HomeMy WebLinkAboutMiscellaneous - 15 WRIGHT AVENUE 4/30/2018Date .-1 --
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
A
. 41.. AA4 7�vval/
This certifies that .... .....
............................... . ......................
has permission to perform ...
wiring in the building of .. kAf ............................................................
at ........ /47 ........ rth Andover, M
Fee.,4r .... Lic. No. .3. �2—gr ...............
ELE ICAL INSPECTOR
Check #
M&tr d4ur
06'12
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.Occf
BOARD OF FIRE PREVENTION REGULATIONS [Rev. PO ly and Fee Checked
(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:—
City
ate:_City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice /ofs or her intention tperform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Telephone No.
Owner's Address S
Is this permit in conjunction with a building permit? Yes rtz f-" No El (Check Appropriate Box)
Purpose of Building_ A61 Utility Authorization No.
Existing Service Amps / Volts
New Service Amps ____.L_Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
OverheadEl Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
e
No. of Recessed Luminaires
—111 t-- "' v ute vuowIng
No. of Ceil: Susp. (Paddle) Fans
taole mav be waived by the Inspector of Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑A
o. of -Emergency L-Egliling
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. TotaTons l
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
—.....' ""' .
Tons.........
KW
No. of Self -Contained
Totals:
Detection/AlertinE Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of WaterNo.
No. of
of Devices or Equivalent
Heaters KW
Ballasts
as
Signs Balts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
rtttacn additional detail j desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under ther ties_ofperi ry,.tha th�rmation on this application is true and complete.
FIRM NAME: �f �Zy LIC. NO.:
Licensee: —99jh_0— Signature LIC. NO.:
(Ifapplicable, enter "exempt" i the lice s armber lin) s. Tel. No..
Address: Alt. Tel. No.:�
*Per M.G.L c'147, s. 57-61, security work requires Department of Public Safe " Lic No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabili� u�ar�r c�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. $
FMECMCALP.UMWN0. JUSPECUONR_ PORT.
ELECT.tdJCCAL I NSPECTOR - • s
I. ROUG7S.X_ N_ SM -MON.-
Passed —f I - Walled—[ 1 De -inspection requi�recT ($50.00) - [ j
Inspectors' comments: '
i.e.
a a •a•. '• S.
(Inspectors' Signature ••no Wtials) Date
2. MAi[, NSFECMN;
Passed' Failed — j) Re -inspection required ($50.00) •- [ j
Inspectors' comma ts:
(inspectors' Si afar •- o initials) Jute
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed — [) Re-insp ection required ($50.00) -• [ ]
Inspectors' comments:
(Inspectors} Signature -• no initials) Date
A. WSPECTION•—SER ICE:
DMAM, CALU rED NATIONAL GIRD,: NAM: -
Passed—[) Failed —j Re -inspection required ($50.00) •• [ ]
Inspectors' eoxnmenfs:
(fnspectors' Signature •• mo initials) Date
DOOR TAGS ARE TO BE FILLED OUT AICD LEFT ONSITE IF THE AREA. TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE INSPECTION OF 850.00 IS TO BE CHARGED.
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ky 600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:� ���ti1� X
��ione #: �O 3 7G J' �,'��..�
Are you an employer? Check the appropriate box:
1P I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:,
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: S City/State/Zip: /
Attach a copy of the workers' compensa on 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 c tify un de
6
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License #
above is true and correct.
. Ur�
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
r'
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
1600 Osgood Street, Suite 2-36, North Andover Ma 01845
NOTICE OF VIOLATION
Date: " / /
� pORTly q
Q 1t LED 16• �O
\7a pDAATlD �'PP,���/
Violation observed:
(16 rVI! II!� --
Failure on your part to comply with this notice within 10 days may subject you to penalties prescribed by Massachusetts Law
780CMRrN h Andover's Zoning By law. Please contact the Building Department for further information at 978.688-9545
Ins ctor
Home Owner
Contractor
Location /,� ^ -- -�>
No. C7, Date ldvb�
�oRTh
TOWN OF NORTH ANDOVER
y A
Certificate Occupancy
of
$
Building/Frame Permit Fee
<
$Hwu
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$ '
Check # '7o
18682
Building Inspector!
v
1.1 / Property Address:
1.2 Assessors Map and Parcel
l/ /
Map Number
Number: `�
Parcel Number
Yd AY400
Gle�, /k2e
1- /VZ) ANO
1.3 Zoning Information:
Zoning Distrid Proposed Use
Address for Service
1.4 Property Dimensions:
Lot Area
Fronts ft
1.6 BUILDING SETBACKS ft
/yi !�T
Address for Service:
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
ReqWred
Provided
Addr
�-yam
/1� —���—� ��
Signature Telephone
d Ila
Expirati Data'
3.2 Registered Home Improvement Contractor
1.7 Water Supply M UI -C.40. 34)
Public ❑ Private ❑
1.3. Flood Zone Information:
Tone Outside Flood Zane 0
1.8
Municipal
Sewerage Disposal System:
0 on Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHMAUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
/`?
1- /VZ) ANO
Name (Print)
Address for Service
Signature Telephone
2.2 Ownneer-o�% c/or�t/l:
Name P 'nt
/yi !�T
Address for Service:
t/,73-7
Signature V Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
�� r Supervisor: H �So/I'S
Licensed struction Su
�s"� �G>✓ � � ^/ / � J �/.��Ua O�2
Not Applicable ❑
p�Zlok1
License Number
Addr
�-yam
/1� —���—� ��
Signature Telephone
d Ila
Expirati Data'
3.2 Registered Home Improvement Contractor
Not Applicable ❑
p—
Compan ame
�/ �, %fly J� �, `Q
rc
{,�
Registration Number
E
Si natureV Telephone
ou
rn
X
3
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rn
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90
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G)
SECTION 4 - WORKERS COMPENSATION (M:G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work: D
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE dNLY, p'
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbin
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZA9fION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1,=%� ,as Owner/Authorized Agent of subject ;
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
moe
Print e
Si afore of Owner/ ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with th7T//4that
isio of MGL c 40 S 54, a condition of Building Permit
at: G� the debris resulhng from this work shall be
disposed of ' a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
Fire Department Sign off:
Dumpster Permit
(Location of Facility)
Signature of Permit Applicant
Date
CS # 022680
HIC# 103358
= ikopool =
A. J. Walsh & Sons
55 Pleasant Street
North Andover, MA 01845
# of
978-688-6737
or
1 -866 -AJ WALS H
Proposal Submitted To: Job Name Job #
9�A'- "
Address Job Location
6,,eA4O_,
a�
Date�O / D� Date of Plans
Phone # Fax # I I Architect
We hereby submit specifications and estimates for:
r
We propose hereby to furnish material and labor — complete in accordance with the ave specifications for the sum of:
$ O'DDd
with payments to be made as follows:
Dollars
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and submitted
above the estimate. All agreements contingent upon strikes, accidents, or delays //
beyond our control. Note — this proposal may be withdrawn by us if not acce/ within _ days.
0cceptance of i3ropogai
The above prices, specifications and conditions are satisfactory and are A Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
& NC3819 MADE IN USA
The Commonwealth of Massachusetts
7i
Department ofInditstrial Accidents
Office of Investigations
600 Washington Street, 7h Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant iniVi a-tf6,'
:
n: eas by
name: IV- Ff� F/!) )Sr S 0
address:/511-, -c-*
city /W state: M Zip: d/Wi:—..._phone # 97�-6,J:i0'-67_3;7
❑ 1 am a horneowner performing all work myself. Project Type: E] New Construction E
❑ 1 am a sole proprietor and have no one working in an capacity. YcBuilding Addition
El I am an employer providing workers' compensation for 'my employees working on this job.
comDanv name: lwlpn� f-1 -V -5 ',W�
address:
city: ,ffe
phone # 7 737
insurance -co. '-/—j0 / 0 cls policy # -70 / 0- 00 7/ ,
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
city: phone #
insurance co. policy #
company name:
address:
city:
phone #•
insurance co. policy #
Attach,additional-shiO if.' Ossary...
17:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cerp;jar under the pains ns an d p en a 1ties ofperjury that the information provided above is true a n d correct.
Signature_ Date le — a?
Print name
�O 73
-Phone #
official use only do not write in this area to be completed by city or town official
city or town: permitilicense #
—[]Building Department i��
ElLicensing Board
❑ check if immediate response is required
ElSelectmen 'sI N
E]Health Department
contact person: phone #;
DOther
(revised Sept. 2003)
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INSTRUCTIONS
1. All sections of this
form must be completed
In order to comply with
the Department of
Environmental
Protection notification
reauvemerts of 310 CMR
1.15 (ten working days
prior notiration is
required of any abatement
project); and the
Department of Labor
and Industries
notification iequiremerts
of 453 CMR 6.12 (ten
days prior notification is
required ofANY
abatement project greater
Chan three linear or
square lest).
2. Submit (kipinal Form
To:
commonwealth of
Massachusetts
Asbestos Program
P.O.B. 120087
Boston, MA 02112-
co87
3. This form maybe
used for notifying the
U.S. Environmental
Protoction Agency Region
I of asbestos demolition/
renovation operations
subject to NESHAPS (40
CFR Subpart M).
for Otflaal Use only
1180w d Date .
le
Rev. 6/92
Commonweaith of Massachusetts ,;=
Asbestos Notification Form -- ANF -001 - N -Q' 766251 `J
cm
r
Asbestos Abatement Description � �-�� ' • = .
1. Facility location:
Fred Russo 15 Wright Avenue
Name Address
No. Andover, MA 01845 978-681-8832
Clry/Tokrl ZJp mde Te/eplarie
Basement
WAar Is Cie IlaJalle ibration7 bu/ldinp name, /, wing, lJoor, room
2. Is the facility occupied? 9 Yes O No
3. Asbestos Contractor:
Asbestos Free, Inc. 42 Broadway
Kame............................................................................................. � .........................................................................................................._.......—
ress
Wakefield, MA 01880 (781) 245-4403
........lip .....no....de ................................................. :...................-
....................................--
Clry/Town isle
AC000133 Written
.....................................................................................................................................................................................................................................
IX I lkense / can1w Type (wrrlterVlerbal)
4. On -Site Project Supervisor/Foreman:
Terry Sharkey AS 51070
ou cerIlk 29on /
5. Project Monitor.
..............................................................................................................................................................................................................................
Name Ix! CerCOca ion /
6. Asbestos Analytical Lab:
Environmental Remediation Services AC000122
.................................................................................................
Name U Cer9flaion /
7. Project start dale 2 /19 /03 end date?� —9 /03 specificwork hours (Mon. -Fri.) 7-5 (Sat. Sun.)
8. What type of project is this? (circle one): &vwihbn IepN/i revio,7eon oo1rr(exptalnJ
9. Describe the asbestos abatement procedures to be used (circle): yloyebrg &xIAnure anconnmenr cleanup
encapsulation disposal only octet (e>,plaln)
10. Is the job being conducted 99 indoors ❑ outdoors ?
11. Total amount of each type of Asbestos Containing Materials (ACM) to be handled on pipes or ducts (linear It.) or other
surfaces (square ft.) 600 to be removed, enclosed or encapsulated:
linear/square feet
boikv, brcadiirrg, durl, tank sullxae coatings... Clnvinal, solid core pipe insulation ...... _J
ebirupled or layerod paper pipe insulation....
spray -on fireproofing ................... _1 nose lspr c�rirent . coatings
............. _J _
clotlrs,woven fabrics '•—� trove(/spayevcoarinps.............. _f
other (pk�ase describe) .. ................ —J transile board, wall board .............
FLOOR TILE 600
12. Describe the decontamination systems) to be used:
3 Stage Decon
..........................................................................................................................
13. Describe the containerization/disposal methods to comp with g10 CMRR 715 a d dd53CM q
All ACM to be doubled bagged in � mil. iatielLe� Jlffi s A.A U&val Bags
�1. r a.n�ciycilby..�I•I011l ......::...........`.............................................................................,..........................................,..................................................................................... .: A rvifVON
liar Gl q:i:/irJ, till: U:r WIU l LI VIIIGIdI$ WIIV dVdlU4lbU IIIE drndl yullC%:
............................................................
.........................................................................................................................................................
Name daalOnida/ TIlk
Date dAumoJiaalbn
..................................................Wa...ler/ ..........................................................................................._.`....................._.—
........................................................
Named W Olfidal....................................................
Tllk
Qakd Auuiorltallon iliv.................................................................................................................
Waller / ......_
15. Do prevailing wage rates apply as per M.G.L. c. 149, § 26, 27, or 27A - F to this project? O Yes ❑ No
Note: Transfer
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note: Contractor
must sign this
form for DU
notification
Purposes
Facility Description
1. Current or pnoT` a of facility:
Residential
..................................................................................................................................................................................................................... ` _.......
2. Is the facility owner -occupied residential with 4 units or less? ® Yes O No
3, Facility Owner:
SAME
'..............................................................:.............................. Address
........................................................................................................................................................... Iry/Town Dp code Teleprimne
4. Facility's Owner's On -Site Manager:
...............................
..........................................................................................
ame Address
Clh%Iown........................................................................................P.D.......................................r....................... , .._..... ._. ._...._._
5. General Contractor.
.............................. ..............- -
................................................................................................................
Name Address ""
.....................................................................................................
ttp code
Tobphone
The St. Paul Cos 883X2253 May 21, 2003
Contreetor's Workers Cavnp, Insurer Polley/ fxp.Date
6. What is the size of the facility?.'
(sq ft) _ (/ of floors)
Lg Asbestos Transportation and Disposal
1. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal site:
Asbestos Free, Inc. 42 Broadway
Add
........................................................................................................................
ress
Wakefield, MA 01880 (781) 245-4403
.................................................................................................... .
C/ly/fown
./epAork .........
tp wdeTe..............................................................
2. Transporter of asbestos -containing waste material from removal/ temporary storage site to final disposal site:
.Recoyerx Express, Inc. 180 Canal Street
Name Address '.:.......................................
Boston, MA 02114 (617) 523-7740
..................................... .
....................................
cr►Y/fown...........................................................•..
DO Code Totem"
3. Refuse transfer station and owner (if applicable):
...............................................................
NameAddress
....................
Address......................................................................................................
Crty/Town..............
ZIP Code IeAo......................../epn
4. Final Disposal Site:
......'r.:'�. Itt.p�yial, Landf.. P Box 47_.,'1 Boggs Road
LaraGmName Airs ................................................................................................................
Imperial, PA - 15126
Address..............................................................
724-695-0900
.........................................................:......
t..ip..CO .............................
_..... reieptione .............................
................................
n Durr:; lea tlor,
iiia t,Iruo;,{gr�ad horeby s;a;es, a;,�c,-tt:: Fc;�!;icc ;erj�� �,, tti,. h frhe has rand the Commonwealth of Massachusetts Regulations
for the Removal. Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in
this notification is true and correct to the best of his/her knowledge and belief.
Frank L.
....rsenault ��j �,�^ ' February 3, 2003
Print NameI� S�!c f�yl
Aueiorired slgnmun .... `�� . . ......
.....................................................
President Dai
Asbestos Free, Inc. (781) 245-4403
.......i;#e.........................................................
..................................... TNep/pne
pesenfinp .............
42 Broadway
Wakefield, MA 01880
.................................
:........................
CrN/rown
Fee exempt (City, Town, district, municipal housing authority, owner -occupied residential of four units or less
_ ) ?Z yes Clno
Stickerl (from front of form): 766251
PATRICK J. DONOVAN ASSOCIATES, INC.
Claim and Xoss Adjustments
P. O. BOX 110
WAKEFIELD, MA 01880
TEL. (781) 245-5540 — FAX (781) 245-7016
December 6, 2002
Building Commissioner:
City or Town Hall
North Andover, MA 01845
Insured
Property Address
Insurer
Policy Number
Type of Loss
Date of Loss
Our File #
HEAv; H
r DEC 1 6 M
i
: Alfred & Mary Russo
: 15 Wright Avenue, North Andover
: Merrimack Mutual Insurance Company
: HP1726444
: Fire
:12/06/02
: WAP34179
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000 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 file number.
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
Vern Laws, Adjuster
VL/so
OF INDEPENDENT INSURANCE ADJUSTERS
of Massachusetts
,4 350
Date ...... W/ .. ... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that...........
...............................................................................
r ( /),
has permission to perform .......... f.. ..... ....... ................................
wiring in the building of ............. ................................................
at ....... G il ..... ......... : ..... ...... . North And ver,
W -t.. / / , mass.
Fee.�� ........... Lic. M6.23yk: ..... 7 ....... ..............
Check # /EL�EC-MICAL INSPECTOR
�� ��d7lPnL�YIZk/��,C'?� d� SSr�L.'�ZtS�77S
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
Official Use Only
r
Permit No.
Occupancy & Fee Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North And
The undersigned applies for a permit to perform the electrical work described below.
Date ���
To the Inspecto of Wires:
Location (Street & Number��
Owner or Tenant
Owner's Address Ivo
Is this permit in conjunction with a building permit Yes ❑ N (Check Appropriate Box)
Purpose of Building S Utility Authorization No. �U
Existing Service IOU Amps
!New Service Amps Voits
Number of Feeders and Ampacity
i:.ocation and Nature of Proposed Electrical
Overhead &3---' Undgmd ❑ No. of Meters
Overhead ❑ Undgmd ❑ No. of Meters _
OTHER' Sc, 6 f CLA � C '* cam: P/- �Y
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER (Please Specify)
(Expiration Date)
Estimated Value of Electrical Workb
Work to Start Inspection Date Resquested Rough Final
Signed under the Penajties of perjury:
FIRM NAMEf 1 ' t� �"t Z r LIC. NO. ��� ��' 3,
Lfh,ensee Signature LIC. NO.
Bus. Tel No. �7 &) 21 1
Address AH Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my,signature on this pe ' application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $ ' ii
of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑
In ❑
No. of Lighting Fixtures
Swimming Pool grnd ❑ grnd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
No. of Sounding Devices
No./ of Self Contained
�No. of Di osal
Heat Total Total
No. Pumps Tons KW
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
Local Connection
No. of Dryers
Heating Devices KW
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Widn
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER' Sc, 6 f CLA � C '* cam: P/- �Y
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER (Please Specify)
(Expiration Date)
Estimated Value of Electrical Workb
Work to Start Inspection Date Resquested Rough Final
Signed under the Penajties of perjury:
FIRM NAMEf 1 ' t� �"t Z r LIC. NO. ��� ��' 3,
Lfh,ensee Signature LIC. NO.
Bus. Tel No. �7 &) 21 1
Address AH Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my,signature on this pe ' application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $ ' ii
of Owner or Agent)