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HomeMy WebLinkAboutMiscellaneous - 173 MASSACHUSETTS AVENUE 4/30/2018 (2)n Libertv Mutual. INSURANCE July 20, 2012 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 173 Massachusetts Ave, North Andover, MA 01845 Policy Number: H3121864451340 Underwriting Company: Liberty Mutual Insurance Company Claim Number: 023406373-0001 Date of Loss: 7/14/2012 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 313, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, � 9, or Mass. General Laws, Ch. 111, � 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Kristen Hart Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Ext. 70417 E-mail: Kristen.Hart@LibertyMutual.com Date /Z1.:.��� ....... . TOWN OF NORTH ANDOVER A PERMIT FOR GAS INSTALLATION This certifies that.. has permission for gasinstallation... RC Trs ! ............... . in the buildin�iqs3 of .. {� V �. `............................... . at .. �! ? .. .. �' .... ,ZNNh�A41,dover , Klass. Fee. Z`. Lic. No.. 29Y�. . . ........... GAS INSPECTOR Check # �'� v� s 0 AASSACHUSE M LINUORM APPUCATON FOR PERINIlT TO DO GAS FIT1 NG (Type or print) Date `�" /y '-� el/ NORTH ANDOVER, MASSACHUSETTS Building Locations 1 ';7 3 1W.4 S )a r Permit # _ amount $ Owner's Name New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Name ;Mame of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. Firm/Co. NSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes L3'— -- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13— Other type of indemnity ❑ Bond M Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 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 1:1 A.ent ) hereby certify that all of the details and information I he fitted (or entereck in above application are tru lccurate to the, hest of m� knowledge and that all plumbing work an installation. perfnrmc41-' x j Permit Issued for this �licat'. n will be in l compliance with all pertinent provisions of the blas ichusctts Slit Gas Co c ut ( iptq(142 oflJ�tC; al I. s By: Signature uF Liccnsumber (Sr Gas Fitter I Title Planiher City/ I own Gas Fitter License um er Master ,'APPROVED (OFFICE USE ONLY) Journeyman w Q H x O a t- ✓� x V w U rA z J x En z d z o C z w p H > lu w w F a 0 w a 3 0 a> SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TI3. FLOOR 5TH. FLOOR 6TH . F L O O R i 7TH. FLOOR STH. FLOOR , (Print or type) Name ;Mame of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. Firm/Co. NSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes L3'— -- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13— Other type of indemnity ❑ Bond M Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 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 1:1 A.ent ) hereby certify that all of the details and information I he fitted (or entereck in above application are tru lccurate to the, hest of m� knowledge and that all plumbing work an installation. perfnrmc41-' x j Permit Issued for this �licat'. n will be in l compliance with all pertinent provisions of the blas ichusctts Slit Gas Co c ut ( iptq(142 oflJ�tC; al I. s By: Signature uF Liccnsumber (Sr Gas Fitter I Title Planiher City/ I own Gas Fitter License um er Master ,'APPROVED (OFFICE USE ONLY) Journeyman .I'd The Commonwealth of Massachusetts Department of Industrial Accidents A Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual):�y�(�� Address: 6o City/State/Zip: AE ��uP�D�r�� AA/ Phone #: 5_D'' =fid y' -941q 9 Are you an employer? Check the appropriate box: 1. HT -am a employer with C-- 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. -[No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must13ubmit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 herebyftrtify�inder the pfy Wnd penalties of perjyr tJeyt'the information provided above is true and correct. �2_r-1 y -,-z ©// Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date ...Z,� qI .o :�... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION o .ty This certifies that ... � 1P r .�.... ... � ............. . has permission for gas installation .... in tie buildings of . ro55 ( ...................... at )/ISS...A. V f ..... , North Andover, Mass. Fee...34. -Lic. No..l(? ya8�b� 2( ........ GAS INSPECTOR Check # q 430 MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date (�,-�� /v Building Locations 1 �%� Ni 4-1 S tet/' Permit # Amount $ 3-0 Owner's Name IF4,Alt�c l�vSs� New ❑ Renovation 1 Replacement ❑ Plans Submitted ❑ Name or type) (� ` n^ , n� � � � n�G� Check one: Certificate Installing Company lJQ/ " l 0 r Corp. Address ►` ❑ Partner. 61Y2A✓ A/11, ot &P❑ Business Telephone / -13 5L �G? Finn/CO. Name of Licensed Plumber or Gas Fitter Oe�/✓,` INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0— No ❑ If you have checked M, please indicate the type coverage by checking the appropriate box. Liability insurance policy ©— Other type of indemnity ❑ Bond ❑ -'s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Owner ❑ Agent ❑ i rterevy ceruty mat an or me oetatts ano mR manon 1 nave suomined (or entered) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts a Gas Code and ChaMer j*2 ofthe General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter © Plumber / pY a.� ❑ Gas Fitter Icen Number ❑ Master ❑ Journeyman • I—ST. FLOOR Ella I Name or type) (� ` n^ , n� � � � n�G� Check one: Certificate Installing Company lJQ/ " l 0 r Corp. Address ►` ❑ Partner. 61Y2A✓ A/11, ot &P❑ Business Telephone / -13 5L �G? Finn/CO. Name of Licensed Plumber or Gas Fitter Oe�/✓,` INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0— No ❑ If you have checked M, please indicate the type coverage by checking the appropriate box. Liability insurance policy ©— Other type of indemnity ❑ Bond ❑ -'s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Owner ❑ Agent ❑ i rterevy ceruty mat an or me oetatts ano mR manon 1 nave suomined (or entered) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts a Gas Code and ChaMer j*2 ofthe General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter © Plumber / pY a.� ❑ Gas Fitter Icen Number ❑ Master ❑ Journeyman Location 1172 No. 3,0 / Date At TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 30 Check # C A 5 /V-- t i7b,5b `'� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUMDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Comtnissioner/InEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: /73 /marl, P-45: 1.2 Assessors Map and Parcel Number: /0 Map Number Parcel Number ny/��vr 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide red Provided Regaired. Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT r 10 ulj ,-triCt: Ye 2.1 Owner of Record 7 3 A%09`SJ— Name (Print) Address for Service Signature Telephone 3 9� GPS _4 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signa2ire Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor /p/c Not Applicable ❑ A eo Company Name P e G / /1 ��' �Gp/' �j G/�� Registration Number tf ^� q G, (� Address tel. aJe � � x Expiration Date Si nature Telephone 00 rn X z O 1 0 z M 0 Mn a. r rn _r 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 a8 in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check ad applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: 14WCTInN 6 - TQTTMATFTI trnNcmnt rT7nu ell% T( t z will result Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building a () Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (,) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5)Check Number CF.CTTnN 79 nWNVD ATV1 UnD17iT7AwT CLGAJ " V1111'vll 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. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION property as Owner/Authorized Agent of subject Hereby declare that the statements and information on the foregoing application are Lrue and accurate, to the best of my knowledge and belief Print Name Signature of NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TIMBERS — SPAN DIMENSIONS DIMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NA1 2 _ GAS LINE Date SIZE 2 THICKNESS X h ti North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) c Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 ' Workers' Compensation Insurance Affidavit Name Please Print Name: ✓�i�l� J!�',D PlPe�i� ye,,4 L Location: 1.22 1W5'Y City Phone # Fr c -3 I am a homeowner performing all work myself. 0— I am a sole proprietor and have no one working in any capacity F7 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # vl� � Cfir. Ol<l'L !,7/ Phone # 4,'�3' /b /CAC,gc//moo Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of crirrdnal penalties ora fine up to $1,5oo.00 and/or one years' Imprisonment -as we ll.as_civll..penalties in the fmn d a..STQP YORK ORDER aid.a.fine ..of.(S10o.00) aAclay.sgainst-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certifyunder the pains and penalties of perjury that the information provided aboveis true and correct. Print name R/ch ,�/� ��G ��� ✓y�,�� Phone# al JG9JZ Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensi ❑Check if immediate response is required ❑ Building Dept ❑ Licensing Board Contact person: ❑ Selectman's Office Phone #.• ❑ Health Department ❑ Other PROPOSAL AND CONTRACT THIS PROPOSAL AGREEMENT IS BETWEE RICHARD PROVENCAL MA. 131656 (Contractor's Name) 20A COLLETTES GROVE ROADnse Number) DERRY NH 03038 (Contractors Address) (Citv.State2io) 603-235-5713 603-893-2698 (Telephone - FAX) DATE: 11/30/2004 PROPOSAL NO. 195 ANN BEVIN ( 173 MASS. AVE Owner's Name) (Job Address) IN, ANDOVER MA. 01845 (Gtv.State,zip) (Lot) (Block) (Tract) 978-686-3697 (Telephone - FAX) We hereby propose to furnish all material and equipment, and perform all labor necessary to complete the following work: REMOVE & REPLACE 4 WINDOWS INSTALL 3 HARVEY AWNING WINDOWS W/LOW-E/ARGON INSTALL 1 HARVEY DOUBLE HUNG WINDOW W/LOW-E/ARGON & REPLACE STORM DOOR IN FRONT OF HOUSE. )N ( TRADITIONAL DOOR) REMOVE & REPLACE 12' OF FENCE ON LEFT HAND SIDE OF HOUSE. NEW VINYL FENCE. fill material Is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of x, aar n, an payments to be made as follows TO START, BALANCE AT END OF JOB. You, the homeowner(buyer) or tenant have the right to require the contractor to famish you with a performance bond. You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See attached Notice of Cancellation by the buyer after the right to rescind has passed, shall be deemed a material breach of this agreement and entitles the contractor to damages. State law requires contractors to substantially commence work within twenty (20) days of the date indicated below. Failure to do so without lawful excuse is a violation of the law. Contractors are required by law to be licensed and regulated by the Contractor's State License Board which has jurisdiction to investigate complaints against contractors if a complaint is filed within three years of the date of the alleged violation. Any questions regarding a contractor to your state Contractor's License Board. Respectfully Submitted, Contractor's Nam By SAME Contractor's License # MA. 131656 Address 20A QQ1 I ETTFS ROV ROAD DERRY City State NH Zip 03038 Phone 603-235-5713 Fax 603-893-2698 Note: This proposal may be withdrawn by us if r accepted within 30 days If accepted, work will begin (approximately)_ You are hereby authorized to furnish all material, equippmeennt aannnd labor to commpNe the work described in the above proposal, for which the undersigned agrees to pay the amount stated in said proposal and according to the terms thereof. Any change involving extra cost of labor or materials will be executed only after submission and acceptance of written change order. CONTRACTOR: 't A , OWNER: o � ' Gf/e �ammtnvuaea�i ����uaett4 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR R.&tra fc;n 131656 doiration: .422/2006 Tip.e. Iiodividual RICHARD PROVENCAL' ' RICAHRD PROVEN AL 20A COLLETIES GROVE R� !'.G--,►" DERRY, NH 03038 Administrator ` ui am c o L) o y � L a cy O a _v V ; �► ti :•nom c. OM } 3 �v m Om C �A ' o � E a Q• L C Go O a y m O O av - o O A v ca w w a a U 3 � .o m a _o y Z`o � w ocm C p 1 O O. C = Q�iVy+ W �4 "a w° y V) c9� ,9 as �' r. w° ° p°G y , U w ►/ e a -� w '� w ° ww" j � V ° rsw a w Cq 0 z cn 5 to ui am w C r..r • �; w d LES LD o fi dA c o L) E y � L J� cy O C _v V ; �► ti :•nom c. OM } 3 �v m Om C �A ' o � E a Q• L w C r..r • �; w d LES LD o fi dA z V 0901., oo� t CIO y a ccO v ZE CO2 O .CL y 0 C O CO) 0 W CM C m m U) Y/ 19 W 19 W U) : "Oki•meC L) E y � L Cc ; �► ti yon32: } 3 cm y i a W C Go O y m O O av - o t ca 3 � .o m _o y Z`o ocm C p 1 O O. C = m y C CL N ~ $ 0 vim $ �' m COD LU o .00. •_N dt W C o H C.3 ` e CA $. o g _ Go .0G o Z «O. arm z V 0901., oo� t CIO y a ccO v ZE CO2 O .CL y 0 C O CO) 0 W CM C m m U) Y/ 19 W 19 W U) Date.. . .... ............ .. Illa-3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........12 ......... ...................... has permission to perform ........ 5.r.f.? V 1 ............. C ........ ................. Alring in the building of ............... ....... ................. . . .... ....... .... ...... .. . .. .... at North Andover, .. ............. .... ,North 7() ti Fee... .................. L i c. N o ........ ..... ................ > ELECTRICAL r;�PR Check # 7. 45110 aebgntxext o6 �u6lle Saaety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only Permit No. Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Date .JqL y / i D.3 To the Inspector ofWires: Location (Street & Numbeer/ L % % I%I S S AVE, Owner or Tenant A V I' 54 041.4 r/t/e Owner's Address/ 7 -7 lwsf live C�Dor, P/i N---#(? 7 r) 4g 7 adsa Is this permit in conjunction with a building permit Yes ❑ No V/ (Check Appropriate Box) Purpose of Building / Utility Authorization No. Existing Service -a Amps 120 Voits Overhead �l Undgmd ❑ No. of Meters New Service 02 0C Amps / -70 Z O Voits Overhead (T�' Undgmd ❑ No. of Meters Number of Feeders and Ampacity Locatign and Nature of Proposed Electrical 1) OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin pleted Operations Coverage or its substantial equivalen YES NO = have submitted valid proof of same to the Offi ES NO = if u have checked YES please indicate the e o overage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) 4L ( xpi on Date) Estimated Value of EI ri al Work$ Work to Start Inspection Date Resquested(_e-IL C,41 t Rough Final Signed underth Pe ies f erju FIRM NAMEi LIC. NO. Lrkensee '0,446417-1 S 7 Signature LIC. NO.�M� f Y- A� Bus. Tel No. f r� I Address 1(%K if/L; 414,Eft 7 �P � JVI�� / Aft Tel. No._� OWNER'S INSURANCE WAIVER: I am aware that th icenses does not have the insurance coverage General Laws. And that my signature on this permit application waives this requirement. Owner (Signature of Owner or Agent) its substantial equivalent as required by Massachusetts Agent (Please Check one) Telephone No. PERMITfEE $ d 1 Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. c; Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin pleted Operations Coverage or its substantial equivalen YES NO = have submitted valid proof of same to the Offi ES NO = if u have checked YES please indicate the e o overage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) 4L ( xpi on Date) Estimated Value of EI ri al Work$ Work to Start Inspection Date Resquested(_e-IL C,41 t Rough Final Signed underth Pe ies f erju FIRM NAMEi LIC. NO. Lrkensee '0,446417-1 S 7 Signature LIC. NO.�M� f Y- A� Bus. Tel No. f r� I Address 1(%K if/L; 414,Eft 7 �P � JVI�� / Aft Tel. No._� OWNER'S INSURANCE WAIVER: I am aware that th icenses does not have the insurance coverage General Laws. And that my signature on this permit application waives this requirement. Owner (Signature of Owner or Agent) its substantial equivalent as required by Massachusetts Agent (Please Check one) Telephone No. PERMITfEE $ d 1 Name Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am.an employer providing workers' compensation for rry employees working on this job. Company name: City: Phone #: Insurance. Co. PolicV # Company name: Address City: Phone#: Failure to secure coverage as required. under Section 25A or MGL 152 can lead to -the irnposition of criminal penalties of.a;fine up to $1,6 arxVor one years' imprisonmentaswell_as_civil.penabes-nlhelmnida-STQPVAK)RK.ORDER,and_afne"ljW- B)-ajjayagainstme understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby eerary tinder Me pains and penafties of perjury that the information provided above is true and co►rect. Signature fate Print name Pbone.# Official use only do not write in this area to be completed by city or town drwiar City or Town Permit/L-icensing El Building Dept ❑Check if immediate response is required 0 LAcensmg Board El Selectman's Office Contact person Phone # ❑ Health Department E] Other Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I 1� This certifies that .... ..... ........ ( ............... . has permission to perform ....�.`?.n.b.�.'�. \................. plumbing in the buildings of ...�— .�?.SS..f................... . at .......... ...... , North Andover, Mass. Fee .. 3O... Lic. No... �y a ......1(° 2 -L1 ./ . 1 ......... . PLUMBING INSPECTOR `Check # b _G 5642 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the 1best of my knowledge and that all plumbing workand instal tions performed under Permit Issued for this application will be in Qompliance with all pertinent provisions of the Massach tate Plumbin g.C* pd Chapter 142 ofthe General Laws. 'Jy: Signarnre 371 Licenseaum r Type of Plumbing License Title b y City/Town License lNumDer MasterJourneyman ❑ APPROVED (OFFICE USE ONLY • 1 1 :l -------------------.---mom MMMMONOMMMMMMOOMMM- OM mom WOMMMONOMMOMMMMM i e e • MMMMMMMMMMMMMMMMMMMMMMMM Maile e • MMMMMMMMMMMMMMMMMMM=MMMM 1 i e e • mmmmmommmmmmmmmmommmmmmm i • e • i==Mmommommmmmmmmmmmmmmomm All MAI1 s . 1 1' J '/ 1 1 w:.l i 1' M' • 1 1 t K 1• 1• w • • 1 • /• - I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the 1best of my knowledge and that all plumbing workand instal tions performed under Permit Issued for this application will be in Qompliance with all pertinent provisions of the Massach tate Plumbin g.C* pd Chapter 142 ofthe General Laws. 'Jy: Signarnre 371 Licenseaum r Type of Plumbing License Title b y City/Town License lNumDer MasterJourneyman ❑ APPROVED (OFFICE USE ONLY