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Miscellaneous - 120 BRENTWOOD CIRCLE 4/30/2018 (2)
/ _. jW00D C\RCIE 12�9REN rig-0�0 0 �_ _�_ � - -- ---- - - - - -- 2101064� � Date........................ - &OAT#, TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING ss�CHUs� This certifies that ........................ ......C_ l.. ,1./.2. . ;Z'/:..,-2............. has permission to perform ............c. Z wiringin the building of.......................................................`....................... .......................... Z /1�X �'cc,........... orth Andover,Mass. at ..................................................i: f`? ............ Fee................. ...........Lic.No. ................. Y-A........... ECTRICAL INSPECTORf� Check# /®5� 1332A Commonwealth ®f Massachusetts Official Use Only Department of Fire Services Permit No. l 3 Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev.1/o7] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),5 7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL.INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives notice of his or her intention to perform the electrical work described below. Location(Street&Number) W D t-to 4 c�JooJ 6 Q Owner or Tenant Telephone No. Owner's Address 00 ta,ol ujo ) "rL -R Is this permit in conjunction with a buildin permit? Yes No F] (Check Appropriate Box) Purpose of Building �5�lQ,r. cr Utility Authorization No. - Existing Service 100 Amps 1J,0 d` 0 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 thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Batter Units i 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 Tons No.of Waste Disposers Heat Pump Number Tons KW 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 Devices or Equivalent No.of Water No.of No.of KW _ Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent r OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lec ical Work: (When required by municipal policy.) Work to Start: � �Q 1 4� 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 0, BOND ❑ OTHER ❑ (Specify:) I"certify, under the ns and penalties of er,*u that the information on this application is true and complete�Q l FIRMN r `� �CWC`(A"\ S- rU1 CAS (� LIC.NO.: (/o93 1 Licensee: tl 0 Signature LIC.NO.: (If applicable _ r "exempt"in the license nv b r line.) t Bus.Tel.No. Address: 2 Alt.Tel.No.: *Per M.G.L c. 147,—s.57-61,security work requires Departme t 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 b hereby waive this requirement. I am the(check.one)❑owner ❑owner's agent. Owner/Agent - Signature Telephone No3 yd 149 PERMIT FEE:$ i ❑ 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 ,P 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 F?1 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed IM Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: I Inspectors Signature: Date: FINAL INSPECYAKN7 Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts f Department of IndustrialAceldents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lel4ibl Name(Business/Organization/Individual): �/���� �,�C, C.k A 0 a GP < < C Address: U City/State/Zip: ® Phone#: (?6D'3 q( Cl�C—f Are you an employer?Check the appropriate box: Type Of project(required): 1.F1 I am.a employer with employees(full and/or part-time).* 7. ❑New construction am a sole proprietor or partnership and have no employees working for me in 8. IffRemodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. r 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We 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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-corilractors 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::.t , Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ertify under t pain penalties of er u that the information provided abov is true and correct. ,Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: � f 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'ori'hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of - Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their c 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 pennit/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 1m;:,00mmoNwg H OF fAAS.SACI-IUSETT B©ARD'QF E L CTM C I ANS ISSUES THE FOLLOWING' L' CSE ` AS A REG JOURNEYMAN ELECTR d� ,JA.REl3 J CARVELLO 88 EAST BROADWAY: AP'T ... .'......�_.....+ J GIERRY N;H 03038-20 20 2823) _..._07/31/?6 t X334 w �Date."1��.�.��.`.�.. ....... i F r&ORTh, I ti TOWN OF NORTH ANDOVER 3?: -�: • °oma ° 9 PERMIT FOR PLUMBING ,88ACMU'S�t {. This certifies that.... ....... ��..�,t 1....................:. . . . .has permission to perform...—Ayr.4!.... �. .P..�..�.:0.�................................. plumbing in the buildings o ..... . f'!�:A�. ................................................ at....... ....`..-......r�...........!... .� . ..�........................... North Andover, Mass. Fee.��.6�. .....Lic. No.� "? a.. .............................................. . ................................... PLUMBING INSPECTOR Check# ��_ S �v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE �_.�., PERMIT _- CITY ._. JOBSITE ADDRESS O �� Wil c1�U ' OWNER S NAME &kk-W I OWNER ADDRESS $p`,y� Y—_-._., TELi FAX1 TYPE OR OCCUPANCY TYPE -_ EDUCATIONAL - RESIDENTIAL IVII IAL COMM _. PRINT ,-- PLANS SUBMITTED: YE N0. CLEARLY NEW: _ RENOVATION. REPLACEMENT::__F FIXTURES 1 FLOOR HSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE ' -` --- DEDICATED SPECIAL WASTE SYSTEM —I _ l --t _ .' { :,_ ._ DEDICATED GASIOILISAND SYSTEM --_.i i . 1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _� _ _ `_—_#____i' ____i'__.__!: DEDICATED WATER RECYCLE SYSTEM ^`---_r--_--- -; _._-._'_ ' DISHWASHER _ _ _ _ _ __ _ __ _ 41 DRINKING FOUNTAIN _J FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) i KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINKTOILET 1 URINAL , _ � -. E._--if JWASHING MACHINE CONNECTION WATER HEATER ALL TYPES WAIER PIPING OTHfR11 1 INSURANCE COVERAGE: I have a current liabil- 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 ._. 1. 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 mall be in complian77 rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Kevin Scott --- -` —T^ �— ;LICENSE# 13258 — SIGNATURE MP JP-- CORPORATION_�_I t 2438- :PARTNERSHIP' _#` LLC.._i# COMPANY NAME Kevin Scott Plumbing&Healing INC.w ADDRESS P.0 Box 446 CITY i Wilmington w-- � STATE MA ZIP 01887 — TEL.978-988-3632 ..�� FAX 19-78-694-9977 1 CELL[978-479-8966 EMAIL kevplumbing@comcast.net _ r;.� .. _ -� .' �,� ,'i mss/ ,�� �(J f n; Date... . Z. ................... - o�' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,s`SACHU5�t This certifies that .......... .....� this permission for gas installation ............ .a$$ .. '�??Je .......................... in the buildings of............ :�I .z �V,^(cit...... .... . ... ... . .. .... ... .......................... at... .... ......... .............................1.z4/� `` � �"veMass. .. O gNorthAco , Fee..�0............ L . ... ......... GASINSPECTOR Check# 09955 /��- { � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK PERMIT# - CITY __ - - _ MA DATEtf� v JOBSITE _ ADDRESS: _-li� /� �nIJ�_.Ca,F�!' __. OWNER'S NAME - _a_ .1 �G OWNER ADDRESS TE � -- - ;FAX: _._-__ --- TYPE OR OCCUPANCY TYPE COM ERCIALin ; EDUCATIONAL:_ RESIDENTIAL PRINT CLEARLY NEW: RENOVAT10 : -_+ REPLACEMENT:_. PLANS SUBMITTED: YELN0: APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER J BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 �---- -- -.----_-- ---- --- FIREPLACE FRYOLATOR FURNACE __ 1 --i- GENERATOR - - - - --- GRILLE ----- ----- _-- INFRARED HEATER -—-=--_i _ - LABORATORY COCKS __ -- MAKEUP AIR UNIT I _ OVEN POOL HEATER -- ;. - ROOM(SPACE HEATER - ROOF TOP UNIT TEST ' --- UNIT HEATER . �,--_1 — UNVENTED ROOM HEATER __ __-_� WATER HEATER I. OTHER --_ -- - i _.. I. - _..• ` __._'- - _ f -- ' INSURANCE COVERAGE Fbave a current Iiabil' insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �. NO t P Y q I1IF 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: 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 py knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:Kevin Scott LICENSE#:13258 IGNATURE MP•- MGF:_-..: JP: JGF �I LPGI _� CORPORATION: '4.2438 - PARTNERSHIP:__;# ;b-c-_#:y-- _ COMPANY NAME:;Kevin Scott Plumbing&Heating INC. (ADDRESS P.O.Box 446 CITY :Wilmington - STATE MA ZIP 01887 :TEL 978-988-3632 FAX:978-694-9977 CELL`_9781179-8966 :EMAIL:kevplumbing@comcasLnet �� -� - �`-,. a q.._. - `�, 1, l S t f2 Z- � ss✓� �/ � / � J 1 � Print Form The Commonwealth ofMassachu'setts a Department of Industrial Accidents - �, Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApRlicant Information Please Print Le glibIv Name(Business/Organization/Individual): VQJ\Xv� Address: $ N 44, �.N.,,� L5,n r 0 1& pp �, City/State/Zip: Phone#: - Y! 10 Are you an employer?Check the appropriate box: Type of project(required): 1.( ►,Yam a employer with 4. ❑ 1 am a general contractor and I VVVVVV have hired the sub-contractors 6. ❑New construction employees(full and/or parttime). 2.❑ I 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. ❑ Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Filectrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their i 1 Plumbing repairs or additions myself_ [No workers' comp. right of exemption per MCL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also rill 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: wL 3 K Ys Policy#or Self-ins. Lic.#: Expiration Date: �-lall S _ .lob Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MCL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Itereby cert#yunder the ain d penalties of perjury that lire information provided above is true and correct. Si Z/1/1/—,- ature: Date: 7 -,-/ Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: �COMMONWF ►LTH OF MASS CHIfSETTS BOARS OF PLUMBERS AN ' GASF;ITTERS SSUES THE FOLLOWLNEi L10EC+.SE $ I S71?IID AS A PLUMB I NG�CORP oc KEUkIt# A SCOTT = 1 ,� �{EVIN SCOTT P. HTG I PO B;OXA6 LM1 tGTON MA O 1887 04b 248� 05/01%16 a 99+99 {g; OMMONWFJIL'TH OF_M55AHlSETTS BOARD:OP PLUMBERS AI+O GASF ITTl:RS i SSUES THE FOLLOW f fJG I CENSE t CEjiAb .AS A MASTER PLUM16E1 � ". KE�F11 A SCOTI RA T ; } �. _. Po sox 446 t 1. 11 IdGTON MA O l$87 04�rEi 0 , 135 a�/o�/16 21484 � Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: F JACOB STEIGERWALD and LORIE A STEIGERWALD Property Address: 120 BRENTWOOD CIRCLE,NORTH ANDOVER, MA Policy Number: HMA 0060891 Claim Number: BOS00040234 Date of Loss: 11/24/2013 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Anne Dunphy Claim Examiner 12/16/2013 Safety ety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3061 Fax: (617) 531-6644 Email: AnneDunphy@Safetylnsurance.com it qq Date.... ......................... r" NORTH i Ott«ao .e,ti0 TOWN OF NORTH ANDOVER 0 _ 0 PERMIT FOR WIRING �SSAtNus� This certifies that ........../ �. T........U. .4 w....................... has permission to perform � ' x T wiring in the building of at...... ,North Andover,Mass. Fee...~S�g'o—. Lic.No,;2447-'P(;........ dC� ELECTRICAL INSPECTOR 77 Check # _ 6447 __� Commonwealth of Massachusetts t)nici it 1:sc only 17 Permit No. 7 7 I3 Department of Fire Services j 11x. _ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ![Rev. 9,05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .SII %Mork to he performed in accordance x\ith the klassachusctts Electrical Code(\11:0. 52, C IR 1'.0O (l'LL I SE PRINT LVINK OR TYPE.ILL LVFORI N TION) Date: City or Town of: � ��C6l/C�r-Vl TO rhe I17S/VC101- 0/ Y�'it ens: By this application the undersigned gives notice of his or her intention to perform the elect ical work described below. Location (Street& Number) A 0 Owner or Tenant 610, KI t EI!2 Telephone No, 6p -S-7?25' Owner's Address Is this permit in conjunction with a building permit? Yes No ❑. (Check Appropriate Box) Purpose of Building jDIAJ ---Ili 14g Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ('unr (ctiCm aJ tlreJi,Nrneink table nrav,he waived by the his)eLtcir <iJ 41'ires No.of Recessed Luminaires _ No.of Total e a es No.of Ced. Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA %bove In- o.o mer=enc in No.of Luminaires Swimming Pool rnd. EJ In- ❑ Battery Units y g _ g No.of Receptacle Outlets llD No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and Initiatinz Devices t No. of Ranges No.of Air Cond. Total No,of Alerting Devices Tons g Heat Pum Number Tons KW No.of Self-Contained No. of Waste Disposers Totals 113etection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KWSecurity Systerns:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: i . Heaters signs Ballasts g No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:. No.of Devices or Equivalent OTHER: Sul (;NLS'-/ �® f00/— I Ncrch crcldiliclrtu!delad it desired. or as rcrtuired by the lri,S1,T0 1'cq' 1171'0.1. Estimated Value of Electrical Work: (,When required by municipal policy.) Lk ork to Start: o? Lo Inspections to be requested in accordance with ;EIEC Rule I q c 0, and upon completion. INSURANCE C VERAC:E: 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. ]'he unde(sit�ned certifies that such '0vA" *c is in force,and has exhibited proof of same to the permit issuin'r.office. (:'I-IECK ONE: INSUR•\N(:•E 1.30ND ❑ O rl II::R ❑ (Spccily:) I eerlgJ,, .render the pains and penalliev of periurp,that the in%urination an this rep licatia istI'IAe andeuir�plete. f'IRIVI N,��IE LIC.. N0.:,27�s��� Licensee: uXK1-PVt_ :iWilat •e _ LIC. X10.: r/l;;p/;/iruhle, _nt r "e:;v tlrJ r Ic}cr:,rrrrmbrriine.i �� t�/° Bus.Tel. No.: 3�Z-1Z5(0 Address: 1�� / 1� t� 'e I : -- Aft. Tel. Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURA VER: I n aw,u•e that the Licensee dOl,S 1701 huvc the liability insurance covera(_e normally required by-J, my i« ture below, I lercby waive this requirement. I amt the(check one)❑ owner ❑ owner's ;iggent. Owner/ -? ;�ign:tture T.:lephone 'lo. PERrVf17' FF.F': Commonwealth of Massachusetts t)rlici,tl t ;e t)nl, rmits. 6 7 Department of Fire Services Pe " - Occupancy and Fere Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9.051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK SII ,cork to he perforn)ed in accordance with the.Massachusetts f:lecu•ical Code(\lFC). 52'CAIR I?.00- rj'LE.ISE PRI,\T LV IXK OR TFPE.ILL LYFORJLITIO,Vl [date: �2 z 13 Gtr Ch or Town of: To 1he hzs eclor• (1J Wires: By this application the undersigned glyl'S Ilotll'e elf hIs l)I'her IIIICIItloll (O pel'fol'ill till'. eleCt'll'a1 work described below. Location(Street& Number) �c'�M (,�,2J0 Owner or Tenant 't' 6902/'C Telephone No. Owner's address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �,ht� Utility Authorization No. Existing Service ,nips / Volts Overhead ❑ Undgrd ❑ No.of'deters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: O on7,lelioll a/llte dlrming lahle rrury he waivud by the hr.c sector•o/ lf'rel 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.o Emergency .. rg rng-- - .. No.of Luminaires Swimming Pool i nd e ❑ In ❑ Batter Units__ No. of Receptacle Outlets No.of Oil Burners FIREALARM �No.of Zones No. of Switches No.of Gas Burners •No.of Detection and L Initiating Devices ' No.of Ranges No.of Air Cond. TotalTons No.of alerting Devices 1 No. of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals I Detection/,k lerting Devices No. of Dishwashers Space/Area Heating KW Local❑ 'Municipal ❑ Other Connection No. of Dryers Heating Appliances KW/ Security S stems:* No.of Devices or Equivalent No. of Water No.of No.of KW 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: SU tj 0 19Ta1w ZA e Ilruch,rd.lirinrui Irtrril r/ lr,�irrd, ur a,c rrriurrcd ht. the hispcchx• ,` I Estimated Value of Electl'cal Work: /�� (1�l hen required by municipal policy.) 1kork to Start: 13 Inspections to be requested in accordance with 'VIEC Rule 10, and upon completion. INSLRANCE C VERAGE: L;nlcss waived by the owner, no pernlit for the performance of electrical work Inay issue unlcs:-, the licensee proyieles proof of liability insurance including" omplcted operation'euvera�e or its substantial equivalent. The undcrsigned certifies that such •o e is in force,and has e:.hibited proof of:.anle to the pernlit i:;suin ,office. C I IF:CK OSE: INSI R,\�C'I 13(?vI) ❑ OT'fII.R ❑ (Spccily:) /�err1/j,, ander rhe prlins 111111 pcnrl/lies of perjuq, zhnl the information on,'his up /icrrliu is True um/ruurp/cle. r/ FIRM NANIF: LIC. 1`1 0.: Licensee: K I?L'5X 1zI'Fvt >i!;nate e _ LIC. ll.; nli. k P r I} :, r:rrnri::r irkus . e S . Tel. No.•��:2 ,address: /�" /� �` � /�4 e 1/r�"�"�I /� uta Tel. No.: —. "Security System Contractor License required for this v ork; if applicable,enter the license number herr: OWNER'S INSL'R,\ _ , 'VER: I n aware that the Licensee do(!-k,nol have the liability insurance covera`1Le ncrnurlly— Iecluired by lacy'' my i« tore below, I lercby waive this rcquircnunt. 1 ;1111 the(check one)❑ ovvncr ❑ owner's J"Cilt. Owner/ —± i+�rtatur•e jc-c. _'"`',,.,,_.e...-- 4 , , , AF'lj.A,l1T O'F'F• f n a'._ ltrr.io]f i iu. �. a �-� X12 �. _ �� - a � � a Date..... . ........... ..�J.. HORTM 3?p,!'..r�•D^•� �OpL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING •,r.o.�` SSACMUS� This certifies that .... .. X14 cPCS has permission to perform ......'.-� G S wi.dna in the building of ......... . . e.r ?t.,► ..u! ...................................... ' / � at....��f.. .l. 'a �!`! U//..... .. , h Andoverss.� Fee..4 .. Lic.No!i S l(,v ECBCTRICAL INSPEG OR Check Check # P 5292 TRE COA MOAM ALTHOFMASSACHUSETTS Office Use only DEPARTIVMVT0FPUX1CS4FMY FPermditNo. BOARDOFFREPREVEMON_RFGULAHONS527CMRI2.-Q0 Occupancy&Fees Checked APPUCATTONFOR PERAIRT TO PERFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) ,N —,( LkJ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building tQ�C .,—k) Utility Authorization No. Existing Service Amps / Volts OverheadUnderground No.of Meters New Service Amps / Volts Overhead Underground r--J No.of Meters Number of Feeders and Ampacity Location andl�Nature of Proposed Electrical Work -�pA ( t= L1.T- 'S 14 S(-15 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round eround No.of Receptacle Outlets No.of Oil Bumers No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No:of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons. KW Initiating Devices No.of Dishwash Space Area Heating KW NQ of Sounding Devices No bf Self Contained .�� u DJ tion/Sounding Devices No.of Dryers` Heating Devices KW Local Municipal Other-r----- Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP THER- uanceCov=ga PunianttDthewqukmimtsofNla%wbug�tGenualLaws aveaamfftLiaAtyh teelbhcyiwbdongC,on4)kv GoverdWorilssubslantialegivalat YES NO awatn cdvandproofofsnietothe0�YES � Ifyouhav drel�dYES,Pleas Mdicatethetypeofoovaageby SRANCT- EZ BOND a CIIIIIR (Please Spa*) EVhfim Date Estimatedva1aecfEk0calwo&$ xktoStart hTectionDateRequesed Rough Final nedTldffTr, esofpetjtuy. :MNANE A-C— LicemeNo. -So nsee I� CCS A��C,/�/L>�C-i�7y/.�c-c� Signahue Iii No l�--l!�S �U `� Tel No. �,o 1J �t �- 1��✓� �'S +�ti �vLP At Tel No. 2_a- 3"7 S'b�6 Z NM'S INSURANCEWANE R;Iam warethattheLimwdoesnothayetheinsuarre-covff ageoritssubstantialegr4entasmgmedbyMassat- uscmGenetalI-am [hat mysignatrueon this pan itapplication waives this mglmm-olt :ase check one) Owner ® Agent ® Telephone No. PERMIT FEE$ Igna ure oT Owner or Tgenf _ The Commonwealth of Massachusetts w 7. ? Department of Industrial Accidents a 1 d Offi=ce of Investigations. Boston, Mass. 02111 Workers'Compensation insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. 0 I 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. Company name: " Address City: Phone# I Insurance Co. Policy# Company name: Address City: 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.lhefnrmnf-a_STOP WORK ORDER.and_a.fine.of.(.$1A0.00.)_aday-against.me. I 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 pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required !] Licensing Board p Selectman's Office Contact person: Phone#. E, Health Department Other Location �n No. Date NORTH TOWN OF NORTH ANDOVER F? •. • OAL 9 Certificate of Occupancy $ s,��N�s<� Building/Frame Permit Fee $ a Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C�? d .-- Check # 15 $ 83 Aq Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING � � s,� e. ��"`r���CC$bI9'�llrr�, ...°: �' ism z��� �`•' ��" BUILDING PERMIT NUMBER. , j DATE ISSUED. 5 x �J o2 00 Q, SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION I k Z 1.1 . Property Address: 1.2 Assessors Map and Parcel Number: O 3/-e4WD o� C1Ycft � L/ Map Number Parcel Number /Uy 64hc���er y�y� 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 red Provide Iteqttired Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 1 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record / �O�a�f'r!av'i 5�21^G Cr'L,JY4�� f.2 O /�l1%1277,✓aaal CiI�G�e Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Lrcensed Con1truction Supervisor: O }- License Number off-D �C-!i C tel✓ O!r U1�1/7' �? on Address D <'9;I Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ t3 C,//�'D S/ t°f W t1TI'Y�ct�)r•e Company N me 102662 m l Registration Number r• a 19�c y,� �/�r-✓e l/h � iii r Address ��J�� d Sy/b xpiration ate Z Sr nature Tele hone 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 all a Iicable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify 777EX40 v ine U Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant y,, 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 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 permit application. -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I 1, as Owner/Authorized Agent of subject propertv Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TBiMERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIIWNSIONS 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 The Commonweafth of Wsachusetts Wi 1 i Department of indk;tI bLL[,qxid=t Office of Investations 600 Washington Street Boston, WA 02111 Workers'Compensation Insurance Af davit APPLICANT,"INFORMATION Please PRINT Legibly Name: (�(/il�ll4✓Lv.r�e�. Location: City: Telephone#: E3 I am a homeowner performing all work myself. 1] I am sole proprietor and have no one working in my capacity )�I am an employer providing workers' compensation for my employees working on this job Company Name: ` o kz Address: City: M<JyC-,, Telephone#: Insurance Company: Gr U Policy#: C- EW C- I I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name.- Address: ame:Address: City: Telephone#: Insurance Company: Policy M Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information above is true and correct. Signature:�.c/` _ Date: 7`/l D Print Name: 11110' v1 1U S`A`C Phone Official Use ONLY-Do not write in this area ❑Building Department City or Town: Permit/License#: ❑Licensing Board ❑ Selectmen's Office o Health Department 0 Check if Immediate response is required 0 Other »ORIAnON &INSTRUCTIONS 4 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, 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 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. 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. City or Towns 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 v y 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. 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 your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston, MA 02111 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406, 409, or 375 1 6S®8�0 CONTRACTING BUILDING • REMODELING I This agreement made this day of year Two Thousand and Two by and between Cote and Foster Contracting, in . hereinatfter called the Contractor and Jake f and Lori Steigerwald, 120 Brentwood Circle, North Andover, MA for the renovations of existing f common bathroom��and master bathroom. � ARTICLE 1 The Contractor agrees to provide all the labor to do all things necessary for the proper construction and completion of the work shown and described on drawings. The drawings and specifications are he basis of the contract. ARTICLE 2 In consideration of the performance of the contract, the Owners agree to pay the Contractor, in current funds as compensation for his services hereunder$13,970. master bathroom and $14,720.00 common bathroom to be paid as follows: c,V- 1 `�71-1 �� .Payment 1 -$3,000.00 at the signing of the contract. Payment 2-$4,5W.00 at the start of first bathroom. Payment 3-$4,500.00 at rough of first bathroom. Payment 4-$4,500.00 at the completion of first bathroom. Payment 5-$4,500.00 at the start of second bathroom. Payment 6-$4,500.00 at rough of second bathroom. Payment 7-$3,190.00 at the completion of second bathroom. Total-$28,690.00 I ARTICLE 3 I Final payment on contract amount as agreed above to be paid within ten(10)days of project completion or occupancy. If final payment has not been made within this time, a 10%charge per month on the balance due will be charged, All minor punchlist items will be complete as part of the one year wamanty on the finish product. Failure to pay balance within ninety(90)days.may result in legal action. Initials/i.a ✓ J i ARTICLE 4 Additional work above and beyond the contract agreement. All additional work done to be quoted at the time the client request the work. The will be done and billed at its completion. The client has ten(10)days to pay the additional cost after he or she has been billed for it. Initials 20 Aegean Drive • Unit 15 • Methuen, MA 01844 • 'Tel: 978-682-6518 • Fax: 978.682-1221 Sep 04 02 12: 24p Jackson Lumber 9786891066 p. 2 7)C ROOM 1 1/4 " ' N UNG: TEX S , q WAIN 1 46'BEDROOM 11 CH 91 u Z� '`HARDWO( I I F•)-OOF: HARDWOOD ��• iFLOMP s. CEILING: TEXT. PLASTER 1A ALLWAY ;.H 91 FLOOR: CARPET CEILING: TEXT, PLASTER H•: •;.., u u — — u x _ x VT1 " SAIW MASTER p 0016 EDR00M --"- a IN'idOD CH 91 a CElLQKk,JEX r.',EPLA FLOOR: HARDWOOD _ ■ ti:~ 'y,''''`-'i . ry TEXT. PLASTE CEILING: BATHROOMCH 91 II 114 i' iy 11 FLOOR: TIL.£ JL CEILING: TEXT. PLASTE II TILE W/UNSCOT 4 n I I z• �- �-1-T z' 7 ,/2.- Y-1 — z'_� �z- , , 3e7_,_, is , 112� 1/z 44.; t , c. ' -SECOND FLOOR PLAN L � I f MY` ..x, 1 00.f r NORTH Town of Ando* ver 0 c~ yA T 116 rd L �oC„,C 10 dover ., Mass , ORATED S H E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �I, ._• � �� BUILDING INSPECTOR THIS CERTIFIES THAT..... .a..0 ...... .. .O^.1............ �. ... :r..W A '� Foundation Ih a cle /' C#PC. AL has permission to e�est..�............................ buildings on .....I....a.............�.........:.............................................. Rougt, to be occupied as......14....... n!.. 0 O .5....�..N... .a.5 t0�•�N t 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-Law relatin to the Ins ection, Alteration and Construction of Buildings in the Town of North Andover. t1 �� a 9►0 0 � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Fina' UNLESS CONSTRUCTIONAR S ELECTRICAL INSPECTOR 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. 3485 Date. .. .. _. .... . .... . .. . NORTh TOWN OF NORTH ANDOVER OF .,,eo ,e 1tip 0 ' � pp PERMIT FOR GAS INSTALLATION �9SSACMUSE4 GVThis certifies that . . `''` fi " `'` ` . . . . . r . . . . . . . . . . . . . . f'has permission for gas installation ,:=�4'-:-!.-y. - # the buildings of . .'�'�� . . . . . . . . . . . . . . . . . . . . . . . . . at .1-�f? ! tet "z c�+-��-�' . ��.-. . . . ., North Andover, Mass. Fee;:7? .5!. . . Lic. No.?0z-,. . . . �� /( i� ,j�� . . . . . . . � GAS INSPEc•T n ,f WHITE:Applicant CANARY: Building Dept. PINK:Treasurer V 1 MASSACHUSETTS UVIFORM APPL,ICATON FOR PERMIT TO DO GASB G ` f �I Type or print) Date NORTH ANDOVER, MASSACHUSETTS 3uiidine Locations AZO 5,rentc000cd CP ,re-, er �y Owner's Name `t:W ❑ Renovation ❑ Replacement a Plans Submitted 70 '1 1 Y yU .Zv )) V 7it3 f '•'i til A ` �_ I 6�• Z `fit ',Mf 4 C � v� i� '_O � •G " L. CLQ" .�� ArL; Z C C 'q L F Z -ie- Z c, N i7 L C i •s ii Ll. Z -! W E- y Z W 5 U [i -U .-% SEM ENT B;>, SEM EN T Awr 5 r . F L U 0 R ZN U . FLQ U R ak( R D . F L 0 0 R `..aj P1t Y Nt, . 777 ;T I1 F L 0 0 K 8T 11 FI, nt) R , i ?-.n[ or rVpr) Check,one: Ccrtifi., a Installing Company amr Andover Plb4. & Htg. Co.. Inc. Corp. �coress 20 Agean Dr., Unit-10 ❑ Partner. Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑ FimVCo :ame or Licensed Plumber or Gas Fitter George 1_aRose !NSL,R.-\,NCE COVERAGE Check one: have a current liability Insurance policy or it's substantial equivalent. Yes ED No . .,ou have checked ves,please indicate the type coverage by checking the appropriate box. bilin insurance policy 0 Other We of indemnity IDBond 0� ner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 1.42 of the Aass. General Laws,and that my signature on this permit application waives this requirement. � Check one: i,nature of Owner or Owner's Agent Owner ❑ Agent ❑ Pay-certify that all of the details and information I have submitted(or entered) in above application are,; aand accurate.to.the. o f vl'my knowledge and that all plumbing work and installations performed under Permit lssued for tltt k'' ,;d4don will be in :omoiIance with all pertinent provisions of the-Massachusetts State Gas Cad d Chapter 142 OfAhe Grnei Laws.'' ignature of Licen ed Plumber Or Gas Fitter " s Tike Plumber 9983 Ci R-,Town ❑ G Fitter License I umner - Nla,ter �2PR0VEDIorI:icF IISEONI.Y) ❑ Journeyman f Location No. �y� Date 3 NORTH TOWN OF NORTH ANDOVER r • 1 AL i + ; , Certificate of Occupancy $ ��s'••°'Eta Building/Frame Permit Fee $ �CNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # X916 Building Inspec n e i � TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER DATE ISSUED: SIGNATURE: 14 Building Commissioner/lEECEtor of Buildings Date SECTION 1-SITE INFORMATION.. 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O 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 R redProvided R red Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: v Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal Public ❑ Private ❑ Zp System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record ame(Print) Address for Service r-7 : 7 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 1 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Nob/ (J12 Licensed Construction Supervisor: ©O (�/�y 2 ' 33 License Number mn Address v vt Q/7 Expiration 15ate ic Signature elephone r - r 3.2 Registered Home Improvement Contractor V V Not Applicable ❑ 0 �/� ,� � � 2 Company Name ' / — � 1/6� /3 � /G DRegistration Number Address L r Expiration Date ^ Signature Adekphone �i/ T ? e SECTION 4-WORKERS COMPENSATION(AG.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 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY r Completed by permit applicant 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 -23(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 OxAmer/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 Date I SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION F t I, DA N! C/�2�i v as Own /Authorized Agent o subject ' property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief � '� e PmLNaik Si at of Owtier/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 I SPAN DIMENSIONS OF SILLS j DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS _ 11EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND — IS BUILDING CONNECTED TO NATURAL GAS LINE• _ • NORTH E ' TOVM . Of Aitidover0 No. crq4 CHICw � over, Mass., RATED P?C2 �• BOARD OF HEALTH PERM D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT.......... ....... :................... Foundation has permission to erect........................................ buildin on ./z.0........ .... Rough • ......................................... to be occupied as Chimney provided that the person accepting permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions o 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 PERMIT EXPIRES IN 6 MONTHS Fina' UNLESS CONSTRUCTION ST �/ ELECTRICAL INSPECTOR ��i ��"l /�" 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. i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Afdavit Please Print Name: Location: Citv Phone am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers'compensation for my employees working on this job. Company name: D A >J I C C Address /3 3 lk't City: �� ��J `� , /r!�l Ul �U Phone#: 929-32c),—d 2J' InsuranceCo. 1,VM6e1?WA-).:ZD1P1il/Al61 a4Z Poli # fie 006 79 7 W9dO Company name: Address City: Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the=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 copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under t pains and penalties of pe "ury,that the information provided above is true and correct. Signature �L(�.� Print name �> /ee V Phone# Official use only do not write in this area to be completed by city or town official' Building Dept []Check if immediate response is required Building Dept p Licensing Board El Selectman's Office Contact person: Phone#: rl Health Department Other FORM WORKMAN'S COMPENSATION 1 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 c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit MPlicadt U Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code 780 CMR APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OF OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number: Dale Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION 1-SITE INFORMATION LI Property Addn 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Lot Area(sq) Frontage(ft) Zonin District Proposed Use 1.6 Building Setback R Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 Water Supply 91vt.G.L.C.40.4 §54 1.5. Flood Zone Information: 1.8 Sew a Disposal System: Public a Private Zone Outside Flood Zone D Municipal On Site Disposal System 2.1 Owner of Record 4 JaCa6 lav -el)*(2 L)� Ct l-cb Named- e'/`/ Ad ss- 19 s: Signator Telephone e m �� -?92 2.2 Authorized Agen: Name(Print Address A Signator. Telephone SECTION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE 3.1 Licensed Construction Supervisor: Not Applicable Q Licensed Construction Supervisor. License Number Address Expiration Date S elephone 9 6 3 3.2 Registered Home Improvement Contracto. Not Applicable 0 1 Company Nam v, Registration umber Address y� Expiration Da 52 , Signa re %jephone Revised 1997 JMC SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New Construction [3 Existing Building E3 I Repairs [3 Alterations Q Addition Q Accessory Bldg. [3 Demolition I Other [3 Specify Brief Description of Proposed SECTION 7-USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly A-1 A-2 A-3 IA 13 A-4 A-5 IB D B Business Q 2A Q E Educational Q 2B 1:1 F Factory 0 F-1 F-2 2C El H High Hazard 0 3A 13 I Institutional Q I-1 I-2 I-3 3B 13 M Mercantile 0 4 13 R Residential 13 R-1 R-2 R3 5A 13 S Storage 0 S-1 S-2 5B U Utility Q Specify: M Mixed Use Q Specify: S Special a Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index(780 CMR 34) Proposed Hazard Index(780 CMR 34) SECTION 8-Building Height and Area BUILDING AREA Existing(if applicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor(sf) Total Area(sf) Total Height(ft) SECTION 9-STRUCTURAL PEER REVIEW(780 CMR 110.11) I Independent Structural Engineering Structural Peer Review Required Yes 0 No 1 SECTION 10a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR PLIES FOR BUILDING PERMIT I, ,As Owner of subject property hereby authorize G to act on my behalf,in all matters relative to work authorizW by this building permit application. Ja- u5/ lo, S�gnature of Owner U Date revised bldg form/state JMC i . y • SECTION 10b-OWNER/AUTHORIZED AGENT DECLARATION I, F".' DA-n ze L ` as Owner/Authorize .m'e'n ereb declare �"� Y that the statements and information on tee application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Aame Signature of Own gent Date SECTION i 1 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to Official Use Only be completed b permit applicant 1. Building (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee(a)x(b) 4. Mechanical(HVAC) 5. Fire.Protection 6. Total= 1+2+3+4+5 Check Number i i SECTION 4 WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM 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 13 SECTION 5- PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name(Registrant): Address Registration Number Expiration Date Signature Telephone 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Expiration Date Signature Tele hone Name): Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone 5.3 General Contractor Company Name: Not Applicable 13 ` Responsible in Charge of Construction Address Signature Telephone