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Miscellaneous - 140 HICKORY HILL ROAD 4/30/2018 (5)
140 HICKORY HILL ROAD \ 210/062.0-0105-0000.0 Date... �. ,��. ...... NORrM,ti� TOWN OF NORTH ANDOVER ° 11010 % PERMIT FOR PLUMBING '" ori,.•q,�9 s`4�C14US� M Thiscertifies that............................�../...............' ................................................h...-........... has permission to perform.....1� plumbing inrr thebuildingsof.......... ......................................Y................................� at.....� I I_�-!t-c?�2............ !. .................................... North Andover, Mass. Fee,,,.,-.��....:'....Lic. No. . .. ................................................................................. ,� PLUMBING INSPECTOR Check# � '�J 2- Date... i 1% ...... ......................... OF r►Oi1T�y,h TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HUS� This certifies that ...hi,2�el ... L - -rC-0 ....... ......... \... ................................................ w has permission for gas installation ..................... .,,., in the buildings of..........J��✓ _ > ' ............................................ ..........................�........... at........�. . ................... ���.............................., North Andover, Mass. Fee.�.� Lic. No. ,.1.3... GASINSPECTOR Check# e� 5")- -C\- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � 44`-� MA DATE �/�1(� PERMIT#I ,� JOBSITE ADDRESS [�-(o rL( OWNER'S NAME �(e-/1 t'�' lee- P OWNER ADDRESS I q� � '� I I� L l TEL 7 V-2 3 V•` R 3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALD PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ N0AT FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: •;have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Or NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY K 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT E] I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER'S NAME Mdufv--"nm�u LICENSE#J SIGNATURE MPO JP❑ CORPORATION[N#32 t, PARTNERSHIP❑# LLC❑# COMPANY NAME"K('C,, byztWf-S ADDRESS 3 CITY Rimm +MA STATE QA ZIP FAX CELL EMAIL K��gf11��Cd� t?r(•C?j�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: I V U� �O&'4 MA. DATE: PERMIT# JOBSITE ADDRESS: 140 IA-� �' 1 G7l t� +�-s�7 OWNER'S NAME: Q.�l�- `� G►l�it� GOWNER ADDRESS: �o I'll L�(�� 1 ��� TEL: `Z>�l`� 3 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES El NO APPLIANCESZ FLOOR- Bsmt 1 2 3, 4 5 6 7 8 9 10 11 12 13 14. BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [YINO ❑ If you have checked YES,please indicate the type of coverage.by checking the appropriate box below. LIABILITY INSURANCE POLICY [K OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee oes not have the insurance coverage required by Chapter 142 of the. Massachusetts General Laws,and that my signature on this p rmit application waives this requirement. _ 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT f 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 Ender the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME:mair�, ,Cb LICENSE# 13S '91-GNATLTRE COMPANY NAME: ADDRESS:3 j !'p Irtst 5 7- CITY: CITY: & -e STATE: L[A ZIP: G L.Ci Liq FAX: trig 9?k Vk TEL: g36-Z.I 5 CELL: 936- 4-/ 6 EMAIL: MASTER GK'JOURNEYMAN❑ LP INSTALLER❑ CORP,ORATION LJ 3a&0' PARTNERSHIP❑# LLC❑# Department gjlndustrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 wwiv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): n ACy-OJ J 1 C p 2 cti 4 _ L Address: 31 &�-VtAk 5 ' ' City/State/Zip: /YN' r ,1 Phone #: 1',!�) Z 1 S 3 Are you an employer?Check the appropriate box: Type of project(required): 1.2Iam a employer with .3 4. ❑ I am�a general contractor and I employees(full and/or part-time).* have hued the sub-contractors 6. ❑New construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. [❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right;of exemption per MGL 12.E] Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.$d Other )ST 6 TV 6 o,l V comp.insurance required.] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ` �,. f , Insurance Company Name: go,�`C"YJ Policy#or Self-ins. Lie.#: _ 0 kS RAV 0�93 7 d Expiration Date: Job Site Address: `l� l�� 11 b� ►z-(Jl City/State/Zip: m,, t`lftbH/,UA 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 file 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 ce!gk under the gins and enalties 2f EELugthat thein ormation provided above is true and correct. Signature: -- - -- Date � -------= Phone#: k 9 7 3 G— Z/- 3 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 b.Other Contact Person: Phone#: i 1 ACC>REP CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDD/YYYY) 3/20/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(tes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAMEAC' Eva Caperon EA Stevens Company, Inc. PHONE ' (781)322-2324 p/X 0.(781)397-7672 389 Main St. no RESs.evac@eastevensins.com P. 0. BOX 188 INSURERS AFFORDING COVERAGE NAIC 8 Malden MA 02148 INSUREIiA:Bartford Fire Insurance Company 19682 INSURED INSURERB:Safety Insurance Company 9454 MAGNIFICO BROTHERS PLUMBING HEATING & GAS INSURERC:Twin City Fire Insurance Co. 29459 FITTING, LLC. INSURER D: 31 FOREST STREET INSURER E: MIDDLETON MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR1 ;POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WV0 POLICY NUMBER M/D M/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B COMMERCIAL GENERAL LIABILITY PREMISES Me occurrence $ 300,000 A CLAIMS-MADE ®OCCUR 08SBAUQ5370 /24/2015 /24/2016 MED EXP(Any one pen-on) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEWL AGGREGATE LIMIT APPLIES PER: j PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY $ JFCT PRO- LOC $ AUTOMOBILE LIABILITY COMBBIINdED SINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED y SCHEDULED 5053635 3/24/2015 /24/2016 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS S NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Medical Dayments $ 10,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 DSSBAUQ5370 3/24/2015 /24/2016 $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N % TORY LIMITS R ANY PROPRIETOR/EXCLUDED?/EXECUTIVE Q OFFICER/MEMBER EXCLUDEN/A E.L.EACH ACCIDENT $ 5-0-0—'000 (Mandatory in NH) OBWECRJ9050 /24/2015 /24/2016 E.L.DISEASE-EA EMPLOYEE $ 500.000 Nyes S6 describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE !EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hartford Fire Insurance Company ACCORDANCE WITH THE POLICY PROVISIONS. One Hartford Plaza Hartford, CT 06155 AUTHORIZED REPRESENTATIVE Thomas Cares, Jr/EC � ✓�^ �ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. WS095l9Mnmi n1 The ennon name and Inns are renieferaA marlea of arnon COMMONWEALTH $ r -�OF MASSA CH T 77 M5- PLUMBERSBOARD AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP t, cc MARK MAGNIFICO \ � ~ a MAGN I F I CO BROS PLB&HGT,GAS F I TTI w3; 31 FOREST ST I MIDDLETON MA 01949-2015 - 32b6 05/01J16 ^-� 7,1204666 COMMONWEALTH OF MASSACHIJSE�i'S BOARD PLUMBERS AND GASFITTERS � ISSUES THE FOLLOWING LICENSE ' LICENSED AS A MASTER PLUMBER MARK B MAGN I F I CO SE .ZJ 31 FOREST STREET -lo MIDDLETON 'MA 01949-2015 13559 05/01/16 204667 : MONW 1 7 MASSACHUSETTS . BOARD OF PLUMBERS AND GASFITTERS - I{"~ ISSUES THE FOLLOWING LICENSE I LICENSED AS A JOURNEYMAN PLUMBER CO Z ftARK B MAGN I F I < f} t u z. s IS4� 31 FOREST ST Z ' U " RI DoLETON 11A 01949-2015 _ 25002 05%01/16 204668 NUNN ti i fir., Date..... 1... ............ or x TOWN OF NORTH ANDOVER PERMIT FOR WIRING W HU N-Z This certifies that C- ........................................... has permission to perform ....f.f... ....................................................................... wiring in the buildig of GIS . at ....... ......................... ...... .......North Andover,Mass. ......... ......... Fee ...........Lic.No! ................. ................................................................................... ELECTRICAL INSPECTOR Check# Commonwealth o/MaMaclWetb Oficial Use Only •�"� {� Permit No. 20fartment of—7ire Jervice6 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ev. 1/071 (Waw.blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTININK OR E LL INFORMATION) Date:,.20 GAN City or Town of: 01/CR To the insp&46r of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Plumber) 1-3 0 Owner'or Tenant 6—Z&-A.1A Z, Telephone Owner's Address _e Is this permit in conjunction with a building permit? Yes [] No Lo (Check Appropriate Box) Purpose of Building L�� 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: PA�� 27D1 10,4- ckh,e Com letion of the ollowin table ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.ot Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No,of Luminaires Swimming Pool Above ❑ In- ❑ o:of Emergency Lighting grnd. grnd. B!gn Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners / o.o etechon and �-� Initiating Devices No.of Ranges No.of Air Cond. ��s Na of Alerting Devices ,J No.of Waste Disposers Heat Pump umber Tons _ o.o e - ontained Totals; "- Detection/Alerting -IN)Devices No.of Dishwashers Space/Area Heating KW Local❑ Muni cipai ❑ Other Cyyonnection No.of Dryers Heating Appliances KW Sectio of Devicts or Equivalent KW No.of Water No.of o.o Heaters Si Data Wiring:s Ballasts No.of Dvices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP "Teietommunieations 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 Stat / Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE VERAGE: 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 operatiod'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: INSURAN CE BOND ❑ OTHER ❑ (Specify:) i 1 certify,under the pains and !ties of perjury,that the information on this application is true and complete. 1 FIRMNAME: Aries Electrical Service and Con _tr.oLs LLC LIC.N015650a Licensee: Norland Michaud 4e _ _ _ .IC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.• 978 Address: 290 Broadwaysuite 117 Methuen ma 01844 hR7 0544 *Per M.G.L.c. 147,s.57-61,security work requires DepartmentSafety"T,of Public Safe S License: Alt.Lie.� � 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 waivethis r Owner/Agent equirement I am the(check one)❑owner ❑ Ment. ent. Signature Telephone No. PERMIT FEE: $ - The Commonwealth of Massachusetts Department of Industrial Accidents 5 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 j I Name(Business/Organization/Individual): (/T/?/(' Address: �j(LL�(i�i It � SC j z r6. //a. City/State/Zip:�(=T�I t, Phone #: 9 28 6Z i, 6�21V t Are yowan employer?Check the appropriate box: Type of project(required): G 1. I am a employer with �. 4. [1I am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I 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.❑ Electrical repairs or additions 3.F] I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions s myself.[No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' } 13.❑ Other comp.insurance required..] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 4 t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: r 7?-b E i Policy#or Self-ins.Lic.#:�14T 14/ Expiration Date: f 1 �0/6" 1 Job Site Address: /`7''G C ®UJ City/State/Zi • Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 3 3 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date / 1 Phone#: 7�� _- G� � 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#: i COMMONWEALTH OF'MA ACHl SE. pp I !~ECT131 I ANS ISSUES THE FOLLOWING ..LICENSE...,.., AS A RI JOURNEYMAN ELECTRYI`C-I IN NORMAND D MICHAUD. 13 S I MR:SON RD A �. #� �� y Lu N. 03087-221< <:;:>::: 34594 ,E 07/31/:1:6 36167 .. COMMONWEALTH:OF MASSACHUSETT 3 o. a, . • o BOA3F EL1=CT !( I ANS ISSUES THE FOLLOWING >10EN5E qS,., REGITERD MASTER. ELECtRICI A N , ._ N4RlAND D MIC A 13 s I IPS17 ! I7D /JJ i a. 1 Lu ► Auz NU7iM NH 03087-2215 1.5650 36166 , .. ....... ..........s..-..+.:r:�._.w,..-...�_..,.may. .w'�wwn+.-•-+...�„,l c ' Date... .................... 10 OF OORTI# TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING NZ!CH U��S'- This certifies that...... ....t..........Y-r6 ...................—......................................... has permission to perform...... .........4.............ry plumbing in the buildin s Of......... .......................................................... at..... J YO --)r............7, ............................... .................. North Andover, Mass. Fee-36.......Lic. No.A,6/...... ................................................................................. PLUMBING INSPECTOR Check# Date- ......................... OF NORTH, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,SSgCmu ------ J / /-i� Thiscertifies that ........................................................................"1..................................... has permission for gas installation ..... ..................... ............................................................................... in the buildin7 of......... ....... ...... at.. LP. '.../.............................................. North Andover, Mass. Fee.4. ..��..... Lic. No.'��..3q.......... ..................................................................... GASINSPECTOR Check# 15�64 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r CITY r MA DATE(41- -Z6 ( PERMIT# 6 t Z— JOBSITE ADDRESS OWNER'S NAME —� POWNER ADDRESS rJ tr I TEL TYPE OR OCCUPANCYTYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIALA PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES Q NODI FIXTURES-1 FLOOR- BSM 1 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BATHTUB _( __ CROSS CONNECTION DEVICE 6 _ ( —_ DEDICATED SPECIAL WASTE SYSTEM 777 DEDICATED GAS/OIL/SAND SYSTEM �1 _ 1 DEDICATED GREASE SYSTEM .__J f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER [ __ i _j= ._.v DRINKING FOUNTAIN FOOD DISPOSER _j ._.._._1 I 1 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK —IIL .__..I LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK l _( _. _..( I 1 TQILET URINAL I .._. _ - _._.._1 .._..___1 �SHINGMACHINECONNECTION WATER HEATER ALL TYPES WATER PIPING I OTHER ..__ _ _ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YESPNO Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0/" OTHER TYPE OF INDEMNITY Q BOND 0 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 requirem mit. HECK ONE 0 LY: NER EG _I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this apfIllLcation are true an acc ra o the bes kn ledge and that all plumbing work and installations performed under the permit issued for this application wilTZ-FtnToMpli erti a rovisi the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAE I a 6 y t LICENSE# - C` G ( SI NATURE IVIP� JP CORPORATION V-J1#L=PARTNERSHIP E]# ' i LLC COMPANY NA 1 l ADDRESS CITY 1 STATE _� ZIP TEL - FAX CELL��EMAILI ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL MSPECTIONXOTES Yes No U I THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT It PLAN REVIEW NOTES Y r •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 0 PERMIT# �� JOBSITE ADDRESS M� OWNER'S NAME. { G OWNER ADDRESS TEL +_ _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL ( RESIDENTIAL PRINT CLEARLY NEW:[j RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOQ APPLIANCES-1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER D1 E: _ —I=- = .I� BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE __ __� . _r_ -- - _ GENERATOR GRILLE INFRARED HEATER __ LABORATORY COCKS MAKEUP AIR UNIT � �. OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNI HEATER UNVENTED ROOM HEATER WATER HEATER -- OTHER - ---II-1�II( __ I L -_ 4�_I --- - - L.-- _ --- .--- - -- ---- — —_.-- - .-INSURANCE COVERAGE — - - - -u � -- - ---- have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j _1 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY' OTHER TYPE INDEMNITY © BOND 0[] 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. SIGNATURE EH CK ONE 0 �i SIGNATURE OF OWNER OR AGENT NER" 1 hereby certify that all of the details and information I have submitted or entered regarding this a&lication are true and a folthe b of knowledge and that all plumbing work and installations performed under the permit issued for this application ' e in complian IIP rtin rov' ion of the Massachusetts State Plumbing Code and Chapter 142 offt�the --General Laws. � PLUMBER-GASFITTER NAE -f,__ n: �� �y � J LICENSE# 4 IGNATURE - ---� MP ZMGF EjI JP ® JGF LPGI Mj CORPORATIO4# ��PARTNERSH P®#=LLC D6# COMPANY NAW-1 i _ - �� _ ADDRESS CITY _ _ _ _I STATE ZIP QI TEL r FAX CEL ��-Vr _q EMArE G 0 ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIO NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 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 Le 'bl Name(Business/Organization/Individual): "� F'r Address: L City/State/Zip: - M,A Phone#: 0 6H::PJ(_,0 Areyouan employer?Check the appropriate box: Type of project(required): l.0 1 am a employer with�_ 4. El am a general contractor and 1 6. E]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.1 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. El 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 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] !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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. rl Policy#or Self-ins.Lic. Expiration Date: Job Site Address:G• 191 r'' O G 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$25 ,09-.-day-against the violator advised that a copy of this statement may be forwarded to the Office of Ines gations of the DIA r' ance over ge v kation. o`Iereby cert un r tl ins n6 alt's fperjury that the information provided above is true and correct. Si atur Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 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. 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. AIso 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,Commonwalth of Massachusetts Department of ladustrial.Accidents Office ofIavestigat ons. 600 Washington Stroot Boston}MA02111 TQL#617-7274900 oxt 406 or 1-877,7MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwanass,govaa ,COMMONWEAL OMMONWEALTH OF M1SaAN�SETTS B.G00 Of AND GAS FITTS 1 PLUMBER`S LICEN ISSUES.-THE FOLLO ViPL M66 r 1 AS A ,Mp !$ ED G I ARD. 1 J >3THY A T l�► . 60 SAUNUERS ST ,: rnA g1845 2�+fi�+ 2 2481 1 N: :ANi O \1 ER 01. 1 J 101 0• • r�=�s_ Po Box 55098 Boston,MA 02205-5098 617-951-0600 .i Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: ELENA FIGLER Property Address: 140 HICKORY HILL ROAD,NORTH ANDOVER, MA Policy Number: HMA 0308558 Claim Number: BOS00049611 Date of Loss: 2/18/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Temistocles Devers Claim Examiner 2/19/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5415 Fax: (617) 535-5868 Email: TemistoclesDevers@Safetylnsurance.com Date. ../3�!...� ............... �r►ORT�y, ' ° ~ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 188�CHU5�S This certifiesat h �✓Y , � �����' t .............................. .............................................................. 4 ... ..... ...... ....... has permission to perform ............... � ...... ......................................... ............... . rwiring in the building of......... 1 ............................................................ ,at .................................... x ���� ............................................n...``...............Irt Andover,Mass. Fee.��.."�........Lic.No�.7� .....�..:1� .......... . ELEINSP CTOR Check# 12-037 to � �`� I Commonwealth of Massachusetts Official Use Only a Department of Fire Services OccPermit No. I�Q BOARD OF FIRE PREVENTION REGULATIONS [Rev.1 7]y and Fee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co4e(MEC),527 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL.INFORMATION) Date: & City or Town of. NORTH ANDOVER To the thspkaor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)_1 q0 V4C 6 % k Owner or Tenant Telephone No. Owner's Address 3 Is this permit in conjunction with a building permit? Yes YJ No ❑ (Check Appropriate]Box) Purpose of Building $ ' le Utility Authorization No. ? - Existing Service Amps Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters i Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe 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- ❑ No.of Emergency.Lighting rnd. grnd. 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 Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained M p Totals: —— " �""....."...'"."'.."' '"""......."....... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or 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 ValuZ67,'5 f Ectrical Work: K'710 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. j INSURANCE O RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE% BOND ❑ OTHER ❑ (Specify:) I certify,under the pains an penalties of perjury,that the information on this appli on is tri complete. FIRM NAME: . ��c,�.r, 1'E VJ LIC.NO.: 11—ISI Licensee: Signatur LTC.NO.: (If applicable,enter "exempt"in the li nse number line.) / Bus.Tel.No.: q 79 ct 79 S017 Address: *5j, (3-r6 ve 1r h2 S-f- �Jc✓h. //, �A Alt.Tel.No.: 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. Tam the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed " on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an , ►� electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be.deemed by the Inspector of Wires abandoned.and.invalid if he— or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses 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 F71 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comme Inspectors Signature: Date: FINAL INSPECTION: Pass N Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 � 1 ` The Commonwealth of Massachusetts - Department of IndustdqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ] Please Print Legibly Name(Business/Organization/Individual): Address: `/S ("rteove 141 n d 54- city/State/zip: lrt vel4& rl4 4 f Phone 4:_9 7 g' '77ct- SS 4 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I ' employees(fall and/or part-time). F1* have hired the sub-contractors 6. New construction 2.)6I am a sole proprietor or partner- listed on the attached sheet. 7• F1 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.n Electrical repairs or additions 3.01 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. i'Homeowners who submit this affidavit indicating they are 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 andjob site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: 4 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required-under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby cert&under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 1 w 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 till out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant _ that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the , applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Conul onwealthofMassachusetts 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,govaa r ,.. _.. ..>;^a::•;:: ._—,.. . :i:;is:i:;<•:;:;;.:<;;::;r':;_s; .�` =::COMMONWEALTH OF Mi5SACHlfS1�TS;:: '; 91 kyj W rel • - • OF-11MMUM6,111mim f <<:<::>:ROARD'OF F E<�;,<ECTR'I C I I SSUE.S. ... .HE F.OLLOWI NG''`I CENSE " '< e ' JOURN VM:AA<::ELECTR:I'C+I:AN HARO H WH I TAKER......,. c z .: .458 GROVEL`AND ST <NAVE'»' RH t L L<:>::.>:>::<.<< '>.NI:A` 01830 675 13753 > --`--07/311,16 69611 y An dover 'Tolm of ` _ O p tiw 5 yy Cl o dover, Mass.,�a ^r 0LAK COCMICHEWICK A°C�ATED P,0L BOARD OF HEALTH Food/Kitchen f Septic System PERMIT T -0, BUILDING WSSPECTO ` THIS CERTIFIES THAT.................... ........ ........l..l.. ... .*Pwv................................ oundation has permission to erect........................................ buildings on ....'40........Akaoxwm..... ......................... Rough to be occupied as ....... /'!nt...... .... ..... .1 m. ......!A.... ....... .......eu.ns. C ey � provided that the person ac tin lis permit shall i every respect conform to the terms o the application on file in Final ' P P P g this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 0 Buildings in the Town of North Andover. UMBING IN CTO `� Y/ VIOLATION of the Zoning or Building Regulations Voids this Permit. °u 611r_ '�! Final ERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR T UNLESS DONSTRU O ST TS Rough ...... .... ............... ..................................................................... Service BUILDING I SZ TO l� , Final f�// Jr,� ,i Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do .Not�,.ReemoVQ Final No- Lathing or Dry Wall To Be Done 4 FIRE DEPARTMENT Until Inspected and Approved by the Building FBspe + Butner, "+ Street No. Fiki REVERSE SIDE j Smoke Det. r- • F 07 77 153 Maple Street Methuen,MA 01844 Office 978.688-5036 Fax 978.688.4098Steeple�hase June 9 2009 I Subject: Rear Steps of Addition and Bathroom on 140 Hickory Hill Road,North Andover, MA Rear Stens Please be advised that the back steps at the rear of the addition to the property is a temporary solution and not designed to meet the building code requirements of a permanent structure. The homeowner intends to build a permanent structure at a future date that will satisfy the building requirements of the North Andover Town Building Inspector. Bathroom As per the contract dated November 6, 2008 with Steeplechase Builders, Steeplechase Builders had provided for framing, insulation,rough plumbing and installation of tub. The homeowner is to provide for all the finish to be done at a later date. The homeowner will be responsible with the Town of North Andover to file for separate permit to finish the bathroom. Signed by: Elena Figler, Homeowner of 140 Hickory Hill Road,North Andover, MA Sig by: Steeplechase Builders, Inc. MA Home Improvement Contractor Registration#145042 MA Construction Supervisors License#CS 074478, CS 089253 153 Maple Street Methuen,MA 01844 Office 978.688-5036 Fax 978.688.4098 Steeplechase BUILDERS, June 2, 2009 Subject: Rear Steps of Addition on 140 Hickory Hill Road,North Andover, MA Please be advised that the back steps at the rear of the addition to the property is a temporary solution and not designed to meet the building code requirements of a permanent structure. The homeowner intends to build a permanent structure at a future date that will satisfy the building requirements of the North Andover Town Building Inspector. 0-617� S Signed by: Elena Figler, Hom&wner of 140 Hickory Hill Road,North Andover, MA Signed b Ste echase Builders, Inc. MA Home Improvement Contractor Registration#145042 MA Construction Supervisors License#CS 074478, CS 089253 Date.......................... .. f NORTH 3a;•'�`` :'�"�O� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING sS�cMusE� This certifies that ................................................... has permission to perform .!!!!iT wiring in the building of............ �.G`.LE.��^......................................... at .....e.?.�).............. .North Andover,Mass. t Fee...9A:®.'.'..... Lic.No./..71.1 .4............. ,1d� .e: .: .Z'&-.-Q � 7 iallCAL INECMR / Check # 855 r C11mmonwea&of/i'/amachujettj Official Use Only cc�� �7 Permit No. �/�, 9 - aLJeparEment o� ire�ervice9 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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /'.202-to 9 City or Town of: Nolelw 0vc12 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) 15�J y Owner or Tenant 4-5/�_/q F16,44--2S Telephone No. Owner's Address s/- m C Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No..of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: NEw 1121)b/770V QC,0900n" 619/L/f{,[,� Completion of thefollowing table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of .:. Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators . . KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig ing rnd. rnd: Batter '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 TotaInitiatin Devices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices _ No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ..... . .. .................................................. Detection/Alertin 21,Devices No.of Dishwashers Space/Area Heating KW Local Connection El Other No.of Dryers Heating Appliances KW Security Systems: . No.of Devices or E`uivalent No.of Waters KW No.of No.of Data Wiring: HeaterSigns 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: a _ (When required by municipal policy.) Work to Start: ` aa-v 9 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 M BOND ❑ OTHER ❑ (Specify:) I certify,under.the pains and penalties of perjury,that the information on this appli tion is true and complete. FIRM NAME: © S 11/C LIC.NO.: /71tf Licensee: /yj 1 C-44-c--L_ Q S(-{M Signature LIC.LIC.NO.: ,2 JF73r applicable, "exempt"in the license number line.) Address:: //11Bus.Tel.No.: 6/7�J/?_Ohf BOA` �02 0 �n /(V6 �)I q Oey- �, Alt.Tel.No.: *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/Agent Signature Telephone No. PERMIT FEE: S i J The Co manwealth of Massachuseu,s epartnie t oaf Industrial Acciden s i ' 600 Washington Street U i c ostor,JIM 02111 y ov-mass-a Ov1dia Please Pjut Leggibl�; aM— rusijess/GrgaDi7a�zo�i�clz�zraal);— -?Phoiae 777 / 130 & pe o project X�ae eak contra a . ate.: CUT, 6. New cous`uauc oTa ,,,��z�;'CPS (�i!:a�:•''��`J��a.j:t-ikA tij.` �aavPJ;tsxed Llai S�3_b-CO;aita�i?T.S 6 . % %.?�'', amn a Sone pyop X'i'�1 of paX�l.�.ek- listed ow Lhc aaached sb.ec z�PxodeluAg shXp and have m emploUees Best said-miamcto-fs have � 8. E] DeluoPatiXoAk t WOi,x-i.E:.G Ail:me i.�z axiy ca.� aci f. Woklcei'S' Comp. U15-UNIce_ i ®. "uAidg addXuo r �No V flXxCPnJ coixA s aDCP 5. die axe a coi-poTatzou at-id iLc kPG x .l OAXXCeTK j;'Ve e,(,lCkSP'd Fb 1 1.Q. Blecuical igaiTs ad)(Lno-s — Oh i r.eJai.-S 'ivi: ao "Cus am,d E'AO.'A efl':v�,'a) �OG7,all WOAx"C dA�ri.�.. �i;?>e$�). ,.�.Ork�'C'1, -ayse:x EWioWvekcen-, con3p, c. r52 ��, ��,at�r wPbave�c 12 F,00ftegaAi,.s e-S. LINO WOfkCAS coup. Xk�iC;Aiazice J @ l i - ' _- - G'- w - c- 3 u`s.i e _ •::S.ir(iila`Ci1CCfw OOR`-��ialt2.t .50 x`I[EO !1 S 1Q:3 v..t0 510"�%ei7.�ttl ii Oa 6: iS Cua ua2.l:C,iC1e xxxx0 tial. eO , -- � � v c' - .. L'.v-`' �s davii u.d:c2':;_-;,,r f..0.ae J" uCa L'C.,itvil'7]i?.hiS affidp tt 1tldCednX they a-m doi.Ti.�a:�t-wc,,k a°ld tle,>.hiie Outside cont`%ac o%s ii-ast SuGAaJ ane v -aCiOeS Lia2 Check`t,'17S boT,:::.uSr=aitacr.•ed a.-t addi io,.at sheet sho'm-Rg"I al&Axe ox iile Sub-cont aCi0_a aitG.ttlCin.-w'Cz�er? CGTtX1.�,0(iCv feff'T"in-'F,runceat nTx !'rmpfa✓rc F6' -1 ie'c.FJ.l:(.fl'l a;?c o Ce;tk any Narde-,: — — — - - _ _ n' ^ Cy vA SP€`1z)S-ti XC 11- A/C ` XkXo-tAOtu Date. L� f� fX� �.0. o Sltc AGds-ess:—�7m �C.K©2`� f�LG G /��. R%ylSt;elZlp: �/��!/DO✓Er�� /Y/A a£c;,;?of be;workerS' Cdn n�e�.5a r.4�n pc'dicy de61xrabi-m pag7e, ,J;w.Wor.-;F aupd. to sec c cotieea�P as APC�u_:s.eC,v.�XdeA SPe mp,.25.A o iGL C. 152 Cau lea6'LQ Line}J,P xN iii C4 iiO f�i iiR cA J:Af..'�G.f:h�P. C�-Hes !�: P> tC S1.500.00 a d/C?A`OAdC-;Pae 171ijlasowiient, as well as CsvX e Ra1.`cC .ale r r W I ORD ". 'Ec -' s A XO2A'.,of a h J:. O K �J, LO$250-00 a day agaius Lx e tiiClatoT- Be adVised flaat a copy of fl6s s zte-nit7) tjanay be fb waared,to the vz z�� a i vesa_AgaLzons CA tc Did to O's-cT21uCP vO11ela c uEa11-JI �.® v.. a Lai of✓ �E i 7 underr�,,,-prj-TFC r��i���7\\.�rcG��r.FS J� Far-�rli.ham:x�a fr��rr c�A r�Ic f�i'�r k��' rh<JN� ?rr`il 0-T-" � .c,;. S �J,n rr.(ft 'tirI-L4r' tip. hi'r r.-7er i�`J 6J•'��'!jl[a�I FF�./�'f, &V Fi"y-tr a`,A,% Ti.rjfr- s- -: M r ? Jsek nkat nC�r:SP cult Gmy(6Tcle -Z—ou n ^�� _ t.ia A Je 2u 0.aY.Fe k 3_rLr, ti�C SPT F L_- r_i Y Tus ectuj• 5-j,�.Urzpb--Yag 7-'as-^ti .- [_Uu fe4 ft L'1kQC`r.hCa.,t. , - ii LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 April 2,2009 Mr. Chris Smith Steeplechase Builders 153 Maple Street Methuen;Ma. 01844 j RE: Figler Residence, 140 Hickory Hill Road,North Andover,MA. 01845 Dear Mr._i Smith As requested by Mr. Kevin Bruland of Steeplechase Builders I visited the project 4/2/09 to review the 2-1/2"plumping hole in the web bearing area of a TLI joist and the two notches for plumbing in the top flange of two TJI joist approximately 7'8"from the rear bearing end. One notch is in a double joist and the second is in the adjacent joist. These joist are 16"TJI 560 as produced by ilevel Trus Joist. These joist support the second floor Family Room over the garage and are located adjacent to the stair. As a standard practice the flanges of TJI joist should not be notched or cut,and holes should only be of size and placed in locations approved by manufacturer. I reviewed the calculations (copies attached)certified by Norman Scheel Ma. P.E. No, 36044 and concur that the hole and notches are acceptable. Although the hole and notches r'duce the capacity of the joist, which is based on the maximum moment at the center of the span there is sufficient capacity remaining at the location of the notches to support the required loads. The hole in the web is within the bearing area of the joist and does not reduce the required shear or bearing capacity below the required capacity at this location. I can therefore certify that to the best of my knowledge these conditions are acceptable to meet the loading conditions required b the 7t'Edition of Y the Massach4setts State Building Code. Should you have any. questions please do not hesitate to call. Yours truly, S R ly � liAkCLD Lawrence�.H. Ogden ,P.E. Structural 27765 OGDEN 27765 Cc. Mr. Gerald Brown,North Andover Building Commissioner 1 LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978—352-2858 cell: 978-502-5921 April 2,2009 Mr. Chris Smith I Steeplechase Builders 153 Maple Street Methuen,Ma. 01844 RE: >iigler Residence, 140 Hickory Hill Road,North Andover, MA. 01845 Dear Mr. Smith As requested by Mr. Kevin Bruland of Steeplechase Builders I visited the project 4/2/09 to review the 2-1/2" plumping hole in the web bearing area of a TLI joist and the two notches for plumbing in the top flange of two TJI joist approximately 7'8" from the rear bearing end. One notch is in a double joist and the second is in the adjacent joist. These joist are 16" TJI 560 as produced by ilevel Trus Joist. These joist support the second floor Family Room over the garage and are located adjacent to the stair. As a standard practice the flanges of TJI joist should not be notched or cut, and holes should only be of size and placed in locations approved by manufacturer. I reviewed the calculations (copies attached) certified by Norman Scheel Ma. P.E. j No. 36044 and concur that the hole and notches are acceptable. Although the hole and notches reduce the capacity of the joist, which is based on the maximum moment at the center of the span there is sufficient capacity remaining at the location of the notches to support the required loads. The hole in the web is within the bearing area of the joist and does not reduce the required shear or bearing capacity below the required capacity at this location. I can therefore certify that to the best of my knowledge these conditions are acceptable to meet the loading conditions required by the 7th Edition of the Massachusetts State Building Code. Should you have any questions please do not hesitate to call. Yours truly, w F g R HAROLD Lawrence H. Ogden ,P.E. Structural 27765 U ocDerr y 27765 c0 Cc. Mr. C erald Brown,North Andover Building Commissioner Lm:9,i aik„reT:Slrt,sDeJa VNVE.RSAL FOR ST PRODUCTS-Belchetto rn,MA TIRS COGPORENT13 DES1Cf1ED TO 3UPPT1 pNly LOAD TABLE THE 7MRS.TICA/LOAICA S(a'"A'S OETERMWED BY IIOTE: LOADS SHOtRflARE Foa t4PUT LQAM C115C(i) Oi}iFR LOAD C.�5E5 t T 11 pEPTH 16,1300" LIAMA(S.NS.F. A TIDN OFCOACINa,0'FLEG7K T4 FOR PA7TERM tiiE LDgpUJC AR:CHECKED AS REO RED. b'C!1 a•4SYa° DESIM`�1T'-fit+ : ti/5L 0.95 BRA)OM,AND. ; ..RAXER L•TERALS,ACINitio AND SEISM (1311/.EP/510NS LIFASUREO FRDMLEFT DID OF EPA14 OR CAHTP-EVEA.) FLANGE 1.50��.. VC^.0,13 BtiAiAYSREHD:OThERLATEHJaBRACIA0MATIS Mt.C21. .LLVtAYSR_pt/tREDISTHERESPD.VBIBIUfyCFTHE DtSzttipattca' BCVACg sYPg COP/S1DE lgtr GLt'g t4vm PJJOTc`CTEM1'C NMR ORARCJTITECT.I Qts �`'{' To LOAO tmr DR" LnA2) 40 PSP RESC6NS19LITY FOR ALL PLANS,SPECMCC-na,,S VN IFORH FLOOR LIVE 7pP 7,T-ItJ-SX P'C-tN-SK 'DM`AL�� 20 PST OR OTHER OCCUII<NT3 TWX A41Y BE USED To IJNIFARH 1'V_'QB OZAD TDP 53 PLP OD-0D-0D p5-00-00 - t0 JS? L4GORP-R;\TEFHIS 27 P6P DO-G0-013 a5-00-00 2-AD RUILDINGOES1114 L'O•�7h-.4TIP1T4TKE V/ARIClJM,4OTES: 0.00 M.-ACING n t0 00 I> C C 2.FROV DE pESTRhINT AT SUPPORTS TO ENSURE SUIS COTAPDNESST'DE910t115.5PE.C/PIGALLY FOR I?'ENOl`IEERgO V/OOD PRODUCTS, DGPLBCCICtJ CE 173RSR c LATERAL0N,0STAH.UIY. TUE O Ordp` DEMON It SP CIF Z.IV3 L040 OE:6e I. 3,.00 h'07 GUT,ttOTCH Wt DRILL.LPI FLAKOES. OTHER THAN LP TOTAL LOAD pgPL. / 360 4..SHIIAALLOEAFiIHOSFORFULLMIJT/d:T. SMGTLVPROHIBITED.AVYMOO.7FICATIOU i•VLURLPLSL.ORLPW015TS1S G / Tq0 D.VERIFYDIIZENMr•18BEF BYADB5IGRpRDFESSIOMA_ OF7HlS.DpC{Jb1E1+TREQUIRESREv1EN W-DU mm G MLPI{470 we f1cc OREC.ItTRAGLPfTO StLE, PL LAt7CES T.COf/PRESStOIJ a 8 FS A RmR'+ffit.O Y fd'NItN1A DEf•RLyO SITES ARE SUIF{CIEtt7 TOPR64£Nt CRilSHD1GOF TI Lp1 N OR;p ..AGE BRAfS01OHEOtftRED�AT JUST AS DESIGNED.tTISME.RESPQ4ORI)itYCFT}{gp;OJEC2EHGIr7EER. iCC•� TLSR-113a -kC £0.130 CDVPOHEr. _ ARCMtEC'TOR6ESI&t1EftTO 4•A. City IM 2SL75 JO{STISGgPA1L:EDF9U::OR114t3FI}fE1tEACTiDN5F�3TRUCIUREFORTHIS hIS^ct'S= 200114-ff ICY. CITT NFA 96-90-g .t1iCHOR LPI:01STgECUREYT88JtgRJG5 D1(HPrlGER5. CCHC 11694_R HW SeB Lo91 M;W:l StlKL3 CON P0SiT61-3/4" LUBp Ally2'-1/20 DIA HOLE ,SPA JwTmIt $PhilRATIft FPAIRR REQUIREDESIGN IS FOR THE REFERENCED PROJECT ONLY OULD NOT BE-USED WITH.ANY OTHER PROJECT IGN! . . ��� 1/1 ` O suv7?anT nEacrlaYs tLeSJ: 3-1i2" '1l1 VixIt+T1 tl C A a I N 6 S V It] 6.H 15.000 1 OWN 350 -360 f T1PLIFT - __ 1 DETAIL � .; 3.51313 4WHE�. M1.11 ERIURIlt SI2S3 tr.T-sxi NTS STMTURAL . .3- 8 `�� - 9. C20.939?C17IOtt . CALCUL rJPF 9E1'T.Ll•'9'LCtTB XCUI:T'u0 LIIr .LORD G.01`. 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I.IMala.ppc„haral.•dt`imt-Tpypgl,ticln7.lP ape:n:tNrhha OYailtWUtOev�pn L•daipi tiLLtlms.il htY:i fn•caep, ervats h:peafn�TjhdnM:p ai�alhtrreann:edati4p•Gn;1+:trc17f.11'ACOPY 6F THS r•Laiit:ncan.h,nsUnhnwua_ Dt`,rG rY 0903-937 jrna.»bY ant Cmsd.n:En;lneatg O:ammL Via'/lir+'+f9 T4 JiE GK'Or1 T07HE iNST/J1tt0 COLITM^TCt{ FPa.GaDOtameni:avLSu111�00i�atal[O,tyDutURlanilL'P�20D$yy1.t�Lj{ydli3TeRC orn• U't°Or°?itnfpdVadtmLMctLudt'ans•ParifeC SHEET R HaH.SPJC 9'Pna/°•t r f'1 f 2 >{OTE: XIIi-I NvaaltaSl�,-L--n > OTE, CQraPavyfT Iso�gtpyED.Ta suPPnara+ilY %'A U►4JVERSAL FOREST PRODUCT THE VERRCALLOnDSS}{O1VI/ASDEijJIiJEDDY kDTE LOADS LOAdTADLE 5-Bercherlaw + OT11ER8.YERF (1 +J1A LRAITATUtfS,F tAA110)I OPLOAO!NO,DEFCECTJOV FORFA S1JO►YNARE FOR 01PU7 LOW CASE��� 2 02 0. DEPTH l6AD6" BRACRdO,/dJO RnGItf0 t7ET/fppg.WIVDFLE TloSj >C lDrTJcG7-rETRuI4 VE LOMjl.,,,RE CHECKEDASREOIlIR a7HER LOAD CASES; H2D, 0,9375•• OTHER LA -r1AE, �`ASVRED FFLOth LEFrE[t'O OF FLA7OE 1. DYBZO7r CRIFgRIA r '�=+ 0.36 ACV:AYSREGIhIZpIg7.4.9POMS471lRY0FTh'S VrsTR280;10q SDO ^h OA CdNTLEVER.) DESiOtr Ca$0{.,SFs00P 3 vii, 0.22 PRO.'EOTENatAeEFa4ARCH,7£Q7.(OISCLOFrNS RCC TYFS 7oF/SEDa LCX, 70D81TH8R FETES :-ABTeHao RSI1 0.14 tZESPONSiaLt7YFp,�ALLF Diu:Vo Man Ca <RBpm TO 407861. OR OTMER DOCVttEHTS 11C 13,8PcC,FICAT1Ot,15 '.R.YFOFu: YLOOR LTVB 7aP PT-ItI-OX Pa•-IIf-aX ' S'dCOR.aORpTE A7 MAY SE-USED TO PE/)Za 6IAD TDP S3 PLP 110-DO-00 ZS.00-00 OBAD LOAD i0 PSt THIS CQirhDla'SVTItJTtD THE COt{CBtR'tIATSD FLOOR Ta'1'hG LOI:.h 620 6 PFS? 8U1_OIHO D�ION. LL�/Ji a1DC 27 PLF 00.00.00 Z6 QO DO L•00 " 37 2.PRaWrERESTRAIHTATSUF'Fp LDDCptIRJ!73D ?L6OR DeAD 9163 133 L139 49-04-ODSIAg60 3.5 0.90 BPAD/Ha 16.a0 LH, D TERAL 7.CLfr .L17Y, RTS iO E►JSllRE IYAR,ViHD 1i0 67 Las DS-40•.00[13213 0" 1.00 ' C/C 3.00PJOT CVL, FES; Atia3.50" 4.SKMA mvisJi an FULLlpIFLANtiE,p. 0'90 A . O3a-GIC7L4tf CAITFAT ALL OEAR,Ye1Eg FpR f�CO1f7ACi, THIS.0OFAJIOtfENTDEsIojq 1S SPECIFiCACLYFOR L• iY� OA DLYLr 4Elt1aY DIhJE1fSIOV3 SEForZE D USE OF THIS D-e P EHGIN EFREO Yl000 pRgpU�& 7O7AG LOAD DfiDLt L /360 S• ISLPI 3 TO RE tJSEp g 11TT'tlGLPI7D SIZE, STRICTLY PROIDaiiBp,p?1fYThtiHO OTHER THAI)LP L(n,OR tP DR LD L/ 24a LSL T.OOk1PRESSIgy EDGE BRAG' OQ +01ST O,.Y 6YApE5I6}J p HYLLpbIFJCAitOA DF THIS DOCUMENT RDOV01E8 EQISTS IS CODY OC%%pLIA;{CyD j fd p t'OR °SS. 11Q ticpuyTED A7aa1dHA!» IE1Y RGPORT V IfOTEFOR PRDLIOERESTRAlliTATCCdJCEA?R/i7EpLC1f40Tfl5 ran 1340 DCl/8LE'LPI. ENSURELtTERALS•t,�gC�, tl' AR 25L76 rARtiUiJAfDEaRIHGSIZESARE50FFIC1E7TR&y>fdiC ts { 700111-K fOp A.CO}JHECTDOUc1Lc'LPTV51MG2?Jr$ .:D15T AS OE5�3he-D-ITIS. Ruakk JO aR }1•Y. CLMC MA,9S-94-J1 FILtETf3fl/LCLEh�{7:(4F:IOIST•FCfi; ERE3POHSI41iITYDFTHEPROJECTENGNEEEi1,�1 n 14094-R THATARMATE O.STS GHREC70ROE51{itJEPPOR-TtgGTpNATTK SUPPOAT'STR xOD A7EOIIhtLYFILIERS HEED G%JLY `7lIST tp CAPApLE Cr BUPPORTlVO hiE'REaCTIONS.ENT TUBE FQR 1N'S SED 3091 j BE LOCATED A.EJVCH SUFPORTAHD AT8'aV TOPLOA LDSNUST E--%Iu4:SEATLT�aD S�r'- j'ifDNORLPiJOISTSECC'RELYiOpEAR4dG5.ORfitrt,{fgR,y• a.PA019DEd'LLIVGFIILERSATAR NO REP;gIjR.CQUIREp Ca{JCEN R TED LOpD1-CeuTER F tCrA O0.tDAD: DHaL6CTZOH nSBD.a[s CQpROs1TS C FASTeA FILLERS 1HROVEN-lPl1'lE9511y1N A^1'30.'T HX17[q>:USa J1Efp DSS.UE8T5T CVt1A1F,S.lr71Z'OCFRO%j 1tAYL86 1S/]4* tpn JIATE19 ERROWSA>'mOLIr,CH THIS DESIGN IS FOR.THE REFERENCED PROJECT ONLY �x�i1TJzau (32/19 6PJ+Ef Rarlsvl a�'1 E�Efi:M t� AND SHOULD NOT BE USED VyiTy ANY OTHER PROJEC D AL4Ki�}JLi SIDE•A-LkD LOADS FQR S7AJ'10%RD ouRATL7rJ uH,FasALOAD=<"00 R1', OR DESIGN CQVCE+ITRDj%LOAD,1 CD3188.tO/+OS CAH BE T DOUBLED Fq4 HhILS AT'0'OC.TRL� FOR t, M.titSAT4'OQ, C•,A7tfa1.JAYBEADJGSTED FDA LOOT1 �LOADDVRATIONs. 9-314"DEEP�(4-it2"WIDE .0 s E.FLpORSHEg1H,T•lOToa PIAILEDTO.RAl•JGES.Oi• 'r ao r lolsTs. FLANGE EDGE NOTCH `' TUE• "'- „� ND.3 I 7'-8-414rr �At E%g6 Bopp"T RIAC7I0M (GBS)r L1AXLyD}L a R n R I Tl':a H 1f.y R II A 16.0110 i 2 DOfRr 1171 clay . 1 " a.zao trrr B�1RIS0 BSEH6 f2J7-SX) SECTION 7• 0 3- 9 CROse gSC?LOt{ NTS 3JAJCLK11t1 O'aFESC2SONS LIMB LOMJCI.tcaZA-RD ;krwvAztm 0,23+a •ra LOAD 0.17• 0.95'r TQ7JLL 10 AO 0.35^ 1.20'1 Ermihm To"n;onavc-r tliFaelJynnpus Rtbllnallai 0- a tiunh i!�ntuncnitror♦•a;;rh:fdra2am:an•dr- Taotm "•MISORMI)MGisHaT mdt btm uPlora,d rn'eh„hal to cV,ylic9 cad.e:m+J[la riv;Jsem.pbaG'ol Otoraen, LP L�"•LP LSL and C. To SCALE'•• InsLgkd a/:ihrra HaImth dm to.a tFcl4a b p.e Mrwd edbYO•a,:i-n,tar!'u - Tr1.LP IJ[Jals,,, llann a�a4?�"I.-.VIP hilar cRL4e fnrr►n cndtaetaiFn -atnmrvne.i+n all,dep Vp'ta`•n4J'am-oo ro+alarq'G O ��na;taro furlp iYI LP LS C LPEngfn ttd('1(OCd ueaNuad Alma-3,hrl't s0 ralrr.lMa:d,uae =ooPCMol.Yhhody P1eaUlht m'PVle�o�pav httrro_ff;diS - roli d:vc+p,ialN b4UoR-e,ata TRaNLa1.blo,owlIc Rcf eul:m. P/OdUCLS ntttM caro oeraxi.y,= ►n i:ais ado raos!wnq, D�altai l,led[67,ra dozs n:1 m1e1lc:NI.,iVrt W Od la(,F:c=,te4:n}n:rael d'(nILLr 4/d.�'Cn SUnCt EuW.2D0D A1'' IRC 'M/ oidacntit igdamlWellaad•nen.ViMnlhlavontalhaprudptOnrolc:Cn• B•alit.11d,7M Dollar,Crlxla 11 th3lln,dwd0,da,y arpm.ada,elc.+,to lda rl4,ii, C -tea.a'dl xaatrt�M,LILPL on:CTIL tP1..alre o,eapina igp 'arw en d+W Fm,id,d try Urea:,lonor,LPL In otl ,al mnwbl(1em tParr w,or yL�l e'd focal The Cotten cad aaVd,l, Lvart+ae mcdeeiY - VL.LF LOL and GTR,IP tafielMl;f vetap,h:rao� :clot rn m• C .CP I•Y_Ilt,ecrluj -Fnx •J03.OJ6a carf:tmif(xilhd,oh i4dIA's 4 atal,nl'al tonatl VAI1an:n p.l q++rGr"WAIL,drat.,,.j.bad:Wow 1: d,dam,all I,.,Val marl:Vfi Yam -ri+�'+'d'_Iyafo,oPnAh,l a'nd LP ka!kt�'V/a15 D w1wadot4rl b,lr,irlda�eMHO&a-lfA tc tapNi�•a 1hm br o*ydo1 or re dreyb droci or,f41-aH rrc a.p,dicfro•i,a, 0 o!a;arrranlo,it msm•araatLP oo"IS,76R1 an nd_dnp h 1Lo,atrrer! P 9 fu'a Caninaa. Told a+aeoacaai.n l.:lo-lan 'a:i tocla k'r�y;, ottiilaln,p,rll:,r.114a jai l.la;rht-art!,Cp.I.1P OOalrcA F'o'111 ndiG,e to lanrr/mµt:alfeaa Hcli a"En;l.ejifO,i ea'CldercJ an F.ml+a:dny A,arr.ln, loACIlpY OF TNtS G9+eN T FiO:C;'llscurrhnirandSnta Itis>,7OOEGiVI3JT0Tk'e`aY3A4U.n OiNG it 0943-'}3y nit+1•arollclhly pnprrr0els5LP120CJ c(alsoriO4:,rotl Gdamsr3 of[ea4•, COHrRACraq A3-liarzIe I3TtVADODr.SPX n a Parlre Ca7c,olbn SHEET • NORT1f qw- ° tt l.EO 161 '♦O yo 9SSACHUS�� BUILDING DEPARTMENT Community Development Division March 24, 2009 RE: 140 Hickory Hill Kevin Brouillard Steeplechase Builders After reviewing the I Joist, Allowable Holes Pamphlet, several issues exist with the framing due to the plumbing of the new master bathroom. Please have a structural engineer review.the frame and document the repair. Thank You, Brian Leathe Building Inspector 1600 Osgood Street,Suite 2-36 North Andover,Massachusetts 01845 Phone 918.688.9545 Fax 918.688.9542 Web www.townofnorthandover.com ALLOWABLE HOLES. Minimum distance from Table A Minimum distance from Table B No field cut holes in hatched zones Ph'hole may be cut - anywhere in web outside of hatched zone 6° Li 2 x Di D� Closely grouped round minimum holes are permitted if the 2 x Lz Dz 6 6 Do not cut holes larger group erimeter meets minimum than 10"in can ilever (applies to all holes g P P except knockouts) requirements for round or square holes Table A—End Support Minimum distance from edge of hole to inside face of nearest end support Depth TJI® 4)Round Hole Size M1Square or ectan ularHole Size' 2 3" 4" 5„ WI 7" 87/81 11° 13" 2" :. 3". 4" . , 5" II&I 7" 87AI-. 11" 13" -0--T-2'_6 _ — 1'-0" 1 6" 2,6#4'-0" 4,-6 I 91h" . 210 '1'-0" 1'-6" 2'-0" 3'-0" 5'-0° 1-p 2_p" 2_g5 0 230 1'0" j 2'-0" 2'-6" 3'-6" 5'-6" 1'-0" 2'-0" 3'0 5'-0" 110 1 0 1'-0" P-0" P-0" 2'-6° j 2'-6" 5'-0" 1'-0" 1'-0" P-6" 1 2'-6 4'4" i 4'-6" 6'-0" 210 1 0" ; 1'-0" 1'-0" P-6" 2'-6" 3'-0" 5'-6" 1'-0" 1'-0" 2'-0" 3'-0" 5'-0" 5'-6" 6'-6" �- -- --- — 11�1e =-0- P-0-__P-0" 2'-0" 3'-0" 3'-6 6'4- 114" 1'4" 2'4- 1 3'-0" 5'-6" 5'-6" 7'-0" 360 : P-0" J P-0" P-6" 2'-6" 4'-6" ' 5'-0" 7'-0" 1'-0" 1'-0" 2'-6" 4'-0" 6'-6" 6'-6" T6° 566 " 1'0" 1, 1'-0° 1'6" 3'-0" 5'-0" f 5'-6" 8'-0" 1'-0" 2'-0" 3'-6" 5'-0" , 7l-0- j T-6" Volt i 110 P-0" P-0" P-0" P-0" P-0" 1'4- 2'-6" 5'4' P-0" P-0" P-0" P-6" 3'4" 4'4" 1 6'-0" ( 8'-0" 210 1'0" 1'0" V-0" 1'-0" P-0" 1'-6" 3'-0 6'-0" fi'-0" 1'0" 1'0" 2'41 4--0- 4'-6- 6'-6" 8'-6" 14. 230 ' 1'0" 1'-0" 1'0° 1'0" 1'-6" 2'0" 3'6" 6'-6" 1'0" 1._o.. '0" 1'-0" 2'-0" 4'-0" i 5'-0" 7'-0' 9'0" - -_- 360 l'0" ( 1'0" P-0" P-0" 2'-6" 3'4" 5'-6" Volt 1'-0" 1'-0" 1'0" 2'6" 5'6" 6'-6" 8'-0" 9'-6" 560 s 1'00" i 1'4" 1'-0" 1'-0" 2'-6" ( 3'4" 6'-0" 9'-0" P-0" P-0" P-6" 3'-6" 6'-6" 1 7'-0" 9'-0" 10'-0" 210 1'-0" i 1'-0" i 1'-0.. 1 P-0" P-0 P-0" P-6" 3'-6" _6'-0" P-0" P-0" { 1'-0" P-0" 2'-6" 1 3'-6" 6'-6" 8'-0" 110'-6" 16 230.' 1'-0" ' 1'-0" 1'-0" 1'0" 1'0" 1'-0" 2'0" 4'-0" 6'6_ 1-0" 1'-0" 1'-0" 1'-0" 3'-0" j 3'-6" T-0" 11'0" __ —_. _ 360 1'0" 1'0" 1'-0" 1'0" 1'0" 1'-0" 3'0" 6'-0" 9'-0" 1-0". 1'-0 1'-0" 1'0" 4'-0" 5'-0" 9'-o" 10'-0" 11'-6" 560 i 1'-o,, 1'-o" 1'-0" i'-0" 1'-0" 1'0" 3'-0" 6'-6" 10'-0" 1'-0" 1'-0" P-0" P-6" 5'-0" 6'-0" 10'-0" 11'0" 12'-0" Table B—Intermediate or Cantilever Support Minimum distance from edge of hole to inside face of nearest intermediate or cantilever support Depth TJI® ; 0 Round Hole Size �S uare orRectan alar Hole.Size 2" 3" ,;4,, .• 5,, BIA" 7 87A„ 11" 13": : 2- 3,,. , 4" 5..: 6w, .71,: J7A' 11" .• 131, 110 P-6" 2'-6" 3'-0" 4'-0" 7'-6" P-6" 2'-6" ' 3'-6" 5'-6" 6:4- F_ '-6" i 91h 210 2'-0" 2'-6 3'-6" 4'-6° T-6" 2'-0" 3'-0" 4'0" 6'-0" 7'_0" 23D 2'-6" 3'-0 4'-0" 5'0" 8'-0" 2'-6" 3'-0" 4'-6" 6'4" 7'4" f 110 P-0" P-0" P-6" 2'-6" 4'-0" 4'4" 8'-0" I 1'-0" P-6 2'-6" 4'4' 6'-6" 7'-0" 9'-0" 210 •_P-O 1' 0" 2'-0" 3'0" 4'-6" 5'-0" 9'-0" 1'-0" 2'-0" 3'-0" 4'-6" 7'-6" 8'-0"_ 10'-0" 11zA 230 : P-0" 2'-0" 2'-6" 3'-6" 5'-0" 5'-6" 9'-6" -- 1`-0" 2'6" 3'-6" 5'-0" Volt 8'-6" 10--o- .360 2'-0" 3'-0" 4'-0" 5'-6" 7'-0" 7'-6" 11'-0" 2'-0" 3'-6" 5'0" 1'-0" 9'-6" 9'-6" 560 -1'-6" 3'-0" 4'-6" 5'-6" Vol' 8'-6" 12'-0" ( 3'-0" 4'-6" 6'-0" 8'-0" 10'6" 111'-0 12'4" _ 110. P-0" f P 0" 1'-0" P-0" 2'-0" 1 2'-6" 4'-6" 8'-0" P-0" P-0" 1'-0" 1 2'4" 5'4' 6'-0" 9'-0" 12'-0" 210 1'-0" P-0" 2'-6" 1 3'6" 5'-0" 9'0" 1'-0" P-0" 24". 3'-6" 6'-0" T-0" .i 10'-0" 12'-6" _ 14°` 230 -0" P-0" 2'-0" 3'-0" 3'-6" 5'-6" 10'-0" P-0" P-0" 2'-6" 4'-0" 6'-0" 7'-6" 10'-6" 13'-0" 360 10" 1'-0" 2'-0" 3'-6" 5'-6" 6'-0" _87.6 12'-6" 1'-0" 2'-0" 4'-0" 5'-6" 9'-0" 10'-0" 12'-0" 14'-0" 210 P-0" 1'-0" 1'-0" 1'-0" P-0" P-0" ' 3'-0" 5'-6" 9'-6" 1' 1'-0'_ P-0" 2'-0" 4'-6" 5'-6" 9'-6" 12'-6" . —0. _ - —� 130 ;_1'-0" 114. 1'-0" P-0" P-6" 2'0" 4'-0" 6 6" i 10'-6" 1'-0" 1'-0" 1'-0" 2'-6" 5'0" 6'0" 10'-6" 13'-0° 15'-6" — __-__ _ ii 360 P 0 11 0' P-0" 1'-0" 3'-0" 4'-0" 6'-6" 10'0�j 13'-6" 1'-0" 1'-0" 2'-0" 4'-0" T-6" B'-6" 13'0" 14'-6" 1T-0" 560 1'-0" 1'-0" 2'-6" 3'-6" —7'0---,11'0" 51i 0 1'0" 1'0" 3'6" 5'6" 9'-0" 10'-0" 14'-6" 16'-0" 18'-0" ��-- • Rectangular holes based on measurement of longest side. DO NOT How to Use These Tables General Notes cut or notch flange. 1. Using Table A,Table B,or both if required,determine the hole ■ Holes may be located vertically anywhere within the web.Leave shape/size and select the TJI®joist and depth. lib"of web(minimum)at top and bottom of hole. 2. Scan horizontally until you intersect the correct hole size ■ Knockouts are located in web at approximately 12"on-center; column. they do not affect hole placement. 3. Measurement shown is minimum distance from edge of hole to ■ For simple span(5'minimum)uniformly loaded joists meeting DD NOT support. the requirements of this guide,one maximum size round hole cutreinf holes incantilever reinforcement 4. Maintain the required minimum distance from the end and the may be located at the center of the joist span provided that no intermediate or cantilever support. other holes occur in the joist. ■ Distances are based on the maximum uniform loads shown in this guide.For other load conditions or hole configurations,use TJ-Beam®software or contact your iLevel representative. iLevel Trus Joist'TJI"Joist Specifier's Guide TJ-4000 February 2009 �.� FEB-13-2009 06 :25 PM LARRY 06DEN 978 352 2858 P. 01 I LAWRENCE H.OLDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978452-8318 fax 978—352-2858 eell: 978-5022-5921 February 13, 2009 Mr. Chris Smith . Steeplechase Builders 153 Maple Street Methuen,Ma. 01844 RE: Figler Residence, 14014ickory Hill Road,North Andover,MA. 01845 Dear Mr. Smith As you requested I visited the project 2/13/09 to review the LVL members,steel beam and TJI Joist used in the framing of the addition to the above residence. These are shown on a Drawingsl thru 5 Dated 11/28/08 prepared by Steeplechase Builders with the framing plans sheet 4815 and certified by me 12/1/08. Based on these site visits I can certify that to the best of my knowledge the LVL, steel and TJI members utilized in the above structure are acceptable and meet the . loading conditions required by the 7'h Edition of the Massachusetts State Building Code. Should you have any questions please do not hesitate to call. �, y Yours truly, M OF oaf , �a uw /0.9 Lawrence H. Ogden,P.E. Structural 27765 °sosr�Nei NM,E I Date. . . �... . . . t �' 14, TOWN OF NORTH A'N° OVER PERMIT FOR PLUMBING 41 SA US This certifies that . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . &44k .(.N�w plumbing in the buildings off. . Fq.O-�.. . . . . . . . . . . . . . . . . . . . . at . 4.Y�. . . . 71 �. . . / �?�� . . . . . .,, North Andover, `Mass. Fe (/.Lic. No..,/.4 J a . . . . . . . . . . . . . . . . . . . . . . . . . . . . h PLUMBING INSPECTOR Check # J U 7997 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO P (Type or print) LUMBIlVG NORTH ANDOVER,MASSACHUSETTS Building Location J LA C Nl Cq,(7 C c l ��`\\ j Owners Name ( Date 9 Permit Type of Occupancy C- � Amount ��L New i Renovation Replacement ' Plans Submitted yes No ❑ FD,7URES o N � O U O q q a q O U O 134�1T 7ST IIDQ2 MELOCIR 1 i 33Ra li 41fri�t SH II0 CMPI sn�iT�t �R� FLOCR (Print or type) Installing.Company Name_ M- \ \ ��M(r �L Check one: Certificate Corp. Address CVS ti f \Vi 0 Partner. usmess Telephone 1 r Fum/Co. Name of Licensed Plumber. \ U\k q I Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indmani a ty Bond insurance Waiver. I, the undersigned,have been made aware that the lice three insurance nsee of this application does not have any one of the above Signature Owner I hEl ❑ Agent ereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with a1] pertinent provisions of the Mass ch se State Plumbing Code and Chapter 142 of the General Laws. By: brgnature r rcense um er Title Type.of Plumbing License City/Town I -\ Z rcense vumoer Master ❑ APPROVED ro�cE usE orvLY Journeyman Date. . .. . . .. . . .. .. Of NO oTM 14, o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION � 9 a �9SSACHO i This certifies that . . . . . . . . . . . .�. . . . . . . " . ... . has permission for gas installation . . . . . . . . . . . . . . . . . . . . in the buildings of . . . .� :. . !.: . '.r >1` -. . . . . . . . . . . . . . . . . . . . . 'At . . . . . . . . ... . .. . ..� '. . . . . . . . . . . . ., North Andover, Mass. Feer. . . . . . . Lic. No.. . . ./. . . . . . ��.. . !.Yr,�r. . . . . . . . . . . GASINSPECffbR Check# �. r 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING �s� . (Print or Type) - A-914 Mass. Date 2co-2- Permit # �D 9er's Narrf��i'.� / /Z— BundinLocation GIGhla s=' ZType of Occupancy New ❑ Renovation ❑ Replacement 2 Plans Submitted: Yes[] No ❑ y N W Y W N y y V Z W y ccF- x y ft N W O W J y W 0 V ~ = y W F' < ¢ Z 3 O 4C 0W �I W d 'C a W W = _ �. y O > W W W W J Z .< = W W W tt W ~ W O H Z J f' Z F� �W rA m Z 0 Z W O99 N = W < C W > IC WS < O O W dC x 0 d S 3 a tl V W > c d Mme- O it SUB—aSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name Z�AM MA TItj 2O Check one: Certificate Address 3 1QA C H M A ry 4—K. ❑ Corporation M " T H U E 0 J1 A U 1 kq q ❑ Partnership F,1rsiness Telephone /w 2 —(7 9"7 f @--firm/Co. Name of Licensed Plumber or Gas Fitter ' QfBE P_T A• 5AmM r9 i rq C-) INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.. Yes Ll' No ❑ If you have checked ve. please indicate the type coverage by checking the appropriate box A liability insurance policy 0"0' Other type of indemnity❑ Bond ❑ QWNER'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❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the peI ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of her laws. By T of License: L,t3 Plumber n ure of licensedu _ or itter Title tter er License Number 933 APPROVED O IC L Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE moo APPLICATION FOR PERMIT TO DO GASFITTING � I NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR OASFITTER LIG NO. PERMIT GRANTED DATE i 9_ OAS INSPECTOR s�•' 1 Use (Aly p- 77ie Commonwealth of Massachusetts M1•rrlc gin. l ' Department of Public Safety _Qi Occulaincy s ree Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12-00 3/90 ;Ira.e stank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Mauachusetu Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL ItTFORMATION) Date y-3_ City or Town of IVoRra Q A10,0 V,—,e To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) IA16 Owner or Tenant LeIAxlve .S.4O4 O Owner's Address SAME Is this permit in conjunction with a building permit: Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Utility Authorization 110. Existing Service Amps / Volts Overhead F1Undgrdl El t No. of Meters _ flew Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation of Alarm System No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners , Batter Emergency Lighting Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges Total No. of Detection and g No. of Air Cond. tons Initiating Devices No. of Disposals No, of Heat Total Total Pum s Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Water Heaters Signs f Ballasts ranLow o ge No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO ❑ I have submitted valid proof of same to this office. YES❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S /7,S Expiration Date Work to Start X/-R-990 Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME A.D.T. SECURITY -SYSTEMS NORTHEAST INC. LIC. No. 12310 Licensee DONALD A BROOKS Signat a N0, 1231C Address 60 William Street, Wellesley, 8 s. el. No. 413-732-4400 Alt. Tel. No. 617-431-5831 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or is sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent Ns-• 1 5 'i 9 Date.... 1 .....�..� f NpR7H "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 40 3ACHUS� This certifies that .......4.,..p J:....... .................................e60 ..... . has permission to perform ......A1 q.-!M.......... ... ................... wiring in the building of....rJ�? I O w5 ..1.................................................... at....../10...... / ..1 !d ...l.n�... ................... .North Andover,Mass... . g Fee.... , �sl..t.(X).. Lic.No...(...J[ ELECTRICAL'INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer / A Location No. Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ IL Building/Frame Permit Fee $ 7`, J Foundation Permit Fee $ %� Other Permit Fee $ • er Connection Fee $ 41, ,4 ion Fee $ C Building Inspector .,r a Div. Public Works 4 o f Location I rt, No. ��Z Date � �j NaR,M TOWN OF NORTH ANDOVER . p Certificate of Occupancy $ *_ Building/Frame Permit Fee $ 4 <� Foundation Permit Fee $ s�CHU Other Permit Fee $ Connection Fee $ I ,wa er nection Fee $ MAY � 1 �aL $ c� yaa, sv N0, -7 -`! T n t �-ARd�� rr�j0lle wilding Inspe6tor �toq_2 ,�r , `&411 A�4 �� Div. Public Works Location./`/^. /-1lfKl /.r� No. ' -= Date I ` "CRT" TOWN OF NORTH ANDOVER •,hoop ^� F „ Certificate of Occupancy $ Building/Frame Permit Fee $ PAItTon Permit Fee $ /r D- C D Other Permit Fee $ MAY 1 1 �bic%4r Connection Fee $ ter Connection Fee $ No.Andover lector $ /_S-0 ,D 3 r Building Inspector Div. Public Works PERMIT NO. �b L APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. / PAGE MAP 'VO. LOT NO. /L' 2 RECORD OF O NERS!21* iDATE5-� a� B K PAGE ZONE 2 I SUB DIV. LOT NO. 2 i- �- Im - ,LOCA iIONgi( r,A 1 ,o\ k PURPOSE OF BUILDING SI' It I' l �v►�"lQ� OWNER'S NAME -%,Dm3 as b, Z. O � `I IlO NO. OF STORIES Z SIZE 0W0 OWNER'S ADDRESS �y tA�oJ / Q ��j BASEMENT OR SLAB %SeWoo4 ARCHITECT'S NAME �1� AR br UI�O SIZE OF FLOOR TIMBERS IST 2%�O 2ND 2,910 3RD BUILDER'S NAME '��Oi�'I(A� 'yU, zo)AorLkI KO SPAN 1 moa DISTANCE TO NEAREST BUILDING .t Ij21 DIMENSIONS OF SILLS 21 2 x (' DISTANCE FROM STREET it 25 ) "' " POSTS X1,1;11 DISTANCE FROM LOT LINES-SIDES t 201 REAR y- IS'�i "' GIRDERS l`4) �f G VX11•I`D AREA OF LOT 221 oq S� • L FRONTAGE Iwo HEIGHT OF FOUNDATION 21 THICKNESS 'oil yesBUILDING NEW S SIZE OF FOOTING iS 2411 X foil IS BUILDING ADDITION �d MATERIAL OF CHIMNEY Ilre(-K 6`7 IS BUILDING ALTERATION 'Nn IS BUILDING ON SOLID OR FILLED LAND Sia` WILL BUILDING CONFORM TO REQUIREMENTS OF CODE y�s IS BUILDING CONNECTED TO TOWN WATER yeS BOARD OF APPEALS ACTION. IF ANY `,1A / IS BUILDING CONNECTED TO TOWN SEWER yes IS BUILDING CONNECTED TO NATURAL GAS LINE eS INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 REGULATED BY PARA: 112.7 S.B.0 EST. BLDG. COST PER SQ.o PAGE 2 FILL OUT SECTIONS 1 12 DATE: 5-11-"12-FEE PAID: 100, W EST. BLDG. COST PER ROOM - T • SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING - 4' APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULA IL PLANS MUST BE FILED AND APPROVED BY, ILDING INSPECT MIT FOR FRAMUBUILDING DATE FILE. /L�r DATE:�_FEE PAID: BOARD OF HEALTH SI ATURE OF OWN OR AUTHORIZED AGENT FEE 77i,. 0 PLANNING BOARD PERMIT GRANTED t9 1 0010© DUE FRAMMM- ILAZL go BOARD OF SELECTMEN OSS 4 0 Cs�rc�aC11vc5 P1�ohe�k 5��-31�-1'ib7RM PERMIT FE" 7 - 6Ww15 N"t &M FDA FEE_ BUILDING INS OR DAME PERN40 (,r:, (, �. ��, `�. r ', ; - i 11',•1 ¢• •!. ♦S ls •x•: ti • BUILDING RECORD 1 °QCCUPA'NCY SINGLE FAMI,L f.,i STORIESr ' THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ' dFNCES - LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSE.� S.Rrk86QQWPLOT PLAN. CONSTRUCTION r �Us 2 FOUNDATION 8 INTERIOR FINISH CONCRETE �I d t 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER y—_ _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ '/, a �/ e--_ FIN. ATTIC AREA NO BMtT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOA DS 8 t 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMMCN _ VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME I �( BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME I CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ ADEQUATE I \/I NONE 5 OOF 10 PLUMBING GABLEHIP BATH (3 FIX.( v GAMBREL MANSARD TOILET RM. 12 FIX.( FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY j WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ tP TAR & GRAVEL STALL.$NOWER ROLL ROOFING MODERN FIXTURES TILE'F!!OOR' I t Ift„ TILE DADO 6 FRAMING I 11 .HEATINP t WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER B & LS. STE M . PM STEEL B & OL L . HOT W'T'R OR VAPOR WOOD RAFTER AIR'.ON `ITIONING� RADIANT* H'T'G i t UNIT HEATERS l 7 NO. OF ROOMS GAS, of r B'M'T ^ 2nd ELECT4t9 1st 3rNOI NO HEATING ; V HWAL ' cs NO R T1y Town of 0 ndover 0 No. 6 2 .y �. . IVAY ENTRY PERMIT - er, Mass 1 2. oR ?� SS BOARD OF HEALTH PERMIT T, LO . THIS CERTIFIES THAT.�olO.x .....OVA_ W.'10'eular(I•.••••. BUILDING INSPECTOR L k�0 �• O 'Wf" h. ... Rou has permission to er .. di on g • Chimney to be occupied as..% ....P�� ............. Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY Final VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA: 112.7 S.B.C. PERMIT EXPIRES I jO.NTS DATE: FEEPAIG: 100. e ELECTRICAL INSPECTOR Rough UNLESS CONS U C iH T Service PERMIT FOR FRAME/BUILDING Fina' Awo .. ...... .... BUILDING INSPECTORQF GAS INSPECTOR :DATE: "tLt-12-f EE PAID: ( " Occupancy Permit Required to Occupy Building Rough SM PERMIT FEE 5//, O 0 Final LES&FU FE Display in a Conspicuous Place on the P 6 00 PERMIT $ 6`� ' 00 - FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. ell) Building Inspector iQ NORTH F own of _ 6Andover No. O960 v f W/a9cENl - K er, Mass., 19 92 . C ME AOR SS BOARD OF HEALTH PERMIT T L THIS CERTIFIES THAT........ .. ••• •.4..6<. /........�`!�•u ��..... .'.... / ah NSPECTOR has permission to erect .... ................. ;i!�� buildings n ....f. .. ... Ro;otC im tobe occupied as........ . .� ..... .. ..� . . . ............................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in i PLUMBING INSPECT04 this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of ;1 Rough Buildings in the Town of North Andover. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICALINSPECTOR Rough UNLESS CONSTRUCTION STARTS Service .�. ... &Ad44- •21". .. n •r` • BUILDIN64NSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough incl �j I G Display in a Conspicuous Place on the Premises FOE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector Location No. Date N°RTS TOWN OF NORTH ANDOVER OA1 „ Certificate of Occupancy $ Buildi g(F d,Permit Fee $ Fo0ation Permit Fee $ - -- OthnIP4A'�� rre $ �vf Sewer Connection-Fee $ � t•.� 4/yF• - W!aterCorinection Fee $ " TOTAL Building Inspector Div. Public Works Town of, ;l 11{.l)IN(� .• ..,, , NDU` 1^ 1� hl:I}; ::IIltr;i•II';II•Ittl :()Nti1'.I tV/ TION I II\•I';II IN I IF (l i l ill i!(!i-17 d-5 Ii:i\1:1'I i d 'i.�\NNINc� t'1,�1NNIN(; t� (;0111hI1!N1'1-Y UI;VI:I.O1'1\1liN'1' I:AHI:N 1 I.I '. NFLSO )N. IllIW(:•I OIt CHIMNEY APPLICAHON ANO I'L13111' ,TE CATION G AVER'S NAh1E: ILDER'S NAME: • ' ' �C�iyi �����/�� SON'S NAME: SON'S ADDRESS: �� �o� ���� �1 e� SON'S TELEPHONE: �_ FERIAL OF CHIMNEY: FERIOR CHIMNEY: LXILRIOR CHIMNEY: 'ABER AND SIZE OF FLUES: ICKNESS OF HEARTH: U ewunney un. OvAepCace con(jan111 to .tlte. Imimi)(emelt•t:3 u() .the curie and have '(u(n and gu,e•atialv6 been neeei.ved: NATURE OF MASON: zz RM11` GRANTED: 9'L 1:LE BERT NICETTA ILDING INSPECTOR 3PECTEU: 1ARKS: SOLID BLOCK REQU1RE'U r THIS PERMIT MLISV GE O1SPbWL0 ON IIIE PRUAISLS FOIUI U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION � ASSESSORS MAP P(CL� t wit SUBDIVISION LOT(S) PERMANENT ADDRESS SIGNED BY D.P.W. STREET ( ►-() JyD I�n 1G�t�ye/r i APPLICANT 11orna.. Zak D r ut i Ko _PHONE S09 26 2 DATE OF APPLICATION _q TOWN USE BELOW THIS LINE ; PLANNING BOARD Ilk DATE APPROVED �j�� •�("� TOWN ANNER DATE REJECTED CONSERVATION CODIRISSION DATE APPROVED f �Z CONSERVATION ADMIN. D REJECTED BOARD OF HE H DATE APPROVED ` HEALTSANI AR /� DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT O R' YX 2- SEWER/WATER CONNECTIONS �/L1L S `�` Zl, qZ- I FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE - �� This form shall be signed by the agents of tiie Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. A L-.t p - l�l o ov E-r-, W,a oow 2 0 u OF l'yG ILES H 0 0.1397 � U •�, �Fs�S1E�Eo N ZZ,o9SS.F- N Q� 0 \90 t1 t�p' oel 8 Zo.e \v2 I6 Q t6v ------------ \ I \ o0 S Ger � Location 0 / No. Date f NORTH 9 TOWN OF NORTH ANDOVER F 0� Certificate of Occupancy $ Building/Frame Permit Fee $ 4 �' b'�^••'';� Foundation Permit Fee $ ��snc'usa } Other Permit Fee $ 044Sewer Connection Fee $ �11 fl Water Connection Fee $ TOTAL $ I Ing Ins for Div. Public Works I c Location/VO /G1��� %L�- /e\L Xo F z-I No. Z Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ zr Building/Frame Permit Fee $ �+ us`� Foundation Permit Fee $ /��� 00 cN Other Permit Fee $ Sewer Connection Fee $ a Water Connection Fee $ TOTAL x Building Inspector 5171 Div. Public Works HWAL CONSERVATION FIHAL )4 NORTH — ` Town of Andover 0 toNo. s - /�J1JP T '�ER���T - q y1■s�.(`=`K .`M■aer• Mass ` j'iqI Y W V AY EN A C CMI-HE WICK J oR pR` BOARD OF HEALTH PERMIT T LO . Y TI�o., t ..... ..�,�/�., lira........ THIS CERTIFIES THAT... . ! • •� � BUILDING INSPECTOR Al has permission to erk�j0.. . . Aj&ALildings on/.V41.NfC#f W,APW...k Rough 5�AW a�.....,r'Amt lwy. P. Chimney y to be occupiedas... ••••• •••••••••••' Final provided that the person accepting this permit shall in every respect conform to the lierms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY Final VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA: 112.7 S.B.C. PERMIT EXPIRES I ONTHS DATE: FEEPAIG: ELECTRICAL INSPECTOR Rough UNLESS CONS- UC ST T Service PERMIT FOR FRAME/BUILDING Final .. ...... ..... GATE. _.__—FEE PAID: _ • ......•••. BUILDINCT G INSPEOR GAS INSPECTOR Rough t, Occupancy Perivit Required to Occupy Building 8W. PERMIT EEE$ //' ° a Final Display in a Conspicuous Place on the P £ 00, �oo NMW PERMIT 6 ___. FIRE DEPT. Do Not Remove Burner r No Lathing to Be Done Until Inspected and Approved by Smoke Det. R Building Inspector JUN 1612 I I iN G F;Er ARI tfl'N T i i „i I N 1 �dT 2 o j �� IF�o.� o � 1 o o ► _- 2s•o� a cad.00 a; G�iZ-T11`�/ TH t✓'�1S T SitesuM's►J ONWLAI=b'It. -r" �tA`1�H Of THS oF"�,5�2."C"S l�"'►w�"C. O1c' 't""N1� '�VttrL7t►..fC�s Xu5 � � � c' lrlakl L.1 .'Y'�°!.�l.+rt►n.J i7C'L"t e5�..1 O�' 1�.eti A.� ��,►Qir �T'ti � „�,�;, W rrH —i'FIEZ-o►.1�uCs � . F 2�-� L.A�1 S o f= C d�+�o�.M -�-`s� �2. 1.10►,1 Co�-A o C--U CouS'T'1-uc.-rE,t7.. if 5142, i . CERTIFICATE OF USE & OCCUPANCY Vown off North Andouag, Building Permit Number 1 6 2 Date AUGUST 25 , 1 9 9 2 THIS CERTIFIES THAT THE BUILDING LOCATED ON 140 H I C K O RV. HILL ( L o.t # 2 1 MAY BE OCCUPIED AS SINGLE FAM 1.L V DWELLING IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. NORTH 32otzlED 6gtio� CERTIFICATE ISSUED TO T h o ma z D . Z a h o 4 u i k o A 185 Hickory Hitt Road _ r ADDRESS Noath Andover MA SSAE Bui ing Inspector I I A ORT Town of 0 n over No. ^A A% D,i:jjV5 V�'AY ENTRY PERMIT A -rA er., Mass BOARD OF HEALTH PERMI THIS CERTIFIES THAT...W. TM ..... ............ BUILDINGkINSPECTOR & 1b 'I has permission to ere%4010..#AF7!2W(LJWAAjAAWfuildings on/.VO NO Rough "4 le, Chimney4 ai_0 A-a y 7� to be occupied asASIMailliff.....pbA. 141.1ilry....P.&. 1 ............. Final provided that the person accepting this permit shall in every respect conform to the t!erms of the application on rile in (Y - PLUMB I INS 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. PERMIT FOR FOUNDATION ONLY VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA: 112.7 S.B.C. PERMIT EXPIRES I ONTH S DATE:-L-11-1-2-FEE PAID: IC0. e ELEC?fl A IN ECT Rough UNLESS CONS UC ST ARTS Service PERMIT FOR FRAME/BUILDING Final 0/C. 7— DATE: 6 kZ2_)J E E PAID: BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building . 7 Rough clll� BLDM PERMIT FEE$_7 Z/., 0 0 1. /LA� Display in a Conspicuous Place on the PftVf E / 00, 00 -PERM1T ► s 6 V1, 00 6�q- I FIKE DEPT. Do Not Remove Burner 6,4 rA P ;PF, Z-11" I No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector i 0 7170- ,4�4i �� Lj— BUILDING PERMIT o`"I-oT"pro TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - 1.� Permit No#: I Date Received j �gSSAC HU5���� Date Issued: / IM ORTANT: Applicant must complete all items on this page LOCATION qO -C-40Y /�'(/ rPrint � PROPERTY OWNER /� Print 100 Year Structure yesOno MAP PARCEL: _ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other .Septic ❑Well ❑ Floodplain. ❑Wetlands ❑ Watershed Distract. n Wafter/.Sewer DESCRIPTION OF WORK TOE PERFORMED: (A 6 o nA SeCoAf Identification- Please Type or Print Clearly OWNER: Name: �ey)a )C:�'Sler Phone: Address: yU ` Contractor Name: ,E✓i ifi on Se i Phone: e- 1Y7d:—� /,S-- Email: r, e c- �o Address: o° Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ AW. FEE: $ Check No.: eceipt No.: 9 NOTE: Persons contracting with unregistered contr s do nit/�'/ acc to tke guaranty fund M _ _- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swil"ming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. El permanent Dumpstex on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS WEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes F tanning Board Decision: Comments conservation Decision: Comments Water& Sewer Connection/Signature nate Driveway Permit DPW Town Engineer: Signature: Located 384 F�IREDEPAR�TMENT ,, ,rnpDumpster on,s�tex�,yes":-1n�� Osgood odStreet Te R ,} ,y go tLocatedat124Main�Street• .,�` 's � � 7;- . r" ' ,�. :,rSci, aat , � �; ,�,w - .._,�., ,.m_� •f r"Fµ.,.•'P° `.i �"� ,v„ w •.lU.lir'',:.^ �Z.-"t '',rti�tx s h`l t;' sti, ;�'�M S _. .t. - =Firbet' ID— '1Z �epa ,s`z si1• � � L '' 7 k`�4 = ��• ` .��R Y!� � �� I�`t� `.f� �Y '�[ rt?'?' ,, T •: ` 4 ' , e li a<r 4,..�'�=r. •Y i it ,« ,� .��, COMMENTS:- ..} .4r+Y t..tit �• c�� ` r '? Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA,— (For department use) ® Notified for pickup Call Email Date Time Contact Name I Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4, Building Permit Application 4. Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location d4,te�A No. Date • - TOWN OF NORTH ANDOVER . Certificate of.Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector � own o � ...: .X10 R:TIi :�A% ndover No. - 0 h ver, Mass, 2k.2ol�p A.r COCNICMNWICK 1' x.45 RArED U BOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT '••••••• ••��•••••�... �........... ....... BUILDING INSPECTOR has permission to erect .... buildings on 1140.-6.1 �" I Foundation ................. ..... • r................. ... to be occupied as .... ......... l....6� ....��. �....��.. t........ hRough �� d��. m• provided that the per on accepting this permit shall in every respect conform to the terms of the application Chimney on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 0PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR ®' UNLESS CONSTRU ON 4RTS Rough Service ........ ... ...................................... BUILDING.INSPECTOR, Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. � NORTF•r Town of ndover I •• L No. 4 400,2 1.0 dow ah ver, Mass, t.%0W. 28 o L,.K. 1, cocmlc Ml WICK �.90 RATED NPP,`,�5 tl BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ ..ewe..... ... ............... ....... ..................... ... . ................. BUILDING INSPECTOR has permission to erect buildings on ..� � � Foundation �� Rough to be occupied asP& I . ... ........ Chimney .... ...... .............. ........ ..... ...... provided that the per on accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR _ 4 ®' UNLESS CONSTRUF20N RTS Rough Service ........ ... ............................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. i Erinna Construction Services Estimate Ph: 978-478-8215 Date Estimate# 583 North Broadway Haverhill, MA 01832 1/14/2016 1 978-478-8215 Customer Job CS-066182 Elena Figler Figler Bathroom Customer Information Elena Figler Ph:781.234.4563 W:978.682.7689 Em: Elenashana@hotmall.com 140 Hickory Hill Road North Andover, MA 01845 Description Qty Rate Amount The customer will provide all fixtures and finish materials such as: cabinets, mirrors,faucets,tiles,grout, paints,tub and tub surround, toilet,paints,etc. Erinna Construction Services will provide actual construction materials such as underlayment,2x4's, drywall,joint compound, trim, etc. All paints and painting is by others and no estimate is given for paints or painting We will provide an additional$100.00 promotional discount to the customer which will be issued in the form of a rebate check at the conclusion of th job. This estimate is valid until February 1,2016 abd may change after that without warning. Permits for carpentry and plumbing for the second floor bathroom 2 Set-up to protect the floors along the walk path 1 Cleanup and disposal of debris offsite 1 Demolish bathtub 1 Demolish bathroom floring 1 Demolish the above bathtub 1 Demolish bathroom cabinets 1 Repair drywall as necessary 1 Install new two piece tub and shower walls-Provided by others 1 Page 1 Erinna Construction Services Estimate Ph:978-478-8215 Date Estimate# 583 North Broadway Haverhill, MA 01832 1/14/2016 1 978-478-8215 Customer Job CS-066182 Elena Figler Figler Bathroom Description Qty Rate Amount Install new Hardibacker board underlayment on bath floor 1 Install new floor tiles and grout- Provided by others 1 Install new tiles and grout above the tub walls- Provided by others 1 Install new cabinet,sink, and faucets- Provided by others 1 Install new toilet- Provided by others 1 Install new mirror or mirrors- Provided by others 2 Install two new wall sconces above the mirrors in the bathroom- Provided by others 2 Install new colonial baseboard as needed 1 Existing wooden louvers in the bathroom is not to be painted Project material, labor Material, per job 1 2,175.00 2,175.00 Labor, per job 1 5,300.00 5,300.00 *Project Subtotal 7,475.00 *Project Total 7,475.00 6.25%Tax on Materials 1 135.94 135.94 *Tax Charges 135.94 Total 7,610.94 Page 2 CONTRACT PRICE PAYMENT: Owner agrees to pay Contractor a total price of Seven thousand six hundred ten dollars and ninety four cents Dollars ($7,610.94). The payment schedule will be(1)Down payment of$2,283.94 (2)Payment schedule as follows:$761 on the day we start work,$2,283 after demolition, 1,522 afterr the tub and flooring are installed,$761 after finish or substantial completion. $100 rebate to customer after finish and full payment. All payments will be made within five(5)days after billing.Overdue payments will bear interest at the maximum legal permissible rate,if any payment is not made when due,Contractor may keep the job idle until such time as all payments due have been made.A failure of payment for a period in excess of said five(5)days shall be considered a major breach. Contractor or Owner prior to commencement of construction and subject to lending institution(if any)approval,may request funds to be placed in an Escrow or Funding Voucher Control Service prior to commencement of work with funds to be disbursed to Contractor in accordance with the escrow instructions or voucher orders signed by the Contractor.In the absence of an Escrow or Funding Control Service,funds will be paid directly to the Contractor-in accordance with the progress payments schedule referred to above. NOTICE TO THE BUYER:(1)Do not sign this Agreement before you read it or if it contains any blank spaces. (2)You are entitled to a completely filled in copy of this Agreement.Owner acknowledges that he/she has read and received a legible copy of this Agreement signed by Contractor,including all Terms and Conditions herein included,before any work was done,and thathe/she has read and received a legible copy of every document that owner has signed during the negotiation. If owner cancels this Agreement after the right ofrecession has expired,and before commencement of construction,owner shall pay Contractor the amount of expenses incurred to that date plus loss of rofits. TERMS AND CONDITIONS The Terms and Conditions on the following are expressly incorporated into this Agreement.This Agreement constitutes the entire understanding of the parties.No other understanding or representations,verbal or otherwise, shall be binding unless in writing and signed by both parties.This Agreement shall not become effective or binding upon Contractor until signed by Contractor or a principal of Contractor.By Owner's signature below,Owner acknowledges receipt of a fully completed copy of the Agreement. THIS AGREEMENT CONSISTS OFFOUR PAGES AND ONE ATTACHMENTS X OWNERWYER SIGNATURE DATE X-ZT rCONT4-A-eTOR SIGNATURE OWNER/BUYER SIGNATURE DATE U. ©20COI8CAForrrts Page 2 g Iniis Dae Initials Date TERMS AND CONDITIONS ASBESTOS/HAZARDOUS MATERIALS or Owner's agent,acts of God,stormy or inclement weather,strikes,lockouts Owner represents that the property being remodeled does not contain asbestos boycotts,or other labor union activities,extra work ordered by Owner,acts of and/or other hazardous materials.This contract does not contemplate the public enemy,riots or civil commotion,inability to secure material through removal of,testing for appropriate corrective work and any other additional regular recognized channels,imposition ofgovermnempriority orallocation of expenses incurred by the corrective work, materials,failure of Owner to make payments when due,or delays caused by CONTRACTOR'S RIGHTS AND RESPONSIBILITIES inspection or changes ordered by the inspectors of authorized governmental 1. SUBCONTRACTORS.Contractormaysubcontmetalloranyportionofthe bodies,or for acts of independent contractors,or holidays,or other causes work. beyond Contractor's reasonable control. 2. Contractor shall have the right to stop work and keep the job idle if 3. Contractor is not responsible for matching existing paint or texture and payments are not made when due.Failure to make payment within five(5) further,there is no guarantee againsthairline cracks or discolorization in stucco days of the date that payment is due will be considered a material breach of this or concrete. Agreement.If the work shall be stopped for any reason,for a period of sixty OWNER'S RESPONSIBILITIES (60)days,then Contractor may,at Contractor's option,upon five(5)days UTILITIES written notice,demand and receive payment for all work executed and material 1. The Owner is responsible for water,gas,sewer and electric utilities,from ordered or supplied and any other loss sustained including Contractor's usual the appropriate agency to the metering device,unless otherwise agreed.to in fee for overhead and profit based upon the contract price. Thereafter, writing.It is the Owner's responsibility,at Owner's expense,to provide toilet Contractor is relieved from any further liability.In the event of work stoppage facilities,electricity and water to the site as needed by the Contractor. for any reason,Owner,shall provide for protection of and be responsible for, any damage,warpage,racking,or loss of material on the premises. ACCESS TO PROPERTY 3. Contractor,at Contractor's option,may alter specifications only so as to 2. Owner agrees to keep driveway clear and available for movement and comply with requirements of governmental agencies having jurisdiction over parking of trucks and other equipment during normal working hours.If Owner same.Any alterations or work undertaken to further this end shall be treated as denies access to any worker or material supplier during the scheduled working an Extra Work. hours,the Owner will be held in breach of the Agreement and will be liable for CONTRACTOR'S RESPONSIBILITIES AND LEWTED WARRANTY such breach. 1. Contractor agrees to furnish the materials for the project and complete the work in a professional manner.All materials furnished under this Agreement FINANCING shall be construction grade and meet industry standards.Where brand names 3. The Owner is responsible for having sufficient funds to comply with this have been specified,Contractor may select substitutes when such substitutions Agreement.This is considered in law,a cash transaction. are due to unavailability or other circumstances beyond Contractor's control. INSURANCE All substitutions shall be consistent in quality and character to the selections 4. Owner will purchase insurance at Owner's expense before any work begins. previously specified.The liability of the contractor for defective materials or Such insurance will have course of construction,fire,vandalism,malicious installation is hereby limited to the replacement or correction of said defective material and/or installation,and no other claims,or demands whatsoever shall mischief and other perils,clauses attached.The insurance most be in an amount m made on r i allowed at least equal to the contract price and provide that any loss be payable to the up against the contractor.This limited warranty extends Contractor.The insurance is to cover the Owner,Contractor,Subcontractor and onlmerchantability to weer and is not transferable. There is no implied warranty or Construction Lender in the amount of their respective interests. nor any implied warranty of fitness for any particular purpose. There are no warranties either expressed or implied which extend If the Owner does not purchase such insurance,the Contractor,as agent for beyond the description within this paragraph#1.This warranty shall terminate the Owner may purchase it and charge such cost to the Owner, one year from final building inspection or the date of the completion, whichever is first DAMAGE OR DESTRUCTION 5. If the project any portion of it is destroyed or dagedfire,storrn, Note that equipment,assemblies,or units purchased by contractor,included flood,landslide, or assemblies, theft,or other disasterr acccidents,bany work-done in this contract are sold and installed subject to the manufacturer's or by the Contractor to rebuild,etc.,shall be paid for by Owner as an Extra and processor's guarantee or warranties, and not contractor's. To the extent dealt with as herein provided for under"Extra Work". permitted by applicable law,all warranties given by manufacturers pertaining to materials used byto contractor in connection with the project will be passed wkfk In the event of any of the above occurrences,If the cost of replacement or , or work already done by the Contractor,exceeds twenty 20 through and inure to the benefit of owner. ty( ) ercent of p 2. Contractor shall pay all subcontractors, laborers and material suppliers. the contract price,the Owner has the option to cancel the contract but,if the Contractor shall,to the best of Contractor's ability, keep Owner's property Owner cancels, the Contractor shall be paid for all costs incurred plus free of valid labor or material suppliers liens. Contractors usual fee for overhead and profit for all work performed by Contractor to date of cancellation. ITEMS NOT RESPONSIBILITY OF CONTRACTOR I. EXISTING VIOLATIONS AND CONDITIONS.Contractor shall not be OWNER'S PROPERTY held responsible for any existing violations of applicable building regulations 6. It is the Owner's responsibility to remove or protect any personal property or ordinances,whether cited by the appropriate authority or not.Contractor is including,but not limited to,carpets,drapes,furniture,driveways,lawns,and not responsible for any abnormal or unusual preexisting conditions or any shrubs,and Contractor will not be held responsible for damages or loss of said unusual or abnormal concrete footings,foundations,retaining walls,or piers items, required,or any unusual depth required for same,such as,but not limited to that condition caused by poor soil,lack of compaction,hillside,or other slope BOUNDRY LINES conditions.Correction of such violations or abnormal conditions by Contractor 7. The Owner represents ownership of the property where construction is to shall be considered additional work and shall be dealt with as herein provided occur.It is the Owner's duty to point out boundary lines of the property and for under"Extra Work". Owner is responsible for the accuracy of such tines and how they are represented on drawings.If required,the Owner will pay for a survey to chart 2. DELAYS.Contractor agrees to start and diligently pursue work through to boundary lines. completion,but shall not be responsible for delays for any of the following reasons; failure of the issuance of all necessary building permits within a reasonable length of time,funding of loans,disbursement of funds into funding control or escrow,acts of neglect or omission of Owner or Owner's employees e, Cont' Terms and Conditions Page 3 Initials Da Initials Bate EASEMENTS,ETC. ADDITIONAL REQUIREMENTS FOR COMPLETION 8. Prior to construction the Owner is to give the Contractor a copy of any 5. Contractor shall promptly notify Owner of any additional requirements easements,restrictions or rights of way relating to the property.If Owner does necessary to facilitate the project's completion.Any subsequent amendment, not do so,Contractor will assume that none exist. modification or agreement,which operates to alter this contract,and which is signed or initialed by Contractor and Owner,shall be deemed a part of this ENGINEERING AND GEOLOGY contract and shall be controlling in case of conflict,to the extent that it alters 9. Unless specifically agreed upon in writing between Owner and Contractor, this contract. and made a part of this Agreement under "Description of Materials", "Specifications"or"Plans",this Agreement does not include any engineering EXTRA WORK or geology surveys, drawings, studies, reports or calculations as may be 6. The Owner and Contractor must agree in writing to any modification or required by a public body or building authority as a condition for issuance of a addition to the work covered by this contract.The Contractor shall do no extra building permit or as a condition to securing final building inspection.The cost work without the written authorization of the Owner.Any written agreement of any such required professional services shall be paid by Owner. shall list the agreed price and any changes in terms and be signed by.both OTHER parties.Failure to have written authorization shall not be deemed fatal to the DRAWINGS AND SPECIFICATIONS collection of the extra work. 1. The project will be constructed according to drawings and specifications For any extra work performed. Contractor shall be compensated in an that have been examined by Owner and that have been or may be signed by the amount to be determined before the extra work is performed and such amount parties to this contract.Unless otherwise specifically provided.Contractor will including Contractor's usual fee for overhead and profit shall be made as the obtain and pay for all required building permits. Owner will pay any extra work progresses,concurrently with payments,made under the payments assessments and charges required by public bodies and utilities for financing or scheduled. repaying the cost of sewers, storm drains, water service, or other utilities Any change-order forms for changes or extra work shall be incorporated in, including sewer and storm drain reimbursement charges,use fees,revolving and become part of the contract. fund charges,hookup charges and the like. STANDARDS FOR SPECIFICATIONS ITEMS EXCLUDED 7. If all or any part of the following is included in this Agreement under 2. Unless specifically agreed upon in writing between Owner and Contractor specifications,the following will apply:All cabinets to be paint grade,or if and made part of this Agreement,under"Description of Work","Description same is noted to be other than paint grade,to be of veneer construction.All of Material","Specifications",or"Plans",this contract does not include: cabinet doors to be lipped construction.All inside portions such as shelves, a. Plumbing, gas, waste and water lines outside foundations of existing bulkheads,and partitions may be of other species than exposed portions,but buildings or any required relocation or replacement of any such existing lines not limited to solid stock plywood,or particle board with fixed shelve without that may be discovered within the boundaries of any new ground floor addition backs.All plumbing fixtures to be white in color and selected by Contractor. All appliances and fixtures to be Builders models. Medicine cabinets to be b. Electrical service,other than addition of circuit breakers or fuse blocks to single,recessed,and metal.Tile,if ceramic,to be domestic,non-decorator, distribute electric current to new outlets; 41/e"x 4'/<". All fireplaces to be prefab with a metal flue. All extra materials c. Any work which may be required regarding cesspools or septic tanks. remain the property of the Contractor. If any of the materials used vary from d. Rerouting,relocating or replacing vents,pipes,ducts or conduits not shown the above,such variation must be agreed upon between Contractor and Owner, in writing and listed in "Specifications",or those encountered during construction or changes required to existing g this Agreement under Specifications , Description of wiring,vents,pipes,ducts or conduits in areas undisturbed by construction. Materials" or attached to this Agreement and initialed by Owner and Unless specified elsewhere, existing wiring and electrical systems are Contractor. represented by the Owner as adequate to cavy load for existing structure and CORRECTIVE WORK work to be performed herein; 8. If minor corrective or repair work remains to be finished after the project is e. Any additional work required for excavation or foundations due to completed,Contractor shall perform work expeditiously and Owner shall not inadequate bearing capacity or rock or any other material not removable by withhold any payment pending completion of such work.If major corrective or ordinary hand tools repair work remains to be finished after the project is completed,and the cost £ Any work to correct damage caused by termites or dry rot; exceeds one(1)percent of the gross contract price,the Owner may withhold g. Changes or alterations from the specifications which may be required by the work ent sufficient t topay for completion ana of the which irk, ing completion of any public body,utility or inspector. y greater, h. Painting,preparation, filing, finishing, grading, retaining wails,new or GENERAL relocating gutters and downspouts,screen doors,weather stripping,staining, 9. This contract, including incorporated documents, constitutes the entire seeding,landscaping,or decorating.Any work necessary to correct,change, agreement of the parties. No other oral or written agreements between alter or add the above items will be considered additional work and shall be Contractor and Owner,regarding construction to be performed exist. dealt with as herein provided for under"Extra Work". 10. This agreement shall be construed in accordance with,and governed by, MEASUREMENTS the laws of the state. 3. Measurements,sizes and shapes in plans and specifications are approximate NOTICE and subject to field verification.Unless otherwise specified,all dimensions are 11. Any notice required or permitted under this contract maybe given by exterior dimensions.In the event of a conflict between the plans,specifications, ordinary mail sent to the address of either the Owner or Contractor as listed in etc., and the Agreement, this Agreement is controlling. Contractor is not this contract,but the address may be changed by written notice from one party responsible for any existing illegal conditions. to the other. Notice is considered received five(5)days after deposited in the MATERIAL REMOVED AND DEBRIS mail,postage paid. 4. Unless specifically designated by Owner in writing,prior to commencement ATTORNEY FEES of construction, Contractor may dispose of all material removed from In the event legal action or arbitration is instituted for the enforcement of any structures in course of alteration. Contractor is to remove construction debris term or condition of this Agreement,the prevailing party shall be entitled to an at end of project and leave premises in a neat broom-clean condition. award of reasonable attorney fees in said action or arbitration,in addition to costs and reasonable expenses incurred in the prosecution or defense of said action or arbitration. Terms and ConditionsPage 4 4ni_tia*1sate Initials Date .he Commonwealth of t4lassachusetts Department oflndustrialAceldents r X Congress Street,Suite 100 n „ << Boston,MA 02114-2017 Workers'Compensation b1surance Affidavit:Builders/Con.tractors/Electrcicia:aslPlumbers. TO BE FILED WITH THE pERM1fTTING.AUTHOMY. Applxcantluformation Please Print Legibly Name(Btisinsss/orgauizationftdividual): rr;rl110\ (- )&CC- io n Address: SB 3 City/State/Zip: Ole ,)—Phone, Are you an employer?Chedkthe appropriate box: Type of project(required): 1.❑I am a employer with _ employees(full and/or pare tune)* 7. []New construction 2. I am.'a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. !__1 Demolition 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]f 10 0 Building addition 4.[]lam a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions .P-._ . ro'rretors with no employe --,.—�-- -•---�-----�---------f-----,---- . Plumbing repaus.or^ad tions- 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors bade employees and have workers'comp.insurance. 14.El Other 6.Q We are a corporation and its off gers have exercised their right o exemption per MGI.,c. 152,§1(4),andwe have nq employees.[No workers'comp.insurance required.] *Any applicant that checks Eox41 must also 1711.out the section below showing their workers'compensation policy information. f Homeowners who s6rri if{his a. -vit indicating they are doing all work andthea hire outside contractors must submit anew affidavit indicating such. entities have sheet showing the name of the sub-contractors and state whether ornot those n tContractors that check this boxmust•atfached an additional g employees. Ifthe sub-c6nlrac6s Have employees,they must provide their workeis'comp.policy number. X am an employer that is p/'dviding workers'compensation insurance for my employees'Below is the policy and joh site information. Insurance CompanyName: Policy##or Self ins,Lic.##: ExpirationDate: Xob Site Address: �0W,� r City/State/Zip: "i /� ( g�� ttach a copy of the workers' omtion policy declaration page(showing the policy ntumber and e7cpirataon ate). Failure to secure coverage as required under MGL o. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of up to$250.00 a day against the violator.A,copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Zdo hereby c nder thepainsandpen lues ofperjuly treat the informationprovided above is true and correct.Tature: r Date: V /1 U�r � v Phone##: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License## Issuing Authority(circle one): 1.Board of Elealth 2.Building Department 3.City/'T'own Clerk 4.Electrical Inspector 5.plumbinglnspector 6.Other Contact Person: Phone#: Information and. Instructions Massachusetts General Laws chapter 1.52 requires all employers to provide workers'compensation,for their employees. - Pursuant to this statute,an employee is defined as"...evexy person in the service of another under any contract oi?l;ire, express or implied,oral or written." An employer is defined as"an individual,pfttuersliip,association,corporation or other legal entity,oz 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 ofthis chapter have been presented to the contracting authority." .Applicants Please fz1X-out the-workers'compensation affidavit completely,by cheeping tha 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 insurane. —ldmited Liability-C-ompanies-(.LLCror-L-imitezl L�abxlity l'a r�lu (LLF with no emp ogees o er an e members or partners,are notrequired to carry workers'compensation insurance. If an LLC orLLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents foi-confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The'afCdavit'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 regr#ed to obtain a workers' compensation policy,please call.the Department at the number.listed below. Self-iir'sured 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 suave to fill in the permit/license number which will be used as areference 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?.(ifnecessaty)and under"lob 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 0.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. � The Department's address,telephone,and fax p number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Suite 100 Boston,MA.02114-2017 Tel.#617.-727-4900 ext. 7406 or 1-877-MASSAFE Fax##617-727-7749 Revised 02-23-15 wwwmass.gov/dia U1ae �pop�so��zueat�a���ccaaac�cueti� ',' Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 135503 Type: xpiration: -4/9/2016 DBA ERINNA CONSTRUCTION SERVICES' i Ramon Erinna fV_ 583 NORTH BROADWAY;'�", HAVERHILL,MA 01832 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards ti License: CS-066182 ti�;rlS RAMON M ERHOk 583 N BROADWAY q . AAVERHII,L Mk Ol r Expiration Commissioner 04/16/2017 44 !fit MAsachusetts -Department of Public Safety j Bard of Building Regulations and Standards unraTii Cii0ir �u nCi vr�fii � License: CS-066182 r I's ori RAMON.M ERPOk M N SROADW4 3 HAVERHIILLMA 01 z Expiration 04/16/2017 Commissioner