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HomeMy WebLinkAboutMiscellaneous - 169 LACY STREET 4/30/2018 r 169 LACY STREET J 210/105.D-0062-0000.0 ,1 f Date...../6/..............000............................... OF &ORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION t ss�CHUS� This certifies that ...y......................f%- � has permission for gas 'nstallation ... 5 K^ � ��- e- in the buildings of:... .�'�. ? e-- q ................................................................................... at.........?�.../.................................. ........., North Andover, Mass. Fee..Co c�..--.. Lic. No-I.. ............ GASINSPECTOR Check# ;Z Z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — CITY: DIANE CURRIE MA. DATE: 9/30/2015 PERMIT# l JOBSITE ADDRESS: 169 LACY ST OWNER'S NAME: DIANE CURRIE OWNER ADDRESS: TEL: 978-682-6492 FA-X: G TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO P' APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST () UNIT HEATER UNVENTED ROOM HEATER WATER HEATER t/ rpt c !i-�- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 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 permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAMF.A , Gam✓ LICENSE# 3 SIGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE:MA ZIP:01844 FAX:978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM D ,\ MASTER 0 JOURNEYMAN ❑LP INSTALLER "RPO ❑# PARTNERSHIP ❑# LLC [2] #45-326-3311 The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 400 Washington Street Boston,MA 02111 5" f www.mass.gov/dia Workers' Compensation Insurance p Affidavit: Builders/Contractors/Electricians/Plumber s Applicant Information Please Print Legibly Name (Business/Organization/Individual): Osterman Propane, LLC Address: One Memorial Square City/State/Zip: Whitinsville MA 01588 Phone#: 508-234-1573 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 2 7 5 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. t 7. ❑ 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 S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions I myself. [No workers comp. c. 152, §1(4),and we have no P 12.❑ Roof repairs insurance required.] employees. �o workers' 13.2 Other LP Gas Install & Repair 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 their workers'comp.policy information. i I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. i insurance company Name: Insurance Company of the State of PA Policy#or Self-ins.Lic.#:_ VVCO 15883775 Expiration Date: 06/30/2016 Job Site Address: All Locations In. North Andover City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c •tify under thep,*4,and penalties ofpejury that the information provided above is true and correct. Sign re: ��`�`� Date: 07/01/2015 Phone#: .508-234-1573 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 Cleric 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: A CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 06/29/2DATE 0 5 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAMP Willis of Texas, Inc. PHONE FAX c/o 26 Century Blvd. - 877-945-7378 888-467-2378 P.O. sox 305191 E-MAIL certificates@willis.com Nashville, TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Lexington Insurance Company 19437-000 INSURED NGL Energy Partners, LP INSURER B: The Insurance Company of the State of Pen 19429-100 612 0 S. Yale Avenue INSURERC: Suite 805 Tulsa, OK 74136 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:23299818 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL SUB POLICY NUMBER POLICY EFF POLICY EXPITR tmmmnfyyvN LIMITS A X COMMERCIAL GENERAL LIABILITY 034205248 6/3 0/2 015 6/30/2016 EACH OCCURRENCE $ 2,000,000 ppt��qq 77 aocTE1 ce) $ 100 000 CLAIMS-MADE X OCCUR �REMS MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 4,000,000 X POLICY EPRO ❑ LOC PRO- JECT PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: $ B AUTOMOBILE LIABILITY CA4584397 AOS 6/30/2015 6/30/2016 COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 B X ANYAUTO CA4584396 MA 6/30/2015 6/30/2016 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED tid Per accident) $ AUTOS AUTOS BODILY INJURY( ) HIREDAUTOS NON-OWNED PROPERTYDAMAGE AUTOS (Per accident) $ $ A X UMBRELLA LIAB X OCCUR 015881338 6/30/2015 6/30/2016 EACH OCCURRENCE_$ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 51000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION WC015883775&079331530 6/3 0/2 015 6/30/2016 X PE YIN R OT - ANDEMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 f yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additonal Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of North Andover 120 Main Street N. Andover, MA 1845 Coll:4718034 Tp1:1970970 Cert:2 9 18 ©1988-2014ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD NOL Retail SupplyNGL Retail-Su RetailSupply,-LLC NGL Supply Terminal Company, LLC NGL Supply Wholesale, LLC _ GL Water Solutions, LLC NGL-MA, LLC NGL-NE — ------- - -- ------ — - Osterman Propane, LLC Osterman Propane, LLC dba Anthem Propane Exchange Osterman Propane, LLC dba Downeast Energy -- --- —� Osterman Propane, LLC dba Lessig Oil and Propane Osterman Propane, LLC dba Thompson's Oil and Propane Thompson Oil _—.------------ ---- -- — -- --_ � Named Insured Includes: — -- AntiCline Disposal, LLC Centennial Energy, LLC — --- ------- -- --------------------�-- Hickgas, LLC dba DeLuca Hickgas, LLC dba Enviro ' Hickgas, LLC-Lincoln Hicksgas, LLC -------------- ----- — ---- ----------� Hicksgas,_LLC - Blackstone Hickgas, LLC - Bloomington Hicks as, LLC - Braidwood Hicksgas, LLC - Decatur _— — — — — — --- ---- Hicksgas, LLC - DeKalb _Hicksgas, LLC -_Kankake _Hicksgas, LLC - Kankakee Hicksgas,_ LLC - Lowell j Hicksgas LLC - Monticello— — LHicksgas, LLC - N. Pekin j Hicksgas, LLC - Oakwood_ Hicksgas, LLC =Renesselaer -- Hicksgas, LLC - Roberts --1 Hicksgas, LLC - Toluca ' Hicksgas, LLC_-_Urbana Hicksgas, LLC -Vandalia 1 Hicksgas, LLC dba DeLuca H� icksgas, LLC dba Enviro Hicksgas, LLC dba Global Propane Hicksgas, LLC dba Indiana Hicks Hicksgas, LLC dba Liberty Propane _ ! Hicksgas, LLC dba_Pacer_Propane Hicksgas, LLC dba Pittman Propane LHicksgas, LLC dba Rocket Propane ------------ `Hicksgas, LLC dba Rocket Supply, Inc. Hicksgas, LLC dba Service Gas Hicksgas, LLC dba Urbana v LHicksgas, LLC-Utah LP High Sierra Crude Oil & Marketing, LLC j High Sierra Energy, LP ---- ----- ----- ------- NGL Crude Logistics NGL Crude Transportation, LLC —_ ! NGL Energy Operating, LLC NGL Energy Partners, LP NGL Liquids, LLC ! i N G L Propane, LLC_ -- ----- — ------ --- ------ -- - — --- -------------- -—_ a NGL Propane, LLC dba Brantley Gas [ NGL_Propane, LLC dba Propane Central NGI Propane LLC dba Propane Energies Group (PEG) _ NGL Propane, LLC dba North Georgia Propane —_ -- — ! NGL Propane, LLC dba Pro flame NGL Propane LLC dba_RB's Gas NGL Propane LLC dba Woodstock Gas I •�.f Jr - ' +"�� lr 3� r" � �T' � i'�' t � - a•�M+ i- u°E"S x{,— . �>t.�'�► '�-� "'F- �����a :."� to s��` , � �'�i ,rs su £' ��.t ,�_ �� fi. q,+�. ��,ny. �,� n 3 s r •Y _. a i ,.� ��,*. � ,, �k� ���R t:.�•� a h �` •'� t�� ti.-. �'wY�rt�. "'� �y{3 {r�, y , ..,� $ *,x r.. $„ t r .9"�t.`J• 't "i, r�„ 's P ?@ MA 'PSA rn,N, _ =4 }.��3'zlr�s�'� ,rS�� � y* ,b•k. 5 .may` wk, �` �X i-ro s. � $ +sem. r``• 4' `�': '�.•,., �r "�`k4 e. \,. 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' � +P I �/`"C� s• j �,a'?sr�,.. `w�1�pq•'r,; �4 � -,��'��s,���� .�, � � 19; •ty� ��v,.r.'�� t� ��3 •�e., i j Yrv�4*��' ,��a � •� � rot's '' >w �,��` +t{ �t s � '� ^�•�"� R-SMI NO rR MA a'.4a�° 1' p e•� 3.. +' aag,q Ye.- a.• 'a" "i,S v :4t' Fa «w •' .„ccr '=tae `^ 1� 7� r$37 * ti:, + .ti •� � � '`��"�r3'r�.��:�- t {• � 4�"�s .h r kt? � •rte � � "* '�y�����,.�3�'°r� " .t, '���a'�"?�s ;_*{�'s`'`��,7��{F, ��t'ca.. "5,• •+ ?x+ 'a+rJ��"+" 1 $S � sad Date....-?.... . .`..... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHUS This certifies that . ,,,--,I 1 —1 VIVM�.....4. 7.................................. has permission to perform A.:--':tL;rAg l/CG.............. wiring in the building of................ .......................................... at.....0?.9..... S,7. ............... ( ....................... North ftp Andover,Mass. Fee...7 ... Lic.NoA�4.5%7....... P)-4 7r4 .7,11 liv.-C.-,n'A 4., ............... ... .... .V. .. ............. ... ....... ELECTRICAL INSPECrOli Check # 74 7 7328 r -t\- Commonwealth of Massachusetts Official` � 2Use only Department of Fire Services / Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O 7 City or Town of: 1W. A'1.1 0Vt0 f' j l if To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) / 6 9 Za4If/ 3--l- Owner or Tenant Dl!e/(if J�jA r r/ if Telephone No. Owner's Address S474-% Is this permit in conjunction with building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building iz$Ic&ic- a Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location a d Nature of Proposed Electrical Work: J tzl K S C�f Cly�ti� /��� $451� Completion o the followin table ing be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.o Total ti Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- [jo.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. l Total Tons No.of Alerting Devices Disposers eat um Number ons o.o e ontame No.of Waste Dis p Totals ..._...... ................... ........._...__.._ Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ unicipa ❑ Other p g Connection No.of Dryers Heating Appliances KW ecste ho f Devices or Equivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsNo.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the amand p nald S of perju that the information on this application is true and complete: FIRM NA j1 rrSAJ t 4110 Ll,-- LIC. NO.: Licensee rl s t4r I rvlekjSignature,/, LIC. NO.: (Ifapplicable,enter "exempt tp the license numberNA ine. us.Tel.No.: " .Z3 Address: . /f G/AAf21-0 .s* AA0 �nLWP' ' "Vf Alt.Tel. No.- 34 *Security System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: l am aware that the Licensee does not have the liability insurance coverage normally required by law._ By my signature below, 1 hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ d Location No. Date . NpRT� TOWN OF NORTH ANDOVER h 9 ` Certificate of Occupancy $ MU I Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � Check # � f i Building InspgC& 1 TOWN OF NORTH ANDOVER • BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI5 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING tongt g, BUILDING PERMIT NUMBER. DATE ISSUED: ic SIGNATURE: Building Commissionerff2u22Lor of Buildings Date /-dam Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 00 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard` Required Provide Required Provided R red Provided �g 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: 1.7 Water Supply M.C11.(1`"5�0. Public ❑ Private ❑ S Zone Outside Flood Zone 0 Municipal 11On Site Disposal System 0 SECTION 2-PROPERtfY OWNERSHIP/AUTHORIZED AGENT istoric iS rIC : Ye-S No m 2.1 Owner of Record `anz �1r l CgCG1 J� G y Name(Print) Address for Service --� ! r Signature Telephone 2.2 Owner of Record: 9 Name Print Address for Service: Z M Signature Telephone go SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 1 0 O A T( �f 1 W License Number "n Address Q /', ctc,4 A- CC � ` G� Expiratio Date e Signature X7 Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑cc- v e Company Name � lG �lCV C �`�y t54�( Registration Number r Address CC 2 ` f Expiration Da ^� Signaldre I elephone Y' 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 cheek a licabte New Construction ❑ Existing Building ❑ Repair(s) ❑ Ferations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: t V[ac-c SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OF)F'ICIAL USE ONLY Completed by permit applicant 1. Building ., (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee ta) X (b) 4 Mechanical HVAC 0 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 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 permit application. f Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION FR ne� Ce e7� s`Owf/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 NamSignature of Owner/A ent Date M. NO.OF STORIES, SIZE BASEMENT OR SLAB ` SIZE OF FLOOR TIMBERS tSTRD2' 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIlWERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH ^ Town of No. ~ Mal V- LA dover, Mass., 2 COCMICKEWICK y1. 7,9 AERATED `S BOARD OF HEALTH Food/Kitchen PE T Septic System R T D BUILDING INSPECTOR THISCERTIFIES THAT........... ...... ............ . . .... ......... .......................... .. ................................. .... ............. Foundation has permission to erect........................................ buildings on . ...�........'.. .... .... ....... Rough to be occupied as chimney . . .. .. ..... .... . . .. .. .. .. . . . . . . ......................................... provided that the person a pting this permit shal every respect conform to the terms of the application on file in Final this office, and to the pro ons 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ........................ . ................................ Service LDING 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. The Commonwealth of Massachusetts Department o Industrial Accidents Office OffnuestfgaU Ms 600 Washington Street, 7r Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavitm Bullda/Plumbin-Mecti ical Contractors name: ,���dd� C� (',eCI�r�I1G � ®�adlt address: ✓ [ aCN e.! city N. Aaht/,ir state: fa 51 zip: Ol*r phone# (Q p Z— work site location(full address): ❑ 1 am a homeowner perfonning all work myself. Project Type: ❑New Construction❑Remodel ❑ lamaso le proprietor and have no one working in any capacity E] Building Addition ❑ 1 am an: : employer providing workers' compensation for my employees working on this job. company name: address: city: phone4: insurance-co. olio # .`�aqwo:Ck am a sole proprietor,general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: C�U[vat CM i ac l 6�� .(/ /G Q c�rof address: t/a city: insurance'.co. policy.4 a ., � `�. �:�t'fi �U�,.��;'"ut�n,.��roi�;t+,�:"�s�''��'.,.n„i.��,'!..(s�'?- r- � ...: ,'hl't�'4 � t•r�,•�z.. 'i!�`k"r�Xlk��tlrt„C�,�r!, tu?*.�:e.�' `;' �{ j3;<���'��»JC:�;�r�.r-t�� company name: address: city: phone#: insurance co. policy# Attac}r.ad�ibbnn'aNsuuryrytopp++"t�Iin`e essa '�„,' ia5e^� 7 r.': �r s��:.ft'��: ..�!�,t'.�i`��t,�:�if�2J!�t�'iii` ��rrd•'���,�eY��41``elryt�f�r.:�1,.��,`s3 y+��:_.{.;c'5�� 1'�41..�� dc� ..�.... f'.. .4L.r:% .,-�,...�.J....L.aC�h!1 f:” ��,� } i iF 5. 1� !1 �3���,'F �.�M1i••y�t.:ll��! !1� ���:1 Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under tl pains and penalties o perjury that the information provided above is trite an cojrect Signature Date Print name ( A Phone# 6/clt�, 2tV v � sM�� official use only do not write in this area to be completed by city or town official �`• ^! citypermit/license# or town: p ❑Building Department e ❑Licensing Board i! ie ❑check if immediate response is required ❑Selectmen's Office ,CC� a37 []Health Department e contact person: phone#; ❑Other ` (revised Sept.2001) R•J '4�.� YYhf,^sy✓r :"o: rr;:;»k`-y�^rt •i�^ -,lL yYL "`i "�`` ::3ta� '�t,>• •�,!vr ctr,.,.�,�:y.n:F1+ ..;ar J f.4";s,n::� r'1't �+, c r ;�+a'n'7.n JS. ��.t ..t.l'.i.).:,t .+Qt��it1.•W.t�e X44.7:M1:/:JR.N.�C�u'$?,=',s_1:1I,J:Ji:�r.....v..�f2C:`..tfil...,�l,..C1i'�f:.,eYt`Cif.S f.I.eb.,w��3�.TG:isi..,.,fr':11"::.'.`fatv:.n,�F�'I lra-�i..�.:}t.r��(.1.-n°,".'.I... �rii✓�L(.aN✓Y.'1..+'3S•.A�rb�'"1•Y�' r,,. ;• 1.'I p,,,tr t•. �.^+1. i1 z i'�.+ ', ,tr +i�; l 5� { 1! tR t�,,�IiW,1, 'itl� { qqTJ f tj+ I .DATE 6(Mf!21 (Yj ` ''rr�t', r I"I ,4 51.2065 ACOn rr IGib: pal i r iI I iIr It I HCV✓�� I I lyYI UII G6i1 y M EI � n.....n! 'r a,t:{.. .r�::{1I 1_a �kay 4Hh ta. LIR If'.,,d EI r....r..? � I PROD Ssri�Jl# A16442 THIS CERTIFICATE 15 ISSUE A5 A MAI 1 ,:K OF INFORMATION ONLY AND CONFERS NO RIC+HTS UPON THE CERTIFICATE RON RISK SERVICES, INC. OF FLORIDA HOLDER. THIS CERTIFICATE DOES NOT AME-ND, E7l7ENb OR 11001 13RICKELL BAY DRIVE, SUITE#1100 All THE COVERAIll AFEORIDEEI By THE= POLICIES BELOW. ' MIAMI, FL 33131-4937 COMPANIES AFFORDING COVERAGE i.-..... -.... ... .- ._ - 800-743-8130 r..c)MPANY NEW HAMPSHIRE INSUWINCE COMPANY A _.. INSURED C:i1MF AN" ACF TOTALSOUl INC. B i 10200 SUNSET DRIVE r.^JMl'ANY MIAMI,^L 53173 C 'ALTERNATE EMPLOYER -'-' -.. - SYLVAIN CONTRACTING LLC COMPANY I .... .. -, a lriic�I7:l Lu'h�i i! I•�t ,II ! •' V {j , "�..T. i cTS�' ,y:°+•bTi h !t' ':2 f F+ ;{t •15 7••"r.'7I'Ija� +,i;i`�( .;..,1jl�i.q•,' dl' I} T'l i,�lv'If q,r'.w. rl(k rti 1�om;•;..Ili s�k 31�v 4r.4'li,l if.it.,?fid��T'r},Iambdhltl, Tfr,yl .'�, �X1,1 . , 11 +t i Iill;l?'? H;l t 1,t 1�I::r- r ?�t ll.rl L;aFt6 I -..• �., ��,?:r.4l�I.#a„It,r.,SIiP,:. 1. . .. :.f.I,41! . THIS I$''O CERTIFY THAT :HE POLICIES OF INSURANCE lIS7ED BELOW HAVE BPP N` SSUI=O TO THE INSURED NAMED.ASOVE=0R THE POLICY PERIOD INDICATED,NOTWTHSTANDINC ANY REOUIRFMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIT RESPECT TO W11Ch THIS V CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE WSURANCF-AFFORDED B Y THE POLICIES DESCRIBED HEREIN IS SUBJE.C;T TO ALL THE TERMS EXCLUSIONS AND CONDITION$OF SUCH POLICIES•LIMITS S IOW14 MAY HAVE BEEN REDUCED BY PAID CLAIM'S. -. ... POLICY EFFECTIVE I POLICY EXPIRATIONLIMITS co TYPE OF INSURANCE POLICY NUMBER DATE(MWDDl DATE(MMIll LTR' GENERAL LIABILITY GE!iiiFCAI 4(3ciREGhTF COMMERCIAL GENERAL lPRC•L"IUCTS-COI.IPIGr Ar;G S :LAIMQ MADti OCCUR j �E:RSpNP1 6 AD\'iNJ'•1RY S .--- JVINP_RSit COWPACTO"n'3 PROT rP:I\CH OC:Ct1RREt•!CE $ t IRE DAMi+gE (Any ona ire) _ SAE EXP v r ) AUTOMOBILE LIABILITY -- .— - -- !,;OMBINED SINGLE LIMIT ANY AUTO -- y ALL.CANNED AUT05 8<161Li INJURY 5 1 e,-palsof') t SCHEDULED AUTOS —: . IitRE:D AUTOS FSODILY�tF.'l�I+� 3 ' I ' .IPa�aa1de�n1 I NON-OWNED AUTO5 - PROPERTY DP.MAJE S i GARAGE LIABILITY `- _— AWOUNL'Y-EAA(.CIDENT F --- I ANY AUTO 6'1•IER TFIAN A1171;CNU,^.. .____ 4CH ACCIDENTµt AGGRl T EACH OC'�URRI54CE 'S EXCESS LIABILITY �__._.... ..----- •- __._.. '" r .AGGREGATE L UMBRELLA FORM OTHER.THAN UMBREl FORM I - --'-- —' VVORK£.R'S COMPENSAnON Al WC 5218636 07/01/2005 07/01/200(5 ' X�7 Rt ta-n�_ ER--j II - A EMPL.CYERS'LIABILITY EL EACH 4(.;.IUeNT_. S ,`�17�1,0�d0 IME YRUDRIET00., /NCI !F.L pr:iEAS.E POLICY LIbi1T S 1 1000,000 PAATNF RS/CXC4l1tiVF ..._. , I UFFICERB AREF>(CL 'ELOISF.A96 EA EMPLOYa£ 1,0000�O OTHER JE$/:RIPTIOtC OF OPERAPON&'40CATIONSNFHICLESJuPECIAL REM9 _�• ALL EMPLOYEES WORKING FOR THE ABOVE NANIEO CLIENT COMPANY.PAID UNDER .ADP TOTALSOURCE.INC.•S PAYROLL.WILL.LSE CO`lERP-D ! l!NDER THE ABOVE STATED POLICY.'THE ABOVE NAMED CLIENT IS AN ALTERNATE EMPLOYER UNDER THIS POLIO`'. � MIR If._I4 rM77ik: :� j 1f I 111 taY 17 M t :. .. 95 reN.,'rPr4t i�i'' ;r.jf11r'.i�i.I,.a+.fiPtJ {r`�:,.�I{�{hk{fT��4 ��it4 r l,iC � 1+III�I�t - .i,I.A,,,,, , t,+.IN"•VIII!lLl�ill.,,lj:Y,t.:?_.�ltsuprd�l.,i?'r.4 .: ..�.. %1, _ :. SHOULD ANY OF THE ABOVE: DESGRIDED ps3LIGE8 BE CANCELLED gliFORE THE TRA-'TING LLC EXPIRATION DATE THEREOF, THE ISSUINO COMPANY PALL ENDEAVOR TO MAIL SYLVAIN CON S PLAISTOW TAD 3U_ DAYS WRITTEN NOTICE TO'ME CCRTIcICATT.HOLDER NAMED TO THE LEll PLAISTOW, NH 03865 aUT pAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UA81L,rY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR RF.PRCrENTATIVF_S, AUTHOCEEll 9PRESENTATIVI-i — � AON RISK SERVICE,INC .OF FLORIDA II iZyI. 'ii'ir w�{PIBi;tre tar M{ti�i;rFRlfllija 4plgac ;.I'.r iR -I+ L?I�1�11t�`itrtllt pc`�illiu F,:�ilii`rrl.+41i.l. .,,�Q (.,..:j, ,�j .rtt5 !•`raa4Aj �rryn�„ rY�lf I� wS I ,,. wa...�,,.Ywuu 1)m1..4y.JIUIL1S5 tn.alYl)r.:, �Ia Y mL:� sTo-v. !. CM AI s i d e 967862 Window Company NERC g[L 0 0j - EXCRLIBUR ME NUNG CP004-A-011-006 SOLID 1 'YIDSO� BL GLtD National Fenestration i6G, � E Argon Rating Council Energy savings will depend on your specific climate,house and lifestyle. call 1-330-929-1811 or visit NFRC's web site at For more information, l` www.rvfrc.org. I' 1rj�visible Solar Heat Gai: ransmittance•U-Factor 34 Coefficient . •32 • 32able NFC•53 Manufacturer stipulates that these ratings coneorm to a pmance.NFRC procedures for determining whole product energy pert o ratings are determined for a fixed set of environmental conditions and specific roductsixes. �� 6;."madd Board of Building Regulations and Standards i HOME I�$RO VEMENT CONTRACTOR Re isha o : 108985 a.� 2006 SYLVAIN CO Marc Sylvain - 9 PLAISTOW'RD. PLAISTOW,NH 03865 Administrator a� I r 71.�ovnmcaruoea Z o�.l�aaeac�uvelld BOARD OF BUILDING REGULATIONS, License: CONSTRUCTION-SUPERVISOR j Numbem CS ' 069951. . �. Birthdaten 008l27l1955 ("Ex0:,6W712006 Tr.no: 1776.0 ' Restricted:'.'00. ? FLEE G STEPHEN$ i' 81 CHESTERR6#2 RAYMOND, NH 03077`-!` Commissioner � OUR� flf?tr, LotOnl The Commonwealth of Massachusetts Department Of Public Safcty /f11P occulsancV 1,1 BOARD OF FlRE PREVENTION REGULATIONS 527 CMR 12:00 .x/90' (Iran blcnk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 41 Work to be performed in accordance With the Mawchusetts Electrical Code. S27 CMR 32: (PLEASE PRINT IN IHR ORgPE Z ORlidTZON) Date 1City or Tova of T The undersigned applies fora permit to To the Inspect of Wtres: p pectora ctrical work ascribed below. Location (Street 6 NumberC, Owner or Tenant Owner's Address 'W Is this permit in conjunction, with a building permits Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization NO. /D.' M2, rau ting Service _Amps / Volts Overhead EDUndgrd C] No. of Haters Nev_Service �ps / Volts —� Overhead ❑ Undgrd❑ No. of Haters 1.Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /l. v No. of Lighting Outlecs d No- of Hot Iubs Total No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Above d.. ❑ In- rnrad. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting No. of Switch OutlecsSaactery Units No. of Cas Burners FIR]; ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and cons Initiating Devices No, of Disposals No. of Heat Total Total Pt'=DJ KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained No. of Dryers Heating Devices Detection/Sounding Devices KW Municipal nn Other Local❑ No. of Water Heaters Kt) NO, of °• ° ConnectlonU Lov Voltage Signs Ballasts Lorin M No. Hydro Massage Tubs No. ofocors Total HP OTHERt INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts Ceneral Laws I have a current Liabilit Insurance Policy including Completed Operatio�s, Coverage or Its substantial Ifuivalent. YES NO (� I have submitted valid proof of same to this office. YES Q NO you have checked YES, please indicate the type of covers cher ng the appropriate DoxD INSURANCE t BOND ❑ OTHER n (Please Specify) Estimated Value of Electrical`'TWork S p r cion ace Work to Start Ina action Date ce Re uested& Rough qRoughFinal v Signed under the enalties o�f+perjury: / FIRM NAME f-G,`_C r2Tc- C 'o �yc= LIC. N0. .593� Licensee /L Signature Address c.' Ha LIC; N0. G�/�y ua. 1- No. lv�3— OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or is su stantial equivalent as required by Massachusetts General wsTa'and my signature on this permit application waives this requirement. Amer Agent (Please check one) Telephone No. . PERMIT FEE S Signature of Owner or Agent Date............0.7....�. .. 847 N°RTM TOWN OF NORTH ANDOVER PERMIT FOR WIRING SAC US 1 .t.7:. 1.... ..L«...: l This certifies that .......:. . . �..:......... ... has permission to perform1C'G JAI// :2...*.......J..14.j ......9- wiring in the building of...... .`(?�.11 ,.... ��1 l/ at...f(.?.�. /l...��.�'.v.....1J../.:.......................... .North Andover,Mass. Fee....� ..":..... Li .N/9 ��f�3 .................... .................... E CTRICAL INSPECMR MI 1i8:54 15.00 min WHITE:Applicant CANARY: Building Dept. PINK:Treasurer