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HomeMy WebLinkAboutMiscellaneous - 177 REA STREET 4/30/2018Date. Zt - ,:7/. 0. ....'e" ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ................................................................... has permission to perform ...... ...................... wiringin the building ......................................................................... at ................. ............ . North Andover, Mass. Fee.... . ........ Lic. . ......................................... ELECTRICAL INSPECT��'- Check # 'V9'�l 6967 = -N Commonwealth of Massachusetts Official Only Department of Fire Services Permit No. G ��7 Occupancy and Fee checked . Jy� �0 BOARD OF FIRE PREVENTION REGULATIONS pey. 11/99) }� blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wank to be peffwwd in accardam with the Mmsachusms Electrical Code (MEC), Y—n CMR 12.00 (PLEASE PRINT BV INK OR 7YP, F ALL )NFORMATION) Date: 9 2e /b(Q -� City or Towia of: INTo the h&4=torqf Wires: By this application the unidersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 19rl0,06-R-+ . Owner or Tenant Telephone Na g- Owner's Address S Noe oe Is, this permit in conjunction with a buiidiag permit? Yes ❑ No [9' (Check Appropriate Box) Purpose of Building F—esi6e y-mce-, Utility Authorization No. E=istiag S:rviee = Amps 12() Volts Overhead 0- Undgrd ❑ No. of Meters �T New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feelers and Ampacty Location and Nature of Proposed Electrical Work: t-c%ii r 1Ct P'Y.- '10d lI G~i ( -) U ('i. loft n nilho in)/nuwno inhln nsrm ho wnivod In- dw Insnector of Wines_ No. of Recessed Fixtures No. of Cdi.-Soap. (Paddle) FansNoof Transformers KVVA No. of Lighting Outlets No. of Hot Tabs Generators KVA No. of Lighting Fixtures Above ❑ r d. swimming Pool grad. B t te Un g No. of Receptacle Oath is j No. of Oil Bumers FIRE ALARMS Na of Zones No. of Switches No. of Cas Burners o' °I�- m Devices No. of Ranges No. of Air Coad. Total � No. of Alerting Devices No. of Waste Disposers I= � on m omobDevices No. of Dishwashers Spacd/Aret Heating KW Local ❑ C��a� 1 ❑ Other No. of Dryers A gAPP� KW SecuNo.ppofDes team or ivahmt No. o aterKW nesters o, o o S• Ballasts Data V , Na of or FAnivalent Hydromassage Bathtubs No. of Motors Total HP TelecommNo. Nob ofaDevices or aivakat OTHER: hoc» aamaaxa aermi r) aespsq or as,sgm+w ap,m napcc,or v� w,.v. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical Wolk may issue unless the licensee provides proof of liability insurance including "oorspleted operation" coverage or its substantial equivalent. The undersigied certifies that such omqW is in force, and has exhibited proo!pf same to the pera>;t issuing office. CHECK ONE: INSURANCE LJ BOND ❑ O'TilER ❑ (Specify:) ,c- o (EVirabon Daft) Estimated Value of Electrical Work 0J (When re"red by municipal policy) f Work to Start p lnspecti req upw �P ms to be nested in aaxxdance with MEC Rule 10, and completion. I certify, anile a painr and pw aifi s ofperjurp, that the infonnahon on this Wfita don is tate and csa rfaa FLRM NAME: E� ��eC i -e i CCD _S' P�r�, i`c s , `�a�c- Lac. No.:l S rl L R Licensee: E h % Em M e_` Signature LIC. No.:1 s '-L L9A (/f q�tiarhle er ` ' lave tc+r�e erre. Bus. Tel. No.• - `� `Z O Address: `1 fiv r� I�l[� O 1 Ale. Td. Na• = 6 2 p c OWNIrR'S INSURANCE W l am aware that Lice»se does not here the liability insdaarroe tis nornraily requited bylaw. By cry sigiadae below, I hereby waive this requirement. [ am the (clack one ❑owner ❑^owner's a Uwner/Agent - PER1111T F'EE: li i.�U� Signature Telephone Na Date.. V,%?�:!..U.2.... °T ° 1�0 o? °� TOWN OF NORTH ANDOVER f. 9 � �f • PERMIT FOR�GASINSTALLATION . 9 S^C HUSESS This certifies that . �.`.�l.. S,.Xe�`,-, - .. � . `j ....... has permission for gas installation ... !?.`�.? x.. ............ . in the buildings of .. .4J:f' �+? !'`�........................ . at ............. .., North Andover, Mass. Fee..Z.q 4A. Lic. No..0..3. 9. V GAS INSPECTOR Check # ive, 0 6745 MASSACHUSETTS UN1FoRM APPUC kTON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date �� Z Building Loqations / 7 e /y: Owner's Name New ❑ Renovation ❑ Replacement B-BASEM EN SEM ENT JI. r L U 0 R ND. FLOOR RD. FLOOR TH. FLOOR TH. FLOOR TH. FLOOR TH. FLOOR TH. FLOOR (Print or type) lame_ Address _` Permit # Amount S Plans Submitted❑ " � w v� U vi W w FW. Q C C z p Z y4 W Z Q W z F W W C7 > A W Name of.Licensed Plumber or Gas Fitter INSURANCE COVERAGE L Check one: Certificate Installing Company ❑ Corp. ❑ Partner. PFF'irm/Co. I have a current liability Insurance' policy or it's substantial equivalent. Check one: If you Yes have checked es please indicate the type coverage by checking the appropriate box No❑ Liability insurance policy ©/ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does_ not the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner I hereby certify that all of the Agent details and information I have submitted (or entered) in � application are true and accurate best of my knowledge and that all plumbing work and installations performed under Permit Issued for this true anion will to in compliance with all pertinent provisions of the Massac a State rate to the de an�Chapter 1 2 of the,General Laws. By: Signature of �J /J Title ©'Plumber City/Town,❑Gas Fitter Master APPROVED toFFice USE ONLY) ❑ Journeyman sed -Plumber Or Gas Fitter License um er �' Expiration Date: Job Site Address: Attach a copy of the workers' compensation otic declaration City/Stat„ /zip. Failure to secure coverage as required under Section 25A o f 'anon page MGL C. (showing the policy number and expiration date). fine up to 51,500.00 and/or one-year imprisonment as well as civil pe alti52 es inthe forme f imposition STOP WORK O criminal DER an of a In es to .5250.00 t day against the violator. Be advised that a copy of this statement may be forwarded to the Office and a fine Investigations of the DIA for insurance coverage verification. I do herebJ' cer%6,_und the pdrac and the informadon provided above is true and correct Official use nnip. Do not write in this area, to be comple7a bj, cif), or town ntTzcial City or Town: Issuing Authority (circle one): Permit/License 4 1. Board of Health 2, Building Department 3. City/Tow n Clerk 4. Electrical Inspector 5. Pfumbirto fi. Other b Inspector Contact Person: Phone 4- The Co►rrmoRwealth offfirssachusetts J ' '!� De artment o P Industrial Accidents K' MAL, � .f Dice o Office Investigations ,:� r .f 600 Was hin,'on Street " Boston, n, MA 02111 W"'K'-masS.govld.is Workers' Compensation Insuranee.A�£i��,jt; guilders/Coniraciors/Electricia.as/Piumber A>� Iicant Informatiion Name (Business/Organization/Individual): s Pease Prinf Legibly k . `� /0� /v Address. Phare #: �i� � F G � Are you an employer? Check the appropriate box: 1 • �arn a employer with 'Z, 4. ❑ I am a general Type of project (required): employees (full and/or part-time).* 2. ❑ 1 am a sole contractor and I . 6• ❑New construction have hired the sub -contractors proprietor or partner- ship and have no employees Iisted om the attached sheet 1 7• ❑ Remodeling These sub -contractors working forme in any capacity. have workers' 8. ❑Demolition comp. insurance. (No workers' comp. insurance P 5. ❑ We are a corporation and its 9' ❑Building addition required) 3. ❑ I am a homeowner doing ofnce;rs have exercised. their 10 ❑ Electrical repairs or additions all work myself. [No. workers' comp. right of exem tion c 152 P per MGL l I.❑ Plumbing repairs or additions c. 1(4), insurance required.] t lQ' a and we have no [No workers 12 ❑Roof repairs comp, insurance required.] 13.❑ Other t x -mum fill section below�shovring i ion cowuen; wlao subs .flo atiidevii riljuh ethe usdi a; their workera' compensation policy inrormation. IConttactors Ut21 eheok this hos.musi attached ` Ehen hire outside contraciurs an additional lam an. employer that is providing workers' mus( su'mnit a new amdavir ind mun sheet showing the name -of the sub-co-,aactors and their woricets' comp, policy information. information. compenSatiOIZ [nsurarice or employees, fBelow is the policy and job site Insurance Company Name: n1 rqS Policy # or Self -.ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation otic declaration City/Stat„ /zip. Failure to secure coverage as required under Section 25A o f 'anon page MGL C. (showing the policy number and expiration date). fine up to 51,500.00 and/or one-year imprisonment as well as civil pe alti52 es inthe forme f imposition STOP WORK O criminal DER an of a In es to .5250.00 t day against the violator. Be advised that a copy of this statement may be forwarded to the Office and a fine Investigations of the DIA for insurance coverage verification. I do herebJ' cer%6,_und the pdrac and the informadon provided above is true and correct Official use nnip. Do not write in this area, to be comple7a bj, cif), or town ntTzcial City or Town: Issuing Authority (circle one): Permit/License 4 1. Board of Health 2, Building Department 3. City/Tow n Clerk 4. Electrical Inspector 5. Pfumbirto fi. Other b Inspector Contact Person: Phone 4- Information nd Instructions t. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".. every person in the service of another under any contract of hire, express or implied; oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and inciutiiri.g the legal representatives of a deceased employer, or the receiVer or trustee of an individual, partnership, associate on 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 taint.-nance, 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 a r local licensing agency shall withhold tele 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 compl-etely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or, partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have -_ employees, a policy is required. Be advised that this afficliavit may submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit. The,affidavitshouid 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 repaLT it ing the.la"a or if you are required rd to obtain a workers' compensation policy, please call the Department at the nm-rnber:Iistted below. Self insured companies should ener thein self-insurance license number on the appropriate line. ` City or Town Officials Please be sure that the affidavit .is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennit/iicense applications in arty given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Add x—ess" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially starnped 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 Iicenses. A new affidavit must be filled out each year. Where, a home owner or citi=r is obtaining a licenses or permit not related to any business or commercial venture (i.e. a. dog license or permit to burnleaves etc.) said person is NOT required to complete fhis 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 fay, number: The Commonwealth of Massachusetts Department Oflridustrial Accidents Office of Lnvestigatiions 600 Washdn2ton Street Boston; MA 02111 Te1. 4 617-727-4900 C= 406 Qr 1-977-MASSAFE Revised 5-2645 Far, 4 617-727-7749 Wkmmass.gov/dia Location F O _ No. (el Date „ --111_ TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ '�s'•••� tt�' sACMUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 42 17289 %,"- Building InspectoL-7 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING R ` C BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commi sioner/I for of Buildings Date SECTION 1- SITE INFORMATION Property Address: 1.2 Assessors Map and Parcel Number: / r1-.1 .1 ..� / 7 ��A js, [3 121 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 9,EC#�EA7770N -43, 5&a /.5n Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide R red Provided Required Provided It co' 10`4 o zo' 0 3 to 1.7 Water Sypply M.G.L.C.40. 54) 1.5. Flood Zone Infomntion: .8 Sewerage Disposal System: Public Pf Private ❑ Zane Outside Flood Zone ❑ Municipal V On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record a 1 Sf4RJV aL�wo Name (Print) Address for rriSeerrvice c3ti / J !7 Signature Telephone a 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ S72�me"A .k'A4A/7-Z/b/s Licensed Construction Supervisor: License N mbir J%1NF-PS LAU 1/6� i2//Y) X %iG �7 �3°-� Address �� � � ,/ p �_, ,0� i/L.Q /%�/� 6�`b 9 7 6 o?S6 -Qd�D Expiration Date Signature —�_ Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Q Registrations C Ad aQ 6 Expiration ate Si natu Tel hone Ma M 70 3 Z O 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 builging permit. Signed affidavit Attached Yes ....... V No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction V Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: /&57 L M16AQUA1.8 (GUN/TE a� ` SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction b ©D �— 3 Plumbing Building Permit fee (a) X (b) Q 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR APPLIES FORfBnU,HMIN(G PERMIT T_ (CONTRACTOR — 1, S ' 1 A /SCJ 1 U F0 0L D S Co LX /" A V as Owner/Authorized Agent of subject property Hereby authorize to act on M e alf, in all matters relative to work authorized by this building permit application./a/d Si ture of Ownei Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I,as Owner/Au`th_onzed 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 r Print Si ature of wner/A ent U Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEvMERS 1ST2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DR,AENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT f- ni c//Rf)MMj5,g7XL IOWL6 �� _ PHONE 9%,F-0?5"6-Oa00 ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION .LOT LOT NUMBER STREET 9 �7 STREET NUMBER F 77 ..■..■...■.■.■■..■...■■...■..■...■.■■■..■■■■■.REET ......■..T::■■...■■.■■ OFFICIAL USE ONLY REC014RAENDATIONS OF TOWN AGENTS @....■■.......■■■■..■.■....■....■.■r................r...................... DATE APPROVED �S- O CONSERVATION ADMMSTRAT DATE REJECTED CONDAENTS CONMENTS RECEIVED BY BUILDING INSPECTOR DATE DATE APPROVED TOWN PLANNER DATE REJECTED CONMEN'I'S DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON BAENTS PUBLIC WORDS - SEWER / WATER CONNECTIONS DRIVEWAY PERNUT DATE APPROVED FIRE DEPARTMENT DATE REJECTED CONMENTS RECEIVED BY BUILDING INSPECTOR DATE MORTGAGE INSPECTION BAY 100 CUMMIIN S CENTER. ASSOCIATESTE SURVEYING ENTER SUITE 0 31(U. BEVERLYNMA. 01915 LOCATION ...N.ORTF% .�q�vDovER...fl:............. SCALE : 1 50 OATS :... �0.. � :. ! 1 ................... REFERENCF-:.AB —...37Z'i )D&.-75-_.5- .1J G.ZSS..l` TO...... �/SE IfomF /no-cr6AdE- eo The location of the butidingts► as grown, either compilea with the local zoning setbacks at the tine of consauction or la exempt horn vlotauon enterclement action unser Maas, G.L T1tle VII Chapter i= Secuon i 5 �u46bEL�_U1FiLt� NOTE; t) Ttds is a raortgsI lasPaalon survey and not an bnaartaanl ttucv@y. thilre(ore this plot plan Is for mortgage in@F , ri qrt ptepors clay. 2) Tula mwvey is basad an away marts of others. 2) 81+0+ea ab rttb& tosses and Orae Win do not "w► mesa pre"ir tbwa aj 1Mtsrsrrrar M GNM la 1• *• ar laaa an inativn ent avrvfp isrsatorlerdd to dalsimilne property bb+aa ad sof p"on wwro comewa. f) an abaee appretliMWA. and we to be toad"tar tw detbltn111aom of =anteg. Not to be Land to esabMsA property lbws, N) bn sy pretassiattsl epUtlI - the bullding(al are not betrstaa In the @pedal flood hazard zone. as dstbtrmd by tL= MAP@ 250098 6-2:±3 Lor b Z -V3, Srwt hL � Z -LI. tA/�7 T '� 1 7 L. 14 74't RP- A cT 914 &owe~eaa olt-11ta,;JadwdeA Board of Buildincr-RequIations One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 Licen5e: CONSTRUCTION SUPERVISOR LICENSE Birthdate! '12/24/1948 Number: CS 013966 Expires: 12/24/2005 Restticted To: 00 STEVE A KALAITZIDIS 7 POWERS LANDING #203 MERJUNLACK, NH 03054 BOARD OF RUILDIN43:11EGULATIONS License: CONSTRUCTION SUPERVISOR Number.; SCS,,., 013965 girt -9w.- --12/24-/-1.948 2 - /2412-006 Tr. no: 12346 STEVE A 7 POWERS MERRIMACK, NH 03054.Administrator Tr. no: 12346 Keep top for receipt and.change of address notification, 666 0 Board of Building Regulations and Standards One Ashburton Place - Room 1301 13oston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 107083 Type: Private Corporation Expiration: 7/29/2004 ENVIRONMENTAL POOLS INC. Andrew Everleigh 184R Riverneck Road Chelmsford, MA 01824 Update Address and return card. Nlark reason for chanRe. Address f -I Renewal EnrInjoyment j Lost Card Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 107083 Expiration: 7129/2004 Type: Private Corporation ENVIRONMENTAL POOLS INC. Andrew Everleigh 184R Riverneck Road Chelmsford- MA 01824 License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1361 Boston, Ma. 02108 x. Not valid without — + The Commonwealth of Massachusetts Department of Industrial Accidents Office of lmresitigations 600 Washington Street,,` Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - General Businesses working in any capacity. ❑ I am an employer with employees (full & I ype: U Retail U Restaurant/Bar/Eating Establishment ❑ Office ❑ Sales (including Real Estate, Autos etc.) time). ❑ Other ! do hereby cert' uer Y pa's and penal 'es of �yuiy hat the information provided above is true and correct. Signature4 ,�aq�� ��— Date 6 Print name %VDItx1 �y��t /��� Phone # 9-3-6-2—Jrz ,Q .00 official use only do not write in this area to be completed by city or town official city or town: permit/license # ❑70ffice ent ❑L N ❑check if immediate response is required ❑Se contact person: ❑Ht(revised Sept. 2003) phone#; O Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. i. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual ,partnership, association or other legal entity, employing employees. However the owner of a dwelling hous.e..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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. .-_o City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like.to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street, 7"' Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 INSURANCE BINDER °"�""'°°'"� « 3/23/04 THIS DINDER 15 A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDRIONS SH MN ON THE REVERSE SIDE OF THIS FORM. PRODUCER I i .FtlT 81.1843-1000 OOMPANY MNMA Nautilus (Berkley Excess) 5169 I 3/24/04 Curtin-Twinbrook Insurance Age s 2,000.000 CAM I TIME DATE --iI t AME 400A Franklin Str"t 3/24/041 22:01 11 AM 5/24JOA X ts:DtAu araiatxee, MA 02184 5,000 ANY AUTO ALL OMED ALROY SCN®ULWAVIU3 HMDAUTOS HOWtM# DAUTOS ,. PM Noon TH13IMNnUtl$9$31"IUEXMNDCOVERAGEIHTHEABOVENAMED ANY PER EXPIRNQ POLICY A I _ CODE: SIiA com: GU610k1ER ID 557551 045CRaPTION cPGtAN ASNE sc TY OrAu o ) Various locations -- job sites j WSURED Environmental pools Inc. 1848 Rive=eck Road NEOr.A .PAYMEMT4 S Chelmsford, MA 01824 UNINBUREDMOTDRIST S QQVERAUES UAAATry TYPE OF INSURANCE COWPAGEIFIDIMS DEaucnaM QM6% AVOW PROPE17TY CAUSES OF LOSS eAsic F-1 HROAO ❑SPEC L� 09REMUAMT-V yt COWMERUAL GENERAL U &NUTY CLAIMS MADE I n l OCCUR ONFIERS & CONTRACTOR'& PROT Deductible $2,500 BI PD Employee Senafit Liab $lnil RETRO DATE FOR CLUM MADE 3/24/04 GENERAL AGGREGATE s 2,000.000 PRODUCTS • COMP" Aco b 1.000,000 PER8OM%L A ACV INAIRY i 1, 000, 000 EACH OCCURRENCE 9 OO FftDAWAG,iiVMGMTie) S 100,000 N® EXP (AIV ,AleP" s 5,000 ANY AUTO ALL OMED ALROY SCN®ULWAVIU3 HMDAUTOS HOWtM# DAUTOS ,. U NEINED 91NOU LWT S BODILY 1KAM (Pr Iran) j • I BODILY NJURVVP- 0"dwJ 5 _ PROPW"VAWGA( f NEOr.A .PAYMEMT4 S PMSOHAL MJURY PROT A UNINBUREDMOTDRIST S S i AUTOPNY3=LDAWAW _ DETXJCMBLE COLLISION: OTHER THAN COL; ALLYEFMCLES ZEDULEDVEH1CL6S ACTUAL CASHVALLE STATED AMOUNT OTHER S i 0ARAOEUAFWMY A14YALTTO AUTO ONLY-EAA^CiDENT S O1HERVANA(J70ONLY. w —� EACH ACCTDEHT AGGREGATE S EXCM L1ANLFTY LWMFLLA FORM OTHER TFNN UMBRELLA FORM RETRO DATE FOR CU -SAS MADE EAOH OCCURRENCE f AGGREGATE i 6w-(HBU(iED REi@It1ON >} VWORM15COMPEMT1W AND EAOPt.GMER'S LIA®L(TY nAwrORY LMns EACH ACCIDENT ; ^ .._ . .....---- SE DISEA- EACH EMPLOYEE y DISEAGE • POLiCY LIAfT T spacm ranwwal binder FEER S 200 TAUT $ 1,520 65TMATEO TOTAL PREMPJM S 38,000 Pwea a wwtswa MORTGAGE ADORIONAL R16ugED LOib PAYEE ACORD INSURANCE E IS DER iS A (�YPORARY INSURANCE CI r'Iectx:cen A1C. No. Fit � $ I �__ curtin-TwinbrOOk 1r=t=anCe Age 100A Franklin Street Braintree, YA 021$4 CODE: — '; � M�RLa. 557551 Envirormantal Pools Inc. ;84R Riverneck Road rholmsford, M -A 01324 I N D E R GkTE (MM1DD/VY 3/23/D4 NTRACT, SUBJECT TO INE CMDMOkS TtIIS FORW4- j 53-7000 SAW e1NDER# – One Beacon Insurance x170 DATE nm DATE TIME AM 3/24/04 12:01 5/24/04 P"( TWS BINDER M "UED TO EXT EW COVERAGE N THE ABDVE HAM.W CC.Y,PAW, PER VyNkNC POLICY#: i DESCtRi?IMOF0PERnTgWfWTHK WPROMTYpndudr�gLwA"sj Property & Inland Marine Paakage j 1 Commercial Au}anobile rfM OFIY5URANGE cu E- OFLoS—i- 117 ws's BROAD SPEC -- C%0&-WFRCSAL�tJERtLLLLA-7SIlllY r—T� L ' CJCf,S;K f CLmms LL0.7]E 1 Or�NE7t'S B CONTRACTOR'S PAOT If---•••� i AW i AVYA:.nu —I ��N.T6D AtJTGS `� { I S?7P'Jt1LED.•':;Z1 L j HHEDAUM NON•OVBED AUTOS COVERAGEHOUS 184 Riverneck Rd Cholneford HA 184 Riverneck Rd Chelmsford M Ll-usiness Personal Property R6TRD DATE MR CL tws rune y Scheduled vehicles per PSOpCBSa. DEDUC MLA COINS 'A ( J1i0iR1'> 1,000 1;000 1,000 GENERALA( 100 1 500,000 100 1x_.0,000 ; 100 i ?6,750 ATE 7 1 - F�i(}�iCTS-GONPIOPAGG • 8 `--- j PERSONAL 3 t.QJ FACK O�CCtRiRENCE--1— FIRE DAA hGE(My o.G.) 3 -- - 1 i f ABED EXP piny ers pram; 13 i GGAABllE0 814GLE UAOT ; 3 1 ; 000 , MO BOO:LY IIi1LJRY (Per pewcn) ' f_ i DOaL�' OU AV (Por kcWv%) �! �. PROPERTY DWAGE f I MED1CALPAYMBM ___... i S -.. PERSON INdRRY PROT S Q Q UNMUROD MOT ORMT 3.... ZO.Ov% Is 40,kc, AUTO PHYWAL.DAMAGE DEDUCTIBLE X E 11141ON: 1,000 jcTHERT:LANGOL 1 ()00 [C�iRRLi: L IkHILLSY AW FliTt� q'! VEi1EClf9 X ECHEDULEOVEHICLES ' ( s X ACTUALCASHVALUE ST ALIOVNT s AiITO 644Y - EAAtC3W'(T C�TkiEi�i r A_.U, OKLY: i � EACHHA.^.clnevT s AGGREGNTE S QCEB:t tIA81L'TY ` La*LLAFORM I OTHER TION UMERELU FORM J RMD DATE FOR CLAWS NVOE EACH OC RRENCE S AtGRE f I SEL"NS D RETENTION is Prt741fCFA'SC051P@aATION AND ST •ORY LLMITS EACH EKT %s T —,-- DISEASE CH EMPLCYRI S DISEASE OL+CY LIM11 Is N=68, renewal binder COV�t RNM FEES S TJd�S 6 `i ES?W TCTAL PREMRJM $ NAME & ADDRE55 HOKrawEE AODMONAL LOSS PAYEE I I �iA PRODUCER Curtin-Twinbrook Insurance Age ONLY AW CONFERS NO RIGHTS UPON THE CERTIFICATE. AJ HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR 400A Franklin Street ALTER THE COVERAGE AFFORDED BY THE P0961ES BELOW. Braintree, MA 02184 COMPANIES AFFORDING COVERAGE COMPANY A C N A Insurance Company INSURED COMPANY Environmental Pools Inc. B COMPANY 184R Riverneck Road Chelmsford, MA 01824 COMPANY D 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS " CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO.AI.L.ilE� EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVESEEMAEDUCW BY PAID CLAIMS. CO LTRTYPE OF INSURANCE POLICY NUMBER POLICAMM WWM POLICY om» WNi>< GENERAL LIABILITY l GENERAL AGGREGATE $ .2,000,000 PRODUCTS -COMPAOPAGO $ 1,000,000 A X COMMERCIALGENERALWIBRM C 2 067739729 3/24/03 3/24/04 PERSONAL& AM INJURY '. $ 1-000 000 CLAIMS MADE Q OCCUR EACH OCCURRENCE II 1 000 000 OWNERS d CONTRACTOR'S PROT FIRE DAMAGE (AtW—*a) i'" 300,000 X Per Proiect Aaa MED EXP Wy aro prson) $ 51 000 A AUTOMOBILE LIA LITY ANY AUTO 7841028 3/24/03 3/24/04 COMBINED SINGLE LWT s . 1,000,000 BODILY INJURY (Perp-) ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY = (Per ) X HIRED AUTOS j� NON-OWNED AUTOS PROPERTY DAMAGE _ GARAGE LIABILITY AUTO ONLY-EAACCDENT $ OTHER THAN AUTO ONLY: ANY AUTO EACH ACCIDENT S AGGREGATE $ EXCESS LIABLLITY EACH OCCURRENCE $ AGGREGATE $ UMBRELLA FORM OTHER THAN UMBRELLA FORM WOR!(ERS COMPENSATION AND TORY LMITf3 ER EMPLOYERS' LIABILITY EL EACH ACCIDENT $ 500,000 A THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE OFFICERS ARE: EXCL WC 2 70863922 5/14/03 5/14/04 EL DISEASE - POLICY LIMIT $ 500,000 EL DISEASE - EA EMPLOYEE $ 500,000 OTHER BEj�RpTIDN OF OPERATICUM.00ATIONSNEHICLESISPEC1AL ITEMS Evidence of Coverage $MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Environmental Pools Inc EXpRATION CAT! TNEREOF, THE ISSUING COMPANY VALL ENDEAVOR TO MAIL 184R Riverneci Road Chelmsford, MA 01824 10 , DAYS YTTFN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BYW BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS A OR ATNES. AUTHOEUM PAPPAVINTATM Joseph Rizzo 4-4004 Aft -W r--ALf GVA1t.I SNAlL W,q S;xfr c7/1►Al. em O VAA/N A4/AY oc"At POOL Lle.Wr ,wCNe A�SOEt/RED, 5AOrej > zme—er 1PE00 Gw CaD1tM 1— OL 4' /OE S"AwGtE OCG�s�VECT DIRECT TD ItlrlP �,�.� RESIDENnALCOMntRUAt AUTOMATIC SURFACE SXIMilfR • ptArF o, V V • dd['S G'OC _ � dOl7v �vAYG NYDJtO t1J777C 7 C• 1PFUEF YA�VE S COL LL`��T bN TUBE �f Rf O C) Lim — fads •Ia r 0 MAIN OUTLET TOP 0/r d d/VO BEAM " N/A: Ar,ITEot 'war itasirR fA►r"E obw- 3-A�D/YlA/C a�iRD ` LOMM Aft:Er YAtYF 77R,9NS/T/4N PC/NT /t G• MIA' FCaat `t7Y [EDGE � •�__ , JLNC ear 8•tvu✓ 1: ► a ►°► 1 • outr 1� � � 1.• a '► • a -►• • Gax/N0 CLBMP UNDER wRTEx L/GHT 6 r0"»RT- 009OUND .T •3 BAAS /N QONO SEAJO &EYo'o• . _ T ECEvi=O• ` MAn virr lWA14 ELEY2'0' I03BAAS&,frOC SOM�%�rs ELEv3•Li• cur4OFF wLr °MC _ I ELEY*=0' 0.3 ZAR5 SG -DG. _Cura►Ff AS NOr_EP EL EY S=0' S'RADI//S 1. urerFF.r1 rE.PaarE� _ z-CLL'Af v//)V &OUS EL fY'7L q "_ EL EK a -V O • � ' �'n�av trP V f100R RF/NA 0+3 6A -CS L2 /1' aC. 6.OTN wars rrr ST/9NDARD'WR14 SECTlw CONSTR UC TIM NOTES aL C77ON SHA[L COiYrom 7V C/7Y DEPT V SAFETY CODE $? STANDARDS• BOARD NOT PERM/TEO ON POQCS W E/GNT FEET /N DEPTH AT BD�4.PD• DEPT APPROYRL REO&MCD ADR WERCiAC TYPE POOLS. v_ FS/GN COMVR/15 72) LOYAL ^00e AMD UPDiV P. •?F/9SONA&Y LEYEL VrE WPM NATURAL CR'OL/NO 1N/771/N-2 rffr Of BOND 6Fq Aj. i9NY EYCEP77aVVS 9U/RF SUPPLEMEN TRARY Dag& /DFS/ SHALL PROY/DE FENC/NG /N CO1VRZ /ANC,- )CAL C/TY o,C Ad WAI DRD/NANIE 0 6E SELF CLOS/.VG d LATCH/.YG /CRL SHgLL c-avm ch; TO STATE KCAL R� Ou/RE/`IENTs Wal ., LS Design Excellence (Mag 04 �c:1onaC�ouc� Andrew Everleigh president 978-256-0200 load 1-800-696-6976 11824 Fax 978-256-6620 REINFORCING STE. RVNFORC/NG 57FEL SNq-14 CONISO.P/!7 TD A.S.T.M. DES/GNAT/ONS A /Ser!►?GS L f1 PS *S/5/AL L BE A M//V/: 4&H OF TN/RTY" D/Ai�ETERS OR A3- ,a111 R,= SPL/CES L7 MIR _GUN/TE CONSTRUCT/ON GUN 7 SEAL[ 6,e AV gCH1NE /►9/!f0 AND RAOL /FO PNEUMA TICAL L Y. 141.rBE /,r .JH.4LL ONE RI?Rr CEML=/VT - TD FOUR i9N0 A Nk.,c PARTS SAND & 4%z /.//./Zr fLoln'-STiPE/VGTX 3000 PS/ 4S 3S DAYS • /�i9TfR-CEMENT .PAT/D SHALL /IMT t`]'CEfO O,y 3'/z GAL 3 Lt/ATER PER SACK OF C'E.o/ENT • C/!RE GUNME BY A L /GHT a1R r,ER .SP•PRY TNAe.- rlM-S A DIfY FO.P SEVEN DAIS SM OF MAssgcti PAUL AJ--4GN 0 PHELAN R. STRUCTURAL -' No. 42538 N gP01 CSS T rr- SS�ONAL ENG 7--2r3`-� CA m m m N m mm H CD 90 'v O CD CZ z y CD-� CL �• O ? C CL S y o�CD CDCL O Cr CD CCD O CCD C O CA v Cos O C=D CO)1p O 1CD z O CD O CD Cn O Cnn O .Cn ro� � a m Cn 2 O z Cn Cr A -i =mo m O O C9 C. = m z •� -C Co _I 03 Ca ? Ov m a?0 = y Co o O h o N 0 5 Or m = IE = m Co m �•o= o zL.C2 o y Ca ao 3 0 �y� 4 CL CO m C CD m t o m 0 0. O N o CO do ft 1 a y H C h C :• m H N y S ro ft!%�- �A. cli = m CD. L a y D ° CA CA O :dOftMIs 11 ' odW� 1 = go dd o.� c-) � p o C = o M v Cn o Cn Cx7 77 m 00 w n tz w o o to v Cl 1� s 0 c Date.... %7 .'??`?1.... JORTH ANDOVER FOR WIRING This certifies that., ::.k' .............`.`.�.f"'`� Chas permission to perform.............................................................................. wiring in the building of.......'e...'.................................... at ..../�:��.... /................................... ' .North Andover, Mass. ............................ Fee o,aq4: ll �C� L�-C�t �1/,;)z/%ELECTRICAL INSPECTOR Check tl /d� (JJ/ 5210 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION APPLICATION FOR PERMIT T All work to be performed in accordance with th ' (PLEASE PRINT IN INK OP TYPE ALL-INFORMAT City or Town of: By this application the undersigned gives notice of `As tl er Location (Street & Number) Owner or Tenant %�,�(� t Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Eidsting Service Amps / Vo1L New S_ ervice Amps / Volt. Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work- No. of Recessed Fixtures No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switches No. of Ranges A No. of Waste Disposers y No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs TIONS Official Use Only Permit No. t S dlo Occupancy and Fee Checked q ev. 11/991 leave blank FPERFORM ELECTRICAL WORK assachutetts Electrical Code (MEC), 527 CMR 12.00 Date: _ To the Inspector of Wires: to perform the electrical work described below. Telephone No 16 (,6 Yes d No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters _ Overhead ❑ Undgrd ❑ No. of'Meters _ No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Above Swimming Pool grnd. ❑ No. of Oil Burners No. of Gas Burners Tt No. of Air Cond. T, Space/Area Heating KW Heating Appliances KW Ballasts No. of Motors Total HP table map be waived by the Inspector of Wires. KVA FIRE ALARMS INo. of Zones No. of Detection and Initiating Devices No. of Alerting Devices Local ❑ municipal❑ Other !`nnna�riinn No.- of Devices or No. of Devices or communications No. of Devices or Attach additional detail if desired, or as required by the Inspector of Wires. 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. e undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CiEiECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify)%�%6&#J/`t t S /XJ 9 0S (Expiration Dat ) Estimated Value of Electrical Work 00, (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion_ I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: dtegory Taylor LIC. NO.: 32 Licensee: C'RFC'(LR�Ta3�or Signature LIC. NO_: (lfapplicable. enter "ex eimpt"in the license number line.) Bus. Tel. No.: _96 -i06 Address: 7`lL Pike Street Tewksburv-Mn 01 87 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Telephone No. PERMIT FEE: S Signature Receipt 0 COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN ISSUES THIS LICENSE TO ` S GREGORY A TAYLOR �� ry a 71 PIKE STREET N TEWKSBURY MA 01876-2543 '•2268 E 07/31/04 842670 Fold. Then Detach Along All Perforations 1I/AR-1T-04 09:51 AM =ROM-Byu Brothers Insurance 197893TOT45 T -2T6 P.001/001 F-BO2 OF iD _�— CERTIFICATE Off' LIABILITY INSURANCE ��0-�`�1 ON i s o4 AOR x THIS CERTIFICATE IS ! gUEp A5 A MATTE OF iNFORA�ia� ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE pROpuceR EXTEND OR HOLDER, THIS CERTIFICATE DOES NOT AMEND, $sod , yr.Jauranae ALTER THE COVERAGE AFFC- RDE€O BY THE POLICIES BELOW g4 7.131 Pawtucket B vdNAiC 0 r 'Lowell MF: 01834 _ { INgLIRERS AFFORDING COVCRAGE �2926 d: rchsnts ZtsursnQa Go. e�Phar�:9_459Nsur� --- INSURW .� INSURERS' {—~� INSURER C. 6 eg ory Taylor "URERD: y 1a S25 824 CjMCjmSfnxd QiINfiURER E; (,AVERAGES OR 4i ISR iigCUMENT WITH RESP€CT TO WHICH Tp(S1�US)d14S ,htQ COND TIONS OF UCii THE PgL1CIES OF IµSL'RAitGE LISTED pEL dF ANYCcu) N, TEC TG THE INSURED Nf�MED 7 % a TERMpolS PERIOD NS AN CO <�OTlh'ITMSTHNAING ANY REQUIREMENT, TERM OR 001401 lO1vPOLICIESDESCRISpp POLICF- AF CR c zs. AGGREGATE IBD 13Y THE T3 SH01M1`N�MAY 1 A N REUU E 6Y PAIJ CLAIMS � s�ECTfv£_y 1 "T, mI'mi� I�� LIMIT-��-O440 ilk ~� POLICY NUMBER � pATE MMJooIYI. EACH OCCURRENCE11 TR TYPE OF: INSURANC h7At)V�-- c1_ UENL•RALIIA9)UTY r I03/20/0-5--�—' oa/20/04 1 j PRSUIISE (6at�c ucen�e' 4 g� CDMMERCIALGENERA.JApILr.N CCPGO05900 MED GyP(AnyonrPQra,) Is 5_4�—_--- A r i ��- 7 G.AIMS CCCLIR jPEA:+dNAl B Ablr ltGe URY GENERALAGGREGATrz -1 $ 2000000 PROpUCTS.CCMPl4PA3G $200fl000 0 -NL AGCREGAT2 I.IMVT A7PLIE5 PER I { POLICYr� JPFCT 1•� LOC ' I COM<aINEd S{NGL`..OMIT I S L(Ea v-, Want! AUTOMOBILZ t�BIt1Y �' r I ANY AUTO 1 { 1 pODIt.Y InJURY r (Per Ferrer) 1' j ! I AL, OWN-- AU MS --- II H7pROpj!Rj'e WOLYINJURY i HLREb AUTdS (Poe B:CuBnti NOWdVat�ED AUTCo` DAMAGE t�w----- '--j (Purr nCCCldard) AUYD CNLY • EA A..- '-=INT I GARAGE LIA0161rYT I —� EA ACS � { �oHER Tr;Aru I 1 { ANY AUTO I I I AU Ili ONLY: A� I $ r-- I EA0i(=RINENCE E% C&SJUMARELLA LIAOILITY I I AG� CLA MS MASE qtrc uR I _�— ---•F — �— 11 PECUC113LE "trrI ""— r✓ Re=TENRON .. S W9RKER5 COMPENSATICJi AND I, i ELEACH ACCIDENT_.�--��--�--�'--' IF1w7PL0YER5'LA81LlT 1 ! F,I-CISEASE•EARv'• ANY PRQQFp'K��IET'dRrPRRTNrW DunVF I f C Y P,,Rr jETOME�ER EXCL'UDEG7 E.L. U.6> �LICY LfMS' 1 Y. f ]! T ON O7 �KATIANS TL CCA?ION^ TIONS g,�� g'78-255-6624 MW3:11()MO ITAL POOLS 18 9R RZVEF-MCK 110AD CjMyxSgC= NA 01824 u rHOULGANY OFYNEAWVEDI-SL;narwrur-. - -••---- 1�yDAVSwRIYTEN DATE tµEAEOF, THE ISSIJIN© )NSURrR W)LL FNDeAVOR To MAIL _._. NOTICETCTHE CER:rA CATggyyGLDER,NAii1�D,7p,'�MFLF'FTS•�U��AtLU��'jCa:5O55 - .; >..I�U .r •' •r••.JLI {rr��:�)bv17W`r IMPOSE NO tlRL�ATION OR LIA8iL1'FY CF ANV KINd UPON/THS IN5URPJ1, ITS A= ENT OR REPRESENTAT_VEB. I Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ , Foundation Permit Fee $ Other Permit Fee E . - $eVU@f -Congection Fee Water Gonn&tion Fee rLei r14 ,.JAN, 2.6� 1993 oY$ 5 Building Inspector Div. Public Works location No. Date 14ORTR Oft.ao TOWN OF NORTH ANDOVER �.`.ti.00 O? •' s A 41 Certificate of Occupancy $ BuildinfflMeMrG qVi Arlo ''c�' GLLECT�R Found�l�e s s�cMuat Other Permit Fee $ - Sewer Cor�rAEtio jFgee Water Connecti( a �99 - TOTAL rr $ * Building Inspector Div. Public Works Location IN o Date TOWN OF NORTf"OVER t,. p Certificate of Occ&ancy $ `_ ' � p R� nth Building/Frame rr9 Fee $ A. ' SSACNUSE Foundation Perml e " $ V 1 Other Permit Fee 49 Sewer Connection Fee $ 9� Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works z 0 z r Z d W 0 Ir < a O J � n O u 0 z < J �o � � D f.lJ 6a_ m � G N z 0 H u 7 F- N Z en N0 O O W W 0 0 W > p 0 0 0 J J _ LL 0 N m W W N L L O C Z z z Z O lz 0 J V, u W 6 W OC Z _Z W J I�J_ (� 4 7W WIn F- O N Ul I W�- O < W 0 F m \ O W 0 i W N_ O O u z z O LL < r O uu m F j Z < K 0 � W 2 O 4 Z 0 pal D 1 W < m �.. O Z < 1 u W J W ? u F U W N i LL F J( W F w k W < L -C O 2j 0 W IL L 0 ^n 0 C D z Jn 1 DOI f ~ ` 0 m MMO DOHaV DPa N,^ Tv DO 0, Ann C mZC D D 0 OA O rO Z_D W nzm. OO ND v cD3<; Ny{zg mx -1 Z> x-. a i o n rn 6 O mo3 0� DN TO qN mW0 J OOp 0N 'ic)r CNO ?�z ti Om -I 0 =v 0 O O DZ mm N� �m DO ZZAZZO^D ,Y M D O OI m O mm ZyO = Z mw 3: O c NO 3 p O O 'T 0 NF yr 3 z�c vCL N= D zAT { A 0 { { Oyw = o n _ N I—I T F_ I I I I I I I I I I I I �_L_L I I I D _ L C Z�OOCADiy ryZO v y G y DTA O yS A W 0zzO _ ZD ;A2 a D 3: a t ti3N Ati O CDm = y Zi (� ONNxn TNO z Oa D D0ZNCZOW 0 jnO " yp f 0 Z 0 Zx; Z O O O QM O zTA Z Z Z 0" D Ate" Z A Gzlnx T C :� Da pG A_ IIII"O III I zG "A N X o 0 O m Z 0z ZT" (IIII" I I IIIIIIIW I, III IIII IIII 0 ^n 0 C D z Jn 1 DOI n NrN m MMO DO Ni Z C mZC MMO M x .aa D Ox 0 10 t was M— mx -1 Z> x-. a i o n rn 6 �z- mo3 'uOz �min mW0 cncz r W 000 'ic)r CNO ?�z -I 0 =v 0 MD n in mm N� �m DO 3 ,Y M t � it FORM U - IAT RELEASE FORM , INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT' Pt Phone - '7 LOCATION: -Assessor's Map Number Parcel Subdivision Lot(s) Street St. Number ************************Official Use Only************************ �REECOMMENDATIONS OF TOWN AGENTS: LS_ � ! P ('lel'./�, ' Conservation Administrator Date Refected Date Approved - Comments Date Approved 1 Z Town Planner Date Rejected Comments _14-� Date Approved Health Agent Date Rejected Comments 0IQA) c'f Public Works - sewer/water connections .ui Zj driveway permit �S Fire Department z e'8^x'''1 Received by Building Inspector Date ,SAN 1 5 , - p Hl0/M 376W&VA ♦`:iii • Y" It lbbMONA covo 00 08t� y 0 000p, �rri S o N M0 m do �^.,. .. m N zM` a a y 7! ZnLA R1 Q ; 0 a z r ti, D 0 i m0 ADD O C m m MI OX 4%, 4%, x O 00 ua=€ W fN (� t=: 00=;Rz O O n v Oz yL)2 steam r D.0, 3NIl ONOIV 0101 .a 7+�� p m A 002m > s S W 0 N z a :°r O aye p . = Z-17! 'O D O �^ > a arm 40 m (AA o 1— PR T O PRN n .z WMIC s� Z +t O n ►� ~m 3010 00 O N o yr r N O o s Q:0 00 70 0 oom m N cv M 'v -n ONOIV 0101 M N n m �1 —1 M Oz n z D O PR WW s !l NM Z' O O `vN� O m f m D p i A DT M ?wO N'q" n r O D 0 fl# Z M Acn T O 0 z Z D LDm r_ N :0 O m m m 0O M D NO ' N N a M C, M --f M Al of L ANo iN NoATH lQivaovER "Ass, S L/ P, v rEo Fo o w o Al 46 s SC RLx 1 -�� TOWERS PCSOCIArS;S rNC, R E 0 S uRVEYOa5 TAlvV/9RY 1993 /"IETNuBWV.,y mA$S .c-- r - y.r— OF M s HUGH FRANKLIN UUMt LEY o IQ R S T i h JU 7 LOcvs $h/OWN +BE,n/r. LoT 6 syown, 0 A Es SEX RE fs/s TAY OF 0 E 6 L ,9 Al Oo' /z v n r� -0 w n ° z z 0 c z CO) n10 C d T 'v O CD C7 Z CA T CD O '0 CL r— 0 CD CoCo ° °� d °� 0 CD O ��'— vC CD fl. °� '— ZCL CD C) C') Z CD o CD m cf) M CD y� D < av y m zDOo CO• CD oGa z — v Q CD m C CID* � O CD T C z a CD () v� m O m rn rm JI7 C n 0 z n 0 z d 2 O.y t m H y CL C', w to CO3 CD =r to CO) CD o N p N -0 m CD 2 -0cow � 34 o ... to o (A� C) L CA CD 1--'� CD y s mom a m ec aCD CD N C ce =ra cr C C H CD Clit— C2� mCD °y: i CCD) �o a•• CD o 0 ' 2 0 ao W � m fl, -o &'+ c f' m LW cn cn w g c PCJ ° °� °� ��'— °� '— ZCL aGa aCn oCa oGa a tJ7 () Z hd Cr1 C" CD w �, C C/) x o � n y 7d z o co y rA � I� 0 n C7 H 7d �O w o I I . • y 0 9 0 c 6 b wF rnF- E rt F- O= 0 mEEn OD0 0 m --I 0 A m � , 0 z O C �m 00 no CL o0 C C z 0 x ►C tz a O 5 O d cD io cr °z 0 � z V . r� z o � d r� � z d � 0 m --I 0 A m � , 0 z O C �m 00 no CL o0 C C z 0 n -0 n Cy ' z n z 0 z n13 C CA ;r? -n-* 'o CD CD �- r- > d CM O � O CCD �C CL cr C:) C') CD o 7° z < 7z v �= CD T O z < y m _ CD � Tom, C� COO .0 CA O O C• O y E 0 CD O r� �.T CD v a CO3 CD CA l O CD O C CD C 0 -E-1o Z 0 CD E (0�\ FW I ;o: - • V) O CT N Ll O m CA Cc O CO! co m CA �• • a� N �I .O.r 2,"O•' .m N '77 C a i d = CO2 -1 O m N O Cn o =r m = o O N. n .ms►sr1 o CD CD CD N •-� C-3,0 m CL 3 cr C2. � C W o. �i .; _ �O CD N Nit CD O '=N co a � CD mo 1 � o • CD xIt N CD r°► a= m C2 O. ? a� C3 :f = O _ f� o Cncc op O -i ► z Q ,© n 0 , n n •P O W c 91 a nr cn x t� 0 CACDo •`� r� y �J z �� n n � 1�� n E-' 2i Ej 0 v 0 y 0 O C �s Location 4 _ No. 5 Date NORT1i TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # L v S Z) 1636 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING `n7 Mff 2 BUILDING PERMIT NUMBER: 15 DATE ISSUED: 3 SIGNATURE: Building Commissioner/InEeEtor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage (fl) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone 00 M Z 0 X 0 Z M 90 0 mn M Z G) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Com leted b ermit a licant OFFICIAL USEANI " I. Building .� (a) Building Permit Fee Multiplier ' 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) �0 / 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS 'AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 I, As Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB y SITE OF FLOOR TEVIBERS 1s 2 ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS 1)9I, ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Cf) m m m V/ CD 0 Cl y C � d CD 'C O a Z t� d0 "0. r � � o CZ =• y � o � 0 CD a� o Q d CD CD O CD gm y CD CZ CD O y CD �CD I v CO) O 10 Z co o o CD 0 CD n O cn O r ro n H \1J cn 2 0 cn C/) O d cn Z o rn .f D, O -• y O cr nO SmCM N •o tis § p=tm c07 �C')no m C7 rn Z N CD S N• _I o. P-4. O. 0 T m .O~► m CL y y -00 � P-* � IV 7 O N m O O .00 O C2 .••► m 0 O O Cl �+ Z .0 N Cf O : COT W m A CL p A as o � CD C=D,N ' ft C ��m ft d G� m O CA QP : \d= N W N =rCD m :� m C m 03 C42 =,= CD O O C 0 CD :D _C .� N CD �C I dd: CLM n cm oma: C/) O d cn Z o rn .f D, w P vr- G w c� � Cr1 n w w n :71 � �- G w C/) 'O n' O a x �F O O O C) O O H 0 0 c Date .... ...... R Of HORT M ,4 o� O TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that :: ..!-'"..... . . Chas permission for gas installation '4 in the buildings of ......................... ... ::p �/.r. ...... ., North Andover, Mass. Fee`'.. ... Lic. No.!'.d� ... ��Q.n.�. ............ GAS �SP'�,GTOR Check # 6, d _1 4, El S 14 IVIASSACHUSEIIS TO DO GAS FTrHNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS f Building Locations ��% �� Permit # Amount $j cja Owner's Name Newo Renovation El Replacement 11 Plans Submitted El Name of Licensed Plumber or Gas Fittef ,, —1a, 6 /4 '60 t� llo'll Checkone: Certificate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked yes, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity D Bond El Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 I hereby certify that all of the details and info ation I have sub ted jente ed) in above plication are true and accurate to the best of my knowledge and that all plumbing ork and installatio perfnde e r this application will be in compliance with all pertinent provisions oft Ma use tate Gan Ch p 42 oft a General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) nature ofTcensed P mber Or Gas Fitter Plumber 3G ( Gas Fitter License Numoer Master Journeyman 6TH. FL06R Name of Licensed Plumber or Gas Fittef ,, —1a, 6 /4 '60 t� llo'll Checkone: Certificate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked yes, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity D Bond El Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 I hereby certify that all of the details and info ation I have sub ted jente ed) in above plication are true and accurate to the best of my knowledge and that all plumbing ork and installatio perfnde e r this application will be in compliance with all pertinent provisions oft Ma use tate Gan Ch p 42 oft a General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) nature ofTcensed P mber Or Gas Fitter Plumber 3G ( Gas Fitter License Numoer Master Journeyman