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Miscellaneous - 120 CAMPION ROAD 4/30/2018
//�� 120 CAMPION ROAD � � O / 210/062 00.0 }I I I� 4 I t Cunningham Lindsey U.S.,Inc. f P.O.Box 703689 Cunnin jam Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 L CLCAT@CL-NA.COM ****`******************AUTO**3-DIGIT 018 788 T3 P1 95000058978 Building Commissioner or rRM6Inspector of Buildings 'y 120 MAIN STREET N ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building d ng MM Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 3073804 Policy Number: 3073804 00 co Company Name: MERRIMACK MUTUAL FIRE INS a) Cause of Loss: ICE DAM co LO Date of Loss: 3/26/2015 0 Insured: RUSSELL&ANNE SPENCER Property Location: 115 CAMPION RD fi• Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss; damage or destruction of any amount, which causes the condition of a building or other structure to render der section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the'said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and fort -three p forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date .,..yf,1�i7W� M TOWN OF NORTH ANDOVER t PERMIT FOR WIRING This certifies that o e W``�' S' ' has permission to perform . . . . . . . . .! . . . . . . . . . . .r. . . . . wiring i e build ir� of . . . . ..t'(n`-^� at . I t© . . c,°' ,�` '� K o North Andover,t . o , Mass. Fee . . . . . . . . . Lic. No. . . . . . . . . . . . . . . . ELECTRICAL INSP CT R 'C'heck# �L) i 10964 �` F' C' Date TOWN OF NORTH ANDO1P' PERMIT FOR WIRING This certifies that . . . . . . .✓ . . . . . W "U SL oGt, has permission to perform . . . . . . . . . wiring in the buildin of . . . . . Si /. d.?'I. . . . . . . . . . �. . . . . . . . . . at . . . . . . . Z-O ?4rYj'/:)i o.�2/. . 1�2. . . . ,Noa th A fiver M ",S. Feel 4Sr -. Lic. No. . :��e��y�. . . . . . .� 1 !+ ELECTRICAL INSPEC R Check# J40- 11088 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the ;fl permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed ;4 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 constmction activity,and may be.deemed-by.the,Inspector_of_Wires abandoned-and-invalid-if he`.. ._ application, she has determined that the e for cord work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for comp tion ofiwork shall be permitted for reasonable cause.A pe%wt sha11 be terminated upon the written request of either the owner or the installing entity stated on the permit application. 1 ❑ 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 J the Acts of 2012.The purpose of this act is to promote job P rP p j 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 beg' 'ng on August 15,2008 and extending"through August 15,2012. ` —Permit/Date Closed: ** Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts official use only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 7^ P" ( 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) C AyxQ LOP, R11�1> Owner or Tenant ©tA c,�3,r-v1 r Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: S Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires r� No.of Ceil:Susp.(Paddle)Fans No.of Total V Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ INO.of Emergency Lighting rnd. grnd. Batter Units No.of Receptacle Outlets 20 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and r Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis posers Heat Pump Number Tons J.KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other- p g Connection No.of Dryers Dr Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . (n LIC.NO.:o� Licensee: � Signature — LIC.NO.: (If applicable enter "ex e t"in the license n b r line. -� n/ Bus.Tel.No.• Address: Y t Alt.Tel.No.• �33 *Per M.G.L c. f47,s:51-61,securi work requires I)6pdrRerJ of Public Sa ety"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: $ �y Signature Telephone No. f� R J ._ .+:Ji-f�1L�'•V�j��J/��i�J.�.Ir/J-'�R��®gip /'�'�j ti��J.JIUI.a��.47 i-'a.•:�®J.'J.� .— . • � �-, �+ailefl-�[ } �e-zuspeefzou z'equi�'e�'($�O.QO)~[ � YnspectoxSIC e� ' LEE (rnspceforeisz atao••-.okniluals) .^ Slate 'asse -[ aiiec(--[ espectio�xetuixec�( 0.00}w[ �nspectars'comm.enfs: ' (JCtist ecfors'oignatare..m fsufials) Slate X e-insp ect oa,xegid ea(ss0.00)-[ ] l'nspectoxs'comments: (luspectoxs'aignafuxe�+aofnifias} ))ate M PATM,CAI T&A-a XATXOXM� NAME: assert.-[ ) +aile --[ Re-inspection required($50.00)-[ ispeetoxs'commeph: (�specfoxs',�xgnafure�xzo�nzfzals) Jlafe yse��-[ ] �'ailer�•-[ )- '3�e�nspecfzonxer�uiz'et�($50.00)�[ � . pacfoxs'coznm.ents: _ . kspeetoxalMinatuxe"xaoxuifials) date ' \.D)OR T`•A.Qj5.A TO 13E ITME3D 219—T AnD UFT ON BITE IF TBE AA?',EATO 33E INSTXCn D ISNOT r i CIX The Commonwealth of Massachusetts 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ �To� A w t iqL o W Address:—A lf+�(jam Woo City/State/Zip�`'�0 DO Phone#:—q (7 Are you an employer?Check the appropriate box: 1.�] I am a employer with 4. El Type of project(required):I am a general contractor and I Type of construction employees(full and/or part-time).* have hired the sub-contractors 6. 7. Remodeling 2.�] I am a sole proprietor or partner- listed on the attached sheet. 1 ❑ g ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E:1 Electrical repairs or additions 3.Fl I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I 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 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.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 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. 1 Flo hereby certify under the pains andpen erjury that the information provided above is true and correct. Si natur . , Z �j' �^ Date: Phone ( Z Y Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents 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 J of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn 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 Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia Date....�--`..,�'a.����1..... 10 � �7 TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING �s�cMuss j,/� This certifies that 4 /itl...../. has permission to perform..........1�... 'n.. / 4 plumbing innthe buildings of..... . .... .........,................................................... at `.' .!' c.? .... ............M................... North Andover, Mass. Fee/50..........Lic. No. M4;...... ......._l. .'.....:.....:................................................. _ PLUMBING INSPECTOR Check# X5 5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PER PLUMBING WORK I r iPERMIT# _J 12 CITY MA DAT ............ JOBSITE ADDRESS, 0 ER'S NA 0 P , OWNER ADDRESS TEL! FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL "—J RESIDENTIAL PRINT CLEARLY NEw/ RENOVATION:� i REPLACEMENT: PLANSPLANS SUBMITTED: YES—— NO: _4 - FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 1-1 1-2 1-3 14 BATHTUB Ir. CROSS CONNECTION DEVICE =17 .. .......... t r .......... DEDICATED SPECIAL WASTE SYSTEM I _7 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ...... -------- DEDICATED GRAY WATER SYSTEM F J................ ............ DEDICATED WATER RECYCLE SYSTEM ............... ...... DISHWASHER ....... .............. DRINKING FOUNTAIN it ........... FOOD DISPOSER ...........7 FLOOR AREA DRAIN ............. INTERCEPTOR(INTERIOR) KITCHEN SINK 1=t ............. LAVATORY t it it ROOF DRAIN t SHOWER STALL "T U U 51 SERVICE I MOP SINK TOILET URINAL . .......... r ............ WASHING MACHINE CONNECTION QL WATER HEATER ALL TYPES WATER PIPING T OTHER t _Z7 J, F_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES PT-INO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY;' OTHER TYPE OF INDEMNITY i 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: OWNERAGENT SIGNATURE OF OWNER OR AGENT LJ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t the be t of m y knowledge and that 611 plumbing work and installations performed under the permit issued for this application will be r omplia with all Pe ne provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# ! � SIGNATOR —----------------- MoN, JP CORPORATIONX, 1#; 'PARTNERSHIP Fj LLCL j _j# .......----------- COMPANY NAMERIESS, - CITY i STATE!4 ZIP j TEL EMAIL FAX CELL //c��Y7J J'r.� COMMONWEALTH OF & SETTS.:: PLUMBERS SAND GASFITTEIkS f SSt1E5 THE FOLLOWING .>L i CENSE 1 Ri±Crt STIRED AS A P,LtJMB ING'0012' LL Li SAM M KANNAN t-ANNAN >r Pitt OOt+fE PLB HT, 3rWf=ST A�E12,5T V, 1s1 Nis NiA 01$44 550 : .. t 05/01,/ a:t9112 tGtzt/tol5a zi to aF Pt3t11i .' NVNNVN W W1f4 llm J1Ci]ad 'NVWA3N1(t0(' V Sts €l3sN i l 3SN.3O l i `�N:1moi103' 3H1 S3fISS t J. s21�iitjSV;s amv.al awnia • . . Lei SF�HO"S..W.00 HpNpMN0 WOO C+ t�=.+tq$t o V. Nt1H L3 f Da Al1/lElN 119 9 01 .{ NVNN•f1i W; Wtf.i'f'tI;M IM SN33tl': ONtMOli0J 3Hl 53i1SSi 52133 i i 3 S WD AN S039i�illd _:�I?Q2fVEs8 • • em Fol . S.LL3SnH �Si W O Hlllt3MNOINW0OF OP ID:SS ,a.coRO CERTIFICATE OF LIABILITY INSURANCE DATE/14/2014 04/14/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Durso&Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue A/C No Ext): _ _ (A/C,No): North Andover,MA 01845 E-MAIL Durso&Jankowski Ins.Agcy. ADDRESS: g Y• PRODUCER —.. ----------- .... -- CUSTOMER ID#:KANNA-1 INSURER(S)AFFORDING COVERAGENAIC# _ INSURED Kannan Sr Pricone Plumbing& INSURERA:Zurich Small Business Heating,Inc. -_- 3 West Ayer Street INSURER B:Liberty Mutual Ins.Co. – _– Methuen,MA 01844 INSURER C:---- _ – INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - ADDL SUER POLICY EFF POLICY EXP - LTR TYPE OF INSURANCE NS 'WVD POLICY NUMBER MM/DD/YYW MM/DDlYYYY LIMITS GENERAL LIABILITY - EACH OCCURRENCE S 1,000,000 �� DAMA TUMtN1tU -----__. B X j COMMERCIAL GENERAL LIABILITY iBKS56003225 04/01/2014 04/01/2015 PREMISES(Ea occurrence S _-"500,000 : CLAIMS-MADE X OCCUR ! MED EXP(Any one person) S 10,00 A PERSONAL&ADV INJURY $ 1,000,00 ; GENERAL AGGREGATE �S 2,000,000 j GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 POLICY FE LOC j _..._._ S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ;,.S 1,000,000 .(Ea accident) �J ANY AUTO BAS56003225 04/01/2014 04/01/2015 --- BODILY INJURY(Per person) i,S ALL OWNED AUTOS _ — BODILY INJURY(Per accident):S 1 B _X J SCHEDULED AUTOS PROPERTY DAMAGE S B XXXX� HIRED AUTOS (PER ACCIDENT) _ — B X NON-OWNED AUTOS S UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 4,000,000 B IEXCESS LIAB A CLAIMS-MADE; AGGREGATE S -- -- — US056003225 04/01/2014:04/01/2015 DEDUCTIBLE :s X RETENTION S 10000 S j WORKERS COMPENSATION X I ORY LAM TS STAU 'OE_R ._ AND EMPLOYERS'LIABILITY A I ANY PROPRIETOR/PARTNER/EXECUTIVE YIN '� WC05246121 06/01/2013�06/01/2014 E.L.EACH ACCIDENT ,S 1,000,000 OFFICER/MEMBER EXCLUDED? - ---- (Mandatory in NH) A E.L.DISEASE-EA EMPLOYEE;S 1,000,000 If yes,describe under - ---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Plumbing & Heating CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 247 Date..G.11. HpRTN TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION f F SACMU5Et4 This certifies that . . . . .1.C �.0 . . f . . . . . . . . . . . . . . . . . .(Z('� has permission for mechanical installation . . (k-z' . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . at . . . . C.fir.cn�.� �v-. .'��� ., North Andover, Mass. Fee. . `�. . . Lic. No.. . . . . . . . . . . . . . . �1 j2. . . . . . I GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date /L/ Permit# Estimated Job Cost:' /,J Permit Fee: $ Plan' Submitted: YES NO Plans Reviewed: YES NO Business License Applicant License# 7d Q # pP Business Information: Property Owner/Job Location Information: Name: �I! ch a e I e>>�� Name: S Street: d6 cr oo kej Sir/N f 0'�-2-r Street: (, G® 9iAvr ' City/Town: 6, ller (2 /9/ City/Town: lU. 14AI-'- ' Telephone: (q7&) �3 63 y-3 Telephone: q � �saa 2 Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: t Residential: 1-2 family P Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC )< Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: ��'ns"�li �c�v�"�✓a�.� ��iv /Lew v^� '�"� INSURANCE COVERAGE: I,have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ Ido❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A 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 112 of the Massachusetts Genera s and that my signature on this permit application waives this requirement. Check One Only OwnerCp/- Agent ❑ Signat wner or ner's Agent By checking this boxD,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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: 3y' ❑ Master title ❑ Master-Restricted ;ity/Town ❑Journeyperson Signature of Licensee permit# FlLicense Number: =ee$ Check at wvnv.mass.gov/d I ispector Signature of Permit Approval Page 1 Residential Heat Loss and Heat Gain Calculation 6/14/2014 In accordance with ACCA Manual J Report Prepared By: Ron Shaw Heating&Air Conditioning For. Sigman Renovation 120 Campion Rd North Andover, Ma 01845 Design Conditions: North Andover Indoor. Outdoor: Summer temperature: 72 Summer temperature: 97 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range: Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Whole House 17,581 5,140 22,721 25,581 (2torn) Second Floor 17,581 5,139 22,720 25,581 Bedroom 6,033 1,576 7,609 10,460 Bedroom(2) 4,201 859 5,060 6,753 Rec Room 4,273 1,324 5,597 6,318 Bathroom 937 230 1,167 1,025 Bathroom (2) 2,137 1,150 3,287 1,025 Whole House 17,581 5,140 22,721 25,581 (2 tons) HVAC-Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only,actual loads may vary due to weather and construction differences, `T1�1"" ��rnvri v-air,i r P; DRIVER'S LICENSE y, 9aEND 4d NUMBER - F 8 4bQ9.142013 NONE3 S7924795 01-2617 Q9=01A97 cuss`u Resx` is sEx M. tg,"d 'S-95 O NONE - , I. .-. .• �iJE 'MIC y rr9•ukl9xe a 26 CROOKED SPRING RD (/(•/n' N BILLERICA,MA 01862.1742 . - `�(•/L�"✓` S DD 09.17.2012 Rev 07.15-2009 LO 00 CONTROL# MPORTANT L 4—+ CD c C — 0"--. c� c O >, N U cs� O .u) (7, Q ey c d) N� ire -> -o U) • O' 1 co asasoo u) #_ 1- O O O O o .� U " O Q Q O al • -O>, • O OO • U a c N al — N Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING t0/14..,5Z-DI-e„.1 ,4)4r/444c-- has permission to perform 2* /ittae22- 11W-,0 at This certifies that \T wiring in the building of FeeS3Lic.No. 35. t-.41 Check# 12296 , North Andover Mass. /.7 r ELECTRICAL INspkth 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 FRTNTI]\TJNK OR TYPE ALL J1\TFORMATION) Date: r 7211. To the Inspector of Wires: By this application the undersigned gives notice of hi,s or her intention to perform the electrical work described below. Location (Street & Number) in l A. � t 0 h Owner or Tenant S s fd i m Q31 V Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Q No ❑ (Check leropriate Box) . Purpose of Building Utility Authorization N d 68 2 cr 7 32_ Existing Service 200 Amps 17 0 / 2 4 ()Volts Overhead ❑ Undgrd No. of Meters j New Service 20 ) Amps / 2 0 / 21 OVolts Overhead ❑ Undgrd Q---liro. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ufi t'IN (1( -Phi )Wd i I' StRU i CQ, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. fTotal TranoKVAsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- grnd. grnd. ❑ No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and on Devices Initiating No. olRanges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained 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 KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cogels in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: 0E L 4 w I list z ( 3 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Official Use Only Occupancy and Fee Checked [Rev.1/07) (leave blank) City or Town of: NORTH ANDOVER LIC. NO.: j50 f ‘frE Licensee: Signatu /QLJ �C. NO.: (If applicable, enter "exempt" in the license number line) Address:'[Mite IA)pvb •r A; 1 1 *Per M.G.L c. 147, s. 5 -61, security work requires Depattnient of Public Safety ' S" License: 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 Signature Telephone No. Bus. Tel. No.: 4'Z d -923 -q go 7 Alt. Tel. No.: (p 03 —31 2 9 % 3 3 Lic. O. PERMIT FEE: $ 0 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 conceming 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. 0 Rule 8 — Permit/Date Closed: 0 Permit Extension Act — Permit/Date Closed: *** Note: Reapply for new permit 0 Trench Inspection Pass 0 -. Failed 0 Re- Inspection Required ($.) 0 Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: , Pass 0 Failed 0 Re- Inspection Required ($.) 0 Inspectors Comments: 9 hikui091 q, 12 -( Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) 0 Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) 0 f Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) 0 Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. dweinhold@townofinerrimac.com 1 The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston, M24 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly �— �,, Name (Business/Organization/individual): j d� t� ((/1 Si 0 0- LA-) . Address: 144 l g t4- )i) j? City/State/Zip:4V in 60 h b3 I, Phone #: l ? - 12 3 - 7 9 Are you an employer? Check the appr 1. ❑ I am a employer with _employees (full and/or part -lime).* 2. I am a sole proprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t opriate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.01 Roof repairs 13.❑ Other ?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 the doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors #lat 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. Lie. #: Expiration Date: r t Job Site Address: ! 2 6 C4 �frri PI 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 requiredunder 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. I do hereby cert' under the pains andpenalties of perjury that the information provided above is true and correct. Signature: a Date: 1- 2 2- /1- Phone #: `IMP- 423 -5'po7 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 #: Information a d I str ctio rns 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 ofhire,• 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 Iicense 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 beenpresented 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 self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Depatu, ent 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 (ifnecessary) 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 clog 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 Masachusett,s Department of Industrial Accidents Office of htvestIgat1o.Xts 6 00'Wasbbington Street ]Boston? MA 022111 Revised 5-26-05 # 617-7277490Q ext 406 or 1-877.MASSAF Fax <# 617-727-7749 wwwmace anvIrl•;, Date B4J 9521 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that —C/7h74 pQ5 ,GQ� has permission to perform kik f �i 1.[fit ..4/ 0......... plumbing in the buildings of .:, ..1r at .. JZU ..ai►i /411 rth Andy veerr,, Mass. Fee .9..J. ,S.o.. Lic. No../..�ZC 7. .C,�'4�/ I"� ..... PLUMBING INSPECTOR Check ft —. z eS_' 50 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY CITY JOBSITE ADDRESS OWNER ADDRESS OCCUPANCY TYPE MA DATE g 1 I-/ 1 OWNER'S NAME TEL YL,.1 PERMIT # COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL El NEW: ® RENOVATION: ® REPLACEMENT: 0 FIXTURES 7 FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM IL •EDICATED GAS/01USAND SYSTEM DEDICATED DEDICATED GRAY WATER SYSTEM ! 1 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER FAX PLANS SUBMITTED: YES ID NO® 10 11 12 13 14 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE: APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El' OTHER TYPE OF INDEMNITY D 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 PM ill SIGNATURE OF OWNER OR AGENT YES Et NO I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME MPNI JP IJ COMPANY NAME CITY FAX CELL STATE EMAIL LICENSE # LcatiJ WY112 PARTNERSHIP®# SIGNATURE LLC E# ADDRESS 4 ® Spike,. /Ls'✓ /0,1 40 ZIP TEL - a /9;i1A g/t.oz rw/ The Commonwealth of Massachusetts 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 40 S v C -e/- /4-i✓6 . l' City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. 111 I am a employer with 4. ❑ I am a general contractor and I 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 ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3 . ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] These sub -contractors have workers' comp. insurance. 5. 111 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 6j1 Type of project (required): 6. ❑ New construction 7. ❑.Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.11I Electrical repairs or additions 11.1j Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *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. #: Expiration Date: Job Site Address: 0 0 G 6 ►/v.✓ /'1 City/State/Zip: /i/,. 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Phone #: Date: 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 #: . •.. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) 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 self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Investigations 600 Washington Street Boston, MA 02111 Revised 5-26-05 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass,gov/dia AUG/22/2012/VJED 12:22 PM Ortho Surgical Assoc FAX No,1 978 692 7354 P.002/002 yr MU� JR% ENGINE ` ,!a r s, +)l *_..' UCTION Scott S•igman,MD 11 Swan Lane Andover, MA 01810 a 12099. 01 Page 1 of 1 August 22, 2012 Job No. 12094 -�, Re: • Site Visits to the Single Family Home Known as 20 Campion Road, North Andover, MA Mr. Sigm.an, In accordance with Project 12094, I visited 20 Campion. Road, on May 30, 2012, rune 21, 2.012, July 18, 2012 and August 21, 2012, to perform structural evaluations and. .design modifications as needed, and to assure the •const>ruction was performed in, accordance with design drawings .and the. Massachusetts Building Code. It is my opinion that the structural enhancement/modifications detailed in Phelan :Engineering .Drawings, to date, at 20 Campion Road, North Andover, MA, as observed. on August 20, 201.2, were performed in accordance withdesigndrawings and specifications of record and,therefore: meets or exceeds structural requirements per the 8th Edition MBC. Please feel free to copy this letter to building department officials and call if you have any questions or 'comments. Regards, . Paul A. Phelan, Jr,, P.E. 12 SLEIGH ROAD A. CH.ELMSFORD, MA 01824 A PHONE:• (978) 256-4014 A FAX (878) 250-3764 A email: .paulphelanacornc stnet 2555 Date0- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 1r? 1)7 has permission to perform ' a wiring in the building of '`--' at f ' (.) — z ,-�-y'`-, `�= `" } , Noryh Andover, Mass. Fee ' a+" Lic. No. /'S'?,,:,- ,! - L L. J / ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Official Use Onll►y- v �7i Occupancy and Fee Checked c 5 [Rev. 11/99] (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: 8-,2 63- 0 City or Town of: r / / i J d c GYP— 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) / 0 0 rr) p uh n--G� Owner or Tenant Owner's Address rt G.i m, /e-he// Telephone No. 91 - j7.5=;2_4a3 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lf'r'j /Gr 4ta r r) , / V%Yzei e Completion of the followin No. of Recessed Fixtures No. of CeiL-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above In- Swimming Pool 2rnd. ❑ grnd. ❑ No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners 'No. of Detection and Initiating Deg ices No. of Ranges Total No. of Air Cond. Tons 1 No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices Local Municipal O,n ❑ Other No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances KW rit Systems o. Equivalent 1 J 4" No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 ❑ BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrif al Work: " (When required by municipal policy.) Work to Start: 81 a C/A) Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: ADT Securit Services 111 Morse Street, No= oo'. MA 0206 LI Licensee: John S. Bassett (If applicable, enter "exempt" in the license number line.) Address: Signature (Expiration Date) .: 1533C LIC. NO.: 1533C Bus. Tel. No.: 781-278-1169 Alt. Tel. No.: 781-278-1131 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 Signature Telephone No. PERMIT FEE: $c33 ;OLd Location / 9 0 (1 4w,O1 UA.) ?c, No. / ® Date g-3-oc) TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / F Check # / O f 5 14,35 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ., DATE ISSUED: , , 3 C <:::, BUILDING PERMIT NUMBER: ZIv ,_____ — SIGNATURE: �_ Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION l 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Nu Parcel umber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Frontage (It) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. Public 0Private ❑ 54) 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record (br «..-. but 1-k( Igo c_c-Lp /air *A° Name (Print) Address for Service : Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Li nsed Constru ion Supervisor: tQU1,1,1-44 1 (' ov-i Not Applicable 0 G 7 0 65 6 Licensed Construction Supervisor: A t 0 7 tk et An License Number a` `' (/V "'7Addr s ,b efiIP"� 3" Li -90 3 Expiration to/�� Sign a Telephone 3.2 Registered Home Improvement Contractor Cu lest.iCA"L Not Applicable 0 i g 44) V/� Company Name j G , A4/c/ 0 Registration Number V n D U 1 )` Addre �% (L� 3 ` - c�) `� ( 0....1 `/ i Expiration Da Signature Telephone rn Z 0 4 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 0 No 0 SECTION 5 Description of Proposed Work (check all applicable) l New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: `Q-- e__ d-7-) (,ue a c ‘,'y_& p(2._ IfLeA4k, ti, 00-.\ u '374 pbr cA,,,,ot itik,e__ -cam SEC ON 6 - ESTIMATED CONSTRUCTION COSTS Item lj�t /� y 0 VV Estimated Cost (Dollar) to be Completed by permit applicant O1 HCIAI IISE O .Y 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) S6/ �, life 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 QR CONTRACTOR APPLIES FOR BUILDING PERMIT I, r n ' ,i�l a V 1,,t,. (I' ....24,, , as Owner/Authorized Agent of subject property Hereby authorize to act on My be n 11 m rs re five to work authorized by this building permit application. V3/G 0 Signatu e of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I 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 Si • ahue of Owner/A • ent Date :115• NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Date Facility locatiff n Sigiratfire of Applicant 1/3/ UL) NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Lin V)e Fully Insured ipxuj. Paul Quintiliani 583 Main Haverhill, (978) 374-9083 i u Licensed Construction St. MA 01830 PROPOSAL SUBMITTED TO BRIAN & CINDT MITCHELL PHONE 978-975-2603 DATE 6/10/00 STREET 120 CAMPION RD JOB NAME MITCHELL CITY, STATE AND ZIP CODE NO. ANDOVER, MA 01845 JOB LOCATION 120 CAMPION RD NO. ANDOVER, MA ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ROOF iV !r c./ I 1 - -_ r ,. 1) . REMOVE ALL EXSISTING y SHINGLES. rilRliv rarar, n.1. alt ^s„ ;3 2). APPLY 3/8" FIR PLYWOOD SHEATHING ON ENTIRE ROOF STRUCTURE. 3). ICE & WATER SHIELD WALL BE APPLIED TO TEE FIRST 3FT OF ROOF EDGES. 4). 15LB FELT PAPER WILL BE APPLIED TO REMAINING ROOF AREAS 5). 8" WHITE ALUMINUM DRIPEDGE WILL BE APPLIED TO ROOF EDGES �'--'.--/ gi 7). ALL DEBRIS WILL BE DISPOSED OF BY QUINTILIANI CONSTRUCTION ,/- (0.-±-:„......./ q. ?h4 ith vch i 41D-7` 6E. v r P l I:IE t ir.p pgp hereby to furnish material and labor - complete TWELVE THOUSANH DOLLARS for the sum of: 12 000 ($ � ). in accordance with above specifications, dollars Payment to be made as follows: 1/2 DOWN UPON MATERIALS AND BALANCE UPON COMPLETION. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifica- tions involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, acci-,r dents, or delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. Authorized . Signature Note: This proposal maybe---.. withdrawn by us„„if ot accepted with days. ;in / A:tcE itun.ce of Proposal- The above prices, specifications and conditions are satisfactory a d are hereby accepted. You are authorized to do the work as specifielf Pa e t will be made as outlined above. Date of Acceptance: 7 / 3 / lj Signature ( r1. , , a-- cair J J Signature e - �ItP 11. OiI; Y.'tLZILLt ,:lily r/. f! COnSTPtif. 431 StJP,R I, ,: t `f:ot ti cuer: RestrPtml _•. !n POI ; *' ; 5?1'11.4 .:/pisaaniwovirl/��:txuirr�y�jf F 1 NOME-IMPROVEMENT CONTRACTOR' 'Registration 124470 Type - INDIVIDUAL Expiration 06/30/01' Ouintiliani CONSTRUCTAON er.r.giul G. O:intilrani wnnw!sTAATOR - 583 Main St __ _ Haverlri1,1 MA 01830. 3GIS 3SE13A3H 33S O CD CD O ar aCC= -C3D 1 C CD O. Cr G ediC CDCDO CC Ca C CD • CZ• O CD CD g 0 • O CV . 0 y O c 0 c 0 CD 0 . -r CD CD a y CD C/2 0 Z 0 CD O CD p p Permit Required to Occupy Building CD ,4 0 eo rD Cu 04 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name: Location: City Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity' I am an emp!oyer providing workers' compensation for my employees working on this job. I - Companv name: QU+ 1 l l �l�i 1 Con S� 1� v c a 0 III Address k.O P__ECL City: o Eiac-,L - ;ma_ 3(- Insurance Co. Lea 1 on :MSC 0 Company name: Address Phone #: Policy # ('m)3'Nqo 3 wC5 — 0�881 U q City: Insurance Co. Phone #: Policy # 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 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 and a pai and Signature Print name ti'CA-.x Q�L f perjuthat the information provided above is true and correct. Official use only do not write in this area to be completed by city or town official' DCheck if immediate response is required Building Dept Date - t083 ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Date 12_— l 1 —a 7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform , ` PQ/i2 2evA `teRp/�_:.. wiring in the building of ...8 Pi1 r'C�% L L- at 12 ' C. ilf fof/O /Z/ J'T ELEL4-. RICALINSPECTOR j 1 *� Check # ` 0 7863 orth Andover, Mass. f Attach additional detail if desirecZ or as required by the Inspector of Wires. trical Work: ~'' (When required by municipal policy.) Commonwealth. of ��/77/%amache Thepartmeni o/.}ire Serviced BOARD OF FIRE PREVENTION REGULATIONS Permit No. Official Use Only 7II3 Occupancy and Fee Checked [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 TYPALL FORMATION) City or Town of: /lJ0 Date: Q,G 1 11 C)7 To the Inspector of Wires: By this application the undersigned gives notice of 's or her intention to perform the electrical work described below. Location (Street & Number) 12 6 se/CSY\ Owner or Tenant C✓ f yl , 4 611.4,4i 1Y) 1 (c-he ! I Owner's Address -c-e Is this permit in conjunction with a building permit? Yes ❑ No 1/7..--- (Check Appropriate �Box) Purpose of Building ' 015 / i i, (f Utility Authorization No. 3 zJ2 FZ. 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:494/ 7S /G) zoo /0 S212,vi ce Completion of the following table may be waived by the No. of Recessed Luminaires No. of Ceil. Susp. (Paddle) Fans f Ts Total , Trraa nsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- grnd. grnd. ❑ No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons g ert No. of Alin Devices No. of Waste Disposers Heat Pump Totals: Number _ Tons_._ �- KW -- No. of Self -Contained Detection/Alerting Local ❑ Municipal Connection Devices _ No. of Dishwashers Space/Area Heating KW Other No. of Dryers HeatingAppliances ' pp Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of El Work to Start: Z / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ` ' GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same / �to the pe it issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) j es 1 certify, under the pd penalties of perjury, that the information on this application is true and complet v4 FIRM NAME: �4 V e l a it-1 G ^ , LIC. NO v 6 33 Telephone No. Signature /(L L-J?✓iZ� LIC. NO.: (Ifapplicable, enter "exempt" he lic nse number lin /j �T l Bus. Tel. No. r�s Address: 89 1 CfCf Kt n � O v� �'L�i%'l/j Alt. Tel. No.:/ 60 *Per M.G.L. c. 147, s. 57-61, security work rEuires Department of Public Safety "S" License: Lic. No. erf3-1(4 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 Signature Telephone No. Licensee: PERMIT FEE: ,$ TOWN OF ANDOVER ELECTRICAL PERMIT FEES (Ej ective March 12, 2003) NO SE CABLE ON OUTSIDE OF BUILDING Air Conditioners: $40.00 each Alarm Systems Security: (for fire systems see smoke/heat detectors) Residential: $40.00 Commercial: up to 10 Devices $60.00 additional devices over 10- $1.00 each Carnival Equipment: $50.00 each Ceiling Fans: $1.00 each Commercial New Construction or Alterations: $100.00 per 1,000 Sq. Ft. of Construction Space Commercial Service Change/ Repair: Must have Utility Authorization Number $100 (first 100 amperes or fraction, one meter) a) each additional 100 amperes capacity or fraction. $30.00 b) each additional meter $25.00 Commercial Temporary Service: $100.00 Must have Utility Authorization Number Commercial Repair and/or Maintenance Permit: (Blanket Permit) up to 2 Electricians $150.00 per pair of Electricians over 2 $50.00 Data/Telecommunication: Residential: $1.00 per port Commercial: $30.00 up to 10 devices over 10 - $1.00 each Dishwashers & Disposals: $5.00 Each Dryers: $15.00 Each Emergency Lighting (Battery Units) $ 1.00 each unit Feeders or Sub -feeders: each 100 amp capacity of fraction thereof Residential: $5.00 each Commercial: $15.00 each Gas/Oil Burners: Residential: $20.00 each Commercial $20.00 each Commercial: a) including photovoltaic & generating Equip Per KVA $1.00 b) un-interruptible power systems, per KVA $1.00 c) batteries over 100 amp. hours, per cell $1.00 Heat Devices: $1.00 each Heat Pumps: $40.00 each Hydro -Massage Bathtubs/ Hot Tubs: $20.00 each Lighting Fixtures $1.00 each Lighting Outlets: $1.00 each Major Appliances: (not listed) $20 each Motors: (per hp or fractional part thereof) $2.00 Oil /Gas Burners: Residential $20.00 each Commercial $20.00 each Office Furnishings: per circuit $10 (Relocatable Partitions/Cubicles) Outlets & Fixture: $1.00 each Ovens Built in/Counter Top Units: $10.00 each Panel Change/Circuit Breaker: Residential: $20.00 Commercial: $25.00 Phone Jacks: See data/telecommunications Ranges $15.00 each Receptacle Outlets: $1.00 each Recessed Fixtures: $1.00 each Re -inspection Fee: $25.00 Repair to Service Residential: $20.00 Residential New Construction (Dwelling): $220.00 (with service up to 200 amps) Must have Utility Authorization Number for services over 200 amps see below a) for each 100 amps capacity or fraction add $20.00 b) each additional meter $10.00 c) each additional panel/sub panel $25.00 Residential Additions/Alterations: $220.00 maximum Residential Service Change or Underground Service: $40.00 Must have Utility Authorization Number a) one meter, up to 100 amp capacity $40.00 b) each additional 100 amp capacity or fraction $20.00 Sewer Ejection Pump: $25.00 Signs: $25.00 each ballast - Smoke & Heat Detectors & Initiating. Devices: Residential: $1.00 each Commercial: $60.00 up to 10 devices over 10 - $1.00 each Space Heaters: area heating $1.00 each Sub -Panel: $25.00 Swimming Pools: Residential: Above Ground: $25.00 Inground: $50.00 Commercial Pool: $100.00 Switches: $1.00 each Temporary Service: Must have utility Authorization Number Residential $25.00 Commercial $100.00 Transformers: a) capacitors, Per KVA $1.00 b) ducts, conduit & conductors (Associated w/ Padmount Transformers) $25 c) each manhole $10.00 d) each handhold $5.00 e) per KVA $1.00 f) primary feeders, $25.00 each (over 600 volts, non -utility owned) g) vaults and equip. $25.00 each Washers: $15.00 each Waste Disposals: $5.00 each Water Heaters: $30.00 each *For Multi -Family & j Large Commercial Project see Wiring Inspector for qpricing: Paul Kennedy (978) 623-8306 (Office Hours 8 am to 10 am) *Inspection Schedule: s•` 1 ROUGH 1 FINAL 1 TRENCH (if applicable) ADDITIONAL INSPECTIONS *$25.00 (if applicable) (revised 07/05) tr- 11 Location (C fM )0 / b n/ • Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ AtPermit Fee Sewer Connection Fee $ Water Connection Fee $ N TOTAL „� $ ei/z g s :' 9696 Building Inspector S Div. Public Works w 0 W < a 0 0 0 a_ z 0 0 0 cc 0 U W ♦Y PURPOSE OF BUILDING W N m NO. OF STORIES 0 rc M 0 z N SIZE OF FLOOR TIMBERS Z d N DIMENSIONS OF SILLS " GIRDERS THICKNESS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND C W F z 0 r 0 1- 0 W F 0 W Z Z 0 u 0 z 0 J_ 5 IS BUILDING CONNECTED TO NATURAL GAS LINE Q V LOCATION v� H W K Z f i 0 < < 0 N Z Z < N N K Id Id z z O 0 4 ITEC BUILDER' 14 z 0 7 CO DISTANCE TO NEAREST \__11 Otl DISTANCE FROM STREET DISTANCE AREA OF LOT IS BUILDING ADDITION IS BUILDING ALTERATION WILL BUILDING CONFORM TO REQUIREMENTS OF CODE z 4 z 0 f 0 J W a a 4 0 0 C 0 m Z 0 re 0 W 0. 0 a 01 O 0 0 z < J m 0 W 0 a a OWNER TEL. # CONTR. TEL. # CONTR. LIC. # INSTRUCTIONS SEE BOTH SIDES FILL OUT SECTIONS 1 - 3 IJ d PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING N z 0 F J 0 W C W W F < f N 0 F i 0 4 z 0 u N 3 i N W 0 0 W I u W 0 W r z 0 h f cc W SWOO1 dO 'ON 8 TA.1 y a O V1 A03 N 9 00 NN O O O O O T 0 13AV89 4 8V1 CA m 00 O 2 z 0 N 0 0 co x 0 Z co n A x 3WV81 NO 3N0IS MJN0SVW NO 3N0IS )119 830NID 80 'DNO: 3WVMi NO )IDI89 ABN0SVW NO )I)I89 3WV8i NO 0»f11S ABN0SVW NO O»f IS m N 0 o z 0 ONIOIS 11VHdSV S31ONIHS OOOM ONIOIS dO80 S08VO9dV1D O 0 S831V3H 11Nf1 D z D n 0 Z 0 z 0 S 0 0 ma 0 A y D 'N8fli 81V 1OH 03D8Oi 3 z y z 0 O0V0 3111 8OO1d 3111 S38f11X1i N830OW 83M0HS 11VIS O ONI9Wflld n S Z CA z 7c A8O1VAV1 135O1) 831VM O ti N X 0 C 0 31Vf1O30V C O A Z o O z O z 0 8OO1d 9 'S81S JI11V 3111 'HdSV 0 0 z O O 3138)N0) m A N ID 0 WOO8 OV3H Z 0 CD D D c 0 0 z n x z S3DVld 3313 z V38V JI11V V38V .1.W.9 'Nli 1N3W3SV1 z z 11VM A80 70 „4 3138)N0) N0UVONfl0i 3N01S 80 )19189 0 3138DN0D co 4 z S1N3W18VdV c c ti D AIIWV1 31ON1S 0 Fl N (3. co D• 0x P1 r N zm DO 'Az °c rn XNj 0�0 pm mx -1Z> xto) fl moo�z2 m�'3 rr�OZ 0m N C Z r rg0 m -I0r .uy0 r• -I Z• Z ° x° 0-1 D nz xn mm °0 y0 3 0 0 c z^ 1 to n CO z 0 0 0 ON r-4 z THIS CERTIFIES THAT has permission to snot VIOLATION of the Zoning or Building Regulations Voids this Permit. tal Pe CD C3 CC O O 0) c i p • 'C CD Ca O O m m CD O CD L - 31=, CD CD L CC d o c. Co J-O C) c Z a3 CL C1 y C C cv CO) rrtc '':Yi. YT Y� `vfC 3r, ��O,yyC ER Lakeside Insurances Agency Inc. 88 stiles Road Salem, NH 03079 (603) 893-9450 Fax 893-9480 .. �h<4%xi4T:^•'r7:i.Y.{.�;xia; n%xbX�}%�.f,•;i:✓�Y',$ik' ^riCrk•>:::/, n,. 'a'",vi(}, ^G.x:,{;•{•. ; �'S i 'Yi x.x{�Y..}.J..•J.HCk•ii•K:, r7;} ��Y;�:{.k.Yn,{.:7,=i''i�Y''%xNTYu7i•ni•,^ii�xc::::i.!}f;.x.$. 3 24 1996 THIS. CERTIRCATE IS ISSUED AS A MATTE OF INFORMATION ONLY 4ND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE NNAilED CUSTOM QUALITY POOLS, INC. 1.6 WYMAN ROAD BILLERICA, MA 01821 MAPAmY LETTER A CNA INSURANCE COMPANIES LETTER B HARTFORD INSURANCE COMPANY whom t, Lem COMPANY D LETTER COWAN'. E LETTER x W,R x%s's:xC:^iri' ';t4x•>:: �;ra•xv:<•xb: x xsw". 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"��-#.:n•>:.:.,,':.f�, , s�$.><:z�s:xw:4K:�ir:A�a:o:b>:sw:{.:{..:n.n.,:. ,. ,� R;;'£,fs<R:r/x a'.?#:kiN»I:x.>x.u.%a+>}�sus.c,.�..: ,:..,:.,�, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR coNDTTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCWSIONS AND CONDITIONS OF SUCH POLICIES. OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTA TYPE OF RIk?'IRIAMCE POLICE.NUERAM POuCT cFFECiwt DATE (MMODIYY) 3OLICY EIOEATIDN DATE (MM/BOrYY) A DESIEAAL LIARIUIY X ' COM ERCIA . G9•IERAL Lu(Rim ms369415 CLADAS MADE , X ';OCG1f OWNERS Al Cp1 mACT0R's PROT. aurnmaar mown' ANY AUTO ALL cwNED AUTOS SCNEOULED AUTOS S PRIED A uroS NON -OWNED AUTOS OARApE LLABUTY PIMA LIAMLRT .... UMBIm-LA FORM OTHER THAN LAMELLA FOAM • W RKER1 CONIIRESAMN AND 77WZ U143e 06/04/95 • • • • 02/01/96 LIIM PRODUCTS-cCWPAOP A30. s 1,000,,000 $ 500,000 0 2/ 01 / 9 7' 0N41 8 /°'�• °f urri 3 5 0 0 A 009 FJ OCc� s 5 0, 0 0 0 [ ME DAMAGE (Any cm. ere) $ 5 0 L• ... 0 MED. DQ'E7 iSE (Any a s p.r.ai) 3 5 0 0 0 COMBINED SINGLE LIMB BOOZY IHJJRY (Per perm) 3 S BODILY IwuRY (Per occident) 3 PROPERTY DAUADE ENIiOYETtr WARM • • EACH OCCURRENCE AGGREGATE s x • STATUTORY LIMITS 0 6/ 0 4/ 9 6. EApI ACCIDENT • : DISEASE - riLICY MITT 3 500,000 s 500,000 DLSTASE - EACH EMPLOYEE it 500,000 OESCROWN of orommetstOcutostryettCLEIFSPECIAL =ES FAXED TO: 508-663-8288 Irad[!. . Yi�xu• ,:.. R's"'• 'Z•ft:FrffKN:R'1{. .i Yb...x •e: .w •. '"�. Nrk�k. ,�r„auoi�fi ...,.,:,,�7v,'F,?<isi>'�:�:}1xv......:aLx{.wk..v.,v..u.u:,u.v.�.,.. FOR INFORMATION ONLY TI�I°s . +'nx:'i�:>:k x: �,'K:x:vF!Gi f'.,{k:ljp�:Kz�� .�-'�,'v^i:u9 ,'/oi+ PUN::x:�:.ie:w: ' e�:{:1:x:>'•:< br:x,rr>ww:x..e>•.'x�.�:�w�N'i...,ibu:�$.r-..�:;'#3.f ��u..`i,�.:€�:`....,x'$.� •Ku.wwi'�;f;%:.•'%k s<5: I,.I.:,.7x .,:xSSV:f,i�Rd'�(}e•.x Kb,i SHOULD ANY OF THE ABOVE DESCRIBED POUCIES ° E CANCELLED BEFORE THE Wyk EXPIRATION DATE THEREOF, THE ISSUING COWAN' WILL ENDEAVOR TO x MAIL • DAYS WRITTEN NOTICE TO THE CERVICATE HOLDER NAMED TO THE '' = LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHAD. IMPOSE NO OBUGATION OR b•'iiUABIUOF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ? TY Au11IDAQED RFFRESCIATA11VE k •,•. ..n%rvrn•n,.n..r xn>:3k x32i S3a:u:"3•`x:?n?iWrIgr rM, 7ro:bw>pz,, M.x. % K. ;i:: ;aa Kk,;}:': ,:., !:,rrb�o;bxnrx°7x.r.r<. }:¢§%? .. .{fi/.•.t.�..:{.L.� l vS v.. 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Coq/Li --I ,4) N \ .•I'ClC,j --c:7-. k) l' • r,' k (.7) N.1 CSS J2e eciponoitteetza ?aach�e1ti HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 105084 Expiration '07/16/96 Type - PRIVATE CORPORATION Custom duality Pools Inc. Robert A. Bent 16 Wyman Road Billerica MA 01821 COMMONWEALTH %` ^t/ OF MASSACHUSETTS EXPIRATION DATE 01/10/1997 RESTRICTIONS NONE SS N 023-44-1846 PHOTO (BLASTING OPR ONLY) 1i •1�. OTF tMB PRINT FE100.00 HEIGHT: DOB: 01/10/1953 THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF THE HOLDER WHEN EN- GAGED IN THIS OCCUPATION. OEPAPTMENT OF PUBLIC SAFETY g ONE ASHBORTON PLACE BOSTON, MA 02108 LICENSE CONSTR. SUPERVISOR EFFECTIVE DATE LIC-NO. 06/30/1994 040192 ROBERT A BENT 16 WrrL4 RD BILLERIC•A MA C1E21 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY STAMPED - OR - SIGNATURE OF THE COMMISSIONER P-r 4#000014000.74,41:01001,NER SIGNATURE OF LICENSEE L_- gi a 6 m»eo ,wea/G% o� f 1Maaiue HOME IMPROVEMENT CONTRACT Registration 105084 Type - PRIVATE CORPORATI Expiration 07/16/96 Custom Quality Pools Inc. Robert A. Bent 2:-Kof 6 Wyman Road ADMINISTRATOR Billerica MA 01821 Fallen to F . . e aMrrsst Ha►nlleahsr-r"Tr, Mats tERNeJng Cod' 1. Ztetiotworoostion FOR PROTECTION AGAINST THEFT, PUT RIGHT THUMB PRINT IN APPROPRIATE BOX ON LICENSE. i; BLASTMP OPER ° ,A RS UST(! 4LUDE P o)TO. i. Cam— - I MAY 121994 i —awl LT./ SIGN NAME IN FULL Anovt SIOtJATUfiEL11tlE • u FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: frPti\I i T d/I Phone ln -W 3 LOCATION: Assessor's Map Number Subdivision Saw ✓K Street 51oi\I 4 mod(. Parcel Lot(s) St. Number 4IZo ************************Official Use Only******** RECOMMENDATIONS OF TOWN AGENTS: Conservation Adihinistrator Comments W f940Z5neb • )1.10 Vey, ��IdS bksi 142 ?`12D` ed b Eth cM\ack **************** Date Approved / ,2� /6 to Rejected WeLPD. ?Po 4-0A' j h Date Approved Town Planner Date Rejected Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Location Frio. : Er-5- Date Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee Water Connection Fee TOTAL 12779 ca TOWN OF NORTH ANDOVER 8 7S Y five) Buildir g Inspector Div. Public Works Location No. i, , Date TOWN OF NORTH ANDOVEFA Certificate of Occupancy $ Building/Frame Permit Fee $ ''' Foundation Permit Fee $ Other Permit Fee $ R Sewer Connection Fee $ 0.1 Water Connection Fee $ T. TOTAL $ Building Inspector Div. Public Works *NORTII ANDOVER, MA La U Q C C La c a c z 0 dx L^ 6 W I O()R 1IMIuERS 3c z to C Z z u: c Z 4 z w 1 i cc w F- G CONNEC IEl) 1-03 VI ..I LLI z :J do z 0 0 j A4 J z Y w IECI 'S NAM z - w z Y n m O NEAREST B VI oa w C' Y w ce N w z z w z w N z z w M TO R EQ(I I R BUILDING CON z N fit )4121) OF APPEA z `i. W \ u z Y ,J R EST. B1.1ki. C z SEI'IIC PER OWNERS TEL# COM R.IEI # FORMAT' J FORM U LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. `**********APPLICANT FILLS OUT THIS SECTION* APPLICANT?�q(.�/� �1, `i�� �(, ( PHONE g18' 9 5 ' LOCATION: Assessor's Map Number O64. PARCEL SUBDIVISION � ' LOT (S) 0408l0 / STREET CilY11 iCiO/.l I l ST. NUMBER /Z3 ************************ OFFICIAL USE ONLY*****„**'**`*"**'"'*' RECOMMENDATIONS OF TOWS NN AGENTS: CONSERO/ATION ADMINISTRATOR DATE APPROVED 7'_ q9 DATE REJECTED COMMENTS Wt-RoLas -> 10 0' ytThev— Q�I oe94-6-P — J/ TOWN PLANNER DATE lPPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE 3�� 01/07/1994 17:49 5085214669 COWAN INSURANCE PAGE 01 OATS 1MM/0O1TT9 ACORD,� CERTIFICATE OF LIABILITY INSURANCE as 18/98_ PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Agency, Inc.ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Cowan IriSUraflCe A g y, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEr OR 7 Kenoza Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES E!, \OW. Haverhill, MA 01830 INSURERS AFFORDING COVERAGE S'✓ (978) 372-1451 'I,suREO Northway Builders, Inc. INsuRERABmpl y rs. Mutual Casualty Company P.O, Box 552 ,NsuRERsUnited Pacific Insurance Company Hampton Falls, NH 03844-0552 INSUAERC, INSURER 0, INSURER E: COVERAGES THE POLICIES OF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED MAMBO ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE USIRS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. N. POLTCY EFFECTIVE POLICY EXPIRATION LIMIT STYPE OF INSURANCE POLICY NUMILFJt MN tlINm= DATEosisoonM GENERAL UASIUTY EACH OCCURRENCE: is 500,000 X commumm.mmmuoeurT FIRE DAMAGE (Any one flr81 S 10 0 , 0 0 0 . CLAIMS MADE 1I "-X OCCUR MED ErEr(Arty one person) S 5,000. A 1D5-42-53--98 08/21/98 PERSONAL E. ACM INJURY S 500,000 1D5-42-53--99 08/21/99 OENERALAGOREOATE $1, 000, 000. PRODuOTs - COMP/OP AGG Si , 0 0 0, 0 0 0. GEN'L AGGREGATE LIMIT APPUES PER: x POLICY n ,( T n LOC AUTOMOOII.E LIAMM ANY AUTO ALL OWNED AUTOS SOHEDULEO AUTOS . MIRED AUTOS NON•OWNEO AUTOS 08/21/97 08/21/98 GARAGE U NIUTY ANY AUTO cOM61NED sINOLE uUIT (E. accident) SOOgYINJURY (Pit person) BODILY INJURY (Per accident) PROPERTY DAMAGE S (Per eccluenl) AUTO ONLY EAACCIOENT { $ OTHER THAN EA ACC s AUTO ONLY: AGO $ EXCESS UMSIUTI OCCUR ri CLAIMS MADE OEDUCTIBLE RETENTION $ WORKERS CONIPIRMATION AND EMPLOYERS' UAmuTY NWA 175588501 OTHER 12/10/98 EACH OCCURRENCE AGGREGATE S S Waa1 QTR• X TOPV LIMITTATU•S . ER 12/10/99 E.L. EACH ACCIDENT 0.00, 000 E.L. DISEASE • EA EMPLOYE S 10 0 , 0 0 0 E.L. DISEASE • POLICY LIMIT $ 5 0 0, 0 0 0 DESCRIPTION OF OPERATNHIHLOCATIOMBNENICtEA,E)ccu,eIO.B ADDED SY El OORSEMEMTf5PECIAL PROVISIONS Brian Mitchell is Addditional Insured on General Liability only For work at 120 Champion Road, North Andover, MA 01845 CERTIFICATE HOLDER X I ADDITIONAL INEW RED: insulin LETTER Brian Mitchell 120 Champion Road North Andover, MA 01845 Fax: (603) 926-9039 1 ACORD 25-5 (7/97) CANCEL.IATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TINE EXPIRATION DATE THEREOF, THE MOWN* INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERfFICATE MOLDER NAMED TO THE LEFT. ROT FAILURE To D0 $0 SHALL IMPOSE NO OBUBATION OR UASIUTY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRE8ENTATNEE. AUTHOROl0 REPRESENTATIVE o ACORD CORPORATION 108E c� �ie oaivnuYruueaLd o/ zi caiaac/ueiea 1 Restricted To,00 DEPARTNENT,OF PUBLIC SAFETY 4 CONSTRUCTION SUPERVISOR LICENSE t 00.' None Number, : Expires; Birthdate: lA - Risonry only CS 059504 09/19/1998 09/19/1954 i 1G 1 & 2 Family Homes Restricted To: 60 1 Failure to,p4ssess a current edition of the 2.m44, is efl. Rassachusetts`State Buiilding Code, PAUL RABENIUS is cause for revocation of this license. PO BOB 552 HAMPTON FALLS, NH 03844 81877 tiAScheck COMPLIANCE REPORT Massachusetts Energy Code I Permit # MAScheck Software Version 2.01 I Checked by/Date CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 9-3-1998 COMPLIANCE: PASSES Required UA = 360 Your. Home = 328 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA CEILINGS 480 37.0 0.0 15 WALLS: Wood Frame, 16" O.C. 960 19.0 0.0 58 GLAZING: Windows or Doors 117 0.560 66 GLAZING: Skylights 24 0.650 16 DOORS 18 0.560 10 SLAB FLOORS: Heated, 48.0" insul. 240 10.0 164 HVAC EQUIPMENT: Boiler, 90.0 AFUE COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined usin - -• cable Standard Design Conditions found in the Code. The HV equipme sel to heat or cool the building shall be no great than 125$ o. th- sign load as specified in Sections 780CMR 1 Builder/Designer �� � � - Date Cis CI MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.01 DATE: 9-3-1998 Bldg.1 Dept. Use CEILINGS: [ 1 1 1. R-37 Comments/Location WALLS: 1. Wood Frame, 16" O.C., R-19 Comments/Location I WINDOWS AND GLASS DOORS: [ ] I 1. U-value: 0.56 For windows without labeled U-values, describe features: # Panes Frame Type Comments/Location Thermal Break? ( ] Yes [ ] No I SKYLIGHTS: [ 1 I 1. U-value: 0.65 For skylights without labeled U-values, describe features: I # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location DOORS: [ 1 I 1. U-value: 0.56 Comments/Location SLAB -ON -GRADE FLOORS: 1. Heated, 48.0" insul., R-10 Comments/Location Slab insulation to extend down from the top of the slab to at least 48" OR down to at least the bottom of the slab then horizontally for a total distance of 48". I HVAC EQUIPMENT: [ ] 1 1. Boiler, 90.0 AFUE or higher Make and Model Number AIR LEAKAGE: Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. When installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfm (0.944 L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. I VAPOR RETARDER: l ] 1 Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. MATERIALS IDENTIFICATION: Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values, glazing U-values, and heating equipment efficiency must be clearly marked on the building plans or specifications. DUCT INSULATION: Ducts shall he insulated per Table J4.4.7.1. DUCT CONSTRUCTION: All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. I ] 1 SWIMMING POOLS: I All heated awinuuing pools must have an on/off heater switch and 1 require a cover unless over 20% of the heating energy is from I non-depletable sources. Pool pumps require a time clock. HVAC PIPING INSULATION: HVAC piping conveying fluids above 120 F or chilled fluids below 55 F must be insulated to the following levels (in.): PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 Steam condensate any 1.0 1.0 1.5 2.0 COOLING SYSTEMS: Chilled water or 40-55 0.5 0.5 0.75 1.0 refrigerant below 40 1.0 1.0 1.5 1.5 • I 1 I CIRCULATING HOT WATER SYSTEMS: I Insulate circulating hot water pipes to the following levels (in.): PIPE SIZES (in.) NON -CIRCULATING I CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F): RUNOUTS 0-1" I 0•-'_.25" 1.5-2.0" 2.0+" 170-180 0.5 I 1.0 1.5 2.0 140-160 0.5 I 0.5 1.0 1.5 100-130 0.5 I 0.5 0.5 1.0 ----NOTES TO FIELD (Building Department Use Only) • • • • O E-4 z THIS CERTIFIES THAT VIOLATION of the Zoning or Building Regulations Voids this Permit. 0 � 0 • izr • • •0 O C 0 � O d C.• co Q 0ca C ��pp cc C3 J 'p c ▪ Z G3 V C N C ei •C Is co C. 4-- co) da— w Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director Northway Builders P.O. Box 552 Hampton Palls NH, 03844 Mr. Paul Rabenius: 30 School Street North Andover, Massachusetts 01845 September 18, 1998 Attached is a copy of the rules and regulation for application to the Home Improvement Contract License. Please review the attached information and call us with your H1C # once you register with the State of Massachusetts. If you have any questions call me at the North Andover Building Department at 978-688-9545. Very truly yours, Jeannine McEvoy, Secretariat BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Pi R N D F 1 A N.D IN No R T N /4'ND O Y.ER, J11 SS. PR. -p, R.zD FOR B R / AN 1`7�rc��,�.t ScA.t / 1fY 57-0'./1SAs gsSoc/)Qr.&sINC. Rtc• .1-14NO SURV..voks nL).Y 19 9 8 %`/z 7-74 Li /4 /%1 S -locus SN0\+/N Q./NC .Lo7- 9RP SND)✓N 6N /NORTr4 .E. 5Ex REC)STRY OF D .k 05 P,t i' /oG 8 9 0 A v✓ • ()% r /2D ',E x / SYJNG Dr/.xx).1NG /8 -o: • t// 3•/-D 0 P05F0 RDD)T )O7%1 DECK ti 0 oi•y / 45i 0 40 ; 10 This certifies that has permission to perform plumbing in the buildings of at /2 o Fee L Lic. No. U Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 60-7/ 7c lT � orth Andover, Mass. PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATIOOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSE ITS Building Location New Renovation ❑ Type of Occupancy DU,- P /6 Replacement ❑ Plans Submitted Yes Date / L/0 f Owners Name /2 d O4 -t1Ji '-a. Permit Amount No • W ri1 o w H" Zt z 41 Q > as F H- � 4' o=a w �a 0 LAUNDRY TRAYS I WASH.MACH.CONN. E� x � TANKLESS SLOP SINKS 0 IGAS TRAPS I URINALS Z o C7.4 � IAREA DRAIN WATER PIPING Z a o IBACKFLOW PREV. I OTHER FIXTURES i k„ SUIBgVIC B SEIVENN -- - 1ST HEM HEM 41E1 FLCCR 5IH FLf R 6IR FLOCK - 7IH FICCR SIII FLOCK - (Print or type) Installing Company Name r0 _ jj i S s� `-to/K-d --e. "c Address rU re/2-` IT -14 U ft• ' . °4 Business Telephone (G g a Q Z J Check one: ❑ Corp. Certificate ❑ Partner. ❑ —Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity ❑ Bond El Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Is ued for this application will be in compliance with all pertinent provisions of the Massachus tat u bing e and C ter 1 f the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY sigma tr tticensed Plumb Type ofPlumbingLicense License tuber Master Journeyman ❑ N9 294 SACHUS, This certifies that r = `'—' Date " TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform "'�� wiring in the building of "." at Fee ' .4 , North Andover, Mass. Lic. Noic'73n,� XC,,_ a/l' ELECTRICAL INSPECTOR 12/28/98 14:28 150.00 F?M WHITE: Applicant CANARY: Building Dept. PfNK: Treasurer THECOMMOM E4L7HOFM4SSACHUSE77S DFPARTMF sTOFPUBLICS9FETY BOARD OF FIRE PREVEPS JON REGULATION S 527 CMR X2: 00 Office Use only Permit No. G2/9� Occupancy & Fees Checked /ov APPLICATION FOR PERMIT TO PERFORM ] ,ECTRICAL WORK ALL WORK TO BE PERFORMED IN ALLVRDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 12 - 3 - `i Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number). l 7. D L'Arne j v ' s. a To the Inspector of Wires: Owner or Tenant t*'r- . Yv\ S 11-\ 4- kc i l Owner's Address 1 2 6 IA rvx p 1 p •cza Is this permit in conjunction with a building permit: 11 Yesal No a (Check Appropriate Box) Purpose of Building f° l� t c 1.� r; Acid' 41 (5-',-) Utility Authorization No. Existing Service 20n Amps k2. /24(c,VOIts Overhead i Underground No. of Meters New Service Amps / Volts Overhead =I Underground [1 No. of Meters Number of Feeders and Ampacity Ida 4yilio .S c3i3 tl iy»ue A 1 Location and Nature of Proposed Electrical Work 13 as 1 S 1 r10 0, )Z: -c_kc J No. of Lighting Outlets J 1 (Ye)KVA No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures z Generators KVA Swimming Pool Above ground Below ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bumers FIRE ALARMS No. of Zones No. of Ranges Z No. of Air Cond. Total Tons No. of Detection and No. of Disposals t No. of Heat Total Pumps Tons Total KW Initiating Devices No. of Sounding Devices No. of Dishwashers / Space Area Heating KW No. of Self Contained • Detection/Sounding Devices 174o. of Dryers Heating Devices KW Local Municipal a Other Connections 1Jo. of Water Heaters J KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP InstranceCa zage Ptastraritmtheregtmanents i Gar¢al Laws 1haeac ent t1ylrmracePbbcyurhtdutgCcnplete Co►aager� substantial equivalent YES El NO a Iha�esubrni{badwtidpinofofsanetutheollice YESNO a IfycutmedhadcedYES,ple a thetypeofaneageby gthe NSURANCE IZI BOND ED OTFER ED ( Spey) e- 99 ErpiraticnDare / 2 ^ Z g - ci'S Estrirmled Valm cfE9echiral Wak $ cS ; 5" b 0 . .' WaktaStart (2-2-3 - /".3 InspecticnDateRequested/Z- 28 ?a' F¢ral wr'/) cA-)1 Signeduncler ePer,afp rjtay. r FIRMNAME K;�E. E!cc7-t-Ic Servt,-j Liarcse % I D- Licensee L W r v c k •"c- @ Signature Lice seNo I.Z 3 /41i2 1 Business Tel.No. ,?2 ‘30 3 / e AddressP6 ox Iz /Y,l.11,o7`D,v Ps4-115 N SW Alt.TeLNa OWNER'S INSURANCE WAIVER; IamawacethattheLicense does oothove drirmxaneco►e aisakaaltialegrivalaiasre uiedbyMas hseltsGataalLaws and filmy sig ernthsparniteppfaticnwraivesthistagueement. (Please check one) Owner E=I Agent El Telephone No. PERMIT FEE $ 7 S • ear5 TJ-Beam"' a5.20 Serial Plumber 708001� 5.2" x 1 1 .8 E�} 5" 2.0E Paral lam® PSL BEAMl1SA 1111 12/4/98 7:35:09 AM _ , , , Page 1 of 2 Build Code: 070 THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE APPLICATION AND LOADS LISTED Member Slope: 0 Roof Slope: 12/12 KITCHEN BEAM Overall Dimension = 24' All dimensions are horizontal. 12' 2 LOADS: Analysis for BEAM MEMBER Supporting SNOW Application. Tributary Load Width: 1' Loads(psf): 42 Live at 115% duration, 20 Dead, and: TYPE Uniform(plf) Uniform(plf) Uniform(plf) Uniform(plf) SUPPORTS: CLASS Floor(1.00) Floor(1.00) Floor(1.00) Snow (1.15) 1 2x6 Stud Wall 2 2x6 Stud Wall 3 2x6 Stud Wall INPUT WIDTH 5.50" 5.50" 5.50" 12' LIVE DEAD LOCATION APPLICATION COMMENT 420 210 0 to 24' Adds to 0 60 0 to 24' Adds to 280 140 0 to 12' Adds to 714 340 0 to 12' Adds to BEARING LENGTH 5.5" 9.914" 5.5' JUSTIFICATION Left Face Centered Right Face REACTIONS(Ibs.) LIVE/ DEAD/ TOTAL 7749 (S1.15) / 4106 / 11855 13985 (S1.15) / 8134 / 22120 2029 (F1.00) / 1146 / 3175 3 Product Diagram is Conceptual: /690 CA DETAIL OTHER Detail R1 Detail R7 Detail R1 SB Shear Blocking SB Shear Blocking - See TJM SPECIFIER'S / BUILDER'S GUIDES for detail(s): R1, R7. - Bearing length requirement exceeds input at support(s) 2. Supplemental hardware is required to satisfy bearing requirements. DESIGN CONTROLS: MAXIMUM DESIGN Shear(lb) 15359 12612 Moment(ft-Ib) 27351 27351 Live Defl.(in) 0.305 Total Defl.(in) 0.455 CONTROL 13861 34332 0.583 0.778 CONTROL Passed(91 %) Passed(80%) Passed(U459) Passed(U308) LOCATION RT. end Span 1 under Snow Roof loading MID Span 1 under Snow Roof ALTERNATE span loading MID Span 1 under Snow Roof ALTERNATE span loading MID Span 1 under Snow Roof ALTERNATE span loading - Deflection Criteria: STANDARD(LL:U240, TL:U180). - Bracing(Lu): All compression edges (top and bottom) must be braced at 2' 8" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. - Design assumes adequate continuous lateral support of the compression edge. - The load conditions considered in this design include Altemate member loading. PROJECT INFORMATION COM CON JIM LACOURSE JOB #98-060 96 CAMPION NO ANDOVER, MASS OPERATOR INFORMATION: PELHAM BUILDING SUPPLY MARK BEDARD ATWOOD RD PELHAM, NH 03076 603.635.7555 603.635.9627 Copyright a 1998 by Trus Joist MacMillan, a limded partnership, Boise, Idaho, USA. TJ-Beami° is a trademark of Trus Joist MacMillan. Parallam® is a registered trademark of Trus Joist MacMillan. KITCHEN BEAM TJ-BeamT" r5.20 Serial Number: 708001814 BEAMUSA 1111 12/4/98 7135:09 AM Page 2 of 2 Build Code: 070 THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE APPLICATION AND LOADS LISTED 5.25" x 11.875" 2.0E Parallam® PSL ADDITIONAL NOTES: - IMPORTANT! The analysis presented is output from software developed by Trus Joist MacMillan(TJM). TJM warrants the sizing of its products by this software will be accomplished in accordance with TJM product design criteria and code accepted design values. The specific product application, input design loads, and stated dimensions have been provided by the software user. This output has not been reviewed by a TJM Associate. - Not all products are readily available. Check with your supplier or TJM technical representative for product availability. - THIS ANALYSIS FOR TRUS JOIST MacMILLAN PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. - Allowable Stress Design methodology was used for Code NER analyzing the TJM Residential product listed above. PROJECT INFORMATION COM CON JIM LACOURSE JOB #98-060 96 CAMPION NO ANDOVER, MASS OPERATOR INFORMATION: PELHAM BUILDING SUPPLY MARK BEDARD ATWOOD RD PELHAM, NH 03076 603.635.7555 603.635.9627 Copyright 01998 by Trus Joist MacMillan, a limited partnership, Boise, Idaho, USA. TJ-BeamT" is a trademark of Trus Joist MacMillan. Parallam is a registered trademark of Trus Joist MacMillan.