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Miscellaneous - 139 QUAIL RUN LANE 4/30/2018
139 QUAIL RUN LANE 210/060.0-0132-0000.0 Date . c1 • ��� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . .'s1-cUQ-r has permission for gas installation . . . .s.4c�IUi. . . . . . . . . . . . . . . . . in the buildings of. . .,!fin. 1, ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . .k.? 4 . .0.t,c,A,, . I, .. , . . . , North Andover, Mass. Fee . ().�6,. . Lic. No. .t 04( . . ,� q . GAS INSPECTOR--'- Check# -� 8344 3o. .6,0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ do v�" _~� MA DATE 1 PERMIT# JOBSITE ADDRESS _J _ � ,.� _ . � �OWNER'SNAME rjLL�•- _ GOWNER ADDRESS t,a?, I TEL _ _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL __} EDUCATIONAL PST ® RESIDENTIAL CLEARLY NEW:13 RENOVATION:O REPLACEMENT: PLANS SUBMITTED: YES J- NOE- APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER TL=j�.__ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR T---f- �-T - --f 1---- - - - -- - I FURNACE - -__. y - --_( =_- - R - - GENERATOR __ _(i ._I I- _ _!h;_ ( � ( J X1 L (�-- GRILLE ... 1.__._([- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER R OM/SPACE HEATER ROOF TOP UNIT TLST - UNIT HEATER UNVENTED ROOM HEATER ( __.._}C L..._ i. I. ! 1. , �J!- . } WATER HEATER - I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 25 OTHER TYPE INDEMNITY BOND __( OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT (- 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 2comp, cewith all� Pertinent p n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,( LICENSE# SIGNATURE MP MGF JP JGF LPGI ( CORPORATION _�# j PARTNERSHIP El#=LLC D# COMPANY NAME: — y,f,P, J ADDRESS CITY � 5� STATE[ ZIP TEL _ .. 17 FAX CELL ,EMAIL - — --- ----- --- — — ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes , No i4W A" �— THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ -icy�� r M1c s M Will FEE: $ PERMIT# PLAN REVIEW NOTES 10 -45-- J -2- i Cunningham Lindsey U.S.,Inc. Cunnin ham P.O.Box 703689 Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 806 T3 P1 95000058996 Building Commissioner or Inspector of Buildings 120 MAIN STREET NORTH ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 2608116 Policy Number: 2608116 06 Company Name: MERRIMACK MUTUAL FIRE INS 0) Cause of Loss: ICE DAM LO Date of Loss: 3/2/2015 0 Insured: JAMES JOSEPH &ANDRES THOMAS Property Location: 139 QUAIL RUN LN Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4 .eCj Address: /Sr /97 7 City/State/Zip: r/ l Phone#: 7 7 8' 7 Are you an employer?Check the appropriate box: Type of project(required): 1.ElI am a employer with j 4. ElI 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 or partner- listed on the attached sheet. 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. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.Fl I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required]t employees. [No workers' 13F] Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine :)f 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. f do hereby certify d r the pains andpenalties of perjury that the information provided above is trice and correct. 3i ature: 1 Date: ?hone#: 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#: v Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. ##617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www,mass.gov/dia .i II � I •J COMMONWEALTH OF MASSACHUSETTS F.WL LI ENSED=AS A rh 4STER PLUMBER r ISSUES THE ABOVE LICENSE T0: .STEVEN R F ETTI 15 ANNA DR DANVERS MA 01923.-5205 10134 . 05/01/14 14820.9. t r4 • Fold,Then Detach Along All Perforations _ i I COMMONWEALTH OF MASSACHUSETTS REQ !STERE SAS A PLUM NG CORP i ISSUES THE ABOVE LICENSE TO: I STEVE\ R PETTI `STEVEII R PETTI INC M 10134 z 15 ANN.; DR DANVERS MA 01923-5205 1573 05/01/14 148208 • Fold,Then Detach Along All Perforations "1 ------- --- COMMONWEALTH OF MASSACHUSETTS -' PLUMBERS AND GASciTTERS LICENSED AS A JOURNEY164N PLL.MBE ISSUES THE ABOVE LICENSE TO: STEVEN R PETTI �! 15 ANNA DR Cl) DANVERS MA 01923- 5205 j 18765 05/01/14 148210 ►11 • , ; Fold,Then Detach Along All Perforations ' V �j ZGU486NDPSS -48" Professional Gas Rangetop with 6 Burners and Griddle (Natural G... Page 1 of 2 A VS- le find a showroom search monogram cooking refrigeration dishwashers&compactors inspiration&design support why monogram blog ......-.•. nomas ccokrgf.'ki'rnal^��rcruir✓.i:.n?1M>.•.1�Cfi:rrcr.:r�p.ar=r inai�r.v�n.<. 48"PROFESSIONAL GAS RANGETOP WITH 6 BURNERS AND GRIDCLE(NATURAL GAS) ZGU4&OND=55 48"Professional Gas Rangetop with 6 Burners and Griddle (Natural Gas) AdMINIM .. $4,899 h1SRP FIND A SHO AT<OCM S SPECIA_=ROIJOTIOtJ Enter ZIP code PH0T0 GA'_1Fn' 5-fMNING ITEMS 1-E OF 7 'RINTER-F R VSD_`! PAGE. ....-. SCROLL OVER MAGE T:!ZO09 PRODUCTDETA.ILS =RE-PLANNING iNSTA-LATION rs DO:�UN:EhrTATION ACCESSORIE5.RtL:TED PRODUCTS.'',PARTS APPROXIMATE DIMENSIONS(H x D x W) 100 Features&Benefits 8 V2 in x 27 112 in s 47 718 it FEATURES Specifi:atiors Cooktop Burne.,Type 6 Sealed,Dual Fame Slacked Ignition System Electronic Autmtat€c Relgntior. Yes Configuration 6 Burners;Griddle Dimensional Diagram t40Deg-Simmer Burner AllBurners-Adjustable v Control Locator- UpIroM Sumer indicator light Yes Cooktop Sumer Grate Features Porcelainized Cast'ron 3-Piece Reversible (FlatMok)Grates Fuel Type Natural Gas(factory set) LighSrg LED Bullnose Task Lig-ding Stainless Sleet GrAt/Griddle Covers 1 Griddle 18,00C-BTU ThermoslatiraiN Controlled Stainless Steel and Aluminum Clad APPEARANCE ColcrAppearance Stainless Steel Control Knobs Dierast Metallic i1miuced) Design Style Professional Stainless Steel Installation Flrsh tnstallauon Capable WEIGHTS$DIMENSIONS Approdmate Snipping 1Veigh 227.00 Ib Cabinet Width 48.00,n Net Weigh 171-001b Overall Depth 27 12 in Overall Height 812 in Overall Width 47718 in POWER I RATINGS Burner BTU Ratings(060's/13TV)-LP Gas (6,115.0;140 Degree simmer Burner BTU Ratings(06(Tsf6TU)-Natural (6)18 Or,140 Degree simmer Jr Gas Griddle BTU Rating(00YsiSTU)-LP Gas 16.00 Gricdle BTU IRabra(000'sI3TLQ-Natural Gas 18.00 http://appliances.monograrn.com/AppIProducts/ZGU486NDPSS 9/30/2012 6'd �-1790-OZ9-1,2z Auedwo:D xeleo e9C10 Z 1, N I 9388 Date TOWN OF NORTH ANDOVER F PERMIT FOR PLUMBING �SSAC04USE� This certifies that le 41,?n 148 7// has permission to perform . . 1' !�`? /�?!?(�. . . . . . . . . . . . . . ...�, plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at. . ./39 .� /.� . / v� . .r�cY �. .,-. .�/dt h A oVec, Mass. Fee. ,11. Lic. No.�0%�7. . /` ? G�!. ,./ �. . . . . . . . PLUMBING sPECTOR Check # �� /V -TV IWASSACHUSE 9 UNIFORM APPLICATION FOR A PF RMIt TO PERVORPA PLUMBING WORK CITY MA DATE] 54 IPERMIT it J•OOSITEADDRESS ou OWNERSNAME Ames 7-1'%mlq-S OWNER 0DRESS IFAXI 1, TYPE-011 OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I RESIDENTIAL PRINT CLEARLY NEW; yj RENOVATIOW I REPLACEMENT;kj -01 1 NO] I PLANS 8UOMITTED: Y Fixm' RE9 1 FLOOR-' 13sk 1 2 Z 4 -5 6 7 8 9 10' It 12 13 14 BATHTUB ---T CROSS CONNECTION PE-VI01i DEDICATED 8PEOIALWASTE ZY4TEM DEDICATED GASIOILISANDSYSTEM DEDICATED GREASE SYSTEM [)EDicATEo(3RAYWATER SYSTEM ...... DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN TODD DISPOSER . . . . .. FLOORIAREADRAN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL -SER=E1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES. WATER PIPING .OTHER)" j6,41- INSURANCE COVERAGE: I have a ctirrOnt.liability ilisintice pol1q.or its sulistanfial.eqLI!Valeiitwliicli meets the reqtiiremeA.ls of MGI-Ch.142. YES NO 1 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY C14ECKING THE APPPOPRIATF BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I BOND OWNER'S INSURANCE WAIVER:f am aware that the ficensee.6bes not have ihelistirame,coverage requited by Ofiaptet'142 of the Massachusetts General Laws,and that n1y siptiature on t1fi5 perofit application vgaives this reqW(etilen't. OHIECK-ONE0ITLY, OWNER I AGENT-J -j SIGNATURE bF-OWNER.Olt AGENT I hereby certify that all of the delails and information I liava6ubinillted of drilered r&qardiqg:0is application ate true and accurate to the hest of my knovilddge plumbing that alplumbing work and performed perfoied under the perni'll issued for[his application W11 be in compliance' Massachusetts Male'Plumbing Code and Chapter 1142 of Hie General Laws. . Wlh all Pertinent pfoyision of thd .14 ZQ� PLUMBER'S NAME ��e6el) ILICENSE111/0/3,0 1 SIGNATURE MP jJq JP I vt 1,013k- CORPORATION] ;PARTNERSHIP(/�'-76 S' 111I ILLCI* 11#1 I COMPANY NAME ADDRESS 14:5— L—16r— wyl D,417ve� JSTATE I'/�W 'IZIP I 0/1Fa'3 I !ELI FAX I CELL l EMAIL OL i ]2�U"HA P L.UIMMI TG INS7c'JC''CTrON16 OTr,S: rLQ-W rota.0 mm Itm Y75r:olNm ' 7E'AN 7Cl�1spncnGc1T7NdS'y' S Y6s No z3/� THIS APPLICATION-SMYES AS T14E PERMIT ❑ ❑ 1 1�Z FEE: PLAT-,T RjVMW-NoT7CS 4 ' The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,PM 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectriciansfPlumbers Applicant Information Please Print LelOW Name(Business/Organization/Individual): S7�E�E� i�i Address:— City/State/Zip: ,[Dr U t5,g bY�fa Phone#: j1,2 b�- ;7 7S/- A6 5-7 Are you an employer?Check the appropriate box: Type of project(required): 1.ER 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.El Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' comp.insurance required.) 13.[i Other xAny applicant that checks box Of must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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 anti job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address- City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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. Ido hereby cert rider thepafns andpenaI ' ofperjury that the informationprovided above is true andcorrect. - Signature: Date: Z o � Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 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#: e Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. 11f an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whichwill 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 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: Tho Commonwealth of M_assachvsPtls Department ofIndustdalAccidents Office ofInvestigatiom 690 Washington Street Boston}MA,021.11 `1'el.#61.7-727-4900 eyt 406 or 1-877,MASS.Ak'B Revised 5-26-05 Fax#617-7277749 www.znass.govaia. Date. �........ VaORTM 3°:��`":•�"� TOWN OF NORTH ANDOVER AL • PERMIT FOR WIRING !�� ,SSACNUS� Thiscertifies that ............................R.........................`.'..........................:........ i has permission to perform . Q� 5.. !!...��.....�. .. �"D�J�.. T ................... wiring in the building of....... ...�?��r..�... !.�^ c.1N*�"5................................ ........... .................... at......al........ .................................. North Andover,Mass. Fee..�..!.�. ..... Lic.No. /�.►.�1.� .........:..../. .! �.-..... ` ................. y �' �� � ELECTRICAL INSPECTOR Check 11! 0804 t 16- Commonwealth of Massachusetts Official Use Only ' Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 139 Gu cO/ M00-d- Owner or Tenant U-1 P Telephone No. Owner's Address Is this permit in conjunction with a buildin permit?-lJ Yes No ❑ (Check Appropriate Box) Purpose of Building �/ tE�7eh ellen _! eUtility Authorization No. / Existing Service Amps / Volts Overhead Q/Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1XIerg Completion of the llowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans W No.of Total ZAX Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.oEmergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches / S No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges --Z No.of Air Cond. Tons TotNo.of Alerting Devices Into.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dr ers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Rres. Estimated Value W,26112— ctric 1 Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C E GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit iss}�ing ice. *<< CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �/'eTrt'►C� /'r(I /LS CO I certify,under the p insnd penalties of perjury,tihat the information on this application is true and complete. FIRM NAME: t e - LIC.NO.: „ 3031 a mq Licensee: Signature LIC.NO.: 303 !a h76,1 (If applicable,enter "ex e pt"in the tl�censp number line. Bus.Tel.No.:7917d 7/SOS Address: 2 G CaS4-h LH-- C�- e kJ/ m 12?4 Oil Pa Alt.Tel.No.: ZU(4� (2 J *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 agent. Owner/AgentPERMIT FEE: $ Signature Telephone No. r� r ._ J'UJJJL'rtili.R.�i.�.�.C�-�-t��E-..•/���r�'.7CY��.I.F'�(J�--}R..R d�i�•®ppp�'{r.'',��(�yy"PP^pQpp'{;;}{.pp�/��((����yy��//--gyp� .�.ljlJl�Ju�.k.4�.1�1 JCa.w+.G ft.Jr��: . ��ssec�--� _ �+'aileft-•j ] �e-ix�spectZo�xe�wit'ecT($�O.QdJ�j .� ns�ectQxs' ywnwits: / J Jaw ectoreisignatuxe-no•sntfals) _ Pate 3'asseiaiCet jtenseetiox�xeo�uixe ($ 0.00)w j . Zectoxs'cokomelxts; / ps&ctoxs°gzgnatu ••oto inxtia Date ' 3,TTNDNR GROTT.ND INgR CTION. Passed-j +'aflec�--j ate-ns eetio�xe uixe (��0.00) j �ns�ectoz's'commeztts; (J nsp ectoxs'tiignatuxe o?iufiaTs) Pate . ?A.±E ��'p`gNNA+on "��C-110, ; WA-AT � assec�--[ ) �+afIer�--j � �e-znspectiottxeq�riret�($ 0.00)�j � ' tspectaxs'eoxnm.epfs; (�Cns ectoxs' zgnatuxe o jbitzaxs} Data ase t�•-[ ) �'ai�er�-•j )- 'ate�nsp ectton xec�uix'ed( 56.0 d)-•j ) �ectoxs'coznm.e7�ts: _ ,� 'pis�pectoxs'9xgnawe••xto initials) date 3 OR TAQUM TOBY,X&TYD QVT AM YFFTOSS•RITE IF TM MATO BEI NSPECTEDrMNOT The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPlicant Information i PIease Print Legibly Name(Business/Organization/Ind'vidual): - - Address: 26 C es - - -- City/State/Zip: Phone#: r2.Vanm' u employer?Check the appropriIiiiiij] m a employer with�_ 4Type of project(required):' ntractor and I loyees(full and/or part-time).' b-contractors 6 El New construction a sole proprietor or partner- ched sheet t [�.RemodeIing ship and have no employees These sub_contractors have working for me in any capacity. workers'comp.insurance. 8' ❑Demolition 9. EJ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.ElElectrical 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 insurance required.]t 12.❑Roof repairs �kred.] employees. [No workers' comp.insurance required.] 1311 Other "ray EYaIica2�That chec:�s bas 41 nrusi also fill,oaf the section belowsho:"W,f� _ wcz ___ _ T Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors must summit 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 an employer that is providing workers'compensation infoo rmation. insurance for my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: atJa �� /� n. Expiration Date: Job Site Address: ` Pd • � f City/State/Zip: l V eMm Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to$1,500.00 and/or one-year imprisonmentcriminal penalties of a ,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 certify der t e and pen 'es of perjury that the information provided above is true and correct Sitanature: a 6 Q Date.: Phone F only. Do not ws:ite in this area, to be completed by city or town official n: Permit(Licensehority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspectorson: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as""an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,'§25C(6)also states that"every state or local licensing'agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es) and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with.no employees other than the members or partners,.are not 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 bd r•'t Cued t�th@ City or tt7�t that the a�vi I G�ir�L for the p�raraii or License is being requested,not the r partr ent of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 0Mee of Investibations 600 Washington Street Boston,MA.02111 Tel. #617-727-4900 ext 406 or 1-8.77 MASSAFE fax#617-727-7749 Revised 5-26-OS www-mass-gov/dia ti 0 3 5 U Date.... .......................... NORTp 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING S CHU This certifies that .......... .. .1 Y................................................................. has permission to perform ............ L!�.�T�`�....`J .T + !�' k) wiring in the b 'Idi f .7' ,�l ng o ....2-- ........................................................ t 4"., at.... .......� 4.........`.'K. ........................ ...... North Andover]Mass. Fee A1.4 Lic.No....d��.. ........... . . . . . .. .......... -iN INSPECTOR AiLE*CrRIWC�LS;� Check # Comm.onweahk o f//lamackwef Official Use Only AApartment No. � partment of Sire Seruicea BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),5 7 CMR 12.00 (PLEASE PRINT K OR TYPE ALL INFORM4TION) Date: City Tow of: ( V _ To the Inspector o Wires: By this applicati dersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 -Run Wnt Owner or Tenant l atr Telephone No. l Owner's Address .ja/-)'L Is this permit in conjunction with a building permit? Yes ❑ No rg (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity g Location and Nature of Proposed Electrical Work: r?, — 1 .4 111 t1c S hn 5 — Com tion o e bllowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and • Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump I KW No.of Self-Contained Totals: ........................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Loca Mnnici al her No.of Dryers Heating Appliances KW ecurity Systems:* No.of Devices or E uivalent No.of Water KW No.of No.of Da i v'ug.� Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC 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:) Self Insured I certify,under the pains and penalties of perjury,that thetion on this application is true and complete- FIRM NAME: ADT 5ecurit in o►ma Services Inc. LIC.NO.: C-45 Licensee: Mark A. Brophy Signature LIC.NO.: C-45 (If applicahle o�m. OYOYHnr"IN rho Hcence number line-) Bus.Tel.No.,�� � Address: jr . tom /�(r. ��®1�C 5, N C)SO� � �= t.Tel.No.:— *Per M.G.L.c. 141,s. /-61,security work requires Department of Public Safety"S Lic.No. 00953 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent- Signature wner/AgentSignature Telephone No. PERMIT FEE: $ , ( /� Date.....�d:..z. AORT" °�t •�"° TOWN OF NORTH ANDOVER o PERMIT FOR WIRING o • ; a SACHU �I n,tt S �l�C �yCLlt This certifies that ... .................................... ......................................... has permission to perform ....... 5 C C n.! "-f-7. ........................ wiring in the building of.......- at........�. .. .. L.'¢�L... v`...!..............j.......„..,North Andover,Mass. Fee... 0,0 Lic.No. / .. ............... j ` ELECTRICAL INSPECTOR ✓/ � Check It ���/opt' Commonwealth of MamacLetb Official lljUse Only 2epartmment of3ire S Permit No. �F � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC ,527 C R 12.00 (PLEASE PRINT I.X4NK 0 T)'PE LL INFORMATION) Date: City or own f: �r1 � b`Jl(X' To the InspectJ of Wt es: By this application ersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 13 q (�( UFS / ¢ Owner or Tenant Telephone N — 65 y`,,d Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No RJ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Can lotion of thefiollowing table mov be waived by the Inspector of 141ires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No. I Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis osers Heat Pump J.Number 1.19n.s KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Loc onnection er � Secy No.of Dryers Heating Appliances Kin No. f Devices or•E uivale No.of Water No.of No.of ' Heaters KW Signs Ballasts No.of Devices or Equivalent ----]No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: g No.of Devices or Equivalent OTHER: .�� Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5gS, J�o (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 cove age is in force,and has exhibited proof of same to the permit issuing office. NCE ;7 CHECK ONE: INSURABOND ❑ OTHER ❑ (Specify:) I certify,under the pants wid penalties of perjury,that the information on this application is true and complete.j7 FIRM NAME: r) )'O 46rrne. j f cu(i LTC. NO.: 7 ct�t C Licensee: �—'v,,bti 1` ()[rrr,�S Signature��rr�C f� s'��u� LIC. NO.:s'Sc, <, tt4� (Ifapplicable, enter "es napt"in the license number�tipe. Q r� Bus.Tel.No.: j'&67- Address: /,�s 1��s Sr. r 7 1 V ) ry)fn( 61 n D 1 0S / Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Depat4ent of ublic Safety"S"License: Lic.No. v 11 6 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. 1 am the(check one)❑owner ❑ owner's agent. Owner/Agent J Signature Telephone No. PERMIT FEE: $ K Location �" / �-' �.�+- 6�>-✓ . No. /�/l� f Date NORTFr TOWN OF NORTH ANDOVER 3? 0� • Op` 0 9 s i Certificate of Occupancy $ ,5 t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 18522 �71 Building Ins;or r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commgsigne t Date Z SECTION 1-SITE INFORMATION alO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ? � g� ta, o 6 a , D v i z �A,4�k — e , � I Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Munic, at ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) -o Address for Service: Signature Telephone 2:2 Owner of Record: Name Print Address for Service: rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Super//visor: Not Applicable ❑ L Licensed Construction Supervisor: 411 POO / License Number Addres / Expiration Kate ic Si nature Telephone 3.2 Registered /Home yImprovement Contractor f ,* Not Applicable ❑ r v Company Name Registration Number r ddres 3 r' / Z ? �� '(� (� �2 6� Expiration Date /� Si nature Tele hone V I SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......EK No.......❑ SECTION 5 Description of Proposed Work check applicable) New Construction ❑ Existing Building Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: , SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection //,2, 51 11 6 Total 1+2+3+4+5 L70. Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER AGENT OR CON CTOR APPLIES FOR BUILDING PERMIT 1, dA61_yy� ,as Owner/Authorized Agent of subject property Hereby authorize A16 rM /a N / ' />4 A P to act on r My behalt all matters relativ work authorized by this building permit application. Si ature of Owner Date SECTION 7b OWNER/AUTHO D AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST2ND 3RD SPAN DUMENSIONS OF SILLS DMIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Pae If—Z—of_��pages Norman L. Blad Construction—978.687.6263 40 Femvifw Ave.#10, N.Andover MA 01845 MA Lic. 016141 MA Reg. 131950 _ 14\ Proposal Submitted To: JobaName Job# Address / , Job Location 13 /a4--i I D /,? ,';� Date © Daie of Plans Phone# /, �y y/`O Fax# 4. Architect Q (�/ 1 , We hereby sub ' pecifications And estimates for: or il- 141 dp 7 1110: 11, We propose hereby to furnish material and labor_complete in accordance with the above pe i'cations for the sum of: . Dollars with.payments to he made as follows: Any alteration or deviation from above specifications involving extracell 0 Re � y executed only upon written order, and will become an,extra charge over and Submitted--i��� iu�/J�J�.GJ /"'• Above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within _days. A 21cceotiviort.of Prop Ol The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined bove. Date of Acceptance Sighature f 2�:' 'R?v'NC.�S�9 •IGAADE IN USA:: y'. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numb6f.: CS 016141 ii{rthdafe: 03/1571947 i EX�iles [J3/1 ^2006 Tr.no: 2169.0 - - Restricted:•Ob_= t NORMAN L BLAD' YV 40 FERNVIEW AVE#10 N ANDOVER, MA 01845 Commissioner 1. ✓lie �aairnorcurea.�� a�./�,aaaac�ivae�ta Board of Building Regulations and Standards lug HOME IMPROVEMENT CONTRACTOR Registration:_ 131950 Expiration: 1 b/13/2006 lEt.` Type: Individual ;V NORMAN L.BLAD., NORMAN BLAD ;7 40 FERNVIEW AVE' #10 N.ANDOVER,MA 01845 Administrator f NORFOLK AND DEDHAM MUTUAL FIRE INSURANCE COMPANY SMALL CONTRACTORS POLICY Policy # R0412920 RENEWAL CERTIFICATE Named BLAD, NORMAN & DAVID N Agent INTERNET INSURANCE AGENCY, INC Insured 40 FERNVIEW AVE #10 Phone (978) 685-7690 N ANDOVER MA 01845 Agent # 20155 FORM OF BUSINESS: nersh� Policy Period: ONE YEAR from 02/04/05 to 02/04/06 This declarations page together with the policy jacket, the policy form and any endorsements, completes this policy. Coverage begins at 12:01 A.M. Standard Time at the covered premises. P:I� LW. P; CY pR;E. MI � hID CRED `I 'T::: i Basic Annual Endorsements State Taxes Total Annual Add'I/Return $1,488 $1,488 Bid /Location i Address if Different 1 Mortgagee Information Business Description CARPENTRY IE POLICY DEDUCTIBLE $250 BUSINESS PERSONAL PROPERTY Limit $10,000 Included TOTAL PREMIUM PER B U I L D I N G $1,488.00 WZ EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE BUSINESS i LIABILITY COVERAGE FORM. LIAB & MED EXP (OCCURRENCE/GEN AGG/PROD COMP OPS AGG) PREMIUM MEDICAL EXPENSES $300/ $600/ $600 Included TENANT FIRE LEGAL LIABILITY $5 Included $50 Included SEE ATTACHED PAGE Premium I Premium lVt)TE;:.::THE':::POLICY:PRb1l1$it NS:REQEiIf E TMAT A $' :.�o� <::.:,.:`::; : OUNTERSIC�IVEQ%:'`t3Y �t t:," UT#infi Eb REP It tVi1NIW1UM PREMIUM;CHARGE NORMALLY:APPLI#<S 1> ;YOU CAIV CEL p.RlOa Ta iiXplRAtinIV bA C , W(< SFIAL� #lE7 AIN A LEAST so $3D0 REGARDLESS OR TERM BOP-2 (REV.01/94) Type of Payment: DIRECT BILL 10 N. The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations ,•� Boston, Mass. 02111 . Workers'Compensation Insurance Affldavit Name Please Print Name: //`0/?/14 A Al � . AP Location: '/d FRli'N iii c .411,9. ;old City I IS ®L et A4 A 2-4 Zl Phone # 9 7k— � 12 4 3 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone# Insurance Co. POlicv# Company name: Address City: Phone it Insurance Co. Policv# Facture to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment_as well_as_civlt.pmaltiesin the form d a STOP WORK ORDER.and..a fine of.($J0o.00)_aj*against.ma. I understand that a copy of this statement may be forwarded to the Office of investigations or the DIA for coverage verification. I do hereby certify under-Me Dains and penalties of perjury that the information provided above is true and correct. Signature Date el Z � Print namehones Official use only do not write in this area to be completed by city or town official' City or Town Permit/Ucensi []Checkif immediate response is required ❑ Building Dept O Licensing Board ❑ Selectman's Office Contact person: Phone#.• ❑ Health Department ❑ Other NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: La a uA"Z- 2 is that the debris resulting from this work shall be disposed of"m a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: RO 0 (Location of Fac' ' ) To lr �3 d /,-d Signature of Permit Applicant Fire Department Sign off: Dumpster Permit D e NORTH it Town of . _ . Andover No. D - �` i _ dover, Mass*,—,? O COC LA RICHE WICK ' 7d A00ATED PPS` �C5 7S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.: ....... ... ... .. .......................................... .............................Z ................ Foundation has permission to erect..................... rags on Rough to be occupied aS Chimney . ........... .. ................................................................................................................................ provided that the person accepti this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provision of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS _ Rough ....................... ... .................... Service .. .. ..... ..:................................. UIL PING INSPECTOR Final Occupancy Permit Required to Occupy Building J GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location -��-15yA L P.U)�:1 No. ` Date A TOWN OF NORTH ANDOVEla 3?0��•``D- •,hO�L I Certificate of Occupancy $ � s � Building/Frame Permit Fee $ �CH SS Foundation Permit Fee $ us Other Permit Fee>O(L)(. $ 2S Sewer Connection Fee $ ' Water Connection Fee $ M TOTAL ;—,) $ 32, t�z Building Inspector R .-� 794! Div. Public Works PER11IT NO. 0C271—71 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP +JO. /7 ® LOT NO. i ? 71 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE cI SUB DIV. LOT NO.[ J LOCATIONxv- PURPOSE OF BUILDING OWNER'S NAME i '', NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB il �- ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET - POSTS DISTANCE FROM LOT LINES — SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERSAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FI ED AN APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INspzcTOR qj"ATURE OF OW NF.,RIa ED AGENT e ur F E E 2- S OWNER TEL.# r PERMIT GRANTED CONTR.TEL.# 4/0 epA q i 19 CONTR.LIC.#, ��®�� H.I.C.# 2`3317 I BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUSTSHOW EXACT DIMENSIONSOF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- s• APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL K. PINE _ BRICK OR STONE HARDW D — — PIERS PLASTER — DRY WAIL UNFIN. 3 BASEMENT AREA FULL FIN. B M AREA _ 1/. 1/1 1/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING COMIACN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR IJ POOR ADEQUATE 1 NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM_ (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO • 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC Ist 1-3rd NO HEATING IAORTFI Town of Andover No. 0 -1 — bq. dover, Mass.JIAF-C�A 19 9Z- L COCHIC ME WICK ORATE H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ...... ............................................................................................Al� BUILDING INSPECTOR Foundation has permission to erect.. ................ buildings on ...k 3`ft....ow ....................................... Rough .......................................... Chimney to be occupied as.X0.s ........Piv..CD�....V ... ....... -.��4 provided that the person accepting this permit shall In every respect confo%r�-io_the terms of the application on file In Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids,this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CON U Rough ......................................... .. .. ... . ......... . .......... .............BUILDING T ... Service BUILD INS Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT August 4,2004 business license request Mr. Michael Maguire Mr. Maguire, i recently became certified by the "American School of Etiquette" in Atlanta and would like to teach in my home. i would teach children ages 7-18. classes are 1 hour each for 6 weeks.class size maximum is 10. My home is around 4000 sq ft and classes would be in my living and dining rooms. i hope that you can accomodate this request and grant a license. Name of company will be "The Etiquette School of Andover". My phone number is 978-682-8916 for any questions you may have. Thank you very much for your consideration. Sincerely, Teresa Duggan 139 Quail stun Lane North Andover, MA. 01845 y 40RTFf F p N NORTH ANDOVER BUILDING DEPARTMENT 27 CHARLES STREET 4SgACH3gES Tel: 978-688-9545 Fax: 978-688-9542 DATE: �I NAME T reGA —DL� ADDRESS 1 3 v /1 ► I Cu ev L.A,,v-4 - ZONING DISTRICT: TYPE OF BUSINESS: � of BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: '" YES NO BUILDING INSPECTOR SIGNATURE ......n4 RN i Elm- 10 L'I Rt AH 4 V4