O x 3 A C7 U a > a H O SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH . FLOOR (Print or type) Check one: Certificate Installing Company Name T 414 G L O f/-1 n/ /Cy�/ Corp Address d- 13 o Partner. 1..)4 eev c '41 Business Telephone �7 7-Y 6 b(5-- 9 S�o 5' ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 7Ven os W4 My/fIg o"1 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑ Ifyou have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Codeanyl Chapter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title ® Plumber aZ 3.3 City/Town ❑ Gas FitterIcL� ense Number ❑ Master APPROVED(OFFICE USE ONLY) [zi Journeyman MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location AI A0,16100,01f eJ, Owners Nameyh1��f/e�j x'55, ,'//permit# Type of Occupancy Amount New 0 Renovation Replacement ® Plans Submitted Yes No ❑ FIXTURES z Q p z W cc U � W t/� E" r� Ocl) cc w w ° z z 3 U w 0 cr cc Q W z �" Z a a O H F x x z o W Q o x w 3 a A A Q F a Q a s l� SL13-B 1C RAS VM ' ]SB FIOCR M FLOOR M FLOM 4IH HDM 5M HIM 6M HI" 7IH HDD SIH FIIOm (Print or type) Check one: Certificate Installing Company Name ,?4 R U47 j'/�/� ❑ Corp. I Address ® 130? 2- Partner. Business Telephone ej 7 015-27 17� El Firm/Co. I Name of Licensed Plumber: -1179M 4-T yA/loel4�'y Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the .best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State P u i g Code and Chapter 142 of the General Laws. By: Signature 01 1-1censeum er Title Type of Plumbing License City/Town 2`Y3 3 APPROVED(OFFICE USE ONLY icense Numner Master ❑ Journeyman Location No. ri E3 f Date MORTM TOWN OF NORTH ANDOVER 0 41 Certificate of Occupancy $ Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 17 4 U 9 Building Inspector 'i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissio er for of Buildings Date SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 160 27 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 Reqfired Provided Rectwred Provided 1.7 Water Supply M.(:L.C.40. 54) 1.5. 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 ' S t ' Distrior, Yes 1,40 2.1 Owner of Record Name(Punt) Address for Service Signature Telephone Q 2.2 Ojvner of Record: Nam%Print Address for Service: � ,c Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date K Signature Telephone r 3.2 Re'iAered Home Improvement Contractor Not Applicable ❑ Company Name _ Registration Number Address Expiration Date Signature Telephone Y t 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.......❑ SECTION 5 Description of Proposed Work check alta licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition U,-" Accessory Bldg. ❑ Demolition ❑ Other 11 Specify Brief Description of Proposed Work: ' 1 a,)t 18 , &_e_t-X tk'h' *k'1inCJ 1-.m i a,nd QQ'-Qqz� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFk3CIAT;USE ONLY IN Completed by permit applicant •.:` ' 1. Building fj t (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee(e) 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 behalf,in all matters relative to work authorized by this building permit application. Signature of Owner k Date SECTIION 7b-OWNER/AUTHO 1 IRIZED AGENT DECLARATION 11 l 'W nY1 1 0 CL Ssl l l_9__ 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�tn� J 0 14a� Signature o—Owner/Al Vent11111111XM1".11127.117537 V�1 Date x.. NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3RD SPAN q DIMENSIONS OF SILLS J DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ti LET 2 LET 3 - - 100.0' _ LOT 11 S A=10,000 S.F,± . / n►v i5 1� '� LET 12 # 12Tir a LOT 10 2 STY. o WOOD o CD / GAR, a CD 30'± 13'± 0 m) 1 / 100.0' ' H ❑LBR ❑ ❑ K ROAD NOTE: PLOT PLAN OF LAND THIS PLOT PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION, THIS CERTIFICATION IS MADE TO: IN NORTH I T� \ / E((�� WASHINGTON ❑ESNULLANDVOD UPON FUTURE MUTUAL FUANY CYNTHIA SLE AND BECOMES N ❑ R IT H A ND ❑ V R , MAI FUTURE CONVEYANCE. I HEREBY CERTIFY THAT I HAVE EXAMINED THE PREMISES AND THE BUILDINGS ARE PREPARED BY: LOCATED ON THE GROUND AS SHOWN, I FURTHER tHOF a PJF & ASSOCIATES CERTIFY THAT THE PRINCIPAL BUILDING SHOWN DID y►� �`�' CONFORM TO THE DIMENSIONAL ZONING LAWS OF PAUL 11 GLEASON ST. MEDFORD, MA. NORTH ANDOVER WHEN CONSTRUCTED. J. PAUL J. FI.N000HIO-P.L.S. I HEREBY CERTIFY THAT THE PROPERTY IS NOT RNOCCNIO (781 )395-7662 LOCATED IN AN ESTABLISHED FLOOD HAZARD AREA #36115 y F.I.R.M. MAP No. 250098SIO�Pv SCALE I" = 20' REVISION DATE JUNE 15, 1985 ��OsuRv DEED REF.:Bk. 5290 Pg. 188 DATE: APRIL 6, 2001 PAUL J. FINOCCHIO P.L.S. No.36115 DATE FILE No.:(19-101-01) _ The Commonwealth of Massachusetts w M t d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print i Name: Location: la �cnl Y- 2A CityPhone # q`�� 7Q`4" I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#: Insurance.Co. Policy# Company name: Address Citi Phone#: Insurance Co. _-_- -- --- -_-- Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment.as-well_as.civil.,penaltiesin-the form Dfa_STOP.WORK_ORDFR-and_afine-of.($1.DO.DD)-a day against-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify/under the pains and penalties of perjury that the information provided above is true and correct Signature ( 'i �5 � \ _-_ _�s e-ey�0o Date Print name P.hon.e# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing El Building Dept ❑Check if immediate response is required E] Licensing Board r-1 Selectman's Office Contact person: Phone#: ❑ Health Department F-, Other I North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be ' disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of.Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Top View of Your Deck The Scale is 1/4 . 1 3171 68" T 6 1 IV € a 3 s � i a s f i ¢, e { E 7 A� r t � � fye l 2 �� fib-n,✓�s g v�9� � y r 3D View of Your Deck TMr f'3. ; ..,--- r a� WNS 1 / . ��oP C ►s 7#AH 2 1 3D View of Your Deck IN M r��ryx�. ��� ✓r 6'r �' - � 'K h'� �S ��y- � � 3. l '.' t kcsa' - ,, ma 7D C-b P sj I z �Cpyc� M��� �.10RTfy Town of 0 No. rl � � =: _ 7 � �. oO ==` LAK11dover, Mass., NOR y �D y COC MIC ME WICK . ADRATED PP���� `s U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... ... .� ..............C� :'s /Aw..................................... ................................................... .. Foundation has permission to erect.....�, . i buildings on /do �0 �� *so A �� g . ................................ ................. Rough to be occupied as CA •Nrr�� • be 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-Las relating to the In action Alteration and Construction of Buildings in the Town of North Andover. 'V 3 0) SO PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTEIS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO,.4 ST TS Rough ......................... .... Service .. . .. . ... ............ ........... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building cAs INSPECTOR Rough Display in a L 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.