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HomeMy WebLinkAboutMiscellaneous - 173 RALEIGH TAVERN LANE 4/30/2018 (2)1 L Date ....... :..l..< ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................................ rx .............. has permission to perform .....&. .... ........ .. .... .J..C ....................................... wiring in the building of......{,. ,,, ,A, LC,.(. G. Pt,,.I, -A tl-r-AY(J (, A U t at ............. h�� .................................. . , NorthAndover. Mass. pD �,... Fee .............................. L> c. No. . � ter. i 9............ ..... Y.:............................................ `% ELECTRICAL INSPECTOR Check # e75 =I �,� .M 1..Qf'a3irIOfE:lIP.� f L O� ►r�[Z�SkCfL[t3P�3 e�lorin73,Z.Of . 4-m Se,,*. I BOARD OF FIRE PREVEN i 101\1 REGULA i IONS Official Use Only Permit No. Occupancy and Fee Checked [Rev' 1107] (leave blame) ..-.11'v ll.=J U�L�� �-j+�Fl �r lr9n� �l�i�=J �1�i'1� it }�11� � �`_y����, ��i i� 3 .i l�� �S a O_ a _ L11d1`�h_F .1 t, Jm, t „� t��{ � (Lt� Cs - t i��ir((� f� L nJl�;v� �}� .` All %vodsc to ba performed in accordance with the WIassachuselts Eleelrieai Cade {ivIEC). 527 CVR 1240 (Pj,0z4SE nrMT, rtirl- it Qp 1�,, QF .d/r r j-l�C�16-i TQllg Depne: c t 5- [ gc)1 � A --,,,O i`Irt2 _«speefo:• aj Wil -es. Sy this application the undersigned gives notice of his or her intention to perform the electrical worts described below. LoWia11(Street & Number) I -7 3 R4 L 2.k G bL_` �0,:z eteLr?o:tei,?o-57b'-��g -asp ;r:lyner9s A.dress AS oils Permit In conju=ai-�ar- -with, a bu d ax- Ex ? :fiJr� SiQ j � r^ ...�Ln � Z'...}3e£2=r�i_S.rri• i4: F-isrpose o-_ 3URdi=g Existing Ser z ic: ADO Amps 19e: oils t r hen d J_cgrd, Q r t :Y. .'.L 2 ll �'i �ie �2 f: E2eis zrevt 5ertifee Amus I v is :: ":ve ' ��irs:eaC � :l�isg: � 116. O? 1;�{tar S Number or Feeder and A--=<clk�i Location and Nature =s oposed i ie, —ri a= 7;Iflr Ir: v Fav t Estimated %atria of Electrical ldOrlC 1 S - --- - �•.1 L" regrurea at lite tnspecfo - of 1i`irer 00 • \, CJ (tithen required by municipal policy.) :yoFlt t4 Start- (� 1 J S Inspeet}ons .o be requesieet in accordance vtith ivEC Rule I0, and upon completion. 1Jnless waived by the owner, Zo ner,'ni-t for the aerformance o; electrical work may issue unless the Iicensee provides proof of liability= insurance including "completed operattlon" coverage or its substantial equivalent. The undersigned ceriftfles rant sash cavern,,. is in Force, and has rmn, iced proof of same to the permit issuing of�fffce. CHECK ONE: INSuRA1jgCi: 0 BOND ❑ OTHER Q (Speck}:) " ertijjr, r tder ffiepajfLy and aEtt¢I es psFtzy ij!at iim ul o; rpt:? on thk aPPHCefiO,a is _i re and corwleae_ cr}L rvrs�,3 f_ -C.41^_ 1Y'71 g License@: f p�C/t �'PaL g-mne c ( OPPUCable, r nt t-fr,rileli en _ .,.x�.rim /� �S7/9 eer��r� c� P license number ffn� Address. _YO /50>t 7�r''S/ fir ��/e -r 1� C�! 9y� 3 -us. 7s a:. `7P -c�b''T'�, ��CJ *Per Ivi.C.L. c. 147, S. o t -til, seeur:j= �a=ar1: autres Department of Public SaRzy "S" License: =G Lie. No. G _ r gam aura thatt the Licenses doss nor have: the liability insurance coverage normally t ,eau ired by Iav 3y my signature below, F hereby N=aive this requirement. I am the (chests one) 0 ow=ner r ' OSYa'SerfAgent Fjowners 2_,•ent S patm a =eieahcaeTie. P Iii=^ � r �.vv,t�tt ut7t: of rriejorrorvt �table ingt= be jwired b fire In ectal 0 lnfr2� Ph".',1'_`Reaegssee `_ um-IL?Pires 0. 0! :-srs.4P. (Paddle) Fa?s lltld. e: i Q:2I PTO. Or- _ urai?a"sre Oiutiets 11f 0. Of — F s *` NO. G`?�e4rz,srn res rr::�� PflQi 'J07-7 r_1 77- ❑ lie. 1 r %tzesll Units No. or �;.eeptacle 0, Utlets c-25 :, NO. " Burn No. QS vQlE�$ 4 � i cti F 3t Q. Lia :.:r8 fl �On c_?tt ' ��++ Pf0. 0z6sQ its • �0' ° In; tiro. of :s.teaes �r-te. in !i_ ,, ` and. 70ta: v�S' ::j SzLwY ✓e'=aa<�." _ } its rd �,� Devi u G. cid 1�''ij-S¢. Lib fie ices Zli©.L 4i C'1 �'/� .4` ry t 'irVnta ell LCS"E?OSe J .o. o_ lDt "s�5•r 1e:�ccJreL�ev'=cs ' vs �1 ashers {spacelArea 5ea�g - :, r!innic:3a! )woea" OL-er Co eeso3 s ��Q. `Si "^�? jP.TS ! �.n, � 1: � 8f?•^_u r I�sem:L---'•`-.,u a��:, ems:` }LIQ. =s88_E Q_ i�fl. Qs' 0 0'r '-n r-701— e- Cta}vaie t- S;Ens 3aflestS i2:i ut. ;� tw .7. M?yd."OnlcR.�•ssalge BacM=a.GTflus /� No. LL FirQt';aS =a:a: Z'� J�.Vf�;i=Liln�i 1 e:ei.{iTZfl (( �"__=._z. •'1 r°fe. o_ Devices 4. Erin-''a=c:e?L JJlrtrb rtrtilrrin„nl ./ ...:7:P1__r.._ _, Estimated %atria of Electrical ldOrlC 1 S - --- - �•.1 L" regrurea at lite tnspecfo - of 1i`irer 00 • \, CJ (tithen required by municipal policy.) :yoFlt t4 Start- (� 1 J S Inspeet}ons .o be requesieet in accordance vtith ivEC Rule I0, and upon completion. 1Jnless waived by the owner, Zo ner,'ni-t for the aerformance o; electrical work may issue unless the Iicensee provides proof of liability= insurance including "completed operattlon" coverage or its substantial equivalent. The undersigned ceriftfles rant sash cavern,,. is in Force, and has rmn, iced proof of same to the permit issuing of�fffce. CHECK ONE: INSuRA1jgCi: 0 BOND ❑ OTHER Q (Speck}:) " ertijjr, r tder ffiepajfLy and aEtt¢I es psFtzy ij!at iim ul o; rpt:? on thk aPPHCefiO,a is _i re and corwleae_ cr}L rvrs�,3 f_ -C.41^_ 1Y'71 g License@: f p�C/t �'PaL g-mne c ( OPPUCable, r nt t-fr,rileli en _ .,.x�.rim /� �S7/9 eer��r� c� P license number ffn� Address. _YO /50>t 7�r''S/ fir ��/e -r 1� C�! 9y� 3 -us. 7s a:. `7P -c�b''T'�, ��CJ *Per Ivi.C.L. c. 147, S. o t -til, seeur:j= �a=ar1: autres Department of Public SaRzy "S" License: =G Lie. No. G _ r gam aura thatt the Licenses doss nor have: the liability insurance coverage normally t ,eau ired by Iav 3y my signature below, F hereby N=aive this requirement. I am the (chests one) 0 ow=ner r ' OSYa'SerfAgent Fjowners 2_,•ent S patm a =eieahcaeTie. P Iii=^ � r The Commonwealth oflMassachusetts Print Form. z X Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, AM 02114-2017 www mass govIdia Workers' Compensation Insurance Affidavit: B adders/Contractors/Electricians/Plumbers Agplicant Information Please Print Leg bly Name (Business/Organization/Individual): (?,9L SC --RV ICL 1C Address: �C� X50 y City/State/Zip: /J,0/G— 7a -1V ItV- & hone #: g V - 62F i 5?%1�� Are you an employer? Check the appropriate box: Type of project (required): 1.04 am a employer with _— 4. ❑ I am a general contractor and I 5. New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors 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' comp. insurance.* 9. ❑ Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 1 i.❑ Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12.[3 Roof repairs insurance required.) t c. 152, § 1(4), and we have no ME] Other employees. [No workers' coma. insurance reauired.l *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 al l work and then hire outside contractors must submit a ne%v affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and stake 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 the policy and job site information. Insurance Company Name:__ Policy # or Self -ins. Lic. #:_ 0 l/✓G �G' �} p���p Expiration Date:' ��a Q j� Job Site Address: / 7 3 ,9- (,c r 4 > 7).9vc -n L City/State/Zip: 'l )1 e1v ve X104 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 cert ft under !�ePVM11ndpenaldes ofperjury that the information provided above is true and correct. Phone #: 7 6" % - `i -7 -7 v Oficial use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense # Cc / I.J- /l 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 #: Samuel F. McCormack Co., Inc. Insurance Adjusters and Appraisers April 2, 2015 Town of North Andover Building Inspector 1600 Osgood Street Building 20, Suite 2035 North Andover ,MA 01845 RE ASSURED: George Khater & Lynne Leary-Khater LOSS LOCATION: 173 Raleigh Tavern Ln, North Andover, MA 01845 POLICY NO: 3067467 TYPE OF LOSS: Weight of ice and snow DATE OF LOSS: 02/04/2015 OUR FILE NO: 15-04301 To Whom It May Concern: Claim has been made involving Ices, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of this writer and include a reference to the above- captioned insured, location, policy number, date of loss and claim or file number. Thank -you for your anticipated cooperation. Very truly yours, Andrew Sarsfield Adjuster as@mcoon-nackadjuster.com cc: Board of Health 42 Holbrook Avenue, Braintree, MA 021841-800-972-5399 (781) 843-1222 Fax (781) 849-8191 One Jonathan Bourne Drive, Suite 7, Pocasset, MA 02559 (508) 403-2600 Fax (508) 403-2602 www.mcconnackadjuster.com Samuel F. McCormack Co., Inc. Insurance Adjusters and Appraisers ADJUSTERS AND APPRAISERS February 4, 2015 Town of North Andover Building Inspector 1600 Osgood Street Building 20, Suite 2035 North Andover ,MA 01845 RE ASSuR�D: Lynne Leary-Khater & George Khater LOSS LOCATION: 173 Raleigh Tavern Ln, North Andover, MA 01845 POLICY NO: 3067467 TYPE OF LOSS: Ice dam DATE OF LOSS: 02/04/2015 OUR FILE NO: 15-00592 To Whom It May Concern: Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of this writer and include a reference to the above - captioned insured, location, policy number, date of loss and claim or file number. Thank you for your anticipated cooperation. Very truly yours, Andrew Sarsfield Adjuster as @ mccormackadjuster.com cc:,Board of Health..: 42 Holbrook Avenue, Braintree, MA 021841-800-972-5399 (781) 843-1222 Fax (781) 849-8191 One Jonathan Bourne Drive, Suite 7, Pocasset, MA 02559 (508) 403-2600 Fax (508) 403-2602 www.mccormackadjuster.com r. This certifies that has permission to perform .................................... plumbing in the buildings of. . V, . ........... at ........................ ...... . . Nordin ndover, Mass, Fee ......... Lic. No. . .. . .. .... ................... ... PLUMBING INSPECTOR Check # 4 � 3� (_'4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY C> ' _ _ j MA DATE b '_%ZG�� PERMIT #� 1 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES ® NO Q FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 6 _f CROSS CONNECTION DEVICE! DEDICATED SPECIAL WASTE SYSTEM 6 DEDICATED GAS/OIL/SAND SYSTEM I I DEDICATED GREASE SYSTEM I __.__ [ __..__.! _.__ ! f _.___._. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM_j DISHWASHER DRINKING FOUNTAIN ____f FOOD DISPOSER i FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) _ _E _f _i ...... i (___! ___ _.( ___..__ _.._.! __._._._j ....___! ! ; _J1 KITCHEN SINK -i { � ! ..__.._.J _ f { —._—! __._.._1 L—I .__ _! = LAVATORY _f ! .._...__! 1 � _i __. ._1 � ..u__I .._.,__.1 ..__f _---__._f 6 _I __.f ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ ( _.� f _ �1 - _ j _ _ f .__. ,.__ �9 WATER HEATER ALL TYPES i WATER PIPING I _ I 1 _...__. i __.___.! OTHER a_ _ _ I `- } _! i L- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [ NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [2f"� OTHER TYPE OF INDEMNITY BOND Q NER'S IN RANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusett .General Laws, and that my signature on this permit application waives this requirement. _. ECK ONE ONLY:OW R 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regard' g this applicati are tr e n ccurat o th best of my knowledge and that all plumbing work and installations performed under the permit issued for this a tion will in co with i nt provision of the lica Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NA (G+- , _ LICENSE # 6�0 /. SIGNATURE MP JP 0 CORPORATION 0 j PARTNERSHIP _f # G LLC 0� j COMPANY NAMffrZw, ADDRESS G Z CITY ISTATE,/_ j ZIP TEL FAX (_'4 °z 0 H U W a w t 0 of z LU O CL Z U W W Q w Rb w 3 LU a 0 z a w � � a U J a a U) w x w F- a UnH z z C H U W P, z a a a Date ... O". ..-. �..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . 7n n......6.-2 It's- .-�..................................................................... has permission for gas installation . . a ��.c ....... .....�...!tT...'... in the buildings of ...... at ....1.23..... .. a fn... ...... :............ North Andover, Mass. Fee.3q:.a ... Lic. NoaD3.°... ...... GAS INSPECTOR Check # 8908 i w. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY MA DATE PERMIT—# _ - —! - - - JOBSITE ADDRESS �IOWNER'S NAMEa�rSf GOWNER ADDRESS TELF_,� — FAX TYPE 011 OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL VITUNT CLEARLY NEW: V RENOVATION: [_I REPLACEMENT PLANS SUBMITTED: YES D NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4V 5 6 7 8 9 10 11 12 13 14 BOILER J -(.(� I _ I ! BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER_f FIREPLACE FRYOLATOR - FURNACE GENERATOR GRILLE ^T :. _ - --31 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER �I UNVENTED ROOM HEATER WATER HEATER OTHER _ - - - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�I! 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 thisrequirement. CHECK ONE LY: OWNER © T SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this applica i n are true a d ac r t o he best o o edge and that all plumbing work and installations performed under the permit issued for this application will be in pli c a inent p vi ' n of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAM (A(p -__ _. _ LICENSE #,.... � Q/ ( S ATURE MPkg MGF El JP 0JGF LPGI �_ CORPORATION PARTNERSHI #E LLC DI#= COMPANY NA _ ..L� __. - ..__ _ :. _ ; _ - .. ADDRESS—Z__._-_.._.-_.-----.---_------- CITY STATE �ZIP �.S_ TEL q %�- CELL( EMAI FAX L� 1 -- - - -- - W H O O U W a w .Q p a z O CA d� W } LU Z u LU F- 3 a F- w a W 5 D. LLI s 9 w W a z P-( a � U x J F, a IL a w F- a V H z z o H V W P-4 x The Commonwealth ofMassachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass gov/dia Workers' Compensation. Insurance Affidavit: Builders/ContractorslEIectritcians/Plumbers Name Address: P G S( ival): / C I city/state/zip:Phone#: Are yop an employer? Checli tJre appropriate boa: (� 1. am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time)," have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet, x ship and'have no employees These sub -contractors have working forme in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.) employees. [No workers" comp. insurance required Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *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 tie 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 am an employer th at is information. 'compensation insurance for rrty employees. Below is the policy and job site Insurance Company Name:. Policy # or S elf -ins. Lic. #: Expiration Date: Job Site Address: !T cue,-- / y • A_ City/State/Zip: P "/ Attach a. copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine n 500.00and/or one -ye, imp ' nment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o p to $250.00 ay against the viola r. _ e advised that a copy of this statement maybe forwarded to the Office of vestigations of the IA for4sumnc cov v verification. I d,6, ereby cert a enal es ofperjury that the information provided above is true and correct. Si atu Date: 6` (? 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. City1fown Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone 0 Information and Instructions Massachusetts General Laws chapter 152 requires allemployers to provide workers' compensation for their employees. " Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,• express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced •acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checldng the boxes that apply to your situation and, if necessary, supply sub -contractors) 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 maybe submitted to the Department of Industrial Accidents for confnmation ofinsurance 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 p P g :... -P-lease be sure that -the affidavit is -complete and rioted le ibly: The D epartin erit�I�as provided a space at �ihe botEom 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 whichwill 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 homeowner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CQ onwoaltho��iassacl?uset€s f3aparttnent ofladustdat Accidents Office ofIn,Yestigaiiom 60G Wasbingtoii Street Boston,MA02111 ` QL # 617-727-4900 at 406 or 1-877-:MASSAFF, Revised 5-26-05 Fax # 617"727-7749 Installin Addres A%,"Llbt 1 IN UNIFURM APPLICATION FOR PERMIT TU UU rl_UMntnU (Print a Type) NORTH ANDOVER, , Maas. ()ate Building _/.� Parma # ®. t o . / 73 6/Z Lr� Lo I n �/�yI2 tr, � Owner's Name New O Renovation Replacement ❑ Plans Submitted: Yea ❑ No. [I FIXTURES ess T Name of Licensed Plumber Zv1.��1�/� Check one: ❑ Corp. ❑ Partnership O Firm/Co. INSURANCE COVERAGE: ChacK one I have a current liability Insurance policy or Re substantial equivalent Yea ❑ No ❑ II you have checked Ig. please Indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of Indemnity ❑ Bond ❑ Certificate //yam OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent C]a urs o Owner a Owners en I hereby certify that all of the detaMs and Information I have submitted tog entered) In tion are true and *=Kate to a best y knowledge and that ail plumbing work and InstaMallone performed under thepertruM bt s Pkation In a pertinent provisions of the Massachusetts State Plumbing Codan e d Chapter 142 the APPF"d EO (OFFICE USE ONLYI lute Pluuffibef �--z� license be _ J Type of Plumbing license: Master L Journeyman 0 1 ESE��r���li�r■11■111111111111111■ ess T Name of Licensed Plumber Zv1.��1�/� Check one: ❑ Corp. ❑ Partnership O Firm/Co. INSURANCE COVERAGE: ChacK one I have a current liability Insurance policy or Re substantial equivalent Yea ❑ No ❑ II you have checked Ig. please Indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of Indemnity ❑ Bond ❑ Certificate //yam OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent C]a urs o Owner a Owners en I hereby certify that all of the detaMs and Information I have submitted tog entered) In tion are true and *=Kate to a best y knowledge and that ail plumbing work and InstaMallone performed under thepertruM bt s Pkation In a pertinent provisions of the Massachusetts State Plumbing Codan e d Chapter 142 the APPF"d EO (OFFICE USE ONLYI lute Pluuffibef �--z� license be _ J Type of Plumbing license: Master L Journeyman 0 Date .... if TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING M i �,SSAC04 J ,% This certifies that has permission to perform plumbing in the buildings oft. I ; , ,I f :.................. . at../-/-:�NortfifiAndover, Mass. c �' .i Fee. .�� .:'�Lic. No.....: ?.4�f ............................ PLUMBING INSPECTOR "94 11:38 30. CEJ PAFIl WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File f' Location % .>� �-�-r- s No. 0 Date ,2 d - 9Y N0RT1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ c5 Building/Frame Permit Fee $ .ZZyy c►wsec Foundation Permit Fee $ ~Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ —`^�- TOTAL ybg�1:53 154.00 PAI�ilding Inspector t 8 Div. Public Works PF.R W4 NO! APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS���j�� �? PAGE 1 MAP h40. LOT NO. I 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE ZONE SUB DIV. LOT NO. I i LOCATION- 7-&-- �— - - PURPOSE OF BUILDING _ 2� r�ac4et <<r -�- , OWNER'S NAMEn7` i/r/%f �-f - J NO. OF STORIES SIZE / OWNER'S ADDRESS I'7-3 D4 le '6 �1`Y�� /' !y BASEMENT OR SLAB ARCHITECT'S NAME / i / / `/h/`f - 1�0/�7 SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME ��0; �(•�N�t�% �dI' I7 SPAN -- - DIMENSIONS OF SILLS POSTS '/I,)/�`/ DISTANCE TO NEAREST BUILDING DISTANCE FROM STREET 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 SEE BOTH SIDS PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT F E E / As- /'- 0 PERMIT GRANTBD 19 OWNER TEL. # 689-16y6 CONTR. TEL. # `/7G_a 9/P, CONTR. LIC. # 04/241/0 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST /z / oo EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S-011 IES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION. CONCRETE —I 8 INTERIOR FINISH PINE a _ 1 2 I3 CONCRETE Bl K. BRICK OR STONE HARDWD PIERS PLASTER DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B M AREA '/. 1/2 1/1 FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 ��_ 2 3 _ —{I_ J_ DROP SIDING WOOD SHINGLES CONCRETE EARTH HARDWD COMMCN ASPH. TILE ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLEHIP GAMBREL FLAT BATH Q FIX.) _ MANSARD TOILET RM. 12 FIX.I 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 II 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 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ to 13rd I ELECTRIC I NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. s4si f 4 * I t . k north shore NNUW I improvement c o r p o r a t i o n 2 Stevens St. Andover, MA 01810 617-470-2918 General Contractors Residential and Commercial I/we, the Owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necess- ary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, Owner's Name jt/`1...:/1............................p................p.............Y... Tel.../�.'.`Jallwork. terms and conditions, on remise below described. Workmen's compensation and public'liability Insurance are carried on i V h v Y / P V!��� i• •\ Job Address..\ /....04. .(?U.... ... /.�1.,'..... tate......... . .................. SPECIFICATIONS DESCRIPTION DEPOSIT PRICE .��, l TOTAL For the ab undersigned agrees to pay the sum of' i1� ...,?rtt� ......r Dollars $....l .(pQQ.C� - ......... , . • , .. , , as follows: $............1. - cash upon delivery of stock $ • • • ........... t....i�?r QU........ when work 50% completed $ ............. . .. f .�2Q ......... when work is complete. Contractor is not responsible for delay, damage or inability to carry on the work of installation caused by or resulting from strikes, lockouts, fires, accidents, lack of material or any other cause beyond the control of the Contractor either before or after the delivery of the material and equipment at said premises. The Contractor is to be permitted to proceed with the installation of the above specifications without interruption and is hereby authorized to do such work as in his opinion is necessary to complete this installation, but will not guarantee any repairs on gutters. This agreement shall become binding only upon the Contractor's written acceptance hereof or upon the Contractor's commencing performance. You may cancel this agreement if it has been consummated by a party thereto at a place other than an address of the sel- ler which may be his main office or branch thereof, by a written notice directed to the seller at his main or branch office by ordinary mail posted by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. The Contractor will do all of said work in a good workman -like manner according to manufacturer's guarantee. This contract shall be void and of no effect if credit approval of owner (s) is refused. Owner agrees that in event of cancellation of this contract before work is started, Owner shall pay to Contractor on demand twenty- five (25%) per cent of the contract -price as its stipulated damages for the breech, and all reasonable costs, attorneys fees and expenses and any other damagles ng the terms and conditions of this contract and/or any lien in connection therewith. There are no other agreements, understandings, representations or warranties, verbal or otherwise, expressed or implied, which are not contained herein. All extra work and material to be paid immediately. This Contract is subject to Approval of the General Manager. IN WITNESS WHEREOF, the parties have hereunto placed their hands and seal this .................................................. dayof..............................19............ north shore 7"T., vement o I I o n Authorize SigrSa r ........................................................................... General Mananer Signe. .......... ' OWNER Signed...:............................................................... OWNER Signed................................................................... m o m` E r. m .. c -• O C � E o m m B N ;T � O 'O m .w c � N r,•n •- c r. N a..., 44 -• .p a (, 41 G �l t•1 i�, N L Q m [1 W L ( o •}. 41 n) .. m m u v i� � c• r� - on (. (. O O .0 an � . .c + o ,. � n L •L ,i 'c � N °, ,ao cn 'o r -• a m a, F-4 -s .c giw e anm -• on n., J.N ., 0 11 �.a .. ,N a, ._, v w -• m n. .., a, _ c @ � .. .p .f • m w m @ ono w > ❑ 7 O U m c n es J [' . C •m e o N� O •+ i V G u e N 4 a! al A m F o r_ m x m o m` E � E o m m p Q �° OD n) O O .0 w m @ ono w > ❑ 7 O U m c n es O .[-+ N N O @ O Y V a :x @ O o� N� O •+ i V G u e m F o • J m@ O L Un C O d4 N 1) ... m C ...\ J P. L T C +[ O a, L •r a .F al +-+ O J J L m o na oPan o ww > w ,m ncOC @. aF°w m .0v o L a o T -.+ L m m o m .1 a NC sLar v•Oonr. c4` v(NtIapmno.,, +vLam) ,.^.aC.N+., NO/ O .aV.(m4,^., A@OC -t F J+m,4n)) -+•mcc.+• VamLQC ^—C@0. .nC.>a+ln ••.•.S•+.•• Un W 3 '.•.c .1• w.+•cJX.r WmLL ycIen Q. fnFn oPO vD0. mO o a. o c c mo v.3O4. mw 3+ .c OC ° C w +� •,. L r. o— on L m .. ., .0 m .� C N @ @ C m O 3to @ A ... e w- a s a� .L -, nn m a U T 'O GI [� U O1 . P: A, C• L 'C m L C• U . i) B �[ al 3 a, Nl .N 6, 3 U N 3 t �® > al C J F cn V 0 3 J C C .a V C J J C F -• w -- U y 0 .... V in O X cU Q) N L +) 5 o V ^• U N a, U •-J F U -• U U m^ G C -• C ^• -- F C ^• .a V v A +[ V +1 t .m O •� C' C m '�,+ m UD N V > > to O ,C [n na O O O @ O 0.•-C, y m ^• 0. ..., ^ N .. ,. @ y •-• •-• U O [. C' ••+ C C O O C C C -2 r O m ••0.i C .[s C J C C C U Q tl J A V Ln C1 t7 v In (O [� a0 \\ > o v v L o z a z COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF ONE ASH13ORTON PLACE MASSACHUSETTS BOSTON, MA 02108 -5117 1'73 LICENSE EXPIRATION DATE CONSTR. 5 U P E R V I S C R 02/06/199,5 RESTRICTIONS EFFECTIVE DATE LIC -NO. NONE 10/31/1993 C4261� FRANK w KEHOE JP SS 034-30-0915 29 liF:`':?G AVE- REVERE VEREVERE 14.. 02151 PHOTO (BLASTING OPR ONLY) FEE• 1 CG. �3 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: STAMPED - OR - SIGNATURE OF THE COMMISSIONER DOB: THIS DOCUMENT MUST BE --.✓ �L� CARRIED ON THE PERSONOF • THE HOLDER WHEN EN- _ SIGNATURE O LICE' OTHERS - RIGHT THUMB PRINT GAGED IN THIS OCCUPATION. • •- eIj*i4id + OMMI$$IC wegi�tTatOn 106509 i'rpe - PRIVATP- CORPORATION Pxpiration 07/23194 NOrth ShOr e ImpTOVerent COTpor Frank W. 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