HomeMy WebLinkAboutMiscellaneous - 151 SANDRA LANE 4/30/2018 151 SANDRA LANE
`�210/097.0-006&0000.0
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Date... z..3 /z
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HORTI{
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SS^CMUSE�
This certifies that ....... ...............................................
has permission to perform ......If'x- rc ...............................
wiring in the building of.....1 ......... v Q. .........................................
at.... ........�- eH A............ �-........ . .. ,North Andover, S.
Fee... ...1 Lic.No f3 ................. .-C .......... ..
r ELECTRiCALINSPECTOR
Check d Z
' `t 0792
Commonwealth of Massachusetts Official Use Only -
a -
Department of Fire Serv/ces PemutNo,
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07] (leave blank) '
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusefts Electrical Code(MEC),527 CMR 12.00
(PLEASE P)INT.INZNK OR TYPE ALL INFORMATION) Date: Y- 2 3 /Z,
City or Town of- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her int7,,,,,Ope
trform the electrical work described below.
Location(Street&Number) IS _ ,
Owner or Tenant Ja c r�i/� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes n
!� ryM (Check Appropriate Box)
Purpose of Building ,7 , Utility Authorization No.
Existing Service 2 GU Amps /L v/ z ve Volts Overhead❑ Undgrd g oho—.of Meters ^�
' New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
s / tem ,i �•
Completion o the of owin table maybe 3valvedby the Inspector o Wires.
No.of Recessed Luminaires No.of Cell: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 Lighting
rnd. rnd. BatteLy Units
No,of Receptacle Outlets -3 No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches Z No.of Gas Burners No.of-Detection and
Initiatin Devices
No,of Ranges No.of Air Cond. Tonsl No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons ; KW No.of Self-Contained
Totals: ""' !DLe-tectionliAllerting Devices
' No,of Dishwashers Space/Area Heating KW Local❑Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*.
No.of Water No.of Devices or Equivalent
Heaters KW No.of No.of Data Wiring:
Sims Ballasts No.of Devices orE uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or E uivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy,)
Work to Start: 'el'Z 3 -i-2— 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 C4-1�06ND ❑ OTHER ❑ (Specify:)
Icertify,under thepalns andpenalties ofperjury,that the informZtio .on this application is true and corpiEte.
FIRM NAME: s.y l �`t LIC.NO.: A¢ Ifj x '
Licensee: �� c s �n �., Signature LIC.NO.:
(Ifapplicable,ent `exempt"in the license numbe ne.) Bus.Tel.No.:S7Y
Address: � ,-/ Alt.Tel.No.:
*Per M.G.L c.147,s.57-61, curity work requires Departme ofPublic Safety"S"License: Lie.No.
OWNER'S INSURANCE RIVER: 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:$
4
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3,i]MER GP C)D TD-WBPECTION. ,
Passed--[ ] Failed—[ ] Re-Snspecfioz�aetiuixec ( 50.00)[ ]
inspectors'comments.
(Inspectors'Rignature•-no inifials) Pate
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Passed--[ ) Naffed- [ Re-iuspectionrequired($50.00)-[ �
hspectbrs'eoJmmeph:
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'assed•-•[ ) pailed--[ ). teuspectzozxzegvired($50.00)- [ )
aspectors'cozizznents:
�I,�specfors'i9ignatcu e uo initials) Ade
1)GOff.TAGS AM TO BE MIND d117T ASID IMT OXSITE I'TBE.APXA TO BEI SPECnD IS NOT
ACCJENSIBIE.A".A.n INSPECTION•OF S50.0 DIS TORY,CMRGED. -
The Commonwealth of Massachusetts
Department ofIndustrial 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 Lesribly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
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
Y * 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. E]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
3111 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 a're 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.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certto under the pains andpenalties of perjury 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#:
I
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 ofhire,-
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. 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 Commonwealth.of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Strut
Boston.,MA.02111
Tel # 2 4 0
. - 617-7 7,-- 900 ext 4 6 or I-877.TMASSAFB -
Revised 5-26-05 Fax#617"727-7749
www.mass.govfdla
J
9385 Date. .?
HORTM TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SACMUS� ~
This certifies thatmf-?,e. . . . . , , . . .
has permission to perform . . .i. . . mQ�?T.. . . . . .,. .
plumbing in the buildings of . . .l 7e7/. . . . . . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . . /J, N rth Andover, Mass.
Fee . . .Lic. No.. . . . . . . . .
�y-S^v PLUMBING IN PECTOR
Check # 32
MASSACHUSETTS UNIFORM APPLICATION FOR A PERM It TO PERFORM PLUMBING WORK
4- -j6 CITY vl.0- "_' 1U�"'--^
" MA DATE Y 17`/L-i PERMIT 0
JOBSITEADDRESS 5 5��� ��
. � �OWNER'S NAME To
P ONNERADDRESS I I TELT IFAXI I
TYPEOft OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL I.+
PRINT
CLEARLY NEW: I RENOVAT19kI I REPLACEMENT: 1,4 PLANSUMITTED: YE81 I NOj
FIXTURES T FLOOR- 13SM 1 2 3 4 5 h 7 a 9 1Q' 11 12 13 14
BATHTUB
CROSS CONNECTION pEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM l' -
DEDICATED GRAY WATER SYSTEM _i . . : .,......_.: .:_... . ,_... .. __.. .
I I
DEDICATED WATER RECYCLE SYSTEM ;. .;. 11
j.
DISHWASHER
DRINKING FOUNTAIN i
FOOD DISPOSER .—
.I .I
FLOOR IAREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN - -. - --
SHOWER STALL
$ERACEIMOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES.
WATER PIPING - -
.
.OTHER
INSURANCE(:OVERAGE:
have a ctirrent.tiat. �ility ihs0ratice policy.or its meets the requirements oaf MGL Ch.142. YES I(,.;!' NO I I
IF YOU CHECKED YES,PLEASE INDICATE THE TYIPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I ( BOND[ I
OWNER'S INSURANCE:WAIVER:lam aware that the Iicensee.rloes not have the insurance coverage required by Chapte042 of the
Massachusetts General Laws,and that n)y signature on this pertilit application waives this recluicetiten't.
CHLCIC ONEQNLY: OWNER I I AGENT -
SIONATURE OR OWNER OR AGENT
I hereby certify That all of the delails and infonnallon I havesubnilitted oc enlered regardingahis applicalion atcOuehind rate to the best of my k owl' g'e
and that all plumbing work and installations performed under the permit issued for this application Wit be in a i anc i all P'it.nen I 'ovisfo fl.
Massactwsells State-Plumbing Code and Chapter 142 of the General Laws. j
PLUMBER'S NAME[S'17 - �'� ILICENSE iI I b 3 b i L SIGNA RE
MPI I JP I ! CORPORATION] J#' 1PARTNERSHIP1' 1III ,LLCI IIII
COMPANY NAME 11 , S�}- �•SZ_ I ADDRESS /3 o t s tl I
CITY I 7'I v, Y>�"d �--� ... ISTATE 161t ZIP 14 / `�i5� I !ELI �'2
FAX I CELL I .. I EMAIL I
I
i
a(Z� J�"HJ P1G1I71MMMITGrNSP7G'R:91'][QDI1T'NO7CES: MtAT, �731P C_T$O1N 1 OT7CS
Ye$ �Vo
1H—IS A P P L I C A T 10 M'S Vc-S AS T14E PEl M r r ❑` ❑
w
FEE:: QERI(ldV�'
i
ry The Commonwealth of Massachusetts -
Department of Industrigl Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.❑ 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. 9. F1 Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.n 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.
Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name%
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one�year imprisonment,as well as civil penalties in the form of a STOP-WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certiry under the pains andpenalties 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
Informati®n 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. I.f an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained 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 permithicense 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:
Tho Gommonwoalt� ofM-assarhvsPtts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 021 It
TO,#617727-4900 at.406 or 1-877MASSAFE
Revised 5-26-OS Fax#617^727?749
uw.xlrass,govfdia
'�;��'ti.'it•'M"`{r_-:�s^'1.�-:r- ..---,.-'�...��.`r-�•--v-``.r"`i�r•!"-•.+e..:.-�+'s' - r:,,��.r r--,-,'
.uh�.
q'
2063
Date. .. .� '. ..q .
,ORT"
TOWN OF NORTH ANDOVER
pF tit° 0
O PERMIT FOR GAS INSTALLATION
D
�9SSACHUSEt
/ Oti
This certifies that . . Ch
has permission for gas installation . . . 5�c�,.J. . . . . . . . . . . . . . .
0
in the buildings of . . . . ./.
at G. . . . . . . . . . .. North Andover, Mass.
Fee.,a Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . .. .
C k �(Q.J,6 GAS INSPECTOR
WHITE:Applicant / CANARY: Building Dept. PINK:Treasurer GOLD:File
z- o
r
' Date...............................1.
�. t NORTH'1
F:;.,�`".;•:"aop TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSS'AcMusE�
This certifies that ...........� .......4!a. l....................................
has permission to perform .......... !//.rG �E.�......................................
wiring in the building of................... ............................................
at.........LT/...... 4.;. �,!Z4.....L,4�............... .North Andover,Mass.
99 Pe.,�..
Fee..�5...:.— Lic.No. ..... ......
t ELECTRICAL INSPECTOR (✓
i Check # 1 0 2
7243
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 7. Z- 3
Occupancy and Fee Checked
w y 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: j — /2- --
City or Town of: NORTH ANDOVER To the Inspector oj'Wires:
By this application the undersigned gives notice of his or her' tention to perform the electrical work described below.
Location(Street&Number) �j� % S'q y _ `1, 4//—,
Owner or Tenant li/ io T Telephone No.
Owner's Address
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 Services Amps J / z y or Volts Overhead EA-"Undgrd❑ No.of Meters f
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: , ,, /41-, 174nlf
Completion o the ollowin table ma•be waived by the!ns ctor of Wire:
No.of Recessed Luminaires t7 No.of Ceil.-Susp.(Paddle)Fans No.of Tota
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting
rnd. rnd. Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches S No.of Gas Burners No.of Detection and
InitiatingDevices
No.of Ranges No,of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KWLocal❑ Municipal E] Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of No.of Devices or Equivalent
Kms' Data Wiring:
Heaters
Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires
Estimated Value of Electrical Work: 3_/" (When required by municipal policy.)
t Work to Start: -?—/z -e7 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 coversm force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
certify,under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: k7 LIC.NO.: •�lf3?
Licensee: `„ti /' Signatur IC.NO.l�9,f 3 3
(lf applicuhle, e cr "c.eerttpt' in the license number line.) Bus. rrl o:4gE7- 2/!/
Address: Alt.Tel. No.:
*Per M.G.L c. 147,s. 57-61,security work requires Depart nt of ublic SafetyLicense: Lic.No,
OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability insurance coverage normally
mquircd by Im, By MY ttlgtlMUN 1300W, 1110feby wttiVe tlllS r0g111t@t110t1t, 1 0111 111@(olleck title)EJ owngf LJowtler,§agmt,
Owner/Agent �',
Signature Telephone No. PERMCT FEE: $
Date.
NORTH
TOWN OF NORTH ANDOVER
4 a PERMIT FOR PLUMBING
,SS'q us
This certifies that . . .T7 . . . ./. '?- . . . . . . . . . . . . . . .
has permission to perform . . . . . . Y..,!! rAW.
plumbing in the buildings of . . . .r1,!r . . . . . . . . . . . . . . . . . . . . . .
.at, . . �1 . . . . ... . . . . . . . . . . . .. North Andover, Mass.
Fe «�f1G. . .Lie. No.. �3 ;1�� l . . . . . . . . . . .
PLUMBING INSPECTOR
Check #
73,410
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
/� Date L G� �
Building Location/ / 54
✓�� �,�wnets Name �y✓ZK Permit#
Amount
Type of Occupancy
New El Renovation Replacement Plans Submitted Yes No
FIXTURES
V.
A
SZ$1EM
BA4IVII�II'
ZD FIDCR
3MFUM
4M FLOQt
5M FUM
sM lIDM
7MFIDM
say FUM
(Print or type) � Check one: Certificate
Installing Company Name T,5 ��' 044ku e Corp.
Address +5 y ���� d 2 d Partner.
`tit !J . /�'✓U�� V-f✓L ?vc, 4 .
Business Telephone d r z []—Firm/Co.
Name of Licensed Plumber. G J b S-,; 'Ie-
Insurance
ICInsurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy a Other type of indemnity El Bond
insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner
gn Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installati9prerformed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus We PI bin Code Chapter 42 of the eraI Laws.
-
By: igna ure o teens um er
Type of Plumbing License
Title �) 3
City/Town License um er Master Journeyman ❑
APPROVED(OFFICE USE ONLY
Date.. /1 `G . . . ...
Of`NORTH 14,
of TOWN OF NORTH ANDOVER
f _ A
PERMIT FOR GAS INSTALLATION
SACHUSEt
This certifies that . ./�. . . -� ! ��16 �( f
has permission for gas installation . / .
in the buildings of . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . /... . . . . . . ..r/�'�^ y� . . . . . . . ., North Andover, Mass.
Fee.c-?.5—,.G0 Lic. No.. . . . . . C... ...f. :.. . ... . . . . .
GASINSPECTOR
Check#
5923
MASSACHUSETTS UNIFORM APPUCATON FOR PERNU TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations ,�� E,0.41d/t Permit#
Amount$
Owner's Name �-U� /,
New D Renovation Replacement Plans Submitted
w N a
� „wa rn w o � m F �
a H
� a
z
a a o � o z F
w z v w v, w o D q H
z ¢ w Q z N H w c7 p > w Ew, w a F w
3 d w > w a z Q m z o z x o x
>
SU B-BASEM ENT
BASE ENT
1ST. FLOOR /
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7 T H . F L O O R
8TH . FLOOR
(Print or type) Check one: Certificate Installing Company
Name ��1sli�iLz 1
10 Corp.
Address n Sk to, IL J Partner.
`✓f. U p f✓2 0/�y
Business Telephone 46 'Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes D' Noo
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy 13— Other type of indemnity 13 Bond 13
Owner's Insurance Waiver: 1 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:
Signature of Owner or Owner's Agent 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 and installation erform4drider Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuse t Gas C.9de and Chapter 2 of the enera aws.
By: ignature of Licensed Plumber Or Gas Fitter
Title Plumber
City/Town Gas Fitter -cense Nurnoer
0• Master
APPROVED(OFFICE USE ONLY) Journeyman
Location SAN �ti L�
r �
No. ..g Date
r
t
NORTol TOWN OF NORTH ANDOVER
3?0: : ,1•COL
F _ 9
` Certificate of Occupancy $
,SSACHUSE<�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �d
f- Check #
i 64
"` Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER. DATE ISSUED: 777,
9
SIGNATURE:
Building Commissioner/I for of Buildin Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
C 51 5 amara km-cC'N 07C
ll()r 1f1 4/?(Jo V e✓/ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided RegWred Provided
1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ J
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i
2.1 Owner of Record
rn q
Nam Address for Service:
L�L.j
Signature Telephone d
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone 90
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor:
License Number
On
Address
Expiration Date
Signature Telephone
i
3.2 egistered Home Improvement Contractor Not Applicable ❑
Company Name
Suite 21— � Registration Number
Ad S cJ TjIJ 7
A 7 / p (/ a
c�-d f / f0 0 77// A
Expiration Date
Signature Telephone
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:
Sit l (J t au ,A 00p a CA/l.Pg D
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OMCIALUSE E iLy
Completed by permit applicant
1. Building Q¢ (a) Building Permit Fee
U 0 g d
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee tel X tel ^//,�
4 Mechanical HVAC C
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR 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/AUTTHORIZED AGENT DECLARATION
I, De VI as Owner/Authorized Agent of subject
property r
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
CDI &V/ Cl Cai C)A.X-
Prin
oIVer/A en `-" Date
Si
—me -
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 ST2ND 3
SPAN
DIMENSIONS OF SILLS
DWENSIONS 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
Town of North Andover
Building Department o q:
27 Charles Street
North Andover,Massachusetts 01845 , ®"
(978) 688-9545 Fax(978) 688-9542 °4 CO[K1 M KH ,.
r IX
cwus����
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit# the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in/at:
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
DAVID CASTRICONE
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
7 HILLSIDE ROAD,BOXFORD,MA 01921
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverh111978-374-7314
i
Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary
materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions,on premises below des
Owner's Name...........hy ...th.t. ...............................................
............ phone#...
Job Address....../Y.1 5114 f....Lw.................City..../ v....1s `r1'....a..�..r..�...�...,.. ..���.L..................
State... /I.............
Specifications:
+Str
....ip.....ex.......istin......hingl........ .e..s...........
.✓A...pply............ne..........rip.........................g..e..s.......Q................
.........................
....................................
.............................
g s �.LJ w dedge to all edra,
VApply�_feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house. Q °`t ao�1 sir l'
1.........R....... ............ . 9
....y.......................................................
...........
Apply felt paper underlaym nt. nstall ridge vent toff i
4Z �. ..
croof using ♦A) ,. shingles with a _year warranty.
.... .................I............... Ig........P................................................................y...................................
�Counterflash chimney. -N-ew vent pipe flashing. l e al dis osal of all debris.
Areas. t..be worked on:
.................. ...3:'..................... '... .....................
' � ......................... ..........�i......r...u.u.�.,...�.�.1.. .(f..�K..�A..rs... .�...... .:r.w?..:a..ti„.ti.........................
f
... ...P.1. . ,f.:y.. . .r.. ....�. ...... ...��.........C. ...........................................
....................................................................................................................................................................................................................
.........................................................................................................................
......................................................c.V. -.�-.....�. . �................ . ......................
.. ..... .............................
One Year Workmanship Wa t Transferable)
Manufacturer's War 8s specified by mq facturer ,y
Materials and Labor t cost$..,.: .... Payable....... ..........on.......
Payable.......................:..... ............. Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or
conditions resulting from application of materials specified above (i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living
spaces,water stains when roofing shingles have not had adequate time to cure).
Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested
by contractor.Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It
is agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,
that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.
It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates.
The undersigned warrant(s)that-he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s).
There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract
dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:
Director,Home Improvement Contractor Registration
One Ashburton Place
Room 1301,Boston,MA 02108 Tel:617-727-8598
Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-related permit or deals with
unregistered contractors shall be excluded from access to the Guarantee Fund.
Approximate starting date of work..........................................................::......... Completion date..............................................................
Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner has three business days to cancel this contract and incur no penalty. /,)
IN WITNESS WHEREOF,the parties have hereunto signed their names this..........` ,....day of,. i i'. :i..;.............20.AsJ .
Accepted: Q�j
: !,
..
7/1 �GS
Signed..... .. Owner
Signed.........................................................................................Owner
Per.......................................................................
Representative
NORTH
Town -of Andover
No. dy
Waft. L E over, Mass., a'&)
�'� COC HIC HE WICK V
s RATED
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.........AA.. ....'r K A Foundation
has permission to erect..... build;ms o-.n-.................................s �v�i�t.....4. .............. ...,0.6*
......... Rough
Chimney
to be occupied as..........+.?*......OP.*— ..........................I ............................................................
provided that the person accepting this permit shall In every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the nspection, Alteration and Construction of
Buildings In the Town of North Andover. 17 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTIOtJ S_TARTELECTRICAL INSPECTOR
Y- 0 Rough
A.... ...................... ......................0&0 . Service
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous .Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Bumer
Street No.
SEE REVERSE SIDE
__Jl Smoke Det.
Location �gyLN-
,� No. s Date ` a doj
NaRTN TOWN OF NORTH ANDOVER
O
Certificate of Occupancy $
�',s'•••' Eta'
Building/Frame Permit Fee $
s�CHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �J
Check # +
18494
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER. / DATE ISSUED.
ic
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION i-SITE INFORMATION
1.1 P�opefty Address: 1.2 Assess_ots Map and Parcel Number: 000 0
Map Number Parcel Number ^
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage(ft)
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide R redProvided R red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: }
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal S}stem ❑
SECTION 2-PROPERTY OWNERSHIPIAUTHORMD AGENT :1181oric IS P!C : Yes No '
2.1 Owner of Record
7-CSP,�4 AM7—oeK /.S'1 —P,4VJeA LRIUe
Name(Print) Address for Service
Q,
Signature Telephone O
Ga
2.2 Owner of Record: t
Name Print Address for Service: z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: 6 9791,P9
l0 Cr P aC P-eS% License Number
� � ,2 ova �4 ao vp 2 M
Address
�' 3 �S/—d'YS Expiration Date D 7
Signature U Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
/f--c 3 o v Registration Number rw
Address
Expiration Date r
Signatur.4d
Telephone
t
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 rmit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work: Mvo/ & o m )Ckorv,
4&erhey2 �eoo f� -� GL,�CS w.¢LL L /XjsrLC p� wf�oc(� fi ,�ocr►�'i,vo .r,¢rP,��rF C
/Veu> w ,A.clo�
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be _ t3F)(~` CIAL
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)X(b) s.
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5) Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING PERMIT
I, e P gP J if L'(,Se<ti as Owner/Authorized Agent of subject property
Hereby authorize to act on
My b hl I:;� rs relati to work authorized by this building permit application. ^ 5^
_ 4 /
Si�ature of Owner — Date
SECTION 7b�OWWNNE/R/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Signature of Own er/A ent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS ISI, 2 ND 3 RD
SPAN
DEMENSIONS OF SILLS
DIN ENSIONS OF POSTS
DIN ENSIONS 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
I
�o�Ph �- 6�� ve.K-- ��+oe•� •9-l.L GL�•s•s I`
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t
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+
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r a p a s a 1 Page No. of Pages
STEPHEN M. KEISLING
Building & Remodeling
68 Glencrest Drive
NORTH ANDOVER, MASSACHUSETTS 01845
MA Lic. 027489 Home Impv. 101846
Phone 682-2072
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOB NAME
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
..............
........`'......... .................. . _ ...O...yu.....4......(......r.-..v../....Y...i.?...�....�.....`.................�.. .Q...�....�............ .1..+..Z.....t.....a.�.......0.../...y.......�. �(-
................
........................................ .................... .............................................................................. ..................................................... ................... ...................................... . ....... ..............
.................�.�..... ....................................` , ... .......... ._.............. -
v 3p aa.-c.,- o�
p ...............j.........................................................................................................................................................................................................................
.�...._ ......a-�.......u........ �....._�`^�....... ....u- .....``...`:...'.................................................._Q , y a,.... `,................... .......................
or
104
........... .............................................,........................... .............................................. ............................................................................
..........................................................
.................................................................................
...............I.....�.. . .....................l�z.... .... / ....................... .................................................. ......................
.. ................................................................................... ... .......... .......... ............
11
................................ ....................... ............................................................ ... .... . .................... .. ...................................................................................................... ..................................
.................................................................................................................................................................................................................................................................................................................................................................................................................................................
. ..� . .......... ........... ................. .
'.....................'...................... . -s�.�
.. c � 00'w-�r�
.... t, ! ... .................................,......._ ' —............... ................ ;.
`
....w.........................................
. G 'k
WP pr0>]Jm hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
).
P mdollars($
ent to be made as follow
All material is guaranteed to be as specified. All work to be completed in a workmanlike f
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Arceptaure of Proposal —The above prices,specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
offrij To.4
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: LD— _ 0-s—
Signature
DECLARATIONS
Farm PAGE 1
CONTRACTORS ADVANTAGE SPECIAL
Family
Casualty Insurance Company POLICY NO. 2005XO431
® Glenmont,New York
NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591
STEPHEN KEISLING UGONE-JOHNSON AGENCY
68 GLENCREST DR FARM FAMILY INSURANCE
N ANDOVER MA 01845-1315 10 S MAIN ST STE 208
TOPSFIELD MA 01983-1834
978-887-8304
RENEWAL
TRANSACTION EFFECTIVE 03/21/05
POLICY PERIOD FROM 03/21/05 TO 03/21/06 12:01 A.M. STANDARD TIME AT THE LOCATION
THE NAMED INSURED IS: INDIVIDUAL OF THE DESCRIBED PREMISES
BUSINESS OF THE NAMED INSURED: CARPENTRY-NOC
LOCATION OF DESCRIBED 68 GLENCREST DRIVE PROTECTION CLASS IS: 04
PREMISES NO. 01: N ANDOVER MA 01845 CONSTRUCTION IS:
FRAME
PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE
BUSINESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN
INSURANCE PREMIUMS PREMIUMS
BUILDING � _. 0 0 0
BUSINESS PERSONAL PROPERTY 5,000 46 46
BUSINESS INCOME AND EXTRA ACTUAL LOSS SUSTAINED NOT
EXPENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED
BUSINESS LIABILITY COVERAGE:
BUSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT
BODILY INJURY/PROPERTY DAMAGE 500,000 PER OCCURRENCE
1,000,000 AGGREGATE
500,000 AGGREGATE FOR
PRODUCTS - COMPLETED
OPERATIONS HAZARD
MEDICAL EXPENSE 5,000 PER PERSON
FIRE LEGAL LIABILITY 50,000 PER OCCUIRENCE
CODE DESCRIPTION PAYROLL TERM PREM ADDL/RTN
91342AA CARPENTRY-NOC 20,000 379 379
THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED
BY 5% ON AN ANNUAL BASIS DURING THE POLICY PERIOD.
ACTUAL CASH VALUE (ACV) -
BUILDING OPTION DOES NOT
APPLY
DEDUCTIBLE: $250 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED
IN THE POLICY
OR ENDORSEMENTS.
COUNTERSIGNED BY:
BF 30 05 01 98 INSURED COPY PROCESSED DATE: 02/22/05
67'� �� u
BOARD OF BUILDING REGULATIONS
License. CONSTRUCTION SUPERVISOR
Numb ' 027489
f: ,
1 xPMIR
1_rgs 007 Tr.no: 14847
s Rest ctiDO r�lf
STEPHEN M KEIS
68 GLEN.CREST DDt
N ANDOVER, MA 01843..,
t Commissioner
rpt �le �omvno�uuea� a�✓�aac/uvrtta �
�\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:, 101846
Expiration: 61,29/2006
i Type: Individual
STEPHEN M.KEISLING 1,1•
Stephen Keisling
68 Glenncrest Dr. ;
N.Andover,MA 01845
Administrator
i
i
i NORTH
Tovm Of : gAndover
T
Slowover, Mass.,
COCMICMEWICK y�.
ORATED PPS`
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
..........
� w Pk BUILDING INSPECTOR
THIS CERTIFIES THAT
........................... Foundation
d '
has permission to erect... AN� ' uildings on ....45 to N d r�
.. ....................a............. .............. Rough
.. ....... .......
to be occupied as ioSS ilos...... AtewJV 1NAv 3 S* aa0~ ON# � Chimney
......... ............................. ....... ........................................................................ ...........................
provided that the person accepting this permit shall in every respect conform to the terms of theapplication on file in Final
this office, and to the provisions of the Codes nd By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. W/ S fw ft*&P of 0 09 *• Gv ou do a& S PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Reguons Voids this Permit. q 07/4 8 Rough
Final
PERMIT EXPIRES N. 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION !TAART Rough
0000. ..................................... ...<<'�'�......... . ............. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
1
I
NSC Order #V7213 09
k"GRTGAGE INSPECTION PLAN
This is a mortgage loan inpection
for mortgage purposes only
. , LOCATION NOR citycH ANDOVER Town Mate
4-a DATE: October 16, 2001 SCALE i inch=80fe
ig. v4A Z_APrA4
* Certification is hereby made to
�� / CHASE MANHATTAN MORTGAGE CORP.
that the existing structures shown on this plan are
eta �� setbackdren?uirementsdofithetapdpilcabislzoningwbylawse
/ 5+� of the °municipality when constructed. or are exempt
from violation enforcement action under M.6.L. Title VII
Chapter 40A. Section 7.
�+ This inspection was prepared in accordance with the
technical standards for Mortgage Loan Inspections as
?6 adopted by the Commonwealth of Massachusetts
° 2 5rra Q�
,,."OOP V:9A 1E by gist ed Land 5veyor
�� t-1" 151 � •
I- 27 DEED AND PLAN REFERENCE
VOy' 2 ESSEX NORTH DISTRICT REGISTRY OF DEEDS
Deed Book 6120 Page 66
H jr Plan Book Plan #111869-
!5�AN DPS 1-Ag� 'i'IZu ''f —
Certification is hereby made that the structureshown or
this plan IS NOT located within a Special Flood Hazard
fd Area as delineated on
community No. 2500980006C
Effective Date: June 2 1993
OF I}qs By the U.S. Department of Housing 6 Urban Development,
�vcy Federal Insurance Administration.
JEAN
No. A confirmatory survey is advised when structures are
to shown to be situated at I foot or less from Property
lines or repaired setback lines or when potential
encroachments are noted. Certifications are on the
��t� 0 9 A� I_A W� \�0"AL VA" basis of my knowledge, information and belief.
ORTGAGE SURVEY CONSULTANTS, _NC -
M ►- o i eaa
•
126A PLEASANT VALLEY T- -SUITE
M(97)E97,5-:=35
TEL. (970) 975-2700 ,