The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 12 PEMBROOK ROAD 4/30/2018 12 PEMBROOK ROAD 2101021.0-0046-0000- / 1I 9800 Fredericksburg Road San Antonio,TX 78288 U5�® 04664. 1RX3J .JSS1007967576 . 01 . 01 .255 TOWN OF NORTH ANDOVER February 22, 2015 1600 OSGOOD STREET NORTH ANDOVER MA 01845-1048 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Dear Sir or Madam, I am writing regarding the claim referenced below. _ y Policyholder: Christina H Bicksler Reference #-: 008677835-1 Date of loss: February 8, 2015 Location of loss: North Andover, Massachusetts Address: 12 Pembrook Road, North Andover, Massachusetts 01845-3728 A claim has been made involving loss, damage or destruction of the property referenced above, which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 659468 SAN ANTONIO, TEXAS 78265 Fax: 1-800-531-8669 Phone: 1-800-531-8722 x42448 Sincerely, Stedman A Taylor Property-CVA Unit 5 USAA Casualty Insurance Company PO Box 33490 San Antonio, TX 78265 Phone: 1-800-531-8722 x42448 Fax: 1-800-531-8669 008677835 - DM-04664- 1 -4528- 09 54577-0914 Page 1 of 1 Date... 10280 -5..... T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING HU Z-1 e-41— This certifies that..... ............ .......................................................... 'has permission to perform............. ........... ..... ..... ...................... CT.6.-Ir................ -A-7 plumbing in the buildings of—5e� 4-L LOO......,,, pp ....................U at.... ....... ... .Vii`............................ North Andover, Mass. .... ........ ..... Fee.!A.:�) ...Lic. No. .................................................................... PLUMBING INSPECTOR Check# LJa Oct on MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 21-Nov-13 PERMIT# �� V JOBSITE ADDRESS 12 Pembrook Rd. OWNER'S NAME Seaport Homes LLC POWNER ADDRESS PO Box 8225 Bradford MA 01835 TEL 508-509-4018 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES 7 FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING / 1 OTHER INSURANCE COVERAGE: 41 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: 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 an accura to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com Ilan witty all Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert J. Frazier LICENSE#13425 SIGNA MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Bomar Plumbing &Heating ADDRESS PO Box 694 CITY Derry STATE NH Zip 03038 TEL 603-325-8958 FAX CELL EMAIL Bob@BomarPH.com v • �r 6 A )/ y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street re Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bomar Plumbing & Heating Address: PO Box 694 City/State/Zip: Deny, NH 03038 Phone #: 603-325-8958 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp. insurance.) required.] 5. EJ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11. XO Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Fire Insurance Company Policy#or Self-ins. Lic. #: WC2-31 S366059-022 Expiration Date: 22-Apr-14 Job Site Address: 12 Pembrook Rd. City/State/Zip: N Andover MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerci under 7p05ms;pdpenafties of perjury that the information provided above is true and correct Si nature: � Date: 21-Nov-13 Phone#: 603-325-89 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: S �•� �S COMMONWEALTH OF MASSACHUSETTS } <I �,. PLUM-BERS AND GASFITTER.S. OtENSELI AS A JOURNEYMAN P-LUPA I 1SSUES THE ABOVE LICENSE TO. ROBERT. ;J FRAZIER j = :I s PO BQ)C 694 DERRY MH 03038=.069 20499 '05/01/14 2`40125` I ` I Fold,Then Detach A1669 All Perforations �I COMMONWEALTH OF MASSACHUSE.-TTS M, PLUWERS AND GASFITTERS UCENSE'D AS A MASTER PLUMBER l ISSUES THE ABO ER TO i RO$ERT J FRAZIER "I F'0 BOX 694 3u ' `i DERRY — NH 03038 0694 I 13.425 05/01/14 240124 E__ ., _ _ . Date....................................... �rlowrly,� TOWN OF NORTH ANDOVER a PERMIT FOR WIRING 88'�CMU5� C This certifies that ........................... J..'f ....... . `?`P� /t ..:.....:................ has permission to perform ............... @ ?' .... .......................................................... wiring in the building of........ .. la/T� ............................. p `� ate,. ��..................�!... .... ...........�LEcrwcAL � North Andover,Mass. .` Fee..J. T. ...Lic.No. 3.9.Z46.. INSPECTOR Check# 1 ;2:022 w c®IIBITr9®B71!!/�,'ai kid ®f Massachusetts Official Use Only . . a Permit No.Department ®f Fire Services / Occupancy i and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. /07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),.527 CM 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: 0 City or Town of: NORTH ANDOVER To the Inspector of Wiles: By this application the undersigned gives notice of his or her intention to perfoyin the electrical work described below. Location(Street&Number) �! � �i'7Jf� e ��Ct� _ Owner or Tenant ° tr' ,-_S L. Telephone No._50 '.aL� �fL�� `� Owner's Address �L� y ix r r ,-i �y Is this permit in conjunction with a building permit? Yes VJ ''No ❑ (Check Appropriate Box) Purpose of Building e/4, z/L Utility Authorization No. Existing Service_ l Amps ,1-d; Volts Overhead ❑-- 1Undgrd❑ No.of Meters ^1_ New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:' &A vzz^ 77A t.. 1 ;' Completion of the following 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- Elo.o mergency Lighting rnd, rnd. Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances ,y Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: t� Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring. No.of Devices or Equi valent BOTHER: _,,..-Atiach additional detail if desired,or as required by the Inspector of WYres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (]/BOND ❑ OTHER ❑ (Specify:) I certify,tinder the poi s and penalties of perjury,that the informat/ioo on this application is true and complete. FIRM NAME: _ L/11771 c:/�" ' �`�y LIC.NO.: Licensee: 1,n !—/C Signature LIC.NO.: 7 (If applicable,enter."exempt"in the license numb I- e.) Bus.Tel.No.:`�7.��?: 7, Address: 5( V �� Alt.Tel.No.: t. S *Per M.G.L c. 47,s.57-61,security work requires Department'of.Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: ' i, r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: tw 4 ROUGH INSPE TIO -. Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comment XA— 14 Inspectors Signat re: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Commen . Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r i. kw The Commonwealth of Massachusetts Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ' r � Name(Business/Organization/Individual): ��'✓/,� //�� (', 1. /mac �%✓7�� Address: � �rS j/Z�rc= A - City/State/Zip: 1 , ,/��1/� Phone#: �K&7vZ 3)J- Are you an employer?Checkthea�propriate box: Type of project(required): 1.�am a employer with � 4. ❑ I am a general contractor and I 6. Blew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 11. Plumbing repairs or additions 3. I am a homeowner doin all work right of exemption per MGL ❑ g P ❑ . g myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: �� (i✓�'C'c Expiration Date: Job Site Address: -[ PI)o i bao k -pity/State/Zip-&-A AA- IV . A tach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). r,a lure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ,ij e up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert uncle he pains and penalties ofperjury that the information provided above is true and correct Si ature: Date: 1 / 3 Phone#: �� 3 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#: fj - Inform.ati®n 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"...eve person in the service o "....every p f 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)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 anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom . of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to thef applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each ,$ year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigalion$ 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 4406 ori 1-877,MASSAFB Revised 5-26-05 FaY,#617,727;7749 cWWW mass..gov1dia ry, Date.....-7 .....Z.`.r�. ? 3r;.�;�``°.,•_:"�o� TOWN OF NORTH ANDOVER p PERMIT FOR WORING �SSAcmU This certifies that ............... ....�. .AIR-h— L � .... / has permission to perform 14 b.�.�j.� f �Y'G z.. wiring in the building of........1 .��! ......... �'`' r�.................... Gaca f� I` North Andover Mass. Fee...1.7 ........ Lic.No.<�AS ZG� ............ .,� ; Ei ecrRic IIasrecroR 'tl Check # Z 7 3 F u 75 .14 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ! S 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 Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: :711110-7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) i 2 Pt,,TA d (1p Owner or Tenant Duiia fn urPN y Telephone No. Owner's Address 52-we- Is 2weIs this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building cov*req LQ 1 f Qwy�k 1 f\`, 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 r Location and Nature of Proposed Electrical Work: [ ��- �1n St 1 �y ire v. h sec) o� UP GmJe- Sr, oke S NNYNr A&) SVS, P�r�l Completion of the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminairesy Swimming Pool Above ❑ In- El- o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets 5 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No. Devices No.of Ranges No.of Air Cond. Total No.of Alerting g Devices • No.of Waste Disposers Heat Pump Number Tons K.W. No.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 Water No.of No.of No.of Devices or Equivalent `rr Heaters Kms' Data Wiring: Signs Ballasts No.of Devices or Equivalent G No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: oFj Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE J< BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: P,C,Ca(611 1E\f—C—. LIC.NO.: --X0SD�-0A- Licensee: :C Ri CC• Signature ,1 LIC.NO. E�SQa-y (If applicable, enter "exempt"in the license number line.) '/3•7 Bus.Tel. No.: a / Address: S�V$�C 0[c)Q& Alt.Tel.No.: Z U E1_1111(_7%0 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S" License: Lic. No. OWNERS INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityinsurance coverage normally required by law. By my signature below,l hereby waive this requirement. I am the(check one)❑ owner ❑ own is agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 335 1 �r � � Date.. .. .. NORTH TOWN OF NORTH ANDOVER 3? O PERMIT FOR CAS INSTALLATION P • i, • �,SSACMUSEt� This certifies that . . !fir. s . f4 /l ( . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . in the buildings of . . ,r? �.! C. . . . . . . . . . . . . . . . . . . . . . . . at .,/. .� .„ fir. •.. /?G . . . . . . . . . . . . .. North Andover, Mass. Fee.�.� .-. . . Lic. .. . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 1\ MASSACHUSETTS UNIFORM APPUCATON FOR PERIVMII'TO 90 GAS FITTING ype or print) Date /O 1�y-1 O(A. NORTH ANDOVER, MASSACHUSETTS ,,D Building Locations C� V O O !� Permit Amount S Owner's Name f'; New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ m n C Z 5 rn ;r] :c! " ;0- In CCn L t., SUB -BASEM ENT ' BASE , ENT I ST. F L O O R 2ND . FLOOR 3 R D . F L 0 O R C11 F L 0 0 R GIT If F L 0 U R %T If F L O O R 7T 11 FLUO It ST 11 F 1. n O R (Print or type)j� �p y� Check one: Certificate Installing Company Name— 1�V�5 e._S� / /u f t IS �`y� 7t P�fi K� jr�� Corp. ❑ A 7dd ess "' 0/"t / , a/9 1 `'� Panner. yv, 5 S' ►30 v o 01 5 Q ' s Business Telephone 72, ` — - Y� �L /1U— ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 'Al�� &"(j✓-J INSURANCE COVERAGE Check,one: I have a current liability Insurance policy or it's substantial equivalent. Yes �'� No❑ If you 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 Code and Chapter 142 of the General Laws. Bv: Signature of Licensed PI mber Or Gas Fitter Title r7 Plumber �/ City/Town ❑ Gas Iter License i umoer taster APPROVED(OFFICE USE()NLY) ❑ Journeyman 1VJAbbAU"U5ETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 1 (Print of Type) NORTH ANDOVER, , Mass. Date 3 0 19 F Building ' Permit # Location— ��eivrQr,�-�rz all - 2/ 6 Owner's Name aa � New Renovation ❑ Replacement p Plans Submitted: Yes [] No p • N - N N s , K ri � k v t- N aeN ac ee•; tl J N W H U d X M sa N N N d i X N 1! 0O N owe= J w 0 w j Js h i 1 0 o d aZ al, v 19 y d tuA—asst. OA9EMENT 1ST FLOOR 2110.FLOOR i SAD FLOOR 4TH FLOOR 17 8TH FLOOR i 6TH FLOOR r e 7TH FLOOR , 6TH FLOOR installing Compan+ , ( Check one: Certificate ny Name �J {-� ] Corp. Address CON CCp S�- V d Partnership -- ref p�J -� �D t A SS 6hrm/Co. Business TelephoneiCq f;L Name of Ucensed Plumber or Gas Fitter J&yyS 11 C X afle I INSURANCE COVERAGE: Check one 1 have a current IlabMRy Insurance policy or Re substantial equivalent. Yes ASI" No ❑ If you have checked.yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 1k1 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 permPt application waives this requirement. Check one: %nature o Ovmer or Owner's A—ge-n-F 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 the permit Issued for this application will be In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ger= T ofUn e: "umber ns GasTitle Iter • nae Vum eraoter as Filter Master mCfty/Tom umeyman !cense Nu APPrIUVED(OFFICE USE ONLY) BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO DO GASFITTING' NAME S TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFtTTER _. . LIG N0. .. . . .... - PERMIT GRANTED DATE_x_19 s GAS INSPECTOR Date. . 715 �v 0 NORTH TOWN OFysNORTIHrl.401DVER 40AS�JUL 4PERMIT FONSLATION * tom 9SSACHUSEt � This certifies that . . . . { � y -. . has permission for gas installation . . 4 .t►f � , in the buildings of ./ . . (ew'l&Z./ . . . . . . . . . .. . at . . . ' . . . .itw.4 .. . ., North Andover, Mass. Fee. .�5 Lic. No... . .. . . .. :,.... . ". . F GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:.Treasurer GOLD: File NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY CARD FIRST CLASS PERMIT NO.721 LAWRENCE,MA POSTAGE WILL BE PAID BY ADDRESSEE BAY STATE GAS COMPANY ATTN: SALES DEPT. 55 Marston Street Lawrence, MA 01840 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIII Bay State Gas Company GAS INSTALLATION AUTHORIZATION Date 47 C;?_ Ifs Issued toui ,r Address For Installation of: ewsvcG — BTU Input �T � Restrictions BSG Representative PERMIT ISSUED _ BY INSPECTOR This Portion of Authorization To Be Returned to BSG. Inspection Has Been Made of the Following Gas Equipment: ❑ Heating System (BTU Input ) ❑ Range ❑ Water Heater ❑ Clothes Dryer ❑ Room Heater Location Z 2= 422,wd All Work Has Been Done In Accordance With The Massachusetts State Gas Code And Is Ready For Use. INSPECTOR JUL-15-2007 05 : 13 PM LARRY OGDEN 978 352 2858 P. 01 LAWRENCE EL OGDEN,P.E. j 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978—352-2$38 pager 978-502-5921 July 15, 2007 Mr, Kevin Murphy 169 Boxford Street North Andover MA. 01845 1E. Residence Ms. Debbie Murphy,12 Pembrook rd„North Andover,MA. 01845 Dear Mr. Murphy Per your request I visited the above site to review the LVL Beam consisting of 2- 18"LVL beams supporting the second floor wall and roof above,spazWng 12.5 ft. I have reviewed the design of these LVL beams used in the structure and can certi that the beams are acceptable and meet the loading f5' ppb conditions aired the . 8 � by Massachusetts State Building Code. Should you have any questions please do not hesitate to call. Yours truly, O `A CE tawrmence H. Ogden,P.E.�structural 2'7765 N H 1/1407 SSIDNA Et1 I I w Location No. G q Date G2 NpRTM TOWN OF NORTH ANDOVER f �,r � w a y • 'a a Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNusa Foundation Permit Fee $ Other Permit Fee $ � . TOTAL $ Check # e�/Ul 15592- /� `Building InsWor TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ;.. M BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: Building Commissioner/InEeedor of BmIdings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Diaiic—t Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided Q 1.7 Water Supply M.G.LC.40. 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zan "3 Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERS `/AUTHORIZED AGENT 2.1 Owner of Record Na (Print) Address for Service: r W Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O M Signature Tel hone 00 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: t c/L- `� �� ` License Number mn -Address 59 /•79 Expiration Date o Sig ature Telephone r 3&kegistered Home Improvement Contractor Not Applica e 0 ' U - ;r2 f! Si )�t �` �f Company Name Registration Number Address ��+J � ✓✓ Expiration D.to G1 Si ture Telephone V 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 buildina 22rmit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ 1 11 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant I. Building (a) Building Permit Fee t Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel 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 reby a thorize to act on alt,ii ma rs relate w authorized by this building permit application. / f ./ ✓7 a #' at —of Owfier Date ECTION 7b OWNER/A _ IZED 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 e. Si ature of Owner/A ent Date NO.OF STORIES SIZE 6 BASEMENT OR SLAB SIZE OF FLOOR TINIBERS I2ND 3 SPAN DINENSIONS OF SILLS DIMENSIONS OF POSTS DPAFNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE, Town of over 0 0% No. C LA 0 dover, Mass -4� COCHICHEWICK 0 ATED BOARD OF HEALTH Food/Kitchen PERMIT Septic System ........... .4 - - AP +ns on jW...... BUILDING INSPECTOR THIS CERTIFIES THAT......... ... .................................. . ... ... .. ....... ........ ............ .......... Foundation has permission to erect........................................ build! Rough to-be occupied as'000000Chimney provided that the periol'nla �yii�ja_t-this...p e..ri-m-ft.-shal-1.-in-every.-res-pec-t-confor.m.-to.t.h.e.-term.s.-of-the-ap-p-1.1-cation.o.n.-f lie-in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMrr EXPIRES IN 6 MONTHS.. UNLESS CONSTRUCTION STTELECTRICAL INSPECTOR I , C %Nor 4'� Rough ... 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR t Number'-CS'. 021298 Birthdate 05/21/1945 Expie5 05/21/2004 Tr.no: 24063 t ttestrrcted OU /_r�+ 4 JOSEPH P 13RADISH-7 PO BOX 4480 MOUL:TON DR' .t I E HAMPSTEAD, NH 03826,. '' Administrator NONE INPROVEt[ENt Q iT [TO _- , Reyistratioo' 1Q2091� +, fzp�'ration:.� �b/30lO ' Type: Ftldf a1al;: 1 JOSEPH P: RR��s Joseph. Bradssh h +• G- � Iloeltclf ttrioel