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HomeMy WebLinkAboutMiscellaneous - 155 CHESTNUT STREET 4/30/2018 155 CHESTNUT STREET 210/060-C-001 � -- Date............................... 11236 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that... ........ ................ has permission to perform................................................12.........,0 .................... .......... plumbing in the buildin s Of..— .............................................................. at.... ... ..... ................. ........... .................. North Andover, Mass. Yee.75..........Lic. No. !/. ................................................................................ PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover I MA DATE 7/8/15 PERMIT# Z JOBSITE ADDRESS 155 Chestnut Street OWNER'S NAME John and Beth Tan strom POWNER ADDRESS TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONALE] RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:E] PLANS SUBMITTED: YES E] NO® FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM E DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM E DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER 1 FLOOR/AREA DRAIN !I INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY _ ROOF DRAIN SHOWER STALL _ SERVICE/MOP SINK TOILET _ URINAL \ WASHING MACHINE CONNECTION E WATER HEATER ALL TYPES WATER PIPING OTHER I INSURANCE COVERAGE: I' ave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] NO E] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY 0 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 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.4"i com is "th al ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME INicholas Sawas LICENSE# %IGNATUIkE MPO JPQ CORPORATION#PARTNERSHIP[J# LLC[]# COMPANY NAME Nicholas Sawas ADDRESS 111A Mary Jo Lane CITY Derry STATE NH ] ZIP 103038 TEL 978-804-3303 FAX CELL 978-804-3303 EMAIL dearwatemsav mail.comOU I OUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTAON OTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES A Date.. ............. .......... t4o 'r TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION C14 This certifies that .........V.......I...I........../II...........Irl .............................................. has permission for gas installation .......4......I---e........................................... in the buildings of......... ................................................................................... at .................. North Andover, Mass. Feec .......................... ..................................................................... -5.6.. Lic. No. GASINSPECTOR Check# /02 d3 4 16 -.2ol 7/115- MASSACHUSETTS ASS USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE7/8/15 JOBSITE ADDRESS 1155 Chestnut Street OWNER'S NAME lJohn and Beth Tan Strom A t GOWNER ADDRESS ITE IFAX TYPE OR OCCUPANCY TYPE C PRINT OMMERCIAL EDUCATIONAL® RESIDENTIAL CLEARLY NEW:[j RENOVATION:E] REPLACEMENT:® PLANS SUBMITTED: YES® NO® APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 113 14 BOILER _ BOOSTER CONVERSION BURNER r COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER i ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] 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 t e 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 c p a all ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Nicholas Sawas LICENSE# 15234 N TUR MP El MGF® JP® JGF® LPGI CORPORATION®# PARTNERSHIP®# LLC Ej# COMPANY NAME:Nischolas Sawas ADDRESS 111A Mary Jo Lane CITY IDerry STATE NH ZIP 103038 TEL 978-804-3303 FAX CELL 978-804-3303 EMAIL ---IFZea7r7w7a7temsav@gmail.com ROUGH GAS INSPEC IQN NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL SPECTIO OTES Yes No 17 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a- The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibiy Name (Business/Organization/Individual):Titus/NSAV Address:11A Mary Jo Lane City/State/Zip:Derry, NH 03038 Phone#:978-804-3303 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑✓ Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:Hartford Policy#or Self-ins.Lic.#:76WEG VK0289 Expiration Date:2/15/16 Job Site Address:155 Chestnut Street City/State/Zip:N.Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#:978-804-3303 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#: 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 1.52, §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 I 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia -- ---- -- --- � ...vvravrwva►.a C;�7:'-=t':9 �E�.VIriMV.IYYY.G1yLP17t V".T=IY1f�J.3f..iVl7i'L�Ca.'1':�; - / 0 0 � O T •b / 0 6 a 0 � _- BQAtD OF BOARD OF PLUMBERS4fi G1lSF1TTERS p PLU (BERlh)# GASFITTER& 1 ISSUES T}1E f.OLLOWIlifiB L:fiirENSE ISSUES THE .FOLLOWINfiNSE t 1,�IsNSEII AS A MASTER PLUMBER " L I CI~-ND A5 A ''JOURN.EYMAN; PtiMBEI� : ^" "NAS P. S_AVVAS :. N 11�HOLAS P S.AVVA ` 11 A,,AARX 3fl IANE - 11 A MARYtAN1: UL QEE�IIY NR,o3a38 4b23 .{3.E1�RY - NH 03038 462 ` � 1523 =o5yo�1�6 .: . ._. 2ob963 GOMMONINEALTN-,OF,MMM.: Commonwealth of Massachusetts T • 0 0 e *-*4LGU Department of Public Safety BOA-80-10F License: PM-297297-. Res a F � SHEE- I�tETAL WOR: --.E .. Pipefitter Specialty Master ISSUES THE FOLLOW1Nt; LICENSE ,� � 1l5 A:�1ASTER 1iNRI:STR 1-CTED NICHOLAS P sAwAS - h C i 11A MARYJO LN \':. Derry NH 03038 _ CROLAS P SAVVAS' 11A MARY J0 LANE Expiration: > DERRY ' H 03038 4623 Commissioner 07/08/2016 .. ... ..�i}!S�•�'nn is: _ -. - .� �.: b ? The person named below has completed the Tracmpe ' training program and is hereby awarded the • RV LYALif anal Gfltn ars 9nc. CERTIFICATE �gOFTRAININ�G. 1 4P+pingDlstrbutron:Products _ U_IYJAY �j v% >1i 26&SReseerchDrTO. w1 Y CAYona Ca IMPrhia'.92882 Installer's Name- Gomparly Fhone(giV)2'T07$00 Pax(909)2704601 � r _ r N° 2: 893 r sttuetor _: r�-r� r ` .`13730a r � tri ri� $. _ _ , s� ertlficate No. 1 3 ria. r��m a Service Center 301 WOODS PARK DRIVE CLINTON NY 13323 MON-FRI 8AM to 6PM Eastern Time (866)467-8730 SCIC.NewHartfordC hehaWord.com FOR ASSISTANCE WITH A CLAIM CALL (800)327-3636 76 WEG VKo289 Date. ,� re. . . ... .. %O R7 e,�OL p TO NOF NORTH4 ANDOVER PER INSTALLATION INSTALLATION SACMUSEt,( This certifies that . ,?r.� �` >:.� . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . .`IIS: C . . . . . Y/d�. . . . . . . in the buildings of -.4 ! . . . . . . . . . . . . . . . . . . . . . . . . . . . at ... . . . . . . . . . . . . . North Andover, Mass. Fee. 3.f. Lic. No.. . . .`r`• • cns iNSPECToa�K Check# 5623 �� - y�_ MASSACHUSETTS UNiF©R`N# AF'PLlC"ON FQR PE€ M{T T'0 DD GASFITTtNG it?r-I ar f�ypsl -1"1 ��/�'!� , Mass_ Date t' 1'T Percnit .' v:. t, Building Locattoh_ _G9Nd$r�JU Ownef 4 9s Narsiej�� ��/ Type of Occupancy_ - t .91 r�r/� New. [- - Renovation p 9. Re61 placemerit.p Plans Submitted: Yes[) No Q �, �c. W qj �C. .2 N N.. .iN tj. to rL to rC p p y z �r -99 W W •'K -rY U rg -1? u .f- r ct, z = a -F-, w s m :rn F UJ ni o' o a ,�6 119 h W .Ly W 2 : W Yr }. p }. . a U cr w o&; 9 1. }N. X < t .� C t- >. Ih CC-3;, ;Y -Z W 4m:1p tI6 6) X.9 91.91 "Q p 9 . 19-�,,�:� m 6 --�� , - I - , .-. 92, �.16 ,:6., 1 1,Z: , 9: 6 1 . 9. - , .. I . sU8-85MT:= t3ASE .1ETiT, „1ST fLOOR 21T t3 F:;L O O.R 3Ei� f-LOOK 4TFi FLoo STTt FLOOR `44TH f.LOOR - . 7TTt FLOOR BTH F,LOO.Ft installing Company Name G/- 41 �- Check one: Certificate . ' Address ,,. /` � L�. 1. . - :C�"Corpgratlon — = dog, 6 rr n P4A r.shlp BuStress Telephoned �� : ❑ Flrm%Cp. Name of Licensed Plumber or.,Gas Fi#ter . . 1 9. C/ Llr21 INSURANCE C . OVEitAGE, fiave a Curren K y Insurancg-poHey or_tEs subs#antlat equ, aI6ht=which"meets the'requtr tnents of MGI..Ch. 142. Yes No.-L-- '. If you h1-6 ave:checlie#yes; please ndlchte the type coverage;by:chec#cing the appropriate, box: A69 1 6 99 liability lnsvrahce policy Q Other typef�ndemnity:L Bond Q 01YNER'S iNSUnANGE WA#VER-'9- am aware that the lic9 9-ensee does Rot:have the Insurance covera6 9ge required ,by Chapter 141. . of the"Mass. General-.laws; and t.., signature on tMs permft app#lcatlon,valves this requltemen# Check:one: OwneiQ 96 Agent Q ;.-Signature OI O:99wner or Owners Agent. l hereby cerllty{hat all;o.f the details and'In#ormalron t have ,u -i iited(of entered)to abeve appiicatton are.true and accurate is itis best oI my k- 6. . r pe and"lhat all P#umbing work and"InstallagOni eriormed under the ermli"issue=d for this appltcallon w111 be #n cornpllanee with all perilnent prOris#o11 , ns bt fhe"Massach. 9,r State Gas CO e and'Chapter,t42ot lits Gene a#laws. BY T e of Ucense -r r Z {'turnber d I Title Sig u e o c ase urn ret or Gas rtier - ' asfittOr9 996. 9 �/ Cily/Town aster .rr Ucense hiurriber `9 6.9z 9 yrnah " IU'I'f1G7_ -- ) iC" . O Location No. Date TOWN OF NORTH ANDOVER Of �•o ,•'�.yQ � 9 Certificate of Occupancy $ �'�b''••" <� Building/Frame Permit Fee $ L a SswcMusE Foundation Permit Fee $ • Other Permit Fee $ TOTAL Check # 1 41, ;' " Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 'Tj'i ?'� .n: BUILDING PERMIT NUMBER. /3 DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1-SITE INFORMATION 1.1 P operty Address: 1.2 �A-- "d Parcel Number: 40000< a A9 M umber 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 —Required Provided 1.7 Water Supply M.G.L.C.40. 1 A' Flood Zone Information: 54) 1.8 Sewerage Disposal System: Public ❑ Private 0 ZOne Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: i { Signature Telephone r SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0 v TO/Z-- License Number Address v/a S�� r b �/ �!✓ / Expiration Date r re Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name (/a/ — n- Registration i /�f„ �A/ Registration Number dre s �lj /r/y/l�a' y OC;L / ��� //- s Z;,7 Expiration ate 3 i nature 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.......0 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: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be O]F FINAL USE QNLY Completed by permit a licant 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC ce 5 Fire Protection 6 Total 1+2+3+4+5 Check Nurnber SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUn.DING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf.in all matters relative to work authorized by this building pennit application. Signature of Owner Date i SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 1312 - Prt t e SigMature of OwnerrA ent Date O. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUIIDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I r. I BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR �' „rte► Number, CS 021298 Birthdate: 05/21/1945 4*, Expires: 05/21/2002 Tr.no: 22957 { Restricted To: 00 JOSEPH P BRADISH _ PO BOX 448/7 MOULTON DR E HAMPSTEAD, NH 03826 Administrator 4a � --_- - ..- .•-�.... _ �ice=-�� - ..-.. y/ 3722. HONE IMPROVEMENT CONTRACTOR Registration: 102097 Expiration: 6/30/02 Type Individual JOSEPH P:-BRADISH; JR J # oseph Bradish Jr F Ge rd 9 Noulton Orivet 861 448 ADMINISTRATOR E. HaipstPa: NN; 03826 fiQ! 1 Building Department c ti �_ ti 27 Charles Street _ M North Andover, Massachusetts 01845 -X - ti (978) 688-9545 Fax. (978) 688-9542 y 0 y °R _? ,y7Eo �PaL�S �SACHUS�-C DEBRIS DISPOSAL FORM I In accordance with the provisions of MGL c 40 s 54, and.a condition of � Buildin permit-Building.p the debris resulting from the work shati. -disposed of in a properly licensed solid waste disposal facility as defined byposed MGZ: cl I, sl be-dis The debris will be disposed of in/at: Facility location ignature of Applicant Da NOTE.- A demolition permit p from the Town of North Andover must be obta- project through the Office of the Building Inspector. fined for this ` NORTH ED own ® - dover O No. 13 66' _ y C' z- L dover, Mass., O T O COCMIC IC V ORATED BOARD OF HEALTH PERM Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT............... ... .......................... ...... ........................................... .................................................. Foundation has permission to erect........................................ buil ngs on ...� a .... .....ST. Rough tobe occupied a ......................................................................................................................................... Chimney .............. . provided that the person accep g this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisio s of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION S T ELECTRICAL INSPECTOR (� Rough ..................................................................... ........................................ 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. IFSEE REVERSE SIDE Smoke Det. PEa'ltrr NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. V/ PAGE 1 MAP h40. @ LOT NO. d-p (d 12 RECORD OF OWNERSHIP DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. F LOCATION l��i ��LS '� PURPOSE OF BUILDING [/<rr61 ID[K-G � 'L'�L /2, OWNER'S NAME i ,p n J NO. OF STORIES SIZE OWNER'S ADDRESS ` ,5.. LP ,5 BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME -G TomC SPAN E -- DISTANCE TO NEARS11T BUILDING U DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REARGIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST /t�j 0 , ✓ , PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INSIPKCTOR NATURE dF OWF&RIOR AUTHORIZE A NT FEE OWNER TEL.# C � P U PERMIT GRANTED a CONTR.TEL.# 3 ✓ S` 4 1 U i ,I9 CONTR.LIC.# ,I 6 H.I.C.# I O. '6 BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY sPORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d I 2 13 CONCRETE BUK. PINE BRICK OR STONE FLAB D PIERS PLASTER _ DRY VIAIL _ I UNFIN. 3 BASEMENT i AREA FULL FIN. B M'TAREA _ V. 1/1 % FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN G 4 WALLS I 9 FLOORS CLAPBOARDS B 1 22 f 3 1 DROP SIDING CONCRETE I_ WOOD SHINGLES EARTH ASPHALT SIDING HARDVJ'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. ` STONE ON MASONRY I WIRING STONE ON FRAME _ SUPERIOR I-i POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) ! GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING I MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. ' TIMBER BMS. b COLS. STEAM STEEL BMS. &COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G ` UNIT HEATERS E 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING OFFICES OF: ,120 Main Street I APPI=�L.S ►,ri 'may': = NORTH ANDOVER =_massdcndover. I BULDING t�- ';e Ma55aCl1ti5e2LS O I 8-45 ` CONSERVATION DM ISiON OF HEALTH - PI.ANN ING PLANNING & COMMUNITY DEVELOPSIENT KARE:`H-P.`EL.SO`•DIRECTOR - I .. I I II`f f V In 1C,^.,:rC::nwid� he CtiS:C is ::Z ` w.,, S :�. 1 condlt'cn Of Building Permit m Nuber s th:.t Zc ,is resulting ircrn this work shall disnesec: of in a Orcnerl .,:...tscz scud •;as... _s^csa. :aci. :v rs ._:..gid 5y MGL c 111.bS i ne debris will be disposer' cf in: F _ I Z/xf Stcnat::e of Pcrtntt Acplicnt Date NOT=: Demolition permit fro= the ToLna of North Andover must be obtained for this project through the Of-fice of the Building Inspector. i ,'' Location Date TOWN OF NORTH ANDOVER p Certificate of Occupancy $ # Building/Frame Permit Fee $ Foundation Permit Fee $ Other ermit Fee $ .,_�U P_.T'1 f•._... Sewer Connection Fee $ _. Water Connection Fee $ 1993 TOTAL / /A (� Building Inspector t.TL' .~ 6322 Div. Public Works fER1f NO. 1319 00, PAGE 1 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE I SUB DIV. LOT NO. I i OCATION PURPOSE OF BUILDING �ey� •L f K�S�(kS P,!L (S F �AWNER'S NAME L` NO. OF STORIES / SIZE t OWNER'S ADDRESS j �j /v / w BASEMENT OR SLAB - AR HITECT'S NAME) L SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN --- DISTANCE TO NEAREST BUILDING GN DIMENSIONS OF SILLS DISTANCE FROM STREET '" POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COSITryC DO cx, PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS I - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND 9APPROVED BY BUILDING INSPECTOR DATE FI s 3 / BOARD OF HEALTH V RE OF OWNER OR AUTHORIZED AGENT PLANNING BOARD PERMIT GRANTED - /` OWNER TEL,# S �a 6 �A (/6NTR.TEL.#680- 7733 '9 L INTR. Luc.# US3 ZI6 3- BOARD OF SELECTMEN 7- � 13UIL�JDINQ INBP[CTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL'K. PINE _ BRICK OR STONE HARDW D — PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T AREA _ '14 1/1 14 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 22 f 3 DROP SIDING CONCRETE I_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDNtJ'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH.TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK N MAS NRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME ADEQUAATE ISUPERIO -i NONE 5 ROOF 10 PLUMBING }_,�. GABLE HIP BATH (3 FIX.) zl GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 4 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC lsl 13rd I I NO HEATING d r 4 S�N ,ce, PT Decll� �iG X 3x- 9T 'po57" riI �-' 1LI TRea��, A ��izoX _ yq ```�. 1�PP�bX- MON. TUE. WED. THU. FRI. SAT. LOADED AND CHECKED BY DRIVER ❑ ❑ ❑ ❑ ❑ ❑ JaJackson11 "' ❑ A.M. DELIVER ❑ P.M. ❑ PICK-UP Lumber & STORE HOURS MON.THRU FRI. SAT. Millwork 7A.M.-5:30PM. 7A.M.-4PM JACKSON LUMBER&MILLWORK CO., INC. We agree to furnish the below material for the sum indicated in the "TOTAL AMOUNT" box. Compare 15 MARKET STREET • P.O. BOX 449 • LAWRENCE, MA 01842 your list carefully. We furnish no items not specifically mentioned. Prices subject to acceptance within SEVEN days and delivered within 30 days from the date hereof. Customer agrees to pay a 'HONE(508)686-4141 FAX(508) 688-6802 STORE restocking charge on all returned items of fifteen percent (15%) unless returned material was (508)688-6844 OFFICE damaged upon receipt by customer. • • TERMS&CONDITIONS-SEE REVERSE SIDE STORE I!U0TAT10N RE; 155 CHSTIlUT N.AN.DOVER 'IACKSON 1-RR M L W K C ;OLD SHIP TO: (SAME AS SOLD TO UNLESS NOTED BELOW) TO: ,!ACKSON HOME SERVICES 1- Rp-1NK DOANE ATTO GUY RIENDEAU 1103 LOHMANS CROSSING RD . HOLT! PRICE COPIES AUSTINTrXAS: 78734 Lr)WREf4CE MA 01344— 1-512-261--4270 - Transaction Store Customer Code Sequence No. Time Date No. S Tan. oper.No. Date Wanted 190 1 5: 4' 190'42 7-293 1 31 31 7/ 0 f:7129193 Reference Number Customer Order Number Ship Via Terms Salesman 19042 / 72293 TRUCK NET 30 DAYS KEVIN BR0UILLr►RD .N# ITEM NUMBER DUAN.ORD. DUAN.SHP. DESCRIPTION UMI PRICE/UNIT EXTENSION INSTALLATION CONTRACT PHASE 1 1 .REMOVE. EXI8TING TWO. LEVE DECK COMPLETE DOWN TO OLD FOOTIjdGS.. 2.PLACE ALL DEBRIS INTO DU4PSTER. % LEAVE BROOtt, CLEAN FOR SOIL TREATMENT 3.DI:G OUT FOR, NEW; CONCRETE: FOOTINGS . POUR . 4 : INSTALL NEW,;PT IIECfr 15',--2'". X 19`-0" W/A 3—STEP STAIRWAY ON THE, RIGHT FRONT: CORNER? OF . THE DECK 8'-0" IN LENGTH 30PRESSURE TREATED DECKING TO BE 0/­1 " X 6 " 6.PT RAILING WILL BE 2 X 4 TOP RAIL• - X 4 BOTTOM HAIL W/BALLUSTER.S M0..UNTE'Ir ON . THE SIDE► AND A ? X B TOP RAIL CAP 7.AL-L RAIL POST WILL BE OF 4 X 4 PT STOCK 8.FLASHINGPSIItINGrAND NEW CASINGS WILL BE REPLACED ABOUND EXISTING SLIDING DOOR UNIT WHERE NECESSARY. F SPECIAL ORDERED,I UNDERSTAND THAT.THE ITEMS LISTED ARE SUB-TOTAL TAX% AMoX • :ORRECT AND NONRETURNABLE. CONTINUED -�CEPTED BY DATE OFFICE COPY • COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY =� F OF 1010 COMMONWEALTH AVE. MASSACHUSETTS BOSTON,MA 02215 I LICENSE ";7 CONSTR. SUPERVISOR CAUTION EXPIRATION DATE 9 02/28/1995 j FOR PROTECTION AGAINST RESTRICTIONS EFFECTIVE DATE LIC-NO. THEFT, PUT RIGHT THUMB NONE 102/28/1993 053468 I PRINT IN APPROPRIATE ° BOX ON LICENSE. JEFFREY P RICHARDSON 13 PINE STREET 0 ()y FiLASTI'i q OP SS 0 031-50-6243 METHUEN MA 01844 mlr'MUSV4NCLUD��ATORS PHOTO. -PHOTO(BLASTING OPR ONLY) f f0.0o I' Q 5. 993 ' NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY MAY HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER I ., x DOE(' (( ' 5125/1962 �L»� Ii��rL� n '4 THIS DOCUMENT MUST BE I « SIGN NAME IN FULL ABOVE SIGNATURE LINE CARRIED ON THE PERSON OF SIGNATURE OF LICENSEE . THE HOLDER WHEN EN- OTHERS RIGHT N•OTHERS-PoGHT THUMB PRINT GAGED MTHIS OCCUPATION.� � -` MISSIONER �H� — a:'RPw✓��+`S�'Z:rY� "-iw�'bPMi<'fC:�..__.–.s& .. :d.'cwi•An-.� x . I r r •"� � HOME IMFROVEAENT CONTRACTOR � Registration 104270 Type - DIA Expiration 07/13/94 r. �A r J. P. Richardson Const. ` .� Jeffrey P. Richardson 3 Pine St. ADMINISTRATOR Methuen MA 01844 ' I i TOw Of r " 120 Main Street OFFICES OF: North Andover. APPEALS M NORTH ANDOVER ` Massachusetts 01845 ., _ •:•. _. BUILDING t;�•-��"4r (617)685.4775 m CONSERVATION ` DIVISION OF HEALTH PLANNINGPLANNING & COMMUNITY DEVELOPMENT KAREN H.P.NELSON,DIRECTOR In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number ,?1-'i .0 is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: 00 AtlJove,*x, (Location of.Facility) I aj&re of Permit Applicant . �q 9 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NpRTM F 0 of over No. 3 3 3 dower, Mass. 19 2 COCHI HE IC > �AORATED ,qs H 5�� BOARD.OF HEALTH Food/Kitchen Septic System ' . . ., PERMIT T . BUILDING INSPECTOR THIS CERTIFIES THAT....�....w ...�i A0.0 H ............................................................................. Foundation J*rV�has permission to erect...�°.�� ... ........ buildings on...��� �r. . ... . ... ........ .... . ....... Rough ' � h to be occupied as...�Q .n ... x..�/�e� ..tif......�/00 . ........................................... Chimney c • 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 Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Fina' UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .. .. .......... .................... .... .................... 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 .Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL //y0 CONSERVATION FINAL street No. Smoke Det. CFIAIFR /IAIATFR FINAL- DRIVEWAY ENTRY PERMIT Date.... .......... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING �sS�cHusssa This certifies that ........../< ..to 4 ................ ............ . ............................................. has permission to perform ........................... wiring in the building of.....7 J.- at ............................................ North An over,Mass............................................................. Fee..-.74A �'71Tj M a,k. ........Lic. No. .............. ............................... .............................. ELECTRICAL INSPECTOR Check# -7& 12523 Core. q� f j Cord*.monujeaAM.©flPja.mardlwefi, Oficial Use Only 2 �- Permit No.� l ,Fw,.e o/5-4-re Saruae. BOARD OF FIRE PRET EKI i(OIC RECULA 1 IONS �y 110�and Fee Checked (leave blank zAUP P QC;nPM10 ,, "Fn PIER, ARWH rR py �� �AL 11V, RZK ' All c;obi;to be performed in accordance sz'Itli the'Iassachusetts Electrical Code CMEQ} 527 QMR 12.00 {P xSI1*PIMT, ,rjavf'0P,YT-PE Ar-L ft-0BjW--.jT1-01l9 .a2z�e ? City or Toim.o.6 6k t?the 1r7Specto?o,T-j7I7'eS. Ey this application the undersigned gives notice ofhis or her intention to perform the eleC cal work desCrcbeel belot=.'- .oea=?oa(Street�Number) C h.e5�r,v�- 0"I'Mer ur"ant fi ��i 14— i9•)ys err T91'13S -,[5 :i1V�E;�Sl•�dLIigSS Sa/W.�_ 1s+'c is permkin Conjunatj ;:S Boa-) fit ( .he __pprop=iteo ) -laa-;�ose o' u icl � �ti �c.t R45tTag SM-ice al00 GMpg C;-o >T�; , h T • -:� c-_ ��c Lam— u-t'sze❑ 11Io.o=i':reters d a •',1"18 $ n-''r. No. ~ V N?1if2he`dT=SBC}eei3 c3C f`'..z- sc^C''_•%Y •� L8@C-tio€i end P-lanare of proposed Ami c✓�7�c�� �� v Compledop oftliejolltnpltzir table mtn=be~paired bi.the Inspector of Wirer. 11i.4=Recessed Lczm= 'diTE$ addia)Farm ]�Io.G` 'C- 1 ..Lu�ai_e =rho`e. DIG.of• l filA r�� Na ��to.os Ha'fs R C� '•'.� aL'a CL4sS r:�� No.of i,rsiF?trr"sS rMoQ3 Ell, i—� Kw- (--i 1 :3.oz' i;3e'�E ;;y cic,_Fe c c fir, L! Gi- L3 ��32ti2i''J?n€ts r-'io.oz�eeepiatile Omles i)Ie.o_vii���e, Ia.�H li v gin^ e.Sriftehas (� !FG.of`-Gas B:izzmers "No.cT.Detecuo:sad !'I0.t.' /f - cF2.�a�`2e`a�e DEliCes i ..� Aa psi.. Toms ;'No.GfAie:Lng D9c1'Ces F Io.Of Wnsz`-_'•DIS pose m t t m?P Number a Lv= >� ' s I oz Self-Coniec No.i0.Ot 'rtdiS: l�l—" ✓E�`�^ CJ 'ea'£3zceCrS shwTehers / upacslt Feu 1 Mv i oCBl�] r'�unae:pal oa Q �Or Is 1140.Of D-n ez 3 °�`�z�G pplianew M=r�;� �SVc�r� :e:�zs:' NO.C:•Tater m=ar �IZIo.o=" No.01'Devk- �.• 1'14.CT �2 xr�iS -_ r ?masts Q;=mss'Devices t! _ _ l� No.4_'ev ces or E ah .i L' 223.' yd=o-a°see a`-atabs ;o.o=lY_oc�ci:5 _ ITeleeo?�`.^.^�i amsliei Pio.o:-: i . �''� lttaclt additional detail if desired,or os re2nired bi=the Inspector ojI€Tres Estimated Value o::"ElecHcal Evo-,k & /00.00 (When required by rnanicgpal policy.) "Work to Ste `L -71-7131( 5 las115 inspections to be requested in accordance ivM IVEC Rule 10.and upon completion. =NSU `;jiC 5 •='=J`�� less waived try-the Omer_?ic permit for the perfor=mance Gy-e- t �vorl:may issue unless the licensee provides proof of liability insuance including`completed operation"cover a or its substantial equivalent The undersigned ceracies that such covera��is In Force,and icas znbited pmofof same-to the permit issuing arise. CHECK ONE- INSURANCE [9 BOND ❑ OTI�E_R 17 (Spe 'cry:) CeltLf]r3 tf7tt12F if3Bpffitl5 tItttjDBFIQIt erjttt'}.i11a"t112 i;00!-Mfu'ZO j Or,BUS q?,gett'avi:is_bore and Coxwlei& S-';, HETIA-it= ofmewC�- 6- — c _ I c c--1 j C.lyl0� ej 1571 5 • Licensee: (f gaoiirable,e�{er"exen2pt"ir.ale licznsemmzbm-li�r� Address., J✓U C t 75&4 �! ifs e >pttil/j— Dr `i y 9 .MG.: "Per M.G.L.c.1`'7 s.5-1-61,seen= L ,, ;• AIL Tei.Pato.: 7 �'?' &regdms�epsrtment of Public Safer• "S"License: Lic.I4o. O;Jt I1 'S i=ISU _r'��ICI; '_z•_rsI : I am aware Jaz the Licensee does nat li a iTie liability insurance,coverage normally required by lav:. 3y my signature below,I hereby vmjve this requirement. Z ani;he(chec c one)[I oumer ry t3aerlAgeet Q otiRleF'S 2rrent. 8 C`••ev"Iza r, Telezone No. i r .s A\� C91 V 1 '-J �-11112 �� i I .COMMONWEALTH OF e o °... ° MASSq°CHVSE�.S �4ARo 0 ELECT . ISSUES THE RIC'IA FNS { REGIS7f RpOLLOWING LICENSE AS MAST ER LECTRICrLAN R E MM E TTCOPY r � �r IR '0 BOX- 794 MLpb. , t y LETpN 1,, ,;,,, W MA 01 y o 1571 A' , 0731/9(9 2794 50778 r. COMMONWEALTH OF MASSACHt1SETTS 101o reRARDOF EIrECTRICIANS .;. . ISSUES.THE FOLLOW IN ` LICENSE A AG JOURNEYMAN ELECTRI`CI �Ncc KEVIN!` R EMMETT 'W1 PO a0X 794 '4 t ''``. Il d i. III1pLETON !hA 01949-27 * 37431..::,." . 07/31./+"l 50777 M I� The Commonwealth of Massachusetts Print Form y. Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 " f www.massgov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E7 �LtCT2��'i9C SV-KV CGS 1 ti/C Address: �y /✓4 )( 79�/ City/State/Zip: /^-I/Q 0 16'T IV M,-f Dl9Yi hone#: 01V (9 F �7- �1 212v Are you an employer?Check the appropriate box: Type of project(required): 1.94 am a employer with --? _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.2f 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 13.[:]Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: � r Policy#or Self-ins.Lic.#: Q g(�G e� /'� 9J 7l`p Expiration Date: 6/AR 0/6— Job Site Address: `�--�C�� 1�— �� nVox-f?7 � City/State/Zip1i/ 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. Ido hereby certify under the 7* 1ndpenaliks ofperjury that the information provided above is true and correct. Signature: ez Date: Phone#: 7 P_ 7' q -'7 -2 (f) Oficial 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#: