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Miscellaneous - 138 HIGH STREET 4/30/2018 (5)
f I I i I I �\ �t�`' W �� �( y �� Date......, .. .. y... � r►ORT�y TOWN OF NORTH ANDOVER a PERMIT FOR WIRING ♦ i �' • g`4ACMUS� This certifies that ....../... r { v .............. ..................................................... has permission to perform ....... v ,;„< ................ wiring in the building of......0 ..:�.s........... at ...y .... t`r..r-. .......... ...-...........................North Andover,Mass. Fee.. jjf/� ic.Nol.Y3..�/...................lY ..... ..... ....�/N• °.W' CAL INSPECTOR Check# A 11872 v Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE Occupancy and Fee Checked �M PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(AMC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL)NFORMATIOA9 Date:_ j 9 Sep 7- 2©� 3 City or Town of: NORTKANDOVER 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)_3 R 14 (G-tt - 5T Owner or TenantO_/F7:6 6 94 5 ,vo R r H p_A s r o U7 geAcdL t N,Telephone No. I-T7 b- 31- Owner's Address /0 99-61D ST2 yf (J� j// �� _ 3 ioc) Is this permit in conjunction with a building permit? Yes M No ❑ (Check Appropriate Box) Purpose of Building M U 1,7 V V1/ L I-nt Utility Authorization No. fj �q a•cO• (O Existing Service Amps J20/ 2 0d �- � Undgrd❑ No.of Meters New Service 3�gnVolts Overhead mps /20/-11-0 Volts Overhead Undgrd ❑ No.of Meters _! Number of Feeders and Ampacity 3 1 d U AMP 1 5-0 A,M f 1� p c/S E METES Location and Nature of Proposed Electrical Work: —,g ?` w 1 R 1= C v M l'L E7- >✓ g u r L-D 7 rV c- Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets '�Q No.of Hot Tubs Generators KVA No.of Luminaires 2 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units 3 t tl O l t of Receptacle cepace ues II __ No.of Oil Burners � llz � 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 No.of Alerting Devices No.of Waste Disposers 3 Heat�m-) mber .Tons. KW No.of Self-Contained -TP,, Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers ? Heating Appliances Key Security Systems:* No.of Water No.of Devices or Equivalent No.of No.of Heaters KW Data Wiring: Signs Ballasts No.of Devices or Eg uivalent 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) .'certify, tinder the pains and penalties ofperjury,that the information on this application is true and comptete.` FIRM NAME:_J� R 8 !M A C k H V A G LIC.NOMR Licensee: e C H A /I Signature— Ow _ e �14• .LIC.NO.:_ 6 q 5 M ,4 (I.fapplicable,enter "exempt"in the license number line.) Bus:Tel.No.- 6!Z 3 7,9 Address: Alt.Tel.No.: ' JL Z 1'* *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a e Owner/Agent Signature Telephone No. PERMITFEE.$ - ❑ 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' r on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: b Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: 1 D— 1-1 3 Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FIN PECTION: p ❑? Failed 0 Re-Inspection Required($.)El Inspectors Comments: S Inspectors Signat re: D te: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i The Commonwealth of Massachusetts Department of lndustrlalAccidents ` Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organi'zation/l'ndividual): M C—r r 1 M A Gy_ ' v V k U Address: 196 S �Vor-`, pp.,W e _ City/State/Zip: 06 . SA- le-W OW7 Phone#: (A-3- 3 `— LA-W Are you an employer?Check the appropriate box: Tyke of project(required): 1.❑ I am a employer with_�_ 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor orpartner- listed on the attached sheet. �• El Remodeling 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. ElWe 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 11.❑Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they ake doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:. SANT-d 5 /N G tIM N 6 r g T3 L M -N, H.• Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: /G K 5 T 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 maybe forwarded to the Office of 'Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. - Signature: Date: Phone#: 2. 3 1 7 5 .- 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: a Information and Instructiolm"s 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'cairy workers'compensation insurance. If an LL C 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 an�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(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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Co onwealth ofMossa hvsetts Department ofzadustdal Accidents Office QUIRVestigatitolm 600 Wasbiingtoa Street Boston}MSA.02111 TO,#617-72.7-4900 ext 406 or 1-877MASSAF.B Revised 5-26-05 Fax#617-727-7749 Division of Professional Licensure: License Search Page 1 of 1 The Offmat mite of the Ofd of Consumer Affairs and Btme s Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ......................................._...................................................................;.................................._........_...................................................................................... Check a License Ch1 eck A Professional License Locate a Ucensed Professional By the;Division of Professional'Licensure Online Address Change Contact the Agency More... LICENSEE � Name: RICHARD A. MAILLOl1X REFERENCES& SALEM, NH RELATED INFO NEW SEARCH i Disclaimer Regarding `"This Licensee has additional Licenses,click here to view them."" � Website License Searches -- --' Glossary of License Status Codes Licensing Board: ELECTRICIANS TYCTRICIAN PE CLASSMore... License Type: STER MR License Number: 645 Status: CURRENT Expiration Date: 7/31/2016 i Issue Date: 11/27/1995 . l Exam!Date: E School: l q� i This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has'been generated by the Division of Professionat Licensure web serve on Thursday,May 15,2014 at&13.28 AM- 02007-20111 rm92007-21311 Corn onweattha of Massachusetts Site!Fok;km contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type class=MR&1... 5/15/2014 Date.... •... f.................� OF r►OR,r W. TOWN OF NORTH ANDOVER i PERMIT FOR GAS INSTALLATION 83ACSWU `I This certifies that I..AOVLJ lb .1.........................................................,................................. Lhas permission for gas installation .. lT(..�4 .:..L. '?.r !! ....'� inthe buildings of.................................................................................................I.................. is ; at.....� .......v. ..... ....................................... ..... NortAndover,Mass. Fee..... Lic. No. Q35 q M G6I SPECTOR 6 Check# 9250 .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NO, J'� _� MA DATE J—— §:-/ PERMIT# JOBSITE ADDRESS OWNER'S NAME t S GOWNER ADDRESS TEq_ i FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES FO NO[] APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACEIJ FRYOLATOR FURNACE I GENERATOR GRILLE --.- — INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT . OVEN -- - _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST =F UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHE�� ........_............. '...... . - - - ` ^� INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �(NNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY —. OTHER TYPE INDEMNITY Ej 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 0 AGENT O SIGNATURE OF OWNER OR AGENT 1 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 compli a with all Pe ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME rt U t'1LICENSE#� SIGNATURE MP Eg-MGF Ej JP [I JGF© LPGI�] CORPORATION©#=PARTNERSHIP©#=LLC[]# COMPANY NAME: !!' 7_. y ^_ _ ADDRESS — G CITY -- - - - STATE C ? ZIP TEL FAX CELL _ EMAIL (���^n GL P/r��'I C�i"1-kI t " C.O /'►� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTO R USE ONLY FINAL INSPECTION NOTES Yes No e. THIS APPLICATION SERVES AS THE PEI MIT ❑ ❑ j J ( � 1 FEE: $ PERMIT# PLAN REVIEW NO rEs P 1 Ir The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name(Business/Organization/Individual): Address: aa- l t-j4J ' S City/State/Zip: H- 036;'L?3 Phone -63 7 0 l Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.EI am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ` These sub-contractors have 8. ❑Demolition ship and'have no employees 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself, o workers'comp. c. 152,§1(4),and we have no 12. Roof repairs insurance required.]t employees.[No workers' 13.[J Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi 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. y Insurance Company Name:. c ti Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 13 T Gq,�s S " City/State/Zip:T0,� � 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder the pa' andpenalties ofperjury that the information provided above is true andd�coorrrect. Signature: Date: ��, l Phone#: Q / 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 - - - h� Contact Person: Phone#: --r Information and InstructioS ' Y 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." R. 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(LLQ or Limited Liability Partnerships LP with no employees other than the members or partners,are not required to carry workesurance Tf�n T Geri r,S_Cmm�encatinn in 112 lees3a0 employees,a policy is required. Be advised that this affidavit may be submitted to y the Department of Industrial 1 . Accidents for confirmation of insurance coverage. Also be sure to sign date to the affidavit. The . g 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigatitons 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 wWW mass.goV1dia Date...�ft. S�1...�{..... 10 500 �� �'T"�� TOWN OF NORTH ANDOVER t Off?•` ``r••• OO9 * PERMIT FOR PLUMBING HUS� This certifies that......... .! .....�?uo:!........................................................................ has permission to perform. . .............................................................................. plumbing in the buildings of............................................................................................. at J:. ........�!`�q �... ............................................................ No h Andover, Mass. Fee.... .............Lic. No.alas f ......... }.�..... .............yy....................................... UPLUMBING fNSPECTOR Check# i 'f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY _ _j MA DATES I PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:Ef REPLACEMENT:Q PLANS SUBMITTED: YES® NOF -I Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( { __ ._€ l CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GAS/OIL/SAND SYSTEM ! _ ! _. _ _I ( � DEDICATED GREASE SYSTEM _._[ _TJ __.._j L----JIL---J DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER __ l _ . ( __1 I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN I �._1 1 ! _._-_-1 L_j INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK -_ i k _. 1 ! E _.._-._I TOILET ( -- .- _! __1 k _._1 __.__.1 �__ I ___._ ___-_.1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I= .-_-_._S .___..__f __! __ I _____._.€ _..._ _. I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES['NNO ._ IF YOU CHECKED YES,PLEASE INDICATE THE TY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY { BOND ©i 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 a AGENT I0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr and accurate the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lance with al rtinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LJ-1n ____ljLICENSE# SIGNATURE (VIP JP Q CORPORATION D# PARTNERSHIP�# _ LLC -j COMPANY NAME \ h�y V nr� — ADDRESS -r - CITY per,z-�- -- _�STATE ©ZIP TEL FAX L j CELL 11EMAIL CO P11 1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTILON BMTES 's Yes No S S THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: 6,? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.;K I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition 'coin ` working forme in any capacity. workersP•insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ 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' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T'Homeowners who submit this affidavit indicating they ire doing all work and then.hire outside contractors must submit a new affidavit indicating such. tContractors 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 employe'that is providing workers'compensation insurance for my employees. Below is the policy and job site information. SA� Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: �j� Job Site Address: (�t S ST V eta D�,� 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 certio zmder the pains d penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: CEJ 6 Y /) ?o eG J 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 employeiis 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 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 01 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 Gou onwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington.Stxeot Boston,MA 02111 Tel,#517-727-4900 ext 406 or 1-877,MASSAFE Revised 5-26-05 Fax#617-727-7749 wwv�.XnaS�.govf�:ia. 7 CbM 6 W LTH OF M SA&USETT. PLUMBERS AND GASFF -TERS ` LICENSED AS A .MASTER PLUMBER ';i ISSUES THE ABOVE LICENSE TO. i .;DAIMY A DUNK I, 4 INDIAN RD 7 2143 EAST :KINGSTON NH 0 ,827 05/01/14 19350: i G& � 20 E LLQ Environmental/Demolition ContractorsRECEIVED Commercial I Industrial/Residential JUL 6 2013 REC July 12, 2013OUNN OF NORTH ANDOVER HEALTH DEPARTMENT Town of North Andover, MA Health Department 120 Main Street North Andover, MA 01845 RE: 138 High Street, North Andover, MA Dear Sir/Madam: Please find enclosed a copy of the Notification filed with the Mass DEP. The project is scheduled to begin July 29, 2013. Kindly contact us with any questions or comments you may have. Very truly yours, Susan A. Pappalardo E & F Environmental Services, LLC /Enclosures I 86 CAROLAN AVE, HAMPTON, NH 03842 (603)974x2503 FAA: (603)382.3376 Commonwealth of Massachusetts 00181303 Asbestos Notification Form ANF-001' I D JUL 6 2013 TOWN,OF NORTH ANDOVER Important: m A. Asbestos Abatement Description i When filling out p forms on the computer,use 1. a. Is this facility fee exempt city, town, district, municipal housing authority, owner-occupied only the tab key residence of four units or less?❑Yes ❑✓ No to move your cursor-do not b. Provide blanket decal number if applicable: use the return Blanket Decal Number key, 2. Facility Location: RESDENCE 138 HIGH STREET a.Name of Facilitv b.Street Address NORTH ANDOVER 101845 --� c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this RESIDENCE F form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑Yes ❑✓ No DEP notification requirements of 310 , CMR 7.15 5. Asbestos Contractor: and the Division of Occupational JE&F ENVIRONMENTAL SERVICES L 186 CAROLAN AVE Safety(DOS) a.Name b.Address notification HAMPTON —� 03842 6032345581 requirements of 453 j CMR 6.12 c.Ci /Town d.Zip Code e.Telephone Number AC000767 t.DOS License Number g. Contract Type: ❑Written ❑Verbal N/A h.Facilitv Contact Person i.Contact Person's Title 6' FRANK BALOGH I JAS030269 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number 7' N/A a.Name of Project Monitor b.Project Monitor DOS Certification Number j $ FLI ENVIRONMENTAL AA000144 a.Name of Asbestos Anal ical Lab b.Asbestos Analytical Lab DOS Certification Number =0 9 7/29/2013 7/31/2013 a.Project Start Date mm/dd/ b.End Date mm/dd �0 8-4 -_N c.Work hours Mon-Fri. d.Work hours Sat-Sun. io 10. a. What type of project is this? i �0 ❑ Demolition ❑ Renovation REMOVAL ❑ Repair 2)Other, please specify:' b.Describe 11. a. Check abatement procedures: 0 ❑Glove bag ❑ Encapsulation —o ❑ Enclosure ❑ Disposal only �L ❑Cleanup ❑✓ Other, specify: POLY SURROUNDING STRUCTURE ❑ Full containment b.Describe —z iQ 12. Is the job being conducted: ❑ Indoors? Outdoors? anf001 ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 I , e F Commonwealth of Massachusetts 100181303 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) N/A 5' a.Name of General Contractor b.Address c.Ci /Town d.Zip Code e.Telephone Number area code and�� f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date mm/dd/ 6. What is the size of this facility? a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): E&F ENVIRONMENTAL SERVICES, LLC 86 CAROLAN AVENUE Note:Transfer a.Name of Transporter b.Address Stations must IHAMPTON, NH 03842 16039742503 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 SERVICE TRANSPORT GROUP, INC. 158 PYLES LANE a.Name of Transporter b.Address NEW CASTLE, DE 19720 1 18779999559 c.Cit /Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner b.Address I I c.Ci /Town d.Zip Code e.Telephone Number 4. IMINERVA ENTERPRISES INC a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 9000 MINERVA ROAD I IWAYNESBURG c.Final Disaosal Site Address d.Ci !Town OH 7 44688 M e.State f.Zip Code g.Telephone Number �o D. Certification N The undersigned hereby states, under the IFRANK BALOGH— IFRANK BALOGH �0 penalties of perjury,that he/she has read the a.Name b.Authorized Signature �O Commonwealth of Massachusetts regulations OWNER 7/12/2013 for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15, and that the information !(-60397-42503 d.Date E&F ENVIROmm/dd/ww) c.Position/Title contained in this notification is true and correct e.Telephone Number f.Representing o to the best of his/her knowledge and belief. 86 CAROLAN AVENUE o g.Address _ �U_ IHAMPTON, NH 103842 j �Z h.City/Town i.Zip Code �Q anf001 ap.doc•10102 Asbestos Notification Form•Page 3 of 3 Deems, Maura From: Brown, Gerald Sent: Friday, April 26, 2013 11:55 AM To: Deems, Maura Subject: FW: Building Downtown -----Original Message---- From: William Balkus [mailto:billbalkus(@me.com] Sent: Friday, April 26, 2013 11:54 AM To: Brown, Gerald . . Subject: Building Downtown Hi Gerry: I hope all is well. If that group of, I think you said they were Veterans, is still looking for an architect for that multi-unit building downtown, please let them know that I'm still interested. Thanks, Bill Sent from my iPhone Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this .email. TOWN OF NORTH ANDOVER Office of the Building Department o� pORTF/T��o ,,gtio Community Development and Services 4 . A 1600 Osgood Street, Bldg. 20,Suite 2035 North Andover, MA 01845 AD ��SSgcHus���y Gerald a d Brown, Inspector of Buildings Aril 10 2013 p g April , To: Edward Mitchell Fr: Gerald Brown Re: 138 High Street Dear Mr. Mitchell, Per our meeting today,April 10 2013 at 138 High Street regarding the change of use of the structure on said parcel the following bylaws guidelines must be met. The structure at 138 High Street is zoned within the R-4 district. In order to modify the current structure, based on the North Andover Zoning Bylaw Section 4.122, Part C—The conversion of an existing dwelling to accommodate not more than five(5) residential units, by special permit from the Zoning Board of Appeals in accordance with Section 10.3 and 4.122.14D of this Bylaw.The conversion of a single family dwelling to a two-family dwelling must comply with the provisions of Sections 103.4, 4.122.14.13,and 4.122.14.1)a. and b. et al. If a footprint change is proposed for the change(s)to the structure then an application must be submitted to the Conservation Department for their approval. Please see attached Assessor's card on the above property. Sincerely, Gerald Brown Inspector of Buildings UCS TOWN OF NORTH ANDOVER Office of the Building Department � NORTIy q Community Development and Services 1600 Osgood Street, Bldg. 20,Suite 2035 North Andover, MA 01845 O'ArED'r C) Gerald Brown, Inspector of Buildings April 10, 2013 To: Edward Mitchell Fr: Gerald Brown Re: 138 High Street Dear Mr. Mitchell, Per our meeting today,April 10, 2013, at 138 High Street, regarding the change of use of the structure on said parcel the following bylaws guidelines must be met. The structure at 138 High Street is zoned within the R-4 district. In order to modify the current structure, based on the North Andover Zoning Bylaw Section 4.122, Part C—The conversion of an existing dwelling to accommodate not more than five (5) residential units, by special permit from the Zoning Board of Appeals in accordance with Section 10.3 and 4.122.14D of this Bylaw.The conversion of i a single family dwelling to a two-family dwelling must comply with the provisions of Sections 103.4, 4.122.14.13, and 4.122.14.D a. and b. et al. If a footprint change is proposed for the change(s)to the structure then an application must be submitted to the Conservation Department for their approval. Please see attached Assessor's card on the above property. Sincerely, Gerald Brown Inspector of Buildings North Andover Board of Assessors Public Access Page 1 of 1 NORTH North Andover Board of Assessors Of 4«ao I�,tip SSACHt�get 1 ., roperty Record Card Click Seal To Return Parcel ID :21.0/0530-0020-0000.0 FY:2013 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Salesf Summary wy Residence it . Detached Structure r t� Condo 138 HIGH STREET Commercial Location: 138 HIGH STREET Owner Name: FEDERAL HOME LOAN MORTGAGE CORP Owner Address: 8200.TONES BRANCH DRIVE City: MCLEAN State: VA Zip: 22102-3110 Neighborhood:5-5 Land Area: 0.74 acres Use Code: 104-TWO-FAM-RES Total Finished Area: 1902 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR " Total Value: 292,800 317,200 Building Value: 104,600 123,500 Land Value: 188,200 193,700 Market Land Value: 188,200 Chapter Land Value: LATEST SALE Sale Price: 210,546 Sale 11/16/2011 Date: Arms Length Sale L-NO-REPOCESSN Grantor: USBANK/ Code: BONAIUTO Cert Doc: Book: 12699 Page: 0090 http://csc-ma.us/PROPAPP/display.do?linkld=2253563&town=NandoverPubAcc 4/10/2013 Residential Property Record Card PARCEL ID:210/053.0-0020-0000.0 MAP:053.0 BLOCK:0020 LOT:0000.0 PARCEL ADDRESS:138 HIGH STREET FY:2013 PARCEL INFORMATION Use'-Code: "7A04-- Sale Price: 21-0,546`uP 'Book: . 12699"m n Road Typed T; Inspect Date: 08/17/2005 Tax Class: T Sale Date 11/16/11 Page: 0090 y�Rd Condition. P Meas Date 08/17/2005 Owner. - - - FEDERAL HOME LOAN MORTGAGE CORP Tot Fin Area: 1902 Sale Type P. _ Cert/Doc: Ttaffic E -M Entrance: X ' Address: Tot Land Area: 0.74 ssz Sale Valid L Water --Collect Id' SGC 8200 JONES BRANCH DRIVE Grantor USBANK/BONAIUTO Sewer In J �F =4spect Reas: M MCLEAN VA 22102-3110 Exempt-B/L% /. Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style:- DK Tot Rooms: 6 Main Fn-,Area: 804 Attic: k NBHD CODE: 5. NBHD CLASS: 5 ZONE. R4 "` t Area:` Fe 804 ""�Se T a Code Method S Ft Acres Influ Y Value �� Classes Story Height: 2.35 Bm edroos: 3 Up Pn Area: 1098Bsm Roof: r` G F&l Baht s�""'"-3 Add Fn Are6—`—Fn Bsmt Area-* -I 1 P 104 S 32387 0.740 188,246 Ext Wall- ' AB Half Baths. Unfin Area: ,Bsmt Grade: DETACHED STRUCTURE INFORMATION MasonryTrim: Ext Bath Fix: '0__Tot Fin Area: 1902 Str Unit Msr-1 Msr-2 E-YR Blf Grade Cond%Good P/F/E/R Cost Class Foundation: ST'-Bath Qual T RCNLD 98957 - -- --.- - - -- - -- -- - Kitch Qual T Eff Yr Built: 1970 Mkt Ad SE S 100 0.00 -1988 A A 7%/85 200 � n_/- -ue - - G1 S 240 0.00 1988 A A 50///50 _5,400 Heaf Type FA Ext Kitch. Year Built.- '1890Sound Value: Fuel Type: "GGrade:_ _ A� Cost Bldg: 99,000 I VALUATION INFORMATION Fireplace: 0 Bsmt Gar Cap: Condition: A Aft Str Val 1:P �_ : __-.-._.. ,-----.-- Current Total: 292,800 Bldg: 104,600 Land: 188,200 MktLnd: 188,200 Central AC' N tt G Gar: _ Pct Complete: � /100//r 5_' Prior Total: 317,200 Bldg: 123,500 Land: 193,700 MktLnd: 193,700 'Att'Gar SF:� %Good P/F/E/R: /100//75 Porch Type Porch Area Porch Grade Factor E 60 P 150 SKETCH PHOTO Mri fi 27 A0 tgFt FUF8.35 ' 8Q4 Sq:Ft ,l 27 .. �' .. P A , -- '• 1 1 s 114 Sq. - 138 HIGH STREET Parcel ID:210/053.0-0020-0000.0 as of 4/10/13 Page 1 of 1 II � D TOWN OF NORTH ANDOVER NORTH Office of the Building Department o� t��o ,bgti Community Development and Services F 1600 Osgood Street, Bldg. 20,Suite 2035 * _ * North Andover, MA 01845 %P �~ SACH�1`+���y Gerald Brown, Inspector of Buildings April 10,2013 To: Edward Mitchell Fr: Gerald Brown Re: 138 High Street Dear Mr. Mitchell, Per our meeting today,April 10,2013,at 138 High Street, regarding the change of use of the structure on said parcel the following bylaws guidelines must be met. The structure at 138 High Street is zoned within the R-4 district. In order to modify the current structure, based on the North Andover Zoning Bylaw Section 4.122, Part C—The conversion of an existing dwelling to accommodate not more than five(5) residential units, by special permit from the Zoning Board of Appeals in accordance with Section 10.3 and 4.122.14D of this Bylaw.The conversion of a single family dwelling to a two-family dwelling must comply with the provisions of Sections 103.4, 4.122.14.6,and 4.122.14.1)a.and b. et al. .- If a footprint change is proposed for the change(s)to the structure then an application must be submitted to the Conservation Department for their approval. Please see attached Assessor's card on the above property. Sincerely, LTJ toll 3 e MCJP4 J�o di Gerald Brown 1 Inspector of Buildings I COF, TOWN OF NORTH ANDOVER Office of the Building Department � pORTF/ q o tt��o ,6 ti Community Development and Services ` , p 1600 Osgood Street, Bldg. 20,Suite 2035 * North Andover, MA 01845 o oa e^ ��SSACHUs���y Gerald Brown, Inspector of Buildings April 10, 2013 To: Edward Mitchell Fr: Gerald Brown Re: 138 High Street Dear Mr. Mitchell, Per our meeting today,April 10,2013,at 138 High Street, regarding the change of use of the structure on said parcel the following bylaws guidelines must be met. The structure at 138 High Street is zoned within the R-4 district. In order to modify the current structure, based on the North Andover Zoning Bylaw Section 4.122, Part C—The conversion of an existing dwelling to accommodate not more than five(5) residential units, by special permit from the Zoning Board of Appeals in accordance with Section 10.3 and 4.122.14D of this Bylaw.The conversion of a single family dwelling to a two-family dwelling must comply with the provisions of Sections 103.4, 4.122.14.13,and 4.122.14.1)a.and b.et al. If a footprint change is proposed for the change(s)to the structure then an application must be submitted to the Conservation Department for their approval. Please see attached Assessor's card on the above property. Sincerely, Gerald Brown Inspector of Buildings TOWN OF NORTH ANDOVER VIORTF/ Office of the Building Department 0*.0".o #6Community Development and Services o? 6��'`' °m 1600 Osgood Street, Bldg. 20,Suite 2035 70 North Andover, MA 01845 ArED ITS US Gerald Brown, Inspector of Buildings April 10, 2013 To: Edward Mitchell Fr: Gerald Brown Re: 138 High Street Dear Mr. Mitchell, Per our meeting today,April 10, 2013, at 138 High Street, regarding the change of use of the structure on said parcel the following bylaws guidelines must be met. The structure at 138 High Street is zoned within the R-4 district. In order to modify the current structure, based on the North Andover Zoning Bylaw Section 4.122, Part C—The conversion.of an existing dwelling to accommodate not more than five (5) residential units, by special permit from the Zoning Board of Appeals in accordance with Section 10.3 and 4.122.14D of this Bylaw.The conversion of a single family dwelling to a two-family dwelling must comply with the provisions of Sections 103.4, 4.122.14.13, and 4.122.14.D a. and b.et al. CW/1'ZZAb4 If a footprint change is proposed for the change(s)to the structure then an.apptsla'l must be made to the Conservation Department for their approval. Please see attached Assessor's card on the above property. Sincerely, Gerald Brown Inspector of Buildings Gk c. The Special Permit shall be recorded at the North Essex Registry of Deeds. 18.Accessory buildings no larger than sixty—four(64) square feet shall have a minimum five(5) foot setback from side and rear lot lines and shall be located no nearer the street than the building line 1 ofthe dwelling. 19.Day Care Center by Special Permit. (1985/23) 20. Independent Elderly Housing by Special Permit in Residence District 3 only. a 4.122 Residence 4 District 1. One residential building per lot. 2. Place of Worship. 3. Renting rooms for dwelling purposes or furnishing table board to not more than four(4)persons not members of the family resident in a dwelling so used, provided there be no display or advertising on such dwelling or its lot other than a name plate or sign not to exceed six(6) inches by twenty-four(24) inches in size, andfurther provided that no dwelling shall be erected or altered primarily for such use. 4._ For the use of a dwelling in any residential district or multi-family district for a home occupation, the following conditions shall apply: a. Not more than a total of three(3)people may be employed in the home occupation, one of whom shall be the owner of the home occupation, and residing said dwelling b. The use is carried on strictly within the principal,building; . c. There shall be no exterior alterations, accessory building, or display which are not customary with residential buildings; d. Not more than twenty-five(25)per cent of the existing gross floor area of the dwelling unit so used, not to exceed one thousand(1000) square feet, is devoted to such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits. e. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or any other way become objectionable or detrimental to any residential use within the neighborhood. g. Any such building shall include no feature of design not customary in buildings for residential use within the neighborhood. 5. Real estate signs not to exceed twenty-four(24) inches by thirty-six(36) inches in size which shall advertise only the rental, lease, or dale of the premises upon which they are placed. 6. a. Farming of field crops and row crops,truck gardens, orchards, plant nurseries, and greenhouses. b. On any lot of at least three(3)acres,the keeping of a total of not more than three(3) of any kind or assortment of animals or birds in addition to the household pets of a family living on such lot, and for each additional acre of lit six to five(5) acres,the keeping of one additional animal or bird;but not the keeping of any animals, birds or pets of persons not resident on such lot. c. On any lot of at least five(5) acres the keeping of any number of animals or birds regardless of ownership and the operation of equestrian riding academies, stables,. - stud farms, dairy farms, and poultry batteries. d. The sale of products raised as a result of the above uses on the subject land. 7. Swimming pools in excess of two(2) feet deep shall be considered a structure and permitted provided they are enclosed by a suitable wall or fence at least four(4) feet in height to be determined by the Building Inspector to prevent the entrance of persons other than those residing 30 a I c. The Special Permit shall be recorded at the North Essex Registry of Deeds. 18.Accessory buildings no larger than sixty—four(64) square feet shall have a minimum five(5) foot setback from side and rear lot lines and shall be located no nearer the street than the building line of the dwelling. 19.Day Care Center by Special Permit. (1985/23) 20. Independent Elderly Housing by Special Permit in Residence District 3 only. 4.122 Residence 4 District 1. One residential building per lot. 2. Place of Worship. 3. Renting rooms for dwelling purposes or furnishing table board to not more than four(4)persons not members of the family resident in a dwelling so used, provided there be no display or advertising on such dwelling or its lot other than a name plate or sign not to exceed six(6) inches by twenty-four(24) inches in size, and further provided that no dwelling shall be erected or altered primarily for such use. 4. For the use of a dwelling in any residential district or multi-family district for a home occupation, the following conditions shall apply: a. Not more than a total of three(3)people may be employed in the home occupation, one of whom shall be the owner of the home occupation, and residing said dwelling b. The use is carried on strictly within the principal,building; . c. There shall be no exterior alterations, accessory building, or display which are not customary with residential buildings; d. Not more than twenty-five(25) per cent of the existing gross floor area of the dwelling unit so used, not to exceed one thousand(1000) square feet,-is devoted to such use. In connection with such use,there is to be kept no stock in trade, commodities or products which occupy space beyond these limits. e. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or any other way become objectionable or detrimental to any residential use within the neighborhood. g. Any such building shall include no feature of design not customary Y in buildings for residential use within the neighborhood. 5. Real estate signs not to exceed twenty-four(24) inches by thirty-six(36) inches in size which shall advertise only the rental, lease, or dale of the premises upon which they are placed. 6. a. Farming of field crops and row crops,truck gardens, orchards, plant nurseries, and greenhouses. b. On any lot of at least three(3)acres,the keeping of a total of not more than three(3) of any kind or assortment of animals or birds in addition to the household pets of a family living on such lot, and for each additional acre of lit six to five(5) acres,the keeping of one additional animal or bird;but not the keeping of any animals, birds or pets of persons not resident on such lot. c. On any lot of at least five(5) acres the keeping of any number of animals or birds regardless of ownership and the operation of equestrian riding academies, stables,. stud farms, dairy farms, and poultry batteries. d. The sale of products raised as a result of the above uses on the subject land, 7. Swimming pools in excess of two (2) feet deep shall be considered a structure and permitted provided they are enclosed by a suitable wall or fence at least four(4) feet in height to be determined by the Building Inspector to prevent the entrance of persons other than those residing 30 r�eL"/ � . C. The conversion of an existing dwelling to accommodate not more than five (5) residential units, by-special permit from the-Zoning Board of Appeals in accordance with Sections 10.3 and 4.122.14.1) of this Bylaw. The conversion of a single family dwelling to a two-family dwelling must comply with the provisions of Sections 10.3,4.122.14.13, and 4.122.14.D. (;\ IDI �?pebw-1 pew:- D. Special Permit Granting Criteria for Two-Family Dwelling anaOne-Family to Two-Family or Multi-Family Conversions. a_. .The Zoning Board of Appeals may approve a special permit for a proposed use of a building, dwelling or structure provided by Section 4.122.14.A.b., 4.122.14.13 or 4.122.14.0 upon finding that the application complies with the purposes of this Bylaw, and is consistent with,the use of the site for the purpose permitted within the Residential 4 District. In making its decision, the Zoning Board shall consider the following criteria in ., addition to those listed in Section 10.31: 1. Consistency with the North Andover Master Plan. 2. The degree to which the proposed use furthers the Town's interest in providing a range of housing types,where applicable. 3. The degree to which the application addresses the following design standards: i. Achieve compatibility with the established pattern of uses in the district. The Residential 4 District consists primarily of single-family dwellings near the Stevens Memorial Library Area and off of Massachusetts Avenue, and more compact neighborhoods with a mix of residential uses toward Waverly Road. New construction or substantial alteration of buildings must compliment and reinforce the design features of these neighborhoods. ii. Achieve design compatibility with architectural features and exterior materials of ! surrounding structures. iii. Preserve existing structures of historic value. Buildings, dwellings or structures listed on the National Register of Historic Places or the State Register, and are more than 50 years old as of the date of application for a special permit, may be converted, constructed, reconstructed, restored or altered only in a manner that maintains or promotes their status as listed or eligible historic resources. For purposes of zoning compliance, additions or alterations that adhere to the U.S. Secretary of the Interior's Standards for the Treatment of Historic Properties will generally be presumed to maintain orr romote such status. iv. Preserve established,mature vegetation. '`b The right to apply for°,*a;special permit to convert an existing dwelling shall extend to any dwelling to be converted for use as a dwelling of not more than five (5) residential units, and meeting all requirements of the State and Town Statutes and Bylaws, including the Health Codes, Building Codes, Zoning Laws and Zoning Bylaws. Proof of ownership must be supplied with the application. E. Definitions: a. Addition: The enlargement, alteration, extension or change to an existing dwelling unit that does not result in thetreation of an additional dwelling unit. b. Conversion: The dnlargement, alteration, extension or change to an existing dwelling unit that results in the creation of one or more additional dwelling units in a single structure. A property is considered a conversion whether the added dwelling units are included as part of the existing structure,or whether a new structure is built after razing/demolition of the existing structure. , ,t" 15. Municipal recreational areas. 32 at the pool location. Pools shall have a minimum ten(10) foot setback from side and rear lot lines and be located no nearer the street than the building line of the dwelling, except by Special Permit. 8. Museums. 9. a. Public and private non-profit educational facilities. (1986/17) b. Private for profit educational facilities by Special Permit(1986/17) 10.Municipal building or use, and public service corporation use(Special Permit Required). (1986/18) 11. Golf Course. 12. Swimming and/or tennis clubs shall be permitted with Special Permit. 13.Cemetery. 14.Residential Dwellings A. Dwelling types a. One Family Dwelling. b. Two family dwellings, by special permit from the Zoning Board of Appeals in accordance with Sections 10.3 and 4.122.14.D of this Bylaw. B. Conversions - The conversion of an existing one-family to a two-family dwelling, by special permit from the Zoning Board of Appeals in accordance with Sections 10.3 and 4.122.14.D of this Bylaw, provided that conversion from a one-family to a two-family dwelling meets the following additional requirements: a. If a conversion involves increasing the size of an existing structure, the expansion area shall not exceed 50% of the original building's gross floor area up to a maximum of 1500 s.f. The size of the second dwelling unit can never exceed 1500 s.f. b. If a conversion involves razing an existing structure, the gross floor area of the new residential structure shall not exceed 150% of the gross floor area of the original building, nor shall the new structure be more than 1,000 square feet of gross floor area larger than the original structure, whichever is less. The size of the second dwelling unit may never exceed 1,500 square feet. If an existing lot is subdivided to form two or more new lots, and the existing structure lies within more than one of the new lots, and if the existing structure is to be razed in connection with the conversion, then new buildings on any lot formerly covered by the existing structure must comply with all the provisions of 4.122.143 of the Bylaw. Newly created lots not formerly covered by the existing structure must meet the requirements of 4.122.14.D of the Bylaw. c. There must be two parking spaces for each dwelling unit. d. No parking/driveway shall be permitted within 10 feet of any lot line. e. No garage or carport shall face the street unless it is'located at least 10 feet behind the front fagade of the principal structure and in accordance,,with the dimensional setbacks outlined in Table 2 of this Bylaw. f. The converted structure shall meet all of the dimensional requirements of the R-4 District identified in Table 2 of this Bylaw. g. Stairways leading to the second or any higher floor shall be enclosed. h. The principal building in a conversion to a two-family dwelling shall share a connected common wall (or floor) for at least 75% of the wall's,(or floor's) surface. No unheated structure, no structure without foundation, and no structure that is entirely or partially a garage shall be considered as meeting the 75%requirement. i. The conversion of a one-family dwelling to a two-family dwelling: 1. Must not result in any portion of the post-conversion roofline height exceeding the pre- conversion roofline height by more than five(5) feet;tand 2. Must not significantly increase or decrease the pitch of any additional post-conversion roof area 31 Date. . ./"-o. ? .. .... a • Of ,O RT°,ti0 °,- ° TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION 1 �,SSACHUSESSy This certifies that . . . . 14 -1. !!:'. . . . . . . . . . . . . . . . . . . . . . has permission for gasinstallation l /. . . S {�: . in the buildings of . .�. t� .�� !.� . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . 1. 3.J . ./a!!.J. l. . . .S . . . . . . . . . . . .. North Andover, Mass. Fee. Lic. No.. . .. . . . GAS INSPECTOR Check# 4535 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or YM Ty/pe) /� _ z ,W d oycK Mass. Date U �k- 1,069,Permit# 3 Building Location S/ (ms's Name Ci vl•� STpV�--� q Type of Occupancy New p Renovation Replacement Q Pians Submitted: Yes❑ No n W N Y = Q ri N HWo ¢Wr0 J z S�p- �. ?s> z l c i m 1A h y y O ds ¢ W Z V W = W ¢ H O W W h J < = Q . a c W W i7 q tr tl �• 2 J fr' z r f• W M 0ut 2 4 ~ W O S s r� > ¢ W Z_ < < < < O O W C O r1 r ¢ I O d S 4. D O J V C > a b M� O a sue-13SMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET I$ Corporation 103C MIDDLETON, MA 01949 ❑. Partnership Business Telephone 978-774—' 2760 C Firm/Co. Name of Licensed Plumber or.Gas Filter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes. please indicate the type coverage by checking the appropriate box A liability Insurance policy 0 Other type of indemnity❑ Bored ❑ 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: Owner i Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted(or entered)in above ay.cation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit fa the n will be in compf nce with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 c1 nal Lays BY TiJoumeyman of License: Plumber gnature of tuber ar mer Title Gasfiner Master license Number 3785 City/Town APPIROVED(OFFICE USE ONLY) CTry ;� - � Location No. � Date s N°RTM TOWN OF NORTH ANDOVER 3? .. 0 a° a ►. : ; : Certificate of Occupancy $ f Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # i 8 3u' 1 �- - Building Inspe t{r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING TVs 1trOC BUILDING PERMIT NUMBER. ���� DATE ISSUED. �_ ,•, rn 446CA.1� ENRON SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Properly Address: 1.2 Assessors Map and Parcel Number: O -7, 57-5. o OU Zo Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ �1:�1:�itii; iSf.(lC1: ��r 3 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT No M 2.1 Owner of Record PAM &NA1147-0 N°a. (Print) Address for Service �-R.4e-r q 90 Signature Telephone 2.2 Owner of Record: Bn CLhony 0 Name Print Tyepboro,MA 01879 Address for Service: z Si ature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0 License Number Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable 0 Home Deoot Company Name 345 Greenwood Street tf 9 , M Worcester,MA 01607 Registration Number Address /J Expiration Date ria1• Signature Telephone Y� A 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 unit. Signed affidavit Attached Yes......X No.......❑ SECTION 5 Description of Proposed Workcheck as a cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) JY Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: V �. /N sr a C,4- ttivow SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAL USE ONLY Completed by permit applicant 1. Building / (a) Building Permit Fee 39 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(,)x(b) 4 Mechanical HVAC 5 Fire Protection ��- 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUB-DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on j My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION � Lauf# I, `-�y�'�N C�HD V ;,i"S'4'*dei/Aii*ifd kga'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 lit AJ Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1' z• 3 SPAN DINIENSIONS OF STILLS DIMENSIONS OF POSTS DIMENSIONS OF G.MDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X ;�rpit MATERIAL OF CHEMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUELDING CONNECTED TO NATURAL GAS LINE AT-HOME installed .. S Siding and Windows Board of BuMag Regasadoes and Standards HOS MOWVEMENT CONTRACTOR License or registration valid for individul use only R990501-00"..." before the expiration date. if found return to: 3 Board of Building Regulations and Standards ` n t Card One Ashburton Place Rm 1301 ,, Boston,Ma.02108 THE Home[38pa — KJM;tOEUN CHHoWt 3200 COBB GALLER64Gi1�20 *� . ALTANTA,GA 30339 Adadntstrator _ _ _ Not valid without signator Jun 15 05 07t29a Michael Bedard 1 -401-246-2868 p. 3 Fi?GM :SIC 111BLY PHX NO. t,CY 3629674 JL[n. 10 2005 10:47PN PA y HOYiI.TMPiit)VEMF:N f CI)N I'RAC T Sold Furnished and ervit:ts' nc ��jj�� ]'![D.1t•lkvtte Services,lr.c. Brnncll N:+enc: _cV-��1-4��-- Dalc: IUhta T he Hot=Dtpot AI-Liomc 5arvice:; r 3a5!L Grtxw�pctd Slrb^t,Rbrcester,MA G 160? Sob C:! 1..L� Toll igen(800)6,57.1 i R^_; Fax:.SOB-755 2959 Btaneh Number: t�taeral int,Ts•1esSeon mit.jw d c(12479 al CoIlL L1ttr t5c.7 C!'L.i-,4-WS22; MAPnmclmprnvcmentCodtrauatReg.#12085] Installation Addmss: City Statezip W00,Pnent: 'rthxat 7�- RrN_er'A—LI c.k&F.x Horse Address: Clr State Zip (lf different from Installation Address) J 1 pen end Int rm tion: '.fW'Cr t`cu"'Puxhasct"),the owners of Flit Property located uL the above utstallation address,offer to �� 1 furnish,deliver and arrange for the it!stallatiun of all m tcrIt has cc ura,t w fl, ome poi U,S.A.,Ing.(''li trcorporatcd hbrein by reference at'd mado a Part hc:e f• described or the attached Spec S11ect#:_._�._..- Tr1030C L)efiot regerYCS the rify'.hr t6 canoe(this lbntriset if,uPnn ra inFFIeCUUa Of the jolt.Hntite DCItnt deterUtlRes that it cannot Parft rM Its ebtigations due.m R situce"t"'1 problem w'iflt the home or'xcause worm required to complete the job was not included in the contract. Dk.rbs1T pAVM£N'F'OpTlt)NS (Svbitd F tuna vrrir;cmt rn cv.dtorcmlit nLFle''-1) C7ah.LTl't.M1tc4 ar us POSra1 sallct dtoncy Older Pc;�I It tn'[hn Hama Uerot) COi�T1L1C'1'A1TOl:NT Creti:t Card.an;llnruther payment Wions.['Stale Ont Below LESSlDEY06tTf S `laetaCard llixcorr, Amslicar.7xprcSS �-- $A11NCEflL11ti Z She IIon!c Depetllemc!mpnwemal:t Lo;,n -!'Orn Uef x=ienf[Ce� ON C:"PLEl"ON ll����//�� ll[L&HUCC ONLY) AVxi(able f:rtd!t:5 JyT�[�_..T •Minimum 750A I'S Contruet Amount due Upon fx4eution hcetk:/.- 7!!1•� [4$ Q �. _- ftDls rmtracc e[j Ylli rt O�Ar�� TJ aelc ar.it apptat3 on,yr1:!a� � • irdiatte Prymattt lLlathod For 'Ryn:'$t siR'asmlteloty,liw�agteo to n!!ew}iolnc Udpo:to clnoge the abme HAI.ANGTi'DUI O C:C)h11'LET[ON1 n+tat c utd:tcr! + th dt ,[:nd+eaad. - 1 t tadcr'•,SIRt'aturo (—� HIL or HDCC Authorizaltlnn Codes — �Final t,—," o De _ uo5it_ AMI purchaser agrees that,imtr.e lately;llon satisft:ctory winp1euof cn the Work,Pdrehaser wtil exl:cute a Completlolt Ccableat^ and pay my bxlaocc due. Purchaser also aaroe5 to bu jaltttly and severely obligated a.IJ liab:'e hereunder. re A emert'7'hls agreermt end its attachroerts,including any fnanciag tgtccmet+t,contain the t:omolete agreer.:en: pA•cen L e partic>end can not be amzaded or..,nodified unless in wth6lg!n a ytpatate agroement siglitA by bolt p«tics. N OTLCE TO PU RC14ASE R ?7o no1 sign thin contract psfore yore tend it. 't'ou xrc entitled to&COmplttcly filled-Let copy of the contract aCd-itll t the timo e e sign. i[to p;ntcet your r[ghtx- Do not slplt roaiDhz home repairtcoll!v tortagreement from r out ating or ucrepting a ConlUtetion Certi.tieate s Cned befort this project is cen,plwo. Law p by the Qwntr prior to the xatual complctiun ofthc work to he t)trfthe th under the M tenant }'oo tuxy csncel this;mosictilln at any time prior to midniShe ur'tRa third basSncss du5'aHcr the dRta aCtltis contract. See Notice of Cantdlat!on for as explanation Of tblS right, 'lhereT! e a atn•tet chs rvc rGur!l to�Sh of the contract&moon,tf the gob is cancelled by Porci sscr'AY IT the third 11Lcineas day. . B:'b3YlpliR 5'.(i1;aT illtE$ET,OW,)TtrP,n litEF"0 H'}301mQ Bi HT T'>:lL R OF TRIS COTJTRACT. JWE ACI[.XO4,L.ADGE ItJ CETT of a f.f)?Y l)f V-T11,CC1N'"]tACC AND TWO COIv?PL[fFL'COPIL•S Gr THE;NOTICE OF CA eCELL+TIDN. BY'a7YtnLR 51G'7ATt TL 13F.1,D\v.llil'F LINDfifl5"AND T14AT TiiE AGREEMtiNT IS SU6lfC'T"L0 RCV73 W OF �fYlOJR. C0131T Fi�l.4't'10R�7 w�D! N TVP P'E E1�T C 1tEDIT R UIOT PORT�G.U=[CY NI)Q.LEASE T i FRO ALL LIATLILIf S (VC'URRt:D FitOl.t TtAUVE fiN'I��,i1551C�NS OR MROX I70 NCT CFC:N'fTiFS f;t}NTpAC'1'[F T'iLCRG A.FtF ANY g1,.t.Vli r� l (�l Datc: pate: _.. — ACCUPTEDi1Y:- ilolrvvuul Date: rwrtl AnDC IOWA L TkItA•.'St,Cf)^!UCYTOV4 AND WARRANTS FIS ARE STATW ON TOM.IUvt;R3xFIDE"No Aur VAll't ter tells C'LAVYQACT \YNu-n-moo:,f.te YeCa.�-L-Uaom.r Piny-srl to 6:ar,Wtec1 tf�7.Ot GSG V40RToHi CM- o" Of Andover No. rj 01 0o dover, Mass., /doLad MW COCHICHEWICK ORATED 14 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT...........................zoo.. .......... .......... .. .... ................... .......................... Foundation has permission to erect......................................... buildings on 0 Rough ... ........................... ... ....... to be occupied as. 0'*. .........W611 .. so ...........a ......... Chimney provided that the person cepting this permit shall In every respect conform to the terms of the application on file in the Final this office, and to the po slons of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION <f4WT RoELEC'I7RICAL INSPECTOROR Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do N I at Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE__Jl Smoke Det. Location ( 3 8 1-4 ` K k S No. q I (, Date 3- Q-v,� 3 MORTM TOWN OF NORTH ANDOVER 3? � •. hoc 0 I A �e Certificate of Occupancy $ cNust'•CMUS Building/Frame Permit Fee $ s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Y S Check # I R 3 1 16223 �t Building Inspector Inspector �. TOWN,OF NORTH ANDOVER BUILDING_DEPNT APPLICATION I'6C�DNSTRU REP RLKOYA OR DEMOLMR AONE ORTwo FAMILYDw jjVr_ . BUILDINGPEIMW N131MI - % DA I71 SIGNATM: Btlildin Gommissi of Buil ' _ SECTION 1-SITE INFORMATION Z 1.1 Property Addreaa - t.Z Assessors Map and Parcel Numbs. 0 ... Mev . OL$yS P N . ._. 1..3 Zoninglnformation 1.4 D�rid Use LotArea - ' $ 1.6 BUIL DING SETBACKS ft Front Yard . Side Yard .. _.. .. Rest Yard.. .: ... ...:... .. ...._.. r� Ptavide Ropired ~Provided ,.__ ..__.. .... .. .._�_...Pmvidezi_:-.: quired 1:7waaor sappynr<c aero .54) 13., Fiao+7meB�doo-__... . ... .+_.. ..19..... Public 6 NWd. t7 Zaao oobiaoFlooa2 U_ u l o _ onsaensporal sya�m,o.. .. SECTION Z-PROPERTY OWNI�/AIITHORiZSD AGENT. rn 2.1 Owner of Rccord ��K� s Name at) Address for.Service S Teh phone _ .... ... ... 2.2 N t Address for _ Q Z o �s6= .fig �•,�o�«�� .M.�. o�bo� rn Si T hone SECTION 3-CONSTRUCTION SERVICESgo 3.1 Licensed Construcbon Superviswr:-' Not Applicable ❑ Licensed=Cgastruotion-$vpeiyiso� 'N x : . � Lrcense umber :: . M • Adds ._ - ... _ .. .-..,_... ... .. .. _ 99 ExprMfi= Date i •s S' Telepbo-. . 3.2 Registeaed Home Improvement Cm ctor. _ _ ....... Q.. NatAppficable....17... Q.Mf� �or�e� .�o✓�y roe. S � �i�N _. /�� It�straimm!Number rM Add � _ .. .. i 0i r- SUg D z S Tel G) SECTION 4-WOM R$COMP.RNSATION.. CIL C.152 §.2546) Workers Cotapeesation Insuraooe affidavit mirstU epph ,., pmvida this affidavit will result camrpleted and sribmitted<witti this 'cat<op,`F76re to in the denial of the issuance of the Signed affidavit Attached Yes......JY • i SECTION 5 Description'of Work cheek off _ New Construction ❑ .. 81Wding'�❑ Repair(s): `.:❑ ons(s}`-. ddition `❑. - Accessory Bldg: ❑ D�olittvn n:... Other.;. .❑ Specify f Brief Destaiption-ofProposed Work _ . -..... _ ....1�',\�R.OlGl.2?MIX��• I �.n�`.W ,y��ut:s S t: t�.p .`.��Cu C�N.r4�; �Q.S' . SECTION 6-ESTEHATED CONSTRUCTION COSTS Item .. Estimated Cost(Dollar)to be C ]tomb3i, ....lid 1. Building (a) Building Permit Fee_... T to 00 . Multiplier 7 Electrical ' (b)__Estimated Total Coat Of.- Construction f_. .:.. . . . Conshuction 3 PlumbingBuilding -1ee;(a):*'(N) i-✓ 4 Mechanical AC... . ..... 5. ..FireProtection...._ _.... .. .. .- 6 Total 1+2+3+4+5 'LIDOO Au Check Number SECTION 7a-OWNER AUTHORI7.A1ION O BE COMIP'LETED WAN.. OWNERS AGENT.OR.CONTRACTOR APPLIES FOR BUILDING PERMIT_.... k as Owirea/Authorized Agent of subject property Hereby authorize to act on My behalf;in all matters relative to work authorized by this building permit application S" of Owner Date " SECTION 7b OWNER/AUTIiORIZFI)AGENT DECLARATTON _ .. .... _ as Owner/Aathorired Agent of subject preppy Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. i .. ..... Print Name i 3 S of / antDate . NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIIV04MONS OF GIRDERS .. ! HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING g MATERIAL OF CHIMNEY i IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Pc�� \) 9n� ` Qr Location: 119S W, 8 h S� City W - A C-AOU' - Phone 1C Li 50 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity lam an employer providing workers'compensation for my employees working on this job. Company name: AddressC C2.�ri c` 20 d Ci : /'nn� c-v-\V-C�, Phone#: (aQd —S(e L Insurance Co.cc tt\R-k S P r4n Z'nS . Co. Policy# 0 z's — 00600 503 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. I do herby certify under th pa san penalties of pe that the information provided above is true and correct. Signature 3 Date .03 Print name C-iy- Phone# �1_7 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 ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION � .. .� � � .�,.. � ,. � �. .. -, .. -- - .. �..�..., a f � �. a _ - _+ � ,�t I + j� • .-. � r t .A.. � ... ...__. I , i '. .. -. '_.i�.� _ i-_ �i .. ... � �+ . .. .. �. _ -. .. .,... ..... __7. � .,. .._.. ... �.- � .... i.e ..., .., .,e. k a � .. :r.. ..._,�...... . � .. 3 . 1 ., .. ._ .�_....,.. . _._. _.... � _. ._,t .,..,_,:. . ....L � � 11 i 1 . .... ., ,. "� ...., ,y v b `. :.. ,.. ., . . � .., ;. _•. .� tet.. HOME.IMPROVEMENT INSTALLATION CONTRACT Branch Name: ✓�t�_ �.�I r Date: ') Sold,Furnished&Installed by %�— The Home Depot Installed Sales 34PBranch Number: Job#: 345A Greenwood Street,Worcester,MA 01607 Toil Free(800)657-5182; (508)756-6686; Fax:508-756-2859 federal IDN 75-2698460 Rl Cont.Lick 1642'CT Licit 565522 MA Home Improvement Contractor Reg.�NP26893 P 4 Installation Address: f l - C Y �/ a /} ✓C ,'(: �,� t�� City State Zip Purchaser(s):— S�Sy#: _Driver's License: Work Phone: _Home Phone: ;/} /—. �— t,1G•�_�t�..1_ � _ - 1°r� Yf� j .0 t? � �{y�_-� ,GjC) Home Address:_ if different tiorn installation Address) City State Zip Ftta LiS Proiert Information i i We(-Purchaser"),the crNners of the property located at the above mstailation address,offer to contract with The dome Depot9H,me Depot')to fumish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet ilL � ,incorlwrafccl herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that It cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not Included in the contract. DEPOSIT PAYMENT OPTIONS (Sub;ecl to fund vedficauon and/or credit approval.) C, I. Check,Cashiers Chcck or US Postal Sen ice Money Order CONTRACTAMOUNT T s Dep w). Payable to The Home Dc al. , Y Credit C'aN'and%or other payment options-Circle One Below *LESS DEPOSIT $— �—__ Vi,a Mastercard Discover American Express BALANCE DUE r> ){;,,tie hnpxnvement Lnan Home Depot Credit Card ON CODIPLETION $__..�3��c_, _ AsAilableCredh:S (HIL&HDCCONLY) *25%of Contract Amount due upon execution of this s, contract.One-third(113r')of Contract Amount is required AC04'..�j( Exp,Date_ —.,.--_ for MASSACHUSEQ'S RESIDENTS ONLY. N:unc as n appears un card:, JJr /oKfin Indicate Payment.Method For *Hy n,r our signature,below.IPd'e agree to allow The Ftorre Depot m charge the BALANCE DUE ON COMPLETION ahosc Icti• ccd credit card pm the deposit i d$cared. cden Sign Dare , If this is a finance twain/suction/,the agreement for financing is contained in a separate document,which is incorporated herein by Reference,and made a part hereof. At-Home Services Credit/Loan Application Ref.# Purchaser agrees that,immediately upon satistactor) completion of the work,Purchaser will execute a Completion Certificate and pay any balance due(unless the tab is financed,in which,case.upon sub.„:,ston of the executed Completion Certificate,Home Depot will be paid in full by the lende.rl. Purchaser also agrees to be Jointly and severally obligated and liable hereunder. For Mass.Residents Onlv; Contractor,at owner,,expense.shall procure all permits required by law as follows: Owners who secure their own permits will be excluded from the guaranty fund provisions of MSL Chapter 142A. Unless otherwise noted within this document,this contract shall not imply that any lien or other security interest has been placed on the residence. Entire Agreement: This agreement and its attachments,including any financing agreement,contain the complete agreement between the parties and can not be amended or modified unless in writing in a separate agreement signed by both paities. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign any Completion Certificate or agreement stating that you are satisfied with the entire project before this project Is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by lite owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. 'There "ill be a service charge equal to 25% of the contract amount if the job is cancelled by Purchuser AFTER the third business day. BY MY•OUR SIGNA)URE BELOW,I.WE AGREE 70 BF HOL!ND BY TtiF.TERMS OF THIS CONTRACT, UWE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND Ttt'O COMPLETED COPIES OF THE NOTICE OF CANCELLATION. BY MY:'OUR SIGNATURE, BELOW. I,WE. UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY!OUR CREDIT HISTORY AND VWE.AUTHORIZE HOME DEPOT AND RMA HOME SERVICES,INC.,A HOME DkPOT AUTHORIZED CONTRACTOR, To VERIFY D REVIEW MY,'OUR CRF.DiT RECORD W17H AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEAS'1'HE FR ALL 1 fILlTY INCURRED FROM INADVERTF.'NT OMIS_SIQN$,Ol ERRORS. SUBMITTED BY: C �' Date: Sulu schani ` r -- ACCEPTED BY: .. �� _ � ��!Date:_ r” 0' _ Y I flomeuwner Date: Homeowner NO'f tCEr ADDII't(iV:\l.rF.N51S.CORp1TfUN5 Ain w.1 RR:x y'fIF:S ARF:STATED ON THE REVERSE 51DE AND ARE PART OF THIS CONI RACT N'Lnc t i:n,ah Fdr 1'cll:n: Cu,:amc, Pink Sales C.—kart, v m r ar i ::. _�., . ��� .. e , . , _ _ a —. 1 18/2412W 13:18 4155083075 APPI..ZED11 PAGE 01/111 ACQR-D. CERTIFICATE OF LIABILITY INSURANCE- , /M . � ATT is fssulk 0 As k!"non OR<w ORi"Tum QNI.V *AD Career&Ela NO RIGHT& UPON TMt CIRTIII"TIE APPLIED RISK SERVICES. INC. ALFlOTM TIDE V*AAORE AfFOwoeAp. Tim anRa►w OR P.O. 90X 28190C SAN FRANCISCO,CA 241 M 1900 � INSURERS AFFORMNO COVE"Gf NAIC 1 RUA HOME SSRIIICl&INC. k` aC;A•TyIAIGI IRA 3=COBE GALLERIA PARKWAY.STIE.200 r I�f�RR r1Kp1EA c ATLANTA,GA 30= C RAfeiE.JF � THE PAL)CSS SAF 0OLVANCEUSTE0 ULOW KAVZ BEIM t Ufo To Tt4E INSUe60 NAUEo AAAVRF FOR THEM X CY PIAM ONMATE@ N0*nffl ?ObTANGiWa ANY ACOUNEMENT. TEAM Op O Of AW CQNTRlACT OA OT"M 00CWSW t ff"A@SPECT rt.) 'fVM"THIS Cam;V TE MAY RRE ISSUED OR MAY PERTAIN,Uri 601SURANCRE APPOM410 QY THE POLICIES 099CAIGE3,&MIN RS SUE Wr TO ALL704t t tAMR,EXCLUi10004 AMO C000rlaNA Cw Sew POUCIG S.AGIGASGATE Uk*TE 9MOWa4 MAY MAVRR®ERN AEOUCW 0-PAA CLAN4l. _ OWQ1Ai LIAW" iAtJt Ol.G4�10�+t0 WhAiGAO tL arau,M►LrMMOV .. a,Arrt aAOE omli wn axa t_ r_ { 6�RW,A1011{d�Tl,. • OWL A000&UTlI WWT 4w%mm mw PADOIICTl.� O�Qr AOA { �� + { Kr 1 IOTA I Ai1110Mu4,A L1AALlrY � I ,oGdlrrsD sw0►!swR f I AM1"at.,ro IEaoa� ow oAv'Gs owe f,,uuAr t ,.�eoAv-a i i wove �►�a+cv�a�.t,ros � . MIOi'trtYt>�tuGR ' f ! �AA.aaLwaeTr AN1.OGte:.e•R3r.cc�e>r* � 4h+d1 TMA,1 - 1 W1O CMilY _ R4G f ' F�-�accuR ❑CLANSk%K ~ RlTif�*ION f ,f 0►�l0lgiATklN,Nf® ' 1 .� f arvv*+eas�orr.A* nEroaRwe ! 025.00000503 3110/02 # 311=3 flMP�01►MO�O t!f�f'0.L@C'flT �f.l_071tABt•lA AMM.OMIt f [L all!ads,10UCY 6,or, 1 amp { i ssw�nlla.emo.A.eAesOedtwaAT4+61MMA&WILaCur""A0oueeeasAAl wo") CERTW CATIE MOLUX TIOM fi"ft%o ears oP llm AAort a aco"an oftla 0 eo VMS WrATum eAxt tTIARi;o►,Tl6 OIALrra olbAPn*ILA 64eaAwu 10 WA _90_*A" *ftrM% 40111E pO MorArl ADILOIeII YM a,d IM LSA,OUT PA.UM TO 00 00 NUIL rPu,I!MM7�.AM ka"ALf"Do ur view koma 1"a w,*ims.b6*48m"o! 1 al,lNeq�A MA�MAMeaeM A�a�ea rs cswosl •AC4el®C�w�lATacaw IS" \ ✓Af MP+ N f�.. «n6w.oi i®�►A of 9uit41p ltp�ed�tbos�as®Stswa�r�o NOMI WROVEMINT 6ONTRACTOft R9610bt UO": 926403 L°ttOd►sdioet: 8/313004 TAW: s4wismsm Card ►tom•Dow At-Hmo UMoos PAUL VINTRE q 32'M COBS GALLERIA PKWY 928 ... �.�� ALTANTA,GA 30339 AdmdsiwrrWr AORTIy Tovm of Andover O to No. 94110 z1 ;L dower, Mass., — v d o� cocrI�r C G, RATED P'PP'\'- C7 S H BOARD OF HEALTH Food/Kitchen PERMIT I[ U Septic System THIS CERTIFIES THAT.F.A1 . ...14.0*A5 1►V ll•5.....g.t`...?a) .......h. I.N....... BUILDING INSPECTOR "' ' �"�" " Foundation has permission to erect.........4........... g 5................ buildin son .....�...3.....�.......4�.,j..... ........................................... Rough R* POCK N�.i3w� to be occupied as......................................................................W!!V�OUu......t.a...... t3t C.�l.b.ft...... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and D ws relating to th Inspection, Alteration and Construction of Buildings in the Town of North Andover. ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION , S ELECTRICAL INSPECTOR Rough .. ..... ............. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until inspected and Approved by the Building inspector. Burner Street No. SEE REVERSE SIDE smoke Det. 0 2 82 7 Date. �l.S ........ A ,�ORTM TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION F A • i � • SSACMUSEt .a. O This certifies that .I)��.G.�..I'J�. . . . . . . . . . . . . . . . . . has permission for gas installation A)A.'!e./A.. . . . . . . . . . . . . — cl in the buildings of /. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .13 • . S• . . • • • . • • • • . . • • . . •, North Andover, Mass. Fee.;-O'c. . . Lic. No.��� . . . . . . . . . . . . . . . . . . . .. . . . . . . . GAS INSPECTOR '� WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO.GASFITTING + (Print or Type) r}rx};ik,F?� a. �;�--NORTH ANDOV R Maass. Date q- 1* ' building Location Permit # Owners Name ' New Renovation D Replacement ]a' Pians Submitted D FIXTUP_5 HUUl W.• N " �� ti Q as CC .c �- = 1, GmN z W W C Os.. V �w O W H ; ;; a,{„ LLI all '1-7 !£ as cc W W J �. d S a a W W E' z ty ria Y f• W W O O T ILL t. V -9 f. W r oto > C W , 2 G o d O o W O W F- a =10 t7 U. 0 3 a o SUEt—l3SMT. , BASEMENT 1 ST FLOOR , 2HO FLOOR # 9R0 FLOOR 1 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR 8TH 11=LOOR :Srt!�Itin ,:'Nl Check one: ...Certificate�I � 'CompalameANDOVER PLBG. & HTG. CO. , INC® Corp. 212'{' d Address 513 S1. UNION STREET partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone 978 685-8383 Name of Licensed Plumber, or Gas Fitter GEORGE LAROSE $ `i ndicate'I'the type of insurance coverage byi"c eckin approprtat6pbox6tiq, 1 48Ee i• t f� . ,.: 7 R `11i Lehr 4x fi k Liability in urarytre policy` Other type of indemnity Q Bond,` 0 �� ; ?" Insurance Waiver, I,' the undersigned, have been made aware that the licensee of this application sloes not have any one of the above three insurance coverages. Signature o owner/agent of property Owner Agent 1 hereby certify that all of the details and information l have submitted (or entered)In above application are true and accurate to the test of my knowledge and tlat all plumbing work and installations performed under Permit issued for this application will-be In compliance with all pertinent Provisions of the Massachusetts Slate Cas Code and Chapter 142 of the General laws, ' ` By YPE LICENSE: Plumber Title Gasfitter- Si nature of°.Licensed Master Plumber or'Gasfitter City/Town:, Journeyman APPROVED (OFFICE USE ONLY) License Number , U Date.�?A ../ ....... I „pRTH TOWN OF NORTH ANDOVER ,e,'�'O ;? °�.. °� PERMIT FOR GAS INSTALLATION N. s i, • SSACHUSE This certifies that . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . ; in the buildings of :. . . . . . . . . . . . . . . . . . . . . . . . . at / . . . . . . . . . . . . . .. North Andover, Mass. Fee. . 6 . ' . . Lic{1*975142i AdWIPECTOR. . . . . . . . . . . WHITE:Applicant CANARY:Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFI TTl N (Print or Type) I NORTH ANDOVER Mass. Date v? l uil'ding Location �8 , � �T Permit • Owners Name ' t New "1 Renovation j] Replacement Ef" Plans Submitted n FIXTLIR=c a us pl W N m to 30 o m r r as o m a o t• tt� to 1 W W O O tL OC Yr H H O W 7.' WX UA Nf cc to F� ,'L• J H Z �. W W ; ccO O T !L IW. G) 1 P W < ,tt1 > C W 4 G d < O O W O W t- tz x o O r u. c (a 3 rs. P o SUQ—t3Sti1T. BASEMENT 'I ST FLOOR 2HO FLOOR 3RO FLOOR I 4TH FLOOR STH FLOOR I 6TH FLOOR TTH FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company.'.Name ANDOVER PI-BG. & HTG. CO. , INC® Corp. 2122 Address 5731 SO. UNION STREET Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 978 685-8383 Name oft$Lice nsed,�P6lumber,., or Gas Fitter�lEORGE ILAROSE_.. ,�'�+ 3 Insur•ance''Covera el Indicate the type of insurance coverage by theidking the appropriate box: '` Liability insurance policy Other type of indemnity Q Bond Insurance Waiver: 1 , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent 1 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 insmantioru performed under Permit iueed for this application will-be In compliance with ad pallnent Provisions of the Massachusetts State Cas Code and Chapter 142 of the General Lawa. By TYPE LICENSE: . Title Plumber Si atur Licensed Gasfitter- 9 e of City/Town: Master Plumber or Gasfitt=er Journeyman 998 APPROVED (OFFICE USE ONLY) License Number