HomeMy WebLinkAboutMiscellaneous - 120 DUNCAN DRIVE 4/30/2018 �...
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THEPA DRIFOLIK O[SOC AiNGROUPe
August 25, 2015
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Board of Health or Board of Selectmen
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Fire Department or Arson Squad
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
RE: Our File No.: P1599622
Insured: ROBERT WEBSTER
LISA WEBSTER
Address: 120 DUNCAN DRIVE, NORTH ANDOVER, MA
Policy No.: H0924423A
Loss Date: 08/24/2015
Loss Type: Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,
Michelle M. Roust
Senior Property Claims Examiner
1-800-688-1825 x1171
NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109
DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825
FITCHBURG MUTUAL INSURANCE CO. o Fax:(781)329-1818
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°�,�``°:•'"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
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,SSACMUS�
This certifies that .PC) �z 0 El-&Z T
...................... ............................ ..............................
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wiring in the building of ���ss.5 0
........... .. ..... ..........................................
at....'z.... . ...... ...
..... .......... .North Andover,Mass.
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Fee..................... Lic.No.............. ..................... ..... ............�••'•�'—....
ELECTRICAL INSPECMM `
Check # 2-®07 v
9023
U � Commonwealth of Massachusetts Official Use Only
f Department of Fire Services Permit No. �6 Z-9
BOARD OF FIRE PREVENTION REGULATIONSOccupancy 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 ElectricalInspect
de(MEC), 27 CMR 12.00
(PLEASE PRL-IVT ININK OR TYPE ALL INFORMATION) Date: 2 Z Q f
City or Town of: NORTH ANDOVER To the (M*
of ices:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 12 0 Q v t-/C/9 t^/ b r I v e-
Owner or Tenant (,�/ D S k l2 TeIephone No. V- JZco-p v a
Owner's Address SA m Q
Is this permit in conjunction with a building permit? Yes ❑ No
(Check Appropriate Boz)
Purpose of Building_ 1A1{,C I A,4q
Utility Authorization No.
Existing Service`2°`O Amps /V /2-yVolts Overhead 2J' Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and.Ampacity
Loca *on and Nature of Proposed Electrical Work: aS+ I( (,virLtf+ j_
flGOff - - r, r -Iba✓t Sw n d
Completion o the followin table may be waived by the Inspector of Wires.
' No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans 0.0 Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ElIn- ❑ o.o mergency ig g
d• nd. Batte Units
--, No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INO.of Zones
No.of Switches No.of Gas Burners no.of Detection and
No.of Ranges No.of Air Cond. Total Initiatine Devices
Tons No.of Alerting Devices
No.of Waste Disposers eat Pump Number .Tons KW No.of Self-Contained
Totals: _` __...
D leeti,,ou/Aleriing Devices
No.of Dishwashers Space/Area Heating KW Low❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of Devices or Equivalent
Heaters KW No.of Data Wiring:
Si agn s Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
t
Attach additional detail if desired, or as required by the Inspector of Wires.
l Estimated Value of Electrical Work: (When required by municipal policy.)
t Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under 4,thheins
and penalties of perjury,that the information on this application is true and complete-
FIRM FIRM NAME: U 27.0 (��Q(,--y-, LIC.NO.: Z??9-14
Licensee: 4 uV0 Signature
(If applicable, enter "exe t"in the license number line) LIC.NO.: 5-2-7371-3
Address: (� ✓i} pn K r /� OI f Bus.Tel No.: 19-7V3 f 7 5 3 i
*Per M.G. c. 147,s.57 61,security work requires Department of Public Safety"S"License: Alt.L cl.No. ��1 7 7 0
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: $
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The Commonwealth of Massachusetts
Department of Industrial Accidents
;A, Dice of Investigations
• '� 640 ff'rashington Street
Boston, MA 42111
www.)nass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AIiplicant Information Please Print Lt Qibl
Name (Business/Organizafion/Individual):_ p it/-1 U22�
Address: /D
City/State/Zip: eJJ- AAld o t/t r" (/yV4 Phone#: Cj'`Z 312 y'3/
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I Type of project(required):
employees(full andlorpsrt-time).* have hired the sub-contractors 6 ❑New construction
2. I am a.sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity, workers' comp.insurance. g Building addition
[No workers,comp, insurance 5. ❑ We are a corporation and its
required-) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL t 1.❑ Plumbing repairs or additions
myself.[No•worke'rs'comp. c. 1.52, §1(4),and we have no 12. Roof
insurance required.)t employees. ❑ repairs
� [No workers'
comp, insurance required..) 13•❑Other
*Any applicant that checks boz`#I must also fill out the section below showing their workers'oompensation policy information
t Homeowners who submit this affidavit indicating they are daring all worts and then hire outside contractors must submit anew affidavit indicating such.
;Contractors than 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 snsurancefor 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby carry under the pains an enatties of perjury that the information provided above is true and correct
Si tube:
Date. O
Phone 4: 5"317
Of, xial 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]]lnspector
Other
Contact Person: Phone#•
11
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 timstee 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
N 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 certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the '
members or partners,are not requiredto 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 Iicense number on the appropriate line.
City or Town Officiais
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 permittlicense number which%A ill be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The 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.
r
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 102111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
December 4, 2003
I, Joseph Barbagallo, the owner of 120 Duncan Drive North Andover, am no longer
employing Quinn Electric Company to do the electrical work at my home. We would like
to transfer the electrical permit to Ken DiGiulio Electric for the completion of the work.
Joseph Barbagallo
120 Duncan Drive
North Andover, MA 01845
978-686-4222
Date...P`.• ..� l�
f pORTM 1
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACMUSE�
This certifies that �j- n '�` C
has permission to perform ........ 0
P Pe �� •.A.(.....:......zl'. 4
wiring in the building of........ 1 ?�rl.`."........................
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at.......� ..10. .l?.4..!qq.... �...............................North Andover,Mat s.
Fee..-�7 Lic.No. ....... %:.,:,<, .. !�..'::...`.�........
ELECTRICAL INSPECTOR
Check # L_ /
5017
Date..._:::.;....,....
�.���5!..... _
NORTI/
of��,..o.�•1�0
TOWN OF NORTH ANDOVER
" PERMIT FOR WIRING
��Ss�cMusE�
Thiscertifies that ........lt.... ................... ........u............... ................................
has permission to perform ......... ,). .c /G'
................. .......................................
wiring in the building of - � f
� / ,North Andover,Mass
Fee..................... Lic.No. ............................::.:r............................
j ELECTRICAL INSPECTOR
Check #
ry 1 7
BOARD OF FIRE PREVENTION R
APPLICATION FOR PERMIT
All work to be performed in accordance will1
(Please Print in ink or type all information) 0 /l
izz
Town of North Andover CX/
The undersigned applies for a permit to perform the electrical work descril
Location(Street&Number
Owner or Tenant
Owner's Address
Is this permit in conjunction with a buil:7,
r�-
0
Yes
Purpose of Building /�� ,,?
Existing Service Amps Voits
New Service -,100 Amps * u Voits _
Number of Feeders and Ampacity, _
Location and Nature of Proposed Electrical Work W/,2fr/G
No.of Lighting Outlets No.of Hot fuse
Abo,
No.of Lighting Fbdures Swimming Pool gm
No.of Receptacles Outlets No.of Oil Burners
No.of Switch Outlets No of Gas Bumers
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Diposal No. Pumps Tons KW No.of Sounding Devices
NoJ of Self Contained
No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices
0 Municipal 0 Other
No'of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heater: KW Signs Bailases Wiring
No.pHydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO =
have submitted valid proof of same to the Office YES= NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE = BOND - OTHER - (Please Specify)
Estimated Value of.Electrical Works (Expiration Date)
Work to Start Inspection Date Resquested R g Final
Signed under th�Penalties of per'ury: l/ ,
FIRM NAME /If o5 LIC.NO. C�--9 Qq-2
`,,��/
Licensee r7Eit/ �%G�'(/Jl/d Signature C. LIC.NO.�d / 2
t— /y �/ / ,/ B s Tel No.
Address V C/,4TJ/YIF/ (3Gv L�i�� �✓NuC� Alt Tel.No. /
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not hie the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $WAGW
(Signature of Owner or Agent)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Please Print
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 employer providing.workers' compensation for my employees working on this job. +�
Company name:
Address
City: Phone#:
Insurance Co. Policy#
Company name:
Address
City: Phone#:
Insurance Co. 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.
l do herby certify under the pains and penalties of penury that the information provided above is true and correct
Signature Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official' ❑ Building Dept
❑Check if immediate response is required Building Dept p Licensing Board
p Selectman's Office
Contact person: Phone#. ❑ Health Department
0 Other
FORM WORKMAN'S COMPENSATION
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Official Use Only
Permit No. s
Gf/f12Yfld1QZUSs z7w 09SSW;11"US.5?7S
vo-va s 4 PIP&s4wll i Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527,,CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00`
(Please Print in ink or type all information) Date � -rl Jed
To the Inspector of'hures:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number
Owner or Tenant
Owner's Addressp
Is this permit in conjunction with a building pe rmit Yes'0/ No 0 (Check Appropriate Box)
Purpose of Building / Utility Authorization No.
w
Existing Service Amps Voits Overhead 0 Undgmd 0 No.of Meters
New Service c=PC04�9 Amps *2dVoits Overhead 0 Undgmd 41-1 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work W IRI'JG OF ,f/ew owle- -3&-V-V14
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above 0 In 9
No.of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Diposal No. Pumps Tons KW No.of Sounding Devices
NoJ of Self Contained
No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices
u Municipal 0 Other
No'of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
—No.-of Water Heaters KW Signs Bailases Wiring
1
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO
have submitted valid proof of same to the Office YES= NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE = BOND - OTHER (Please Specify)
(Expiration Date)
Estimated Value of.Electrical Work$
Work to Start Inspection Date Resquested Roug Final
Signed under the Penalties of per ury:
FIRM NAME /-SE D% Q LIC.NO. I�S-93
Licensee �1�it/ L�JU/�U Signature \ LIC.NO.Q*2/B -Te
Addresso.
�� dltlll��ru�v� Lr E ///� /ucv AItTeLNO. ���'O/•s'lslo9� /
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not h4yethe insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $V"dGW
(Signature of Owner or Agent)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
N
Please Print
Name:
Location:
City Phone
0 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing,workers' compensation for my employees working on this job. �J
i
Company name:
Address
City: Phone#:
Insurance Co. Policy#
Company name:
Address
City: Phone#:
Insurance Co. 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. 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official' O Building Dept
❑Check if immediate response is required Building Dept p Licensing Board
0 Selectman's Office
Contact person: Phone#: t] Health Department
Other
FORM WORKMAN'S COMPENSATION
7
pOR711
°�t4 `°;•�"° TOWN OF NORTH ANDOVER
- ' PERMIT FOR WIRING
��sS�cMusE�
This certifies that ...:.:`'�'r ?^ �-� .'.r...
.......................................................................
has permission to perform {
wiring in the building of
at //,)...............
G ,North Andover,Mass.
.............................................
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Fee.. . �.......10... Lic.No..............�..`� ... ...!...........t...........................
/ ELECTRICAL INSPECTOR
Check #
4 82 0
TRE C0MM0NWF,ALTH0FM4SSACHUSE7TS Office Use of
DEPAR7NIENT0FPUX1CS4FE7Y Permit No. Zv
BOARD OFFIREPREVEVHONREGMHONS527CM?12.00
Occupancy&Fees Checked .�
APPUCATTONFOR PFRART TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector c
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number) ! 1 0 IJmnC_Tv--N �'A
Owner or Tenant (,
Owner's Address
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building �)CAte,`�� ���c�,� Utility Authorization.No
Existing Service Amps� Volts Overhead Underground No. of Meters
New Service aQQ Amps //A a Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Lighting Outlets No.of Hot Tubs No.of Transformers To
KI
No.of Lighting Fixtures Q Swimming Pool Above TF'cRtE
erators K`
`` ound ground
No.of Receptacle Outlets O No.of Oil Burnersof Emergency Lighting Battery Units
No.of Switch Outlets _
No.of Gas Burners
No.of Ranges 1 No.of Air Cond. Total ALARMS No_of Zones.
Tons
No.of Disposals ' No.of Heat Total f Detection and .
Pumps Tons ating Devices
No.of Dishwashers Space Area Heating f Sounding Devices
f Self Contained
ection/Sounding DevicesNo.of Dryers Heating Devices l Municipal Other
Connections
No.of Water Heaters KW No.of No_of
Signs Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
OTHER'
kmanceCovetage Ptast�antbthe gsofMassad>t>SeusC,ena-alLaws
iha,&aamatLmbfltykam=FbhcynrkxkgConple�opffmmComngeontsatstwMe4rmbt YES O NO
IhaNestbnMdvandpooffofsmrlotbeOJfice YESr—J � If}vuhaved�dYES,ple=md�ihetypeo(oovuag--by
d�aclangthe box
ML RANGE rTJ BOND 01HI R 04ffwSpac�y) c —
�� a "FxptrahorlDa�
Eslirr>"ValtreofEbcbical Wodc$ /q,000
W«ktDStatt I)PkRaO rpt
5ignedunderTr cfperjury:
FIRMNAME Q\ -W<C& E: C.l:ties. \fy . LiMwNo.
_icensee ` a �.c1 Sigrrahue 1�r l / '7 License No DIG3
t BdsiT MTe1No.
AiLTUNo.
OWNER'S INSURANCE WADER;lam aware that the l Mise does nothave the rnsufarm covtnW orits subsMtni afl valent as requited by MassactlseM General laws
ndthat mysignatiueonthis pemtapplicah®thisr�
Please check one) Owner Agent
Telephone No. PERMIT FEE
signature of Uwner or Agent
The Commonwealth of Massachusetts
Department of Industrial Accidents .�
W Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name: \ I `• 1��X.>l�-2
Location: lo ZC-�N')
City t �► �M�� Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name: �fC k C.
Address
City: Phone#:
Insurance.Co. c 7 ��C�[��, Policv#
Company name:
- r
Address
City: Phone#:
Insurance Co. PolicL#____
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$1,5ot
and/or one years'imprisonment_as_well_as-chn.1,penaltiesin2helc m-d-a STOP WORK ORDER and_a.fine_of..($]DO.DD)-a dayjagainst-ms. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date_LO O -cYr-O_j
Print name Phone#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensinq
E3 Building Dept
E]Check if immediate response is required El Licensing Boa,
p Selectman's C
Contact person: Phone#: E] Health Depart)
Ei Other
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
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Building Location �`a CJ 1J K cr— ' Owner's Name H v1 `I��b� 4 y.1 f d
Map: Lot: Zone: Type of Occupancy S%%Xe--c e
New J Renovation's Replacement J Plans Submitted: Yes❑ No
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3RD FLOOR
4TH FLOOR
1 5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name EASTERN PROPANTE GAS INC Check one: Certificate
Address 131 WATER STREET DANVERS MA 01923
.� Corporation
Estimate Value of Work: Partnership
Business Telephone ( 5 0 S) 774-1930 Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesXX No ---)
If you have checked ygs, please indicate the type coverage by checking the appropriate box.
A liability insurance policy N Other type of indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Q Agent C1
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit is d for his appi 'on will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the e era ws
By Type of License:
Plumber ignature of Licensed Plurr�er or Gas Fitter
Title F asfitter
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY)
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
NO.
APPLICATION FOR PERMIT TO DO GASFITTING
NAME & TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR GASFITTER
LIC. NO.
PERMIT GRANTED
DATE 19
GAS INSPECTOR
„ Date.
r- 2387
NpRTM TOWN OF NORTH ANDOVER
0 � pp PERMIT FOR GAS INSTALLATION
SSACNUSES CL
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This certifies that
has permission for gas '�tafllatiion . . . . . . .
in the buildin s f . . . . . . . . . . . .
at . . .l�O. .! ..-fi. . . . . orth Andover, MaS9.
Fee. .4�. . Lic. No../. �.7,.'� �R.
OGAS_ SU� INSPECTOR
WHITE:Apnt CANARY: Building Dept. PINK:Treasurer GOLD: File
Date. '5 - 3- c) Y
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HQRTM
p TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
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This certifies that . �'n` 47 .. . . . . . . . . . . . .
has permission for gas installation . . .��A .C'
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in the buildings of . .�(?.(T a.4-
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at . . . . . .. . . .. . V N C AN , , North Andover, Mass.
Fee. . 30. . . Lic. Ndn3�.n )t
GAS INSPECTOR
Check#
4727
MASSACHUSETTS_UNIFORM APP I CATO_. FOR PERMIT TO DO GAS FMING
(Type or print) ! Date j/304
NORTH ANDOVER,MASSACHUSETTS _
Building Locations i _ - 120 DU L1 an Drive Permit#
Robert Domin as Owner's Name Amount$
New❑ Renovation Replacement ❑ Plans Submitted ❑
was electric
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SUB
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BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH . FLOOR
5TH. FLOOR
6TH. FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type) Check one: Certificate Installing Company
Name EASTERN PROPANE GAS Corp.
Address 131 WATER ST. , DANVERS MA 0192
❑ Partner. �
Business Telephone 1 800 322 6628 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Wayne Forsyth
1
INSURANCE COVERAGE Check %
} I have a current liability Insurance policy or it's substantial equivalent Yes No❑
Ifyou have checked�,please dicate the type coverage by checking the appropriate box
+ Liability insurance policy Other type ofindemnity ❑ Band ❑
Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Ga§Code and Chanes 14�efhe�General Lass_
1
By: Signature of Licensed Plumber Or Gas Fitter
Title Plumber 44824
Cityfrown Gas Fitter License Number
ErMaster
,"kPPROVED(OFFICE USE ONLY) ❑ Journeyman
Town of North Andover NORTN
i E0 4 e of the Zoning Board of Appeals
� ,vDr, ���D h a� o
� Ogkun1ty Development and Services Division b
t E;- H A D��'�� 27 Charles Street
-North Andover,Massachusetts 01845 eHus
D. RA9���� �� L
r ��t I icetta Telephone(978) 688-9541
Building Commissioner Fax(978) 688-9542
Any appeal shall be filed Notice of Decision
within(20)days after the Year 2002
date of filing of this notice 2 v
in the office of the Town Clerk. Property at: Lot 13C Duncan Drive
NAME: Ann T.Barbagallo 77H—EARING(S): October 8,2002
ADDRESS:Lots 13B &13C Duncan Drive PETITION: 2002-024
North Andover,MA 01845 TYPING DATE: 10/15/02
The North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday, October 8,2002 at
7:30 PM upon the application of Ann T.Barbagallo,120 Duncan Drive North Andover,for premises at Lots 13B
&13C Duncan Drive requesting a dimensional Variance from Section 7,Paragraphs 7.1 (Lot Area), 7.1.1
(Contiguous Buildable Area),7.1.2(Lot Width),&7.2(Frontage)and Table 2 to allow a single family dwelling,
within the R-1 zoning district.
The following members were present: Walter F.Soule,John M.Pallone,Scott A.Karpinski,George M. Earley, and
Joseph D.LaGrasse.
Upon a motion by Joseph D.LaGrasse and 2"d by John M.Pallone,the Board voted to GRANT the petition for
dimensional Variance for Lot 13B from Table 2 and Section 7,.Paragraph.7.1(required Lot Area =2 acres– 1.33
acres)relief of.67 acre,Paragraph 7.1.1.(required CBA=75%-50%)relief of 25%,Paragraph 7.1.2 (required Lot
Width'= 100'–50')relief of 50',Paragraph 7.2(required Street Frontage= 175'– 150')relief of 25 andjor Lot
13C from Table 2 and Section 7,Paragraph 7.1 (required Lot Area=2 acres–1.77 acres)relief of.23 acres,
Paragraph 7.1.1 (required CBA=75%-50%)relief of 25%,Paragraph 7.1.2(required Lot Width= 100'-45')
relief of 55',Paragraph 7.2(required Street Frontage= 175'–150')relief of 25',as shown on Plan of Land
prepared for Barbagallo Children Realty Trust showing Lot 13C Duncan Drive certified by Thomas J.Neve,P.L.S.,
Thomas E.Neve Associates,447 Old Boston Road,Topsfield,Massachusetts 01983,dated April 10,2002. Voting
in favor: John M.Pallone,Scott A. Karpinski,George M.Earley,and Joseph D.LaGrasse. Voting against: Walter
F.Soule.
The Board finds that the applicant has satisfied the provisions of Section 10,paragraph 10.4 of the Zoning Bylaw
and that the granting of this variance will not adversely affect the neighborhood or derogate from the intent and
purpose of the Zoning Bylaw.
Furthermore,if the rights authorized by the Variance are not exercised within one(1)year of the date of the grant,it
shall lapse,and may be re-established only after notice,and a new hearing. Furthermore,if a Special Permit granted
under the provisions contained herein shall be deemed to have lapsed after a two(2)year period from the date on
which the Special Permit was granted unless substantial use or construction has commenced,it shall lapse and may
be re-established only after notice,and a new hearing.
Town of North Andover
Board of Appeals,
Walter F.Soule,Acting Chairman
Decision 2002-024
Board of Appeals 688-9541 Building 688-9545 Conservation 688-9530 Health 688-9540 Planning 688-9535
r
Date....
TOWN OF NORTH ANDOVER
mi
p PERMIT FOR WIRING
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This certifies that � ` .
i
has permission to perform �!. .. ^/ f ............••
.. .l........ ................
wiring in the building of.. �l.C.. :
........... ,North Andover,Mass.
Fee.. .., ... Lic.N1. RI
.............................................................
ELEGTCALINSPECTOR
.+�
'heck # //
7
Commonwealth of Massachusetts/ Official Use Only
Department of Fire Servic sl Permit No. J�33 7
Occupancy and Fee Checked —
BOARD OF FIRE PREVENTION REGULATIONS P Y
VkJ / [Rev. 11/991 leave blank
1k,APPLICATION FOR PERMIT TIO 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: July 9, 2004
City or Town of: North Andover,MA 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) 120 Duncan Drive,N.Andover
Owner or Tenant Robert Dorherty Phone No.978/688-9542
Owner's Address 120 Duncan Drive N.Andover
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building Residential Utility Authorization No.
Existing Service 200 Amps 120/240 Volts Overhead ❑ Undgrd ® No.of Meters 1
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Trench and Electrical to Jacuzzi hot tub/Exterior
Completion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs )< 1 Generators KVA
No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o. o mergency ig ing
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE-ALARMSF No.of Zones
No.of Switches No.of Gas Burners No:of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. 1 Total 3 No.of Alerting Devices
Tons g
No.of Waste Disposers Heat PumpNumber Tons KW No.of Self-Contained
Totals: ........ Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
y 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:) Acadia&Hartford 1/01/2005
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: July 12,2004 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: Fisher&George Electrical Co.,Inc. LIC.NO.: A5982
Licensee: John Fisher Signatur LIC.NO.:
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 978-922-0675
Address: 6 Kernwood Ave. Beverly,MA 01915 Alt.Tel.No.:
S
OWNER' 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 a ent.
. Owner/Agent
Signature Telephone No. PERMIT FEE. $45.00