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Miscellaneous - 1430 GREAT POND ROAD 4/30/2018 (2)
1430 GREAT POND ROAD 210/062.0-0026-0000.0 r r- Date.?&./`��.......... of pT"�ti TOWN OF NORTH ANDOVER ° { 9 PERMIT FOR PLUMBING Ij-This certifies that..!�!"' �... ``�.. `.�'...... . ............................................. has permission to perform....�� k b .............n................ ........ ...................................... ........... plumbing in the buildings of tI�,CJtOv'J at.......... Lv ( � PJ .... .......................................................... . North Andover, Mass. Fee..... _ Q.'.....Lic. No. �. �..... ................................................................................. PLUMBING INSPECTOR Check# d ' r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESSOWNER'S NAME U P OWNER ADDRESS ' TEL FAX F -- -- TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL Q PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOQ p_ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 �, 1 BATHTUB w CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM - DISHWASHER 3 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I! ';JAL SHING MACHINE CONNECTION 4JER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc e o e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Gene Jagimnas LICENSE# 8820 NATURE MP❑ JP❑ CORPORATION❑# 3677PARTNERSHIP❑# LLC❑# COMPANY NAME New England Bath Inc DBA Bay State Rebo++ ADDRESS I 55B Corporate Park Drive CITY Pembroke I STATE Ma ZIP 102359 TEL 781-826-4141 FAX 781-826-2333 CELL 508-274-0883 EMAIL info@b ay staterebath.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# i PLAN REVIEW NOTES iock4w OW I �AC R® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYV) 11/27/2013 TH,I,S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Select Dept ext 66807 Eastern Insurance Group LLC-Main PHONE _653-8089 233 West Central Street E MAIi E 1-77 Alc No Natick MA 01760 ADDREsssele twork easteminsurance. om INSURERS AFFORDING COVERAGE NAIC# INSURER A:SeleCtiVe Insurance Co of SC 19259 INSURED 29660 INSURER B:PI mouth Rock 14 7 New England Bath, Inc. INSURERC: Bay State Re-Bath INSURER D: 55 B Corporate Park Drive Pembroke MA 02359-1966 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:328908032 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 I TYPE OF INSURANCE ADD L BR { POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD MM/DDM/YY A GENERAL LIABILITY IY Y S 1959417 112/2/2013 12/2/2014 1 EACH OCCURRENCE $1,000,000 I- DAMA X COMMERCIAL GENERAL LIABILITY I I PREMISES Ea occurrence $100,000 CLAIMS-MADE j1 OCCUR 1 I i MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 i I i { � GENERAL AGGREGATE $2,000,000 j GEN'LAGGREGATE LIMIT APPLIES PER: I i I PRODUCTS-COMP/OP AGG $2,000,000 POLICYX PROJEC- X LOC I I I $ B AUTOMOBILE LIABILITYPRC00001001800 10115/2013 �t0115/2014 Ea accident S1,000,000 { ANY AUTO I I 1 BODILY INJURY(Per person) 5 ALL OWNED j�SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS i 1 NON-OWNED i i �I PROPERTY DAMAGE $ HHIRED AUTOS I X i AUTOS j I Per accident A {X {UMBRELLA LIAB XOCCUR Y {Y S 1959417 12/2/2013 12/2/2014 EACH OCCURRENCE $1,000,000 EXCESS LIAB i CLAIMS-MADE i I AGGREGATE 51,000,000 DED X RETENTION$10,000 5 WORKERS COMPENSATION i 1 { TWOC STAT- OTH-� rR AND EMPLOYERS'LIABILITY YIN 1 I 1 ANY PROPRIETOR/PARTNERIEXECUTIVE F7 E.L.EACH ACCIDENTS OFFICER/MEMBER EXCLUDED? I N/A 1 i (Mandatory in NH) I I { E.L.DISEASE-EA EMPLOYEO S If yes,describe under ! 1 I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ l DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) fl "fl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN New England Bath Inc ACCORDANCE WITH THE POLICY PROVISIONS. 55B Corporate Park Drive Pembroke MA 02359-1966 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD LL/ L / zuiJ7 1) : 4U : 01 !'Ivl V1 U W vim: v� • '�'��� DATE(MMIDDIYYYY) I ,�"arc' CERTIFICATE OF LIABILITY INSURANCE 1210212013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 04331-001 INAMEACT Eastern Insurance Group LLC i AICOIi0.E„d: (800)333-7234 ;tafc.No.: (508)653-8089 233 West Central Streetass. eDocs@easteminsurarrce.com Natick,MA 01760 INSURER[SI AFFORDING G�YERAGE NAIC, '__• INsu RIMA. A.I.M.Mutual Insurance Company (( 33758 INSURED --- --- �INSURER a: I New England Bath Inc Bay State Rebath WSLREFt C. 55 B Corporate Park Drive INSURER 9• Pembroke,MA 02359-1966 WSURM c• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.pp ILTRI D -SUe POLICY NUMBER Map PMIO NYYV LIMITS TYPE OF INSURANCE II .Yus GENE RALLIABILITY E4,-;r.:}CCUR�E•CE T i .-- — 1 Eris afl 5 E�Avv c 5 4,� 3Eo i,_u:-aa_a n y I( I{f 4( I AUTOMOBILE LIABILnY VA'I. StMrsl=tl�1 { I � �.'xrci�ntl z REQ UMBRELLA LIAR ` —•.El(CESS LIAR ( _ .r,CE I I �,� ,r;A— 1' i,l CYOhRFNSAT O (X+AMNOO�0 BI_lpf 1 A��?.�PRIFTOk F hTnlp F(F v'!`�E"N ' $ 1,000,000.00 A to AWC4 -703006-203A 121212013 1212/2014 NI i rA,E _ 1,000,000.00 t(Mandatory in NHI Hs,das nba�n e 1 1,000,000.00 i i I DESCRIPTION OF OPERATIONS f LOCATIONS(VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Now England Bath Inc 55 B Corporate Park Or SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Pembroke,MA 02359 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE < Ir rr? 0 1988- 010 ACORD CORPORATION.All rtghts reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1646 • ==— Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,I A 02114-2017 www mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plu.mbers imUcant Information Please Print - ...v Name (Bureau.�rt}r;an�zatromtndiviauall. NEW ENGLAND BATH, INC. dba Bay State Re-Bath Address: 55B Corporate Park Dnve City'State/Zip.Pembroke, MA 02359 Phone#:781-826"4141 Are you an employer' Check the appropriate bog: Type of project(required): I.Q I am a employer with 25 4, ❑ I am a general contractor and 1 6 Q New construction employees(full and/or part-time).* have hired the sub-contractors 2,❑ I am a sole proprietor or partner- listed on the attached sheet. 7, Q Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9 Q Building addition [No workers' comp.insurance comp.insurance.t required.] 5. Q We are a corporation and its 1o.❑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 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13'0 Other comp,insurance required.] :Any applicant that checks aox?kl must also fill out the sectim below showing their workers'compensation polieY information Homeowaets who submit this affidavit indicating they are doing ail work and then hire outside contmaton must submit a new affidavit indicating such. tContmctors that check his box must attached an additional sheet showing the name of the sub-contractors and;tate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number- lam an Employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information, [nsurance Company Name-. A.l, M. Mutual Insurace Company Policy g or Self-ins. Lic.g. NNC-400-70300046-2013AExpiration Date,12/02/2014 Job Site Address: City%State/7–ip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 ancVor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250-00 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- r do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature_ r Date: Phoneq. 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): L Board of Health 2. Building Department 3,City/Town Clerk 4,Electrical Inspector a, Plumbing inspector b.Outer Contact P,,r,o a• Phone g° —_--- i - la. I I 17 Ibp t.4 �. It w f�"�✓va a��� � � its}.� ,�It)p ,� �1� cy, r r r'A � ..�*t3 �� rs I' 1'' _y t.t' ,A,rEe 0. F ;5 '•d� _..lfl "...`�+a .;�� / ��rr'� t'4r� r �t � `} 11�. 1 •+ s.; t . £.���y 3tl93 - 'SP. f _�k5ry�. �c rI� 34r, z t,+r i s 4 � IL t� 4't'�y i 9 e'+►' w � �r + sltl j '� (},. �.. fi. - � I l B ,t I ^7Y`� E� �n2`lw Q �'�ss-4 k � '*4'�� t, _ r rll •mli i .n. �� �� � �il c-.� �*° �.� m ��>; 7{ "r"'•. c� �...� .*xa _� IUt� ,z i I .. Vf�4<d, L.i� ��� tom, �.i Date.... �1...r/ l�y ..... ......................... NOw7h TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 16 This certifies that41. .............................. ............................................. has permission for gas installations r% ................................................ in the buildings of.............. . ............ ... ............................................................... .......... ......��..�.. ...� ZNK) h "'n over,Mass. Fee•-�.,.0�.... Lic. NofY.11.G....... ;- GAS INSPECTOR Check# ra e� r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY L___Wof d MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME QCG__ OtA�P.Y C GOWNER ADDRESS IQ 2 1+j I_I d V AVf_ TELL(/03-39 y 217fr'jAXG_.._�� TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL L] RESIDENTIALR CLEARLY NEW:W—RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO APPLIANCES Z FLOORS- BSM 1 1 2 3 4 5 6 1 7 8 9 10 11 1 12 13 14 BOILER BOOSTER I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER r DRYER FIREPLACE FRYOLATOR FURNACE i GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS — MAKEUP AIR UNIT -- OVEN QPOOL HEATER ROOM/SPACE HEATER11 IR ROOF TOP UNIT f TEST r-- -- -- UNIT HEATER i UNVENTED ROOM HEATER 1 i WATER HEATER `---- OTHER r i C � INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES dNo ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1� OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 pro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME , LICENSE#30 i SIGNATURE MP❑ MGF E❑ JP❑ JGF❑ LPGI[ CORPORATION 6 I 4-C PARTNERSHIP 0# LLC❑#�� COMPANY NAME: =���y��, ADDRESS q I I U I d st CITY STATE M ZIP I Qj TEL r, $��.3 ( —a2 q FAX q g:S3I'N32 CELLI EMAILL �'{} n I q� ( n-0( 1— co M The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Holden Oil, Inc. Address:91 Lynnfield Street City/State/Zip:Peabody, MA 01960 Phone#:978-531-2984 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 45 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P n'• $ 9. E]Building addition � [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 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.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no q ] employees. [Nb workers' 13.0 Other gas fitting . comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. Insurance Company Name:HDI Gerling America Insurance Co. Policy#or Self-ins. Lic. #:EWGCD000014513 Expiration Date:12/31/2014 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 ce ' der theaimsar d p na ties of perjury that the information provided above is true and correct Signature: Date:01-06-2014 Phone#: 9785312984 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#: Date...!.........1 .......................... V OF NORrh,� o?; oo� TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING # A�� cMu Thiscertifies that ............................... ................................................ ......................................... y bas permission to erformPti�� '` - / P P .....�..................................................................................... wiring in the buildin of.................'.....(.u.��Ua^� .................................................................... at ................. '......,N h Andover,Mass. / .............•�a.. ........�................ �[ — Fee....1...�.......Lic.No.`:...� .! / / f' j.................................. .. . ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked I BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: 3 / City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 14/30 Ce, n d -DiC, Owner or Tenant GGr Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building ,S' ON j,� r,r%.V,I Utility Authorization No. - Existing Service aC)C) Amps 1-16/.4oVolts Overhead R Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Lobation and Nature of Proposed Electrical Work: ��s /C/� ��' �...1 UY h��•G f� Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total t Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA f No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of EmergencyLigliting 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number I Tons KW No.of Self-Contained Totals: "" ... * "" 1* 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 Tres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that suchverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify,tinder tl ods andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: . e _ LIC.NO.: Licensee: t Signature LIC.NO.: (If applicable enter !'exem " r the ice a numb r line. Bus.Tel.No.. yvC) Address: o Alt.Tel.No.• ��6 *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 P ERMIT 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 1 notification of completion of the work as required in M.G.L.c.143,§3L. k 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 M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass EN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors CAents: Inspectors Signature. Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts ' �1rlt�Ft�r�ia xt Department of Industrial Accidents Office of Investigations 600 Washing-ton Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatian/Individual): Address: City/State/Zip: 0 Phone#: © t/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or pan-time).* have hired the sub-contractors 6. M New construction '.❑ I am a sole proprietor or partner- listed on the attached sheet. ?. E]Remodeling ship and have no employees These sub-contractors have $. ®Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9• Building addition required.) We are a corporation and its 102�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.❑Roof repairs insurance required.)t c. 152, §1(4), and we have no 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside cont actors must subrat 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. Insurance Company Name: Gots n1 n Policy#or Self-ins.Lic.#: 690 00 7 Expiration Date: A-54* Job Site Address:/ 30 Cr&>-7�90 j` IJV City/State/Zip: -NurAuy 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 S 1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify r t e p ' and Pena ' s of perjury that the information provided ve is rue and correct. Signature: Date: Phone#: 7OffficialTu.seonh'. Do not write in this area, to becompleted bi,city or town official n: 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#: a t 4 . I I I I i COMMONWEALTH OF MASSACHUSETTS • BOARD aF I ELECTRICIANS I SSUES THE. FOLLOWING L cENS'E AS � REGISTERED MASTER,..ELECTRICIAN - � I w TU I NICHOLAS LLY 92 HI,;LLDALE AVE '` . I :. SOUTH HAMPTON- NH 03827-3512 I 216 A o 16 208766 I '' s GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: I c GC PHONE NUMBER: Ll ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �G O rn t fj , *ZONING DISTRICT: J- 1�2 *PLANNING APPROVAL IF IN WATERSHEDA) PAAC � *CONSERVATION APPROVAL - North Andover MIMAP July 9, 2014 062.0-00 062.0-007 O.C- 0 � 062.0-007 �• �� '090.►-0038 445 #1401 ' N,° '^��,090 ►-OU23. I #1 ,11 62.0-005 + I � #1405 62.0-0060 90.0=00 0 #147(5 1463 2. -0009 �: �; • li I �.� �ti 090.C_0041 a ett 1�.#147•$., �; < 2e0-00 7 �� - �� . �� r 0 3.0-0040 #140 06•. -002!9 Z,J 090.0-0024 '° " .w a� F 0-009.9*. 03. -006 I X18 i 0 3.0-00 8 ii 4` ', , #1408 ,I .a ^�,y •� 062±0-008 4 a 1 - 0• 8 063x0-0 -91 #72' Interstates —I SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, - Roads Meters Data Sources:The data for this map was produced by Merrimack Ci EasementsNORTH Valley Planning Commission(MVPC)using data provided by the Town of pf 4t��p q�0 North Andover.Additional data provided by the Executive Office of C3 MVPC Boundary ? �► ►+► O Environmental Affairs/MassGIS.The information depicted on this map is Parcels F 9 for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING t * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY t i y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT •o�, - ��► i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION �SSAtMU54t 1"=176 ft w ° °North Andover MIMAP July 9, 2014 062:0-00 3 062.0-0075 9,O.0-0039 0 2.0-007 / 0'9050-0038 #1445/ a #1401 #1521 . R090.0-0023 062.0-002 62.0-0071 �� { #1611 062/0-0059 ��� #1405 / 062.Q-000U /// / r �90.G-00$0 91475 91463 62. '0009 #1451 062.0-QO'Y2 #1439 #1427 �, 090.0;0041 133 Water'Protection / #1478 c62 �8// #1.438 090.0-0026 0 .0-0027 62.0-0028 R / 06200'0040 #1430 0 2:0-0025 06200-0029 j/ 090C79024 062.0-0099 �'�2.0-0026 062.0-0098 1 062.0 06200=0079 zj& •__ # 408 :"? •:::_::. A'••.: #48 62.0-0 9 090.070025 ""- •:=• 4_:`=_-' Ob2.0 008 ••i;;`- 16 09 #4 #65 062:0 08 62.0-0082 #72� —Rail Line -,Wetlands Zoning Interstates O Exempt Lands 132—s 1 District _I O Busine s 2 District Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, SR l0 Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Busine s 4 District 14ORTN Valley Planning Commission(MVPC)using data provided by the Town of Roads li Genere Business District Of qy North Andover.Additional data provided by the Executive Office of Co Easements C Planne Commercial Dev j b4+�,to r+ss OO Environmental Affairs/MassGIS.The information depicted on this map is C Comido Development Dist 3 G for planning purposes only.It may not be adequate for legal bounds Q MVPC Boundary O Covido Development Dist O .— A Q g boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 0 Municipal Boundary O Corrido Development Dist h A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Ind 1 District Zoning Overlay ♦ ; THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY t:lndustri 12 District 0 Adult Entertainment # i # OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT D lndustri 13 District Downtown Overlay District o sN ASS Historic District ®lndustriI S DistrUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ict �� 3 Water Protection Reside ce 1 District l,' °++��°. .(aJ THIS INFORMATION ' Reside ce 2 Dia SSA�MUsti O Parcels 0Reside ce 3 Distract C:Hydrographic Features A de ce 4 Distnct --Streams 1"=176 ft ^q}•de ce5 Distract TT de ce 6 District _'.e esidential District LOT 3A n � AREA_43006=11 . AC. N x 177.87 X 176.54 OLLo firJL `°` 0 u X 177.97 U-) \\ J S PROP. WETLAND • \ RESTORATION (3 SHRUBS) i \ AREA-200 S.F. of PROP. 6' WIDE / \\ WETLAND BUFFER AREA=1,114 S.F.NEW SONOTUBE FOUNDATION (TYP.) I I DIG AND CONSTRUCT \ I „ . V6.07 177 26 14'X15.6' ADDITION OVER 7 4 6/ Al2176.81 `✓ I IG 14'X15.6' WOOD DECK. \� IG 3-CONCRETE SONOTUBE A70 ' A15 A9 / A14 178.09 ATIONS TO BE REMOVED AND 174.66 x 177.69 X 177.81 / .03 ;ED WITH 3 NEW CEMENT 7789 ETE FOUNDATION SONOTUBES, 1 ' E 7211-1177.45 X FIRST FLOOR ELEVATION o EXISTING i / WOOD DECK 1�8� cO f/�� 177.99 �' X 178.73 178.14 c r mm 1 94 SILT FENCE e��'`" / j AYBALES 174.26 / S� ON CONTROL) 176.77 : . EXISTING �t \ 17?:35 2 W.F.D.STORY (JoA ��{ A7 \ #1430 n4,78.15 - 1 7'- 173.96 ( I--TF=?81.35 F+iL�apn 178.39 178.11 . n 179.07 } 179.90 a00 178.46 1 % Q 3 178.60 Q m 178.59 Q A6 I I X 179.54 178.64 174.571 179.70X w S� 175.84 i R F N D' �1�. `\ I 179.91: 178.76 178.77 \ \ , \ 178.74 \ 174. \ \A5 I 178.67 178.62 r�8 �Q� , 175.63 ` 178.52 76 ` w \ 1 ,.61 \ 180.6 _ ? 17j1766 IR FN \ 178.68 179.47 x A4 r1 aa'r 1793 � 176.64 179.9 \ � x'179.12 i ! X 179.09 A3 176.25 / 189 / 179 2 178.98 # \ yam 00 .N I X 178.40 a 181.20 t\ x 179.53 O 1-0 180.65 180.66 -192 i .�r � r -182-- -- -- - - - - 182.58 7 gig; 183.13 c� �// a s � - - - - - - -- - - - - - - -184- - - - - - - C/ t 186 0 , / + - - -186- - - - - - - - - - - - - 0 185.26185.00 / 150.00' = - -- - S68e02'03'� IR FND / 4 186.40 STONE WALL 188.67 188.39 \\ 187.89 i 188.45 188.33 186.04 ry-' ` s 188.04 ASP 188.28 188- 186.73 � MAPLE [9188.61 ILBOX MAILBOX / 188.94 187.58 188.69 186.94 / 188.48 188.78 188.94 Date. p'.".� TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SS US ` This certifies that . . . . !!.C.Ci'eI\' .. . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . f??�.r� .. at . // /w�. , North Andover, Mass. Fee. Lic. No.. . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # ?C C 61, 47 Cc MASSACHUSETTS UNIFOR 'APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS Date C Building Location f li wn s Name /P►^ �� /v Permit _ o Y7 Amount Type of ccu anc New Renovation Repla" ment Plans Submitted Yes ❑ No ❑ FIXTURES F Un z W v� SZS)E34a R4S VFI*Ir ISE HOCIR 2�HDC12 3MR" 4M HDM 5MHOM 6TR HOOR MHOM SII1 FLOOR (Print or type) Check one: Certificate Installing Cany Name x! Corp. rl) r V El Add s Partner. JI � Busi s ep one Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate d le type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond El Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work�ioed under Permit Issued for this application will be in compliance with all pertinent provisions of the ng Code and Chapter 142 of the General Laws. 1 By: Sigmture or LicensearIUMDer Type of Plumbing License Title City/Town License INUMDer Master � Journeyman ❑ APPROVED(OFFICE USE ONLY { a/ Location t No. Date �f NORTh TOWN OF NORTH ANDOVER Oft..•° ,"�M F 9 ' Certificate of Occupancy $ Building/Frame Permit Fee $ �cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ d o� Check # Badding Inspect r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T lB for low 01ti BUILDING PERMIT NUMBER. DATE ISSUED: X SIGNATURE: ..� Building Commissioner for of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /430 G-1,^ea f" Po^i o 90✓-tom Q � a A10,004 A 100 V69 , Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: {� \l � Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided —4— v 1.7'Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D PU41ic 0 Private ❑ Zone Outside Flood Zone ❑ Muaicipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I ' 't 1 lot: S 110 rn 2.1 Owner of Record C ✓lam- 1M A t-t�oc�fi+l 1 ,43z) C-M e- `T noNO jZo A-0 Name(Print) Address for Service: U� ��b✓C� Iftt a W a re Telephone 1:10 t o 2.2 Owner�'.Record: Name Print Address for Service: O m Signature Telephone 6ECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ A"DI?-eI,3 C - 1e-�=,l c-,-.--> C, SC) p Licensed Construction Supervisor: 0 Wl A`�T1,3 wt S 1 W �������` A License Number on Address � ck/,� C-� _1O1 SO4- 4o_70— l 2 ti� r Expiration Date — Signature Telephone r 3.2 Registered Home Impr/o'vement Contractor fS1 Sit l3�SWtnl-� - S)5 Not Applicable ❑ v vJl Company Name Registration Number r �i, �o ��p► Ise 5� r. � -2-/ ,2, 1 -?- ss Expiration Date ^� t nature Telephone Y• SECTION 4-WORKERS COMPENSATION(NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the builfing permit. Signed affidavit Attached Yes....... No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ E.Vsting Building ❑ Repair(s) [IAlterations(s) 11 on ❑ Accessory Bldg. ❑ Demolition ❑ Other .9- Specify N t S N --N-i Brief Description of Proposed Work: A'S EmeA7T iSi-H^j6, A-6zmSTV4NC-1 s use, Ccsj LIN(-Jr- �j 5 uj w� P cL S , Cv�rr-PrJ+l Ctr It_(NCLL--A-(L 1S `li oil tj> 6o�ovv' 0f ')D1stS. 5�S N uid-O C�L1V`ec(tic� S C(2Qr kn tg[qt Ot(Ow -7 t- p/t t311 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 1 d 3 Plumbing Building Permit fee(a) X (b) / 4 Mechanical HVAC 5 Fire Protection " 6 Total 1+2+3+4+5 t Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C---7 V"'V? A-,L- as Owner/Authorized Agent of subject property Hereby authorize /`-r"N�12E-1-J F—{�� C s to act on My beh al ers r 1 vete4ork authorize hy-this"building permit application. Signature of Owner Date SECTION 7b O ER/AUTHORIZED AGENT DECLARATION �Z S ,t3A'I 57WIVE &AS e-M(1, rf LLL as Owner/Authorized Agent of subject F property `D3a O wI=NS CO1tN/n�C� r INtS �7 f3 Ash >✓�'�S � Hereby declare that the statements and•information on the foregoing application are tnte and accurate,to the best of my knowledge and belief ; Print N e 4 Si atur o Owner/A ent V Date NO.OF STORIES SIZE BASEMENT OR SLAB �ivl -r SIZE OF FLOOR TDABERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DMIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 06/0742004 16:35 FAX 1 781 659 4725 Andrew G Gordon Inc Q001 �, WCIP Libe OFFICE 354 MUtu '1_ W rkers Compensation and MN ION PAGE jVIAR.IU'raE A. I_ Fs1A�mployers Liabili Pol-- �;` SUB ACCT NO. Liberty Mutual Insurance Group/Boston 0000 LM INSURANCE CORPORATION 2'7243 O TD/CD SALES OFFICE CODE SALES CODE N/R 1ST 4359-4)14 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR ASSIGNED 2003 j Item 1. Name of BAY STATE BASEMENTS LLC Insured DBA OWENS CORNING FINISHED BASEMENT SYST FEIN 14-1885527 Address 960 TURNPIKE STREET RISK ID 000182837 CANTON, MA 02021 Status 46 LIMITED LIABILITY CO y Other workplaces not shown above: SEE ITEM 4 ! Mo.Day Year Mo.Day Year • Item 2. Policy Period: From 05-24-04 to 05-24-05 : —— 12:01 AM standard time at the address of the insured as stated herein. ,... a ..ge ;) -kers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the �{ rtes listed here: 1 � . tv�A B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The Iii-nits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee r C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PaC:F Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and R.i in_ P':a, 1.1i information required below is subject to verification and chap e by audit. AiL Premium Basis Rates LINE 110 • Estimated Per$100 Estimated.11 Code Total Annual of RE-- Annual -asslficatlons No. Premiums muneration Premiums ;ION OF INFORMATION PAGE �'remium $ 500 ( MA ) Total Estimated Annual Premium $ 955 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith,is hereby countersigned by SEE ATTACHED FORM 1710 Authoa•icd Rtyaruntutive Dice 04-24-04 Loc.Code Term. Oper. Audit Basis Periodic Payment Rntiag Basis Pol.i LCr. Home Stute Dividend RENEWAL OF: -- 04-24-04 NR MA WC5-31S-3443=9-0I. Copyright 1987 National Council on Compensation Insurance NC 00 00 01 A BROKER COPY North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 06/07/2004 16:35 FAX 1 781 659 4725 Andrew G Gordon Inc I�]001 q wu`�lkt,- : F: ih,: F AR WCIP L><be I _ 'OFFICE 354 10�.Mute _ W rkers Compensation and _, i ION PAGE MgR.IU�aE A.i. �Y JOmployers Liabili Pol- - —] SUB ACCT N67 LIberty Mutual Insurance Group/Boston l� 0000 LM INSURANCE CORPORATION 27243 O. TD/CD SALES OFFICE CODE SALES CODE N/R 1ST A C )i -4359-014 XXX I WESTON 102 REPRESENTATIVE 3000 2 YEAR ASSIGNED 2003 j Item 1. Name of BAY STATE BASEMENTS LLC Insured DBA OWENS CORNING FINISHED BASEMENT SYST FEIN 14-1885527 Address 960 TURNPIKE STREET , RISK ID 000182837 x CANTON, MA 02021 Status 46 LIMITED LIABILITY CO y Other workplaces not shown above: SEE ITEM 4 _ ! Mo.Dm'Year Mo.Day Year Iturn 2. Policy Period: From 05-24-04 to 05-24-05 12:01 AM standard time at the address of the insured as stated herein. .be -kers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the a:.:iLes listed here: t�x . MA 13. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee � C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PA(,F Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and R.i in, P.a N,II information required below is subject to verification and chap e by audit. Premium Basis Rates LINE 110 Estimated Per$100 Estimated -- Code Tota!Annual of RE Annual — .lassificat(onS No. Premivms muneration Premiums tl _ NI:::ION OF INFORMATION PAGE Premium $ 500 ( MA ) Total Estimated Annual Premium $ 955 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith,is hereby countersigned by SEE ATTACHED FORM 1710 Authuc¢cd Representative Date 04-24-04 Loc.Code Tem fir. Audi(Basis Periodie Payment Rating Basis Pot.i-(.Cr. Home Stute Dividend RENEWAL OF: 04-24-04 NR MA WC5-31S-3443=9-01- uv Copyright 1987 National Council on Compensation Insurance wC 00 00 Ol A BROKER COPY 011ull I NAU I Customer Nz -q V P TP W 7 a 9 10 11 12 13 14 15 5 17 18 19 :!j 2' Z3 24 25 26 27 F .—I -T-T-1- 2 L + 7 X, 1 VA :A L 1 j--T'4t rT /4 1 1 1 12 j; hVLA (+ vo in L J- 146 I F FT .1 T7 tot F��Sr ICA I I 1AN I '41,1 7 1 NT T 1,OT 20 -.4 H 22 x .--!Al .4- DO ,%A AN, + F--I -7 1 23 142 -----27 4jr, '9 3G ) l J- I L-11 I i j 32 NOTES- i I � i - - - - - - - WTI')o.� - ��lr� 11 1 vim+ � �. � � � �.. �1 N .f ,.J -•-7 _ 1 I I i i - - - - - - - - - +- - - - - -�- - -+- - - + - - - - - - - - - - - - - - - - - � - - I - iv I 1 T - - - - - - I - - -I- - - - - - - - - - 02:55 FPCh,,. t 510.'45 Contractor: Say State Basement F—tsms,U0 (f/F."a nw �60 Turnpike StrW,Ganttn,MA 02C21 k_7 4C,4i__ V_ila 4 JJ;j Tax ID#14-1865297 Mass.Home;mprwoment Contractor Reg.# 137943 Date -IC2 pity,State.zip_ 7 I This Is R COntrQrl between the Vin.t pc or V 42 0OV1 1Q.T4d Custcrw',75toa;l tilc 3w: 0 clanilalprC.-IN w: jent Br:- Owe"Is Coming da3Gment Wwj Flnlsnl 14 t %, Street Address City,Stale, Scope or wom Are Svtd%�,.a andlor aW"a pert c: NJIEt 'N f 71 'pe-L-L 4C Work Schedule-; ApproAnn'te Co CP I MMeMement Date': to chappa, r Total 0C.-Itract Prim- VOPOSIt with order. eAlanceCash Check 4 zz, / 17 Tfrms: .-I. !-9-n Commencement,4�i16 on CoMpig(jort) �;iqv Ul Cer- _Due on CHf�iS anti GENERAL DEGCpjpTK)N,gy this CONDITIONS agrees',-)PLlrcfase and Contrac1cr agrees to sell djdd Rom, Contract once and according to and Install&,e Owens Corning Bese. the ie first Page Of this contract in the above iLianjined prern,jes,for the stated latcl )tOVf3ions of the contras documents including(a)th't Contract form (b)the Addlidt,in.11 FnJ ics it--Merit applicable,(c) ketches,materials"StS,floor plan.arKVOr SpeCifIcatlons shijets. SCOPE OF WOAK C;oniraCttr 3hag be resoo .....-.1marta Me Pet$-_-Mance 04 ll�e nstalltti)., cuPPY the BacQmOrlt Wall Finlohing System and'elated products and rcf 1"W u93 and Paint.PaIntinj, �-es,63 required uy the Contract.All drywall,wood Or other pa Inta ble surl aces ItUining or decorating are nota pan of this contract. ShGIJ be Primed and ready PPX'F_The Price OW60 by 0!acrner IT r,I.rfsti .pan ,#y Prs:c?:is Lff j *_xv,d Q"ng duod&ucturroa.!�4er!!'ri 1310fiL as do!erini ;-%ovew"19"o dasQjf*nl System and the;abor neaksary 10 Instant.The ned by corttract:w i -Mfeb anc,Points:Jf attachments.The Prim 3j, .- qII no,Inc"tl�4 cost a reaec'n la to M-00-(11 additlonou products or serAC68 aa a result of detective substructures, 6uPGr tiuctUres,of points Of Attachments end ab au which and(10 any AcUtional goods C,installation Services beyond lhosrj OrIgIna0/ .-Quf&W Or approved by the Custornar and rafteclecim a chanPQ Order aigned MOC1116d fn:he contract RAfME1.1jr.payrnat of d.:A PrIc_0 by C-istome-Is due in fun by the customer e7,0 the 1;ontractof. ,,0-,,.In the event that tf!e COnlrac^for Jadare upon the l8mls set forth In this contract.but In no event later than completion cl a that the n th 3V)GPrq'1'4Cl0OMpleta`dbutlh9C customer Still has some fs8sbn2bla";xnch-lict,tams,It is care ed us ,t Board of Build . ,J61 ions and Stanar s ; 4 One Ashb rton Pk, e - Room 1301 ' Boston Massachusetts 02108 47 Home Improv ment C ntractor Registration Registration: 141047 Type: Individual Expiration: 12/31/2005 ANDREW G. KEYES ANDREW KEYES 10 MARTYN ST. , WALTHAM, MA 02453 Update Address and retuFn carll.All tt`ream ' t ❑ Address E] Renewal F1 Employment _ f <p4\ ✓to �oa�vnaaou��.�i a�iU.rx.�a�,rarlla' - Board of Building Regulations and Standards. Licence or registration valid for individal use only HOME IMPROVEMENT CONTRACTOR' c befor't5e expiration date. if found return to: Roadof Building Regulations and Standards Registration: 141047 ` One Ashburton Place Rm 1301 Expiration: 12/31/2005 Boston,1 a 02108 Type: Individual ANDREW G.KEYES ! ! ANDREW KEYES /� 10 MARTYN ST. . G' , 1, / WALTHAM,MA 02453`'' Not valid without signature t Administrator ✓die �omvmza�uoeall/i �� � ; BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 082162 i Birthdate: 07/14/1954 Expires:07/14/2006 Tr.no: 82162 Restricted: 00 E ANDREW G KEYES 10 MARTYN STS WALTHAM, MA 02453 Administrator ! . �1 vis L FORM U - LOT RELEASE FORM 1 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ********APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT (�=PZ-`4 M"CtO O Q HONE LOCATION: Assessor's Map Number �0 PARCEL SUBDIVISION LOT (S) STREET i ':11P L; ST. NUMBER �j a **"******OFFICIAL USE ONLY *********** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSP CT HEALTH DATE APPROVED DATE REJECTED ECTOR- LTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Date................ ................. fr10RTp TOWN OF NORTH ANDOVER 0 p PERMIT FOR WIRING ,SSACMUSf This certifies that �L �'' ,� ......... .......•°. ................................ ,............................ has permission to perform ..... ..... :. 1(/ �/-��-... 'lll�... wirin in he bui�gf.' ...... f.. ... ......................... at I ":� ...... l �! /t �Nort'`Andover Mass. ................ > Fee�J........... Lic.N.r.:..• !�.O . ............................................................... ELECTRICAL INSPECTOR Check # Jr ° 4 fti 3 �C\, Commonwealth of MassachuI. IONS Official Use on Department of Fire ServicPermit No. BOARD OF FIRE PREVENTION REGU Occupancy and Fee Checked 3 [Rev. 11/991 (leave blank APPLICATION FOR PERMIT TO ERFORM ELECTRICAL WORK All work to be performed in accordance w h the sachusetts Electrical Code(MEC),527 CMR 12.00 i (PLEASE PRINT IN INK OR TYPE ALL INFO 4TI ' ) Date: 9/l /6Y aCity or Town of: /✓urs, fA,c of To the Inspector of Wires: 3 By this application the undersigned gives notice of his dt h intention to perform the electrical work described below. wo Location (Street& Number) �(3 0 Grt6%_ 7d ACL o Owner or Tenant MV;I �ap Telephone No. q7 j—I (p`o El Owner's Address Ig30 &rCA4 ToNd w P, Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) ,za Purpose of Building aaS_V t.-L �F 1y -?--A)0 h. Utility Authorizatior, No. Existing Service A,13 D Amps /" /, 0 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service _N4" Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: p �t wtC1.-wt k —TV %Zo v,.,,, Completion of the following table may be waived by the Inspector of Wires. H H No.of Recessed Fixtures (Q No.of Ceil.-Susp.(Paddle)Fans No.of Total Q A Transformers KVA No. of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o Emergency tg ing rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No.of Switches No. of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tonsl No.of Alerting Devices �~ Heat Pump Number Tons KW No.of Self-Contained z No. of Waste Disposers ...................... W w Totals: Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal Q Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of WaterKW No.of No. of Data Wiring: Heaters Si ns 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�f desired, or as required by the Inspector of IVires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless w w he licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The 6 � undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. Ga Q HECK ONE: INSURANCE Y BOND ❑ OTHER ❑ (Specify:) /0 hy (Expiration ate) Estimated Value of Electrical Work: 5,00 (When required by municipal policy.) Work to Start: Y Z/0 Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. certify, under the pains and penalties of perjury,that the information on this application is true and complete. IRM NAME: <evli, L,S'to Zr 5/e_t ,«Z LIC. NO.: "C5_08-15 cw� !Licensee: K"', Yt6,5co IT Signature L►C. NO.: H W c4(Ifapplicable, enter "exempt"in the license number line. Bus.Tel. No. 7 Sb .78Y.3w F-4 /0 C610/,o/yL, b�, �vyylarp Alt.Tel. No.: 7S 6 73 "' x OWNER'S �'INSURANCIE WAIVER: I at-6 aware that the Licensee does not have the liability insurance coverage normally `Ei E required by law. By my signature below, I hereby waive this requirement. [am the(check one) 11 owner ❑ owner's agent. ,Owner/Agent Signature Telephone No. FPERAII T FEE: $ J �6 WORTH Town of Andover 0 No. :-Tv - dover, Mass., COCMICMEWICK V,� ADRATE D S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......�...�!'+. ... .........�a /'S� 'V ....................................................... .. Foundation y3 0 coot f...p�N� has permission to erect.... /�V.�.................. buildings on.............................................................................................. Rough to be occupied as............... ...... ........R .......................t N........... IChimney 8A.46 . .. . . ... . provided that the person accepting this permit shall in every respect conform to the terms. .......of...the.......application..... ..... .......on.....fi.le. in Final this office, and to the provisions of the Codes and By-Laws r lating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 6 a 14 to 0 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rouge, PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU O aST -TS 4 e Rough ... .. ................................. .. .. Service .. . . .. .. . .... ............................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Bumex Street No. SEE REVERSE SIDE Smoke Det.