HomeMy WebLinkAboutMiscellaneous - 19 MILLPOND 4/30/2018 19 MILLPOND
---- ��- - ----- 210/095.A-0019-0000.0
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9460
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4L
ACHUS
This certifies that ......../,)-
.....................................................................................
has permission to perform ...//-./ >— //,-, ";z .. ......
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wiring in the building of.......zf..t:�r.... .............................
at......... ...... North Andove Mass
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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the ;
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c.166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of..ongoing construction activity,and may be_deemed_by-the,Inspector_of_Wires abandoned_and_invalid,if_he^_. ._
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or-the installing entity stated on the permit application. r
❑ The Permit Extension Act was created by Sectjor_173 of Chapter 240 of the Acts of 2010 and sxtended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012.
AU-,!-S—Permit/Date Closed: / Y ** Note:Reapply for new per
0 Permit Extension Act—Permit/Date Closed:
r r ` ' Commonwealth of Massachusetts
Official Use Only
Department of Fire Services [Occupancy
ermit No.
BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
[Rev. 1/07] (]eave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR
All work to be performed in accordance with the Massachusetts Electrical Code(MEC);527 CMR 12.00
(PLEASE PRDVT IN INK OR TYPEALL INFORAL4TION9 Date: f f�N
City or Town of: NORTH ANDOVER To the nspec r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 4
Owner or Tenant @�' qli�l�
Telephone Owner's Address u/1()
p ne No.
Is this permit in conjunction with a building permit? Yes KJ No
(Check Appropriate Box)
Purpose of Building I(�/I I Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und d
�' ❑ No.of Meters
New-Service Amps. / Volts Overhead
❑ Undgrd ❑ No:of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: h
[e� men
Completion o the ollowin table may be waived y the Inspector of Wires.
No.of Recessed Lamin aires No.of CeiL-Soap.(Paddle)Fans No.of
Transformers ICVA
No.of Luminaire sue Outlets
\ No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In- 0.
o mergency ig g
d. ❑ d. 0 Batte Units
- No,of Receptacle Outlets No.of Oil Burners
FIM ALARMS No.of Zones
No.of Switches No.of Gas Burners o..of Detection and
Initiatitt Devices .
No.of Ranges No.of Air ConcL Total
Tons No.of Alerting Devices
No.of Waste Disposers eat Pump dumber Tons
p Totals; - ___ o.of Self-Containe
__ Detection/Alt-.ryngDevices
No.of Dishwashers Space/Area Heating KW ��❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.ofo. No.of Devices or Equivalent
Heaters KW Sis Ballasts . Data Wiring'
No.Hydromassage Bathtubs No.of Motors No.of Devices or E -mi g: nt
Total HP Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of lectrical Work:
(When required by municipal policy.)
Work to Start 6 /'U Inspections to be requested in accordance with MEC Rule 10 an
INSURANCE COVERAGE: Unless waived b the permit d upon completion.
I� y e owner no
the licensee provides proof of liability insurance including"coleted operation"performance
ovveerage or its substantial equivalent The
ss
undersigned certifies that such coverage is in force,and has exhibited proof of same to theermit issuing
CHECK ONE: INSURANCE g BOND [3 OTHER (Specify:)
OTHER p g office.
I certify,under the ains andpengdties ofperjury, that the information on this application is true and complete.
IBM NAME:
LIC.NO.: AlOw
Licensee: p+ Signature
(If applicable, enter " mpt"int license umber line.)• LIC.NO.:
Address: ( Q, {1� Ci�0�� Bus.TeL No.: fY_"5T
*Per M.G.L C. 147,s. 57-61,security work requires Department of Public Safety"S"License: ��Lic.No. 4 � 13
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑owner ❑ owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: S
v y
152
r r
r The C'ommonweQlth of Massachusetts
Department o f Iradustrial Accidents
Office of Lnvestigations
..600 97ashi baton Street
Boston, M4 02111
wnnv.mass.gorldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ao licant Information
PIease Print Legibly
Name9(Business/OrganizatioDAndi Adual): /^
h
Addt`ess: 2 1`�J' Gfj/J
City/State/Zip: Aw n Phone#:
Are you an employer?Check the appropriate box:
1.❑ I am a employer with q, ❑ I am a v Type of project(required}:
general contractor and I
employees(full and/or part-time).* have hired the sub-contractors ❑Near c0 struction
2 I am a sole proprietor or partner- listed on the attached sheet 1 2• ❑Remodeling
ship and have no employees These sub. contractors have
workingworkers' c
for me in any capacity. 8 E]Demolition
omp.insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
3.❑ required_] officers have exercised their 10. Electrical repairs or
I am a homeowner doing all work right of ex additions
i emption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. . 152,§I(4);and we have no
insurance required.] t cc. to ePs_ 12.[]Roof repairs
P Y [No workers
comp.inst1rance required.] 13•❑ Other
-rev—PPIicant that ch—!--bo:.tl most_is(,nil oui
F2omeowners who submit this affidavit indicating the,are doin = u orkms'comY_c'=eIl Ye� c do
2Contractors that cherir this box must attached an additional sheet aV-Ort a d Them'hireoutside comxuators 4=,submit a new affidavit indicating such.
name of the sub-contractors and their workers'coma.policy information.
lam an employer that is providing workers'compensarion insurance for my employees. Below is the ofi
information Ii1o�' P cJ and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaratioa
n we
p e (showing the policy number and expiration date).
Failure to secure coverage as required under Section 2
fine up to$1,500.00 and/or one-year impris5A ofMGL c. 152 can lead to the imposition of criminal penalties of a
onment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
f of up to $250.00 a day against the violator. Be advised that a co
Investigations of the DIA for insurance coverage verification. PY of statement maybe forwarded to the Office of
I do hereby c under the d realties of perjury thQt the information provided above is true and correct
Simiaturg:
Phone#: �Q `
Official use only. Do not write irc this area, to be completed hil city or town official
City or Town:
Permit/License#
Issa nZ Authority(circle one):
Z. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumuin-
6. Other e Inspector
Contac Person:
Phone
_ �Y
�.
�� � � y _ �U ���
I
'0,
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V
NORTH TOWN OF NORTH ANDOVER
_ 3j �•�`�. .� OL
- i PERMIT FOR PLUMBING
�SSACHUS
This certifies that k)t. . .l. q. . . . . . . . . .
has permission to perform . Kj �!��-+�//. . i??4>1• - -r-- . . . . . . . .
plumbing in the buildings of ., Gt�t. . ?�1 ���
at. 11— .&W. Arm. . e4(?. . . . . . .. North Andover,Mass.
Fee <� . Lic. No.c2�. '�U
/ PLUMBING INSPECTOR
Check #
8644
L
MASSACHUSETTS UNIFORM"PLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
Building Location f Date C( ( (�'p�(yf Date
Permit
Owner A 1A1
Amount
New Renovation Replacement Plans Submitted Yes ❑ No
FIXTURES
IPQ
BMMENr
1 SO�iE�VIC
2M ROCR
M ELOCR
4M IIDM
5MMOM ,
6M EWM
7M E[OM
SIH IIDQZELL
(Print or !�( / Check one: Certificate
Installing Company Name T�'lt C p '�l v Corp
Address Ur'C ❑ Partner.
qt Ol
Business Telephone g Ste/ $y —Finn/Co.
"PIName of Licensed Plumber: 6 I ��D D 0
Insurance Coverage: Indicate the type of coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in 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 m
compliance with all pertinent provisions of the Massachus tate P2mgCode and Ater 142 of the General Laws.
By: igna e o kens• um
Df
Title Type of Plumbing License
City/Town01 q7t�Q
icense um Master ❑ Journeyman
APPROVED tomcE usE ONLY6=1
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ( l
do a (0 W, P.,g
Address: (Q C U Irl S'i
City/State/Zip: DI W- Phone#: G�► 7 ��
Are you an employer?Check the appropriate boa:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or me).* have hired the sub-contractors 6. New construction
part-ti
2.[!f I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. g. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers'
COMP.insurance required.] 13.❑ Other
*Any applicant that checks box#! muni also fall out ice section below c �eir WG it-'comp usaeson poS•cy info.^ tion.
I Homeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors must submit anew affidavit indicating such.
$Conriactors 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 isproviding workers'compensation insurance for my employees Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerd&under the pains andpenaldes ofperjury that the information provided above is true and correct
Signature:
Date:
Phone#: 9 7 V1
Fonly. Do not write in this area, to be completed by city or town official
n: Permit/License#
ority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
a
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 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 checking the boxes that apply to your situation and,if J
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,.are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed to the city or torn mat the application for the permit or license is being requested,not the DepartTMent.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
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 permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(i.e.a dog license or permit to 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investibations
600 Washington Street
Boston,MA 0.2111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAEE
Fax#617-727-7749
Revised 5-26-05
www.mass..gov/dna
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN- G t
•. (Print or Type) '
NORTH ANDOVER Mass. Date
. Building Location Z2 Ppr1) Permit # �/,2-G
4 .� Owners Name NJ
�-'
New _ Renovation II Replacement D Plans Submitted D
�„ • FtY-�tR_c
sz
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!it
O tdG1
d C G Q c _ W
d CS 47 Y tL O d = W d 0
� ut d — F� 4]
t1! � �
W to W J Q �• .� C7 S W W Ii CS C c^
? U. i- -t f- tt1 v l
U4 us
a v c� y Q nQ.� rW-� o
stia-3s".1T..
SASE. F—MT I ! f ( I I ( I I I f ( ! I I ( ! f I I
j
-IST FLOOR ! f I I f ! i I I ► i I I I I E ! ! I I I { !
ZILD FLOOR
i 3RD FLOOR I I I ! ( I ( I I I I I ( I I ( I ( ! ! I I f f
4THFLOOR
STH FLOOR
6TH FLOOR
7TK FLOOR I I ( I f f I I ! ( I I I I I ( I I I
8TH FLOOR I I i f I ! I I I I I
(Print or Type) Check one: Certificate
Installing Company Name Uv- 43 + 4eA4 Q Corp.
Address / Annoyer ni. Partner.
i `be'C 1Ci'9 Firm/Co.
Business Telephone:
Name of Licensed Plumber or Cas Fitter_
Insurance Coverace: Indica--e ,tee ,,/pe of insurance coverage by checking the
appropriate box:
Liability insurance policy =Z,711"Ot^er type of indemnity = Bond
Insurance Waiver: I , the ur.dersicned, have been made aware that the licensee of
this application does not have any one of th,e above three insurance coverages.
Signature of owner/agent of property Owner = Agent F7
I hctcby cettiry that iU of the details and information 1%are submitted (or catered)in above appr'ieation are true and accurate to the best of my
1 nowtcdse and Mat all pluatbin; work and fnsradations —,=formad, unCc ftrr»it iuccd for this sppucation rill be in eompiiarsoa with&a petlaast
Provisions of the Stassae4usetts Slate Cas Cade and C:aptes lt—'et the C.c=zl L w& •.
By TY?r LICZNS Q�
I Plum.,Der
Title I Gasiitter Signature of Licensed
Master p ad r Gasfitter
City/Tcwn: Journeyman
APPROVED (OFFICE USE ONLY1 License Number
`*gaW
/y9�� , 4
Date.ww'.,lo ! `3 .......
2126
NORTH TOWN OF NORTH ANDOVER
Frpya,�ao �a,ti op
PERMIT FOR GAS INSTALLATION
�9SSACMUSEtS q
M
L 4
This certifies that . . . r��?�► �./?. . . . . . . . . . . . . . . .. . .
Lo t
has permission for gas installation .4' t . . . .
in the buildings of . .13,/.9/?P.)/ . -. . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . . . . . .. North Andover M
Fee.a?S '-. . . Lic. No.,)O.4,3.4. . . . mss:
GAS INSPEWS `LT
r.
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:,4%ie
i�
L ,^
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 1
(Print or Type)
NORTH ANDOVER Mass. Date
1iuilding Location / / �� Permit # )Lv3 S
Owners Name
• Y New .Renovation 0 Replacement Plans Submitted D
9 FtXTUo=c
W W N
C*
E ... V
O! O m F s �= of
—
cc
O ul C e C O O W
Z to y N O W 4
Q W d W w `.. a s �,
N t3 V W or .G O G _W
O F.. -� � H 2 t,., W w O T w t•- w � F- w
O t07 W u. n 0di U G y G a hW- O
BASEMENT {I I I I I I ( I ( I I
1ST FLOOR
2ND FLOOR I I I I I I I I I I I I ! I I I I M I
3RD FLOOR I I I I I ( I I I I !I I II I
4TH FLOOR I ( I I I` I I I I I I I
STH FLOOR ( I I I I I + I I ( I I I
6THFLOOR I # ! I
7TH FLOOR I II ! I I I I I I
8TH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name [E orp.
Address Partner.
Firm/Co.
Business Telephone: (/0
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate e type of insurance coverage by checking the
appropriate box:
Liability insurance policy ether type of indemnity = Bond Ej
Insurance Waiver: I , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner u Agent
I hcreby ccrtify that alI of the details and information I have submitted (or entered)in above application are true and accurate to the best of my
knowtedge and that &U ptumbing wort and Installations 7crformcd under'Permit i=rd for this appLicatioo wdl_be in compliance with all pertLn=t',
proviiions of the Massachusetts State Cas trade and chapter 141 of Lha General Laws _.
By TYPE LICENSE:
Plumber
Title Gasfitter Signature of icensed
City/Town- easter Plumber or Gasfitter
Journeyman
APPROVED (OFFICE USE ONLY) License Number
/&97 �"
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING00
(Print or Type)
NO.ANDOVER ,MA Mass. Date 19 "014 permit 0 9 J -.
a Building Location _ M-ILLPOND Owner's Name a/&,
NO.ANDOVER,MA Type of Occupancy ' RES
New ® Renovation Q Replacement ❑ Plans Submitted: Yesa No ❑
N
4
W N
x _ =
N ¢ h rr O a H F-
W W ¢ O U m
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V
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O W ¢ s O O 1-
< m rn F- y W O a. c o
¢ w 4 = F- N > <
Uj
uj
W O h
< W > ¢ W O - 4 ¢ < < O O W ¢ O }1 F-
Q
SUB—aSMT,
BASEMENT I
1ST FLOOR
2ND FLOOR I I I
ORO FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR I I I ( M 1
7TH FLOOR
STH FLOOR
Installing Company Name CALLAHAN AIR CONDITIONING Check one: CerKcate, '72
Address 91 BELMONT STREET C3 Corporation
NO.ANDOVER,MA. 01845 ❑ Partnership
Business Telephone 508-689-9233 O Firm/Co.
Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142-
Yes
42Yes R1 No O
If you have checked Les, please indicate the type coverage by checking the appropriate box
A liability insurance policy Z) Other type of indemnity ❑ Bond []
OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee 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:
OwnerO Agent E]Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in ove application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit sued for this appiicatJ will b In pllance with all
pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the neral Law
By
Type of License:
Plumber gnalur o c nse um a or Gas Fitter
Title sfitler
Master LIcanse Number M-3440
City/Town Journeyman
Mf'f1CT/F(�1Z p .
. '�Ar +•-.�.....�...<-�-w=` °,may-—r>--.�-;z„� .s,,.-�.seab�.arw,�«a�.a.�;��-- ::w�asn.i"�+f'4..
A T2 J 2 6 9 5 Date.�,l 3 �1�. .
l 3
y
NORT1y TOWN OF NORTH ANDOVER - f;
PERMIT FOR GAS INSTALLATION
t i A
9
�9SSACMUSEtt
N
This certifies that +t
has permission- for gas installation . . . . . .. . . . . . n,
in the buildings of . . . . . . . . . . . CU
at . . .� ` . .`1 ri:C. �!'�/ ., . , . . . . . ,, North Andover,Ma
Fee. z.'. : :. . . Lic. No..3 R . . . . . . . . ... . . . . . . . . . . . . . . . . .N
GAS INSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:_Treasurer GOLD:File q
2636
OF NORrh Date j/r
O e O
ow f
o s pE NOF IypR
ssACRUSESSS - OR SAS /NST .VER. A .
This g
Certify ,
es that
has -
Per,ni a
in ssioa forte,
at the buildings o f gas ,nstallation
' �•� ,
Fee , G l
Lie.
WHITE• pplica �. Orth o.
A •� N • •
nt Andov ' • .
CANARY: er,
Buoy; Mass.
ng Dept. Ag INSPECTpR
PINK
Treasurer
GOLD.File
- Commonwealth of Massachusetts
100142050
Decal Number
Asbestos Notification Form ANF-001
Important:
When filling out A. Asbestos Abatement Description \
forms on the
computer,use 1. a. is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
only the tab key residence of four units or less?✓ Yes ❑No
to move your
cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number
use the return
key. 2. Facility Location:
Vol IMAZIN RESIDENCE 19-M!L1—POND—
a.Name of Facili b-.Strfe-t Address
NORTH ANDOVER MA 01845 978618$198
c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this BSMT-L[VING ROOM���
form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room
completed in order
to comply with 4. Is the facility occupied? 0 Yes ❑No
DEP notification
requirements of 310
CMR 1.15 5. Asbestos Contractor.
and the Division
of Occupational DEC-TAM CORPORATION 50 CONCORD STREET
Safety(DOS) a.Name b.Address ..
notification NORTH READING 101IN4 -"� 97$4702$60
requirements of 453 ��
CMR 6.12 c.City/Town d.Zip Code e.Telephone Number
AC000035
t. OS LicenseNumber g. Contract Type: ❑✓ Written ❑Verbal
BRENT MORGENSTERN SALES
h.Facility Contact Person is Contact Person's Title
GEORGE A. PAGE ASO 1
T 933
6. a Name of On-Site Su ervisorJForeman b.Su rvisor/Foieman DOS Certification Number
COVINGAA000006
7' '
a.Name of Proect Monitor b.Pro ect Monitor DOS Certification Number
COVINO AA000006
o' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number
T
0 9. 2/20/2012 1 12/20/2012
A.Proect Start Date(mrn/d51yyyyJ b.End Date mm/dd!
0 7A-4P
�rV
c.Work hours Mon-Fri. d.Work hours Sat-Sun.
,-0 10. a. What type of project is this?
=a ❑ Demolition ❑ Renovation
�.- ❑ Repair ❑ Other, please specify: b.Describe
—r 11. a. Check abatement procedures:
p
❑Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
_U- ❑Cleanup ✓❑ Other, specify: CRITBAR/NEGAIR/DECON
_
❑ Full containment b.Describe
Z
E 12. Is the job being conducted: ❑ indoors? ❑Outdoors?
® anf001 ap.doc•10/02 Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts ■
~; 100142050
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
en aDsuiated: _
10 1 325 -
a. eta pipes�usZwear . Tofal offer su aces square n
c.Boiler,breaching,duct,tank d.Insulating cement
surface coatings Lin.ft. Sq.ft. Lin.ft. (Sq.
ft,
e.Corrugated or layered paper f.Trowel/Sprayer coatings
pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft.
g.Spray-on fireproofing Line Sq.ft. h.Transite board,wall board Lin Sq.ff.
L Cloths,woven fabrics f____e_ j.Other,please specify_ = 325
Lin.ft. S .ft. Lin.ft. So.ft.
k.Thermal,solid core pipe YATIMASTIC
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
THREE STAGE
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g)*
MATERIALS WILL BE WETTED AND PLACED IN DOUBLE BAGS AND LABELED FOR TRANSP
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name o P Official b.Tide
c.Date mm/do/ of Authorization d.DEP Waiver#
e.Name of DOS Official f.DOS OfficialTitle
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
�N
-0 17. Do prevailing wage rates as per M.G.L. c. 149, 3 26, 27 or 27A-F apply to this project?❑Yes V No
o
B. Facility Description
-N
=o 1. Current or prior use of facility: RESIDENCE
�o
2. Is the facility owner-occupied residential with 4 units or less? Yes ❑ No
T 3 BETH MAZIN 19 MILL POND
a.Facility Owner Name b.Address
�o NORTH ANDOVER 101845 978-618-8198
o c.City/Town d.Zip Code e.Telephone Number area code and extension
,BETH MAZIN SAME AS ABOVE
U.
4' a.Name of Facility Owner's On-Site ManIager b.On-Site Manager Address
(
Z LI
Q c.City/rown d.Zip Code e.Telephone Number(area code and extension)
■ anf001 ap.doc•10/02 Asbestos Notification Form-Page 2 of 3
Commonwealth of Massachusetts _
`. 100142050
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor ( b.Address
e.Ci /Town d.Zip Code e.Telephone Number area code and extension
GREAT DIVIDE INS. CO I IWCA153726610 1 112/2812012
f.Contractor's Worker's Comp.Insurer q.Policy Number h.Exp.Date(mm/dd/yyy
6. What is the size of this facility? 1800 1
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
Note:Transfer a.Name of Transporter b.Address
Stations must I
comply with the c.Citylrown d.Zip Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 16.000 ISERVICE TRANSPORT 158 PYLES LANE
a.Name of Trans otter b.Address
NEW CASTLE;DE �� 79720 $ 79999559
c.C" /Town d.Zi Code e.Tele hone Number
3.
a..Refuse Transfer Station and Owner b.Address
c.C" /Town d.Zip Code e.Tele hone Number
4. INNERVA ENTERPRISES INC
a.final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
9000 MINERVA ROAD I JWAYNESBURG
c.Final Dis oral Site Address d.C' /Town
J 44688
e.State f.Zip Code g.Telephone Number
�o
D. Certification
�N
�— The undersigned hereby states,under the BRENT MORGENSTERN Brent Morgenstern
Q penalties of perjury,that he/she has read the a Name b.Authorized nature
�o Commonwealth of Massachusetts regulationsSALES
for the Removal; Containment or 2/3/2012
�r c.Position/Title d. Date mm/dd/
Encapsulation of Asbestos,453 CMR 6.00 and 9784702860 DEC-TAM
r 310 CMR 7.15,and that the information
contained in this notification is true and correct e.Telephone Number f.Representing
to the best of his/her knowledge and belief. 150 CONCORD STREET
.Address
amLL
NORTH READING �� 01864
h.City/Town i.Zip Code
-Z
■ anf001 ap.doc• 10/02 Asbestos Notification Form.Page 3 of 3
DEOT\M CORPORATION 978.470.2860
fax 978.470.1017
Specialty Contractors
R9EID
I-CEb '13 Z01 Z
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
February 6, 2012
North Andover Board of Health
1600 Osgood Street
Building 20, Suite 2-36
North Andover,MA 01845
RE: Mazin Residence, 19 Mill Pond,North Andover,MA 01845
(Basement—Living Room)
Dear Sir or Madam:
Please be advised that Dec-Tam Corporation will be performing an asbestos abatement
projects at the above referenced locations. This work had been scheduled for
February 20, 2012 thru February 20, 2012
All applicable local, state and federal agencies have been notified of this work.
Please let me know if you have any questions.
Sincerest regards,
Brenton Morgenstern
Sales Estimator
BM/cam
Enclosure
Environmental Remediation Services • Surface Preparation • Facilities Services
50 Concord Street • North Reading, MA 01864 • www.dectam.com • solutions@dectam.com
LaMarche Associates
��� �® P.O. Box 179
F(E�.J 1 Natick, MA 01760
APR 1 2 2®10 508-650-9777
Fax: 508-650-9870
T
H
�L
'0�,�® OF HE February 19, 2010
Building Commissioner/Inspector of Buildings RE�+t��V
NORTH ANDOVER, MA
APR � 3 2010
Board of Health/Board of Selectmen
NORTH ANDOVER, MA TOWN OF NORTH����
HEALTH DEPARTMEiVT
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139. SECTION 3B
I
Claim has been made involving loss, damage or destruction of the property captioned below, 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 the writer and include a reference to the captioned insured,
location, policy number, date of loss, cause of loss and LA file number.
Insured: MILLPOND HOMEOWNERS ASSOCIATION
Loss Location: 19 MILL POND
NORTH ANDOVER, MA
Policy Number: PHPK384320
Date of Loss: 2/4/2010
Cause of Loss: Water
LA File Number: MA-2-16554
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
Gregory LaMarche
Adjuster
LaMarche Associates,Inc.-800-349-1525
Page 1 of 1
i
R E C E �0 E LaMarche Associates
P.O. Box 179
Natick, MA 01760
APR 1 2 201Q 508-650-9777
SOAR® OF HEALTH Fax: 508-650-9870
7APR
February 19, 2010
Building Commissioner/Inspector of Buildings 2010
NORTH ANDOVER, MA
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Board of Health/Board of Selectmen
NORTH ANDOVER, MA
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GNER
Claim has been made involving loss, damage or destruction of the property captioned below, 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 the writer and include a reference to the captioned insured,
location, policy number, date of loss, cause of loss and LA file number.
Insured: MILLPOND HOMEOWNERS ASSOCIATION
Loss Location: 19 MILLPOND
NORTH ANDOVER, MA
Policy Number: PHPK384320
Date of Loss: 2/4/2010
Cause of Loss: Water
LA File Number: MA-2-16554
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
Gregory LaMarche
Adjuster
LaMarche Associates,Inc.-800-349-1525
Page 1 of 1
I