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Miscellaneous - 19 YOUNG ROAD 4/30/2018
North Andover Board of Assessors Public Access .1 .. c Ctxk Sad To R{eMm Search for Parcels Search for Sales Summary Residence Detached Structure Condo C�ercial Morth Andover Board Page 1 of 1 I _ roperty Record Card Parcel ID :210/01.6.0-0003-0000.0 FY:2014 Communitv : North Andover Location: 19 YOUNG ROAD Owner Name: GABREE, MATTHEW, P. GABREE, ELIZABETH, H. Owner Address: 19 YOUNG ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.14 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1508 sqft ASSESSMENTIS CURRENT YEAR PREVIOUS YEAR Total Value: 285,500 285,500 Building Value: 136,600 136,600 Land Value: 148,900 1.48,900 Market Land Value: 148,900 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2432086&town=NandoverPubAcc 5/14/2014 N N r r N N I- 0 O,X w 0 0O,Xw0 N .�. 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TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 4117 This certifies that � N'., '�'-4 ............................. 1. - ----- N ... *****-- has permission to perform .....a e ............................................................................................. plumbing in the buildings of.... U `�A-�- at... I � . � (N- - ................................ North Andover, Mass. Fee,?.- .... ...... ric'No. .......... ........ ................................................................................. PLUMBING INSPECTOR Check # f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �- u,p CITY Niorth Andover MA DATE 4-7-16 j PERMIT # JOBSITE ADDRESS 19 Young Rd OWNER'S NAME Elizabeth Gabree POWNER ADDRESS Lsarpe TEL 603-540-5285 FAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAL E] PRINT CLEARLY NEW: 0 RENOVATION: Q REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NOQ FIXTURES 1 FLOOR- BSM 1 1 1 2 3 1 4 5 6 7 8 9 10 11 1 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _1 FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK ffi LAVATORY ROOF DRAIN SHOWER STALL 1 ALL— ERVICE / MOP SINK TOILET - URINAL WASHING MACHINE CONNECTION [ T WATER HEATER ALL TYPES WATER PIPING OTHER - _ INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND E] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Partin t sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEJim Swalgen LICENSE # 15641 M TURE MPQ JP El CORPORATION# PARTNERSHIP# LLC Q# COMPANY NAME I American Generations P & H ADDRESS 120 farrwood Dr CITY Hooksett STATE NH ZIP 03106 TELE 978-548-2000 FAX CELL EMAIL 13 FO WNEDIS UY in cc z ,Z-1 V) wtoa a cn -1 :z F - "tilt cV d3co 0 0 z reN %X --j ce . . . C) In -j =3 z00." <z U - in w -cc z u ix x C c w h - m cr 3c Ln m La C3 < 3: -j =3 Lu > C3 Lf in Ln CZ %X ul z :E C) oc ui w c u z M C4 CY w > rJ LA %D The Commonwealth of Massachusetts Department of IndustrialAccidents Of ice oflnvestigations - 1500 Washington Street r; Boston, MA 02111 www.mass gory/dia Workers' .Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/orpnization/lndividaal): n City/State/Zip: Phone 4: / 1•� Are you an employer? Check the appropriate box: L $3 I am a employerrwith �:�— 4• ❑ I am a general contractor and I employees (full and/or part -tune).` have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.; required.] S. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp, insurance reauired.l Type'of project (requlred): 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 wbo submit this affidavit mdicatmg they are doing all work and then hue outside contractors mist submit a new affidavit indicating such. :Contractors that check this box now attached an additional sheet showing the Mme of the sub -contractors and start whether or not those entities have employees. If the sub -contractors bave employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company -I?,— Policy # or Self -ins. Lia #: A 5 L-Dp 9/605/1 Expiration 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 viol4tor. 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 certify under the pains andpqrltie�ef perjury that the information provided above h true and correct official use only. Do not write in this arn4 to he completed by city or town oBieial City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector . 6. Other Contact Person: Phone #: w 111"14. Date ./dy/�� .,1 .............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that.........................................................�5�................................................:.. A i3 , CCS. has permission to perform .�.�......:�/�....� o� �P �� ................... plumbing in the buildings o ........ ...�.-.... /-OA-k-...................................:............... at ..... ....1..........f u'?, a�...:.......................................... North Andover, Mass, Fee�S Lc. No. ...................... .................................................................................. PLUMBING INSPECTOR Check # 6ti/�- \ ^ .r•. � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT 70 PERFORM PLUMBING WOR MA DATE --�-- [ PERMIT # I I d ��a .. CITY --� —� 'y P TYPE OR PRINT CLEARLY JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL EO NEW:L5 RENOVATION: ® REPLACEMENT: 0] i j FLOOR—� BSMONNECTION DEVICEED SPECIAL WASTE SYSTEMED GASIOILISAND SYSTEMED GREASE SYSTEMED GRAY WATER SYSTEMED WATER RECYCLE SYSTEMHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL ASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHER�,��� � TEL R�FAX RESIDENTIAL PLANS SUBMITTED: YES EO NO 01 10 11 12 [ 13 14 INSURANCE COVERAGE: 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, YES [i NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND EllQ OWNER'S INSURANCE WAIVER: I am aware that the licensee eon {_ not have the lication waves this rove.rage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this p pp CHECK ONE ONLY: OWNER (- AGENT E[1 SIGNATURE OF OWNER OR AGENT Ig knowleage hereby certify that all of the details and information o mate n I nave der he permit issued for this applicationpwlill be nacompliance with all Pertinente rovis on of the and that all plumbing work and installationsp � Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��SI&TATI URE PLUMBER'S NAME I LICENSE # SGS` MPJP CORPORATION DJ#�_�_-PARTNERSHIPQ#�LLCQ� [ � Q _ VQ COMPANY NAME e' �1Cs ;ADDRESS I ZIP STATE ®�1 TEL �y o2 l CITY FAX [ CELL i EMAIL or -1 z to ❑ W H W LM LL a a Lij LL w I The Commonwealth of Massa chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name (Business/Organization/Individual): Address: City/State/Zip; Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with employees (full and/or part-time).* 7. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling any capacity. [No workers' comp. insurance required:] 9. ❑Demolition 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12.Fl Plumbing repairs or additions 5.rJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# IM 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] 14.0 Other The Commonwealth of Massa chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name (Business/Organization/Individual): Address: City/State/Zip; Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with employees (full and/or part-time).* 7. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling any capacity. [No workers' comp. insurance required:] 9. ❑Demolition 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12.Fl Plumbing repairs or additions 5.rJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 13. Roof repairs 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who subrol this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-coritrac'tors have employees, they must provide their workers' comp. policy number. I ani an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjuly that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: _.V 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 othire, 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 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 may be submitted to the Department of Industrial Accidents foi• 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. 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 permit/license 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 ;Revdsed 02-23-15 www.mass.gov/dia 1 jf/ j -J.0 Date ..'��...�.�...�?...�1.`}'...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifiesthatC' .�S.PC has permission to perform ►^ o ..................... �..................... plumbing in the buildings of:.....c ?- at ......... . �..5......�..(S. ..... k. J ....................................... North Andover, Mass. r Fee 4t.:�........... Lic\ltiti... . �, HO..................................................................... PLUMBING INSPECTOR Check # bF4, V-N� 14"--dH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY N Q�2 !�1` �1 _� MA DATE PERMIT # r JOBSITE ADDRESS OWNER'SNAMELP �?f FOWNER ADDRESS „... _/.Of/NG _,. b _ __ _ __ _ _ TELJY '.�� TYPE OR OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL RESIDENTIAL R PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESj NO( FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 w BATHTUB GROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASlOiIlSMiD SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN -__-_ FOOD DISPOSER FLOOR t AREA DRAIN INTERCEPTOR INTERKXt _.._r KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK 1 4 - TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING_ . OTHER INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NOD IF YOU CHECKED YES, i'+LOM INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABRM INSURANCE POLICY OTHER TYPE OF INDEMNITY Ei BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requhement. CHECK ONE 0 Y: OWNER El AGENT SIGNATURE OF OWNER OR AGENT I hereby itify that all of the demos and information i have submitted or entered regarding this application are true angrefixtrateto the best of my krwwledge and that all plumbing work and irstallatim performed under the perrn(t Issued for this application will be in comply all Pertinent provision of the Massadnmtts Siete Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME CSaever► _ ... -.—� LICENSE # — SIGNATURE mpP-1 JPCORPORATION 0#=PARTNERSHIPEj#�,�„_...,.��, iLLC [-;j#[21� 150� COMPANY NAME PC Plumbing &Heating ADDRESS 12 ConooW St. _ CITY _ .. STATE MA ZIP 01844 _ TEL 978815~3936 FAX 978-208-1081 CELL 978�5 EMAIL Date.......................... `? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .�� This certifies that......................9.� .......................;....................................................... has permission for gas installation ....-±-s.... P..?. inthe buildings of ........... ..................................................................... at ........!`'',... .:........................... North Andover, Mass. ........................ FeeN: ... Lic. No...1.!'_t. _i .... ....... ...�. ....................................................... GASINSPECTOR Check # 9208 pp YIN 10t -3h i •� ,, `�`�' ��� l �� ._ ^ - - - - - ,a \� ... .. '� - G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE! PERMIT# q74W6r_ JOBSITE ADDRESSI j OWNERS NAME OWNER ADDRESS T . b ,�FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL NEW-.,:'] RENOVATION: 0 REPLACEMENT: L!_ RESIDENTIAL'! Ar� PLANS SUBMITTED: YES,—.) NO;—_j 1 APPI 1ANCES 1 FLOORS- I BN I 1 1 2 1 3 14- 1 5 1 6 1 7 1 8 1 9 1 10 [ 11 1 12 1 13., L_. 14 "I I have a amwt inwrence policy or its sW)stuAW equivalent which meets to reWirewou of MGL Ch. 142 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 21 OTHER TYPE INDEMNITY "-J 1 SONG YES 2 1 NO Lj OWNER'S INSURANCE WAIVER- I am wm that the licesrsee dogs not bW the Insurme corsage required by Chapter 142 of the Massachusetts GmA Laws, and that my somn on this permit application vmhft this requhmenL CHECK ONE ONLYy OWNER AGENT SIGNATURE OF OWNER OR AGENT — 0 w e!r knowledge I hereby ow that an of the detals arid Iriftnium I havesubmittedor entered regardim this awtedon are Mm and to e MY L #' "21 ag peowt WvAgon of the and that aN owft" work and kswwfts Wbnwd under the pem* issued for tift w0callon wM be in '80" Manedwseft State Plumbing Code and ChapW 142 of the General La**. 5W SIGNATURE PLUMBER-GASFITTER NAME Steven Catr�� LICENSE #! F", LLCLJk, Do MP LD MGF Lj. JP j CORPORATION [J# PARTNERSHIPIE ry COMPANY NAME:F_E ADDRESS C 1y12 STATE MA ZIP! 01844 TEL 97&815-3936 CITY i Methuen ... . ..... .... FAX CELL[978-81W936 JEMAIL� The Contnronlvealth of Massachusetts Department of I►rdustrial accidents Office of Investigations 600 `l'ashington Street Bostott, MA 0.2111 UIP iwviv.mass:govldia Workers' Compensation Insurance Affidavit: BuilderslCorrtractors/Electricians/Plulubers Anlicant IDEOE'M1110- Please Print Le MY lame: pusihessawnizationtUividual): ,) P4 t?t ub 3 to h t t_ C. G Address• tZ 'Con coma Sr City/Statelzip: f t eras _ b a A i l `t n Phone #:_q 7- 1AIG ' Are you an employer? Check tbrappropriate box: Type of project (required): 1. ( I am a employerwith y2 4. ❑ I am a general contractor and 1 employees (NII and/or part-time). * have hired the sub -contractors 6• D New construction 2. ❑ t am a sok proprietor or partner- listed on the attachcd sheet. t 7 Rett,odeling ship and #cavi; no employees These sub -contractors have 8. ❑ Demolition working for me is any capacity. workers' comp, insurance. g, ❑ Building addition (No workers' comp. instuanc a 5. ❑ We are a corporation and its officers have exercised their I0.❑'Electrical repairs or additions required.] 3. ❑ l 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.[3 Roof repairs iasu=ce mired,) t employees. [No workers' 13.❑ Other comp, insurance required.) *Any applicant that chw4 a box tit erwtd also tiff out the swkm below showing their women:' eompenaadon policy intonation: t nwnw w its who wbtnit the affidavit ming they are doing an www tad then him outside contreetort nvad subnit s new affidavit kdicadne avch tCoatnetoes that clack this boa mint MU W an additional And showing the name of the sub-contnetom and their workers' congL policy hirors =ticm I aide an employer that is providing workers' compensation Insurance for my employees. Betow is the P0U9? artd jab sfte lnformatlon. LL DfA&M lw=nce Company Name: i 0401 t Policy # orSelf»ins. Lit #: P-42LWA.Expiration Date: Job Site Address:,..f � �edlzv /0 Cig4StaWZip: odd 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 orMGL e. 152 can lead to the imposition of criminal penalties ora Cute up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in tate form, of a STOP WORK ORDER and a fine of up to 5250.00 a day gaunt the violator. Be advised that a copy or chis statement may be forwarded to the Office of Investigations of the for insurance coverage verification. W, I do hereby certif}� lodk the pains and penalties of perjury that the Information provided abgve tt true and correct Q,A?cial use only. Do not wry in flits area, to be completed by city or town ofciaL City or Town: Permltli.icense # 1-//.s"// Issuing Authority (circle one): 1. Board of health 2. Building Department 3. CttyfTown Clerk 4. Electrical Inspector S.. Plumbing Inspector 6. Other Contact Person: Phone M AcOR CERTIFICATE OF LIABILITY INSURANCE Yteth9 CMUWAM IS UMM AS A MAT= CW WPCUtN,4.TtMNi CWLY IWO O"gn Mp Rt6M II pW TM o"OV"If MOtAM M CItFtY IATA OM iT A"IRMATitR£!.r OR NEOAYW UY AMC, WUID OR ALTER THE tFfAM Ar!'QROEO ill iti! ,POt KUM. TM3 COMM -All OF MUMANM ODES NOT ;*wm VM a cowtpj CT 4STIMN TM MUNo ffaUFX3j, AUTHQr4M RVAMMATM OR PROKW^ A" TME CSIrTiMTZ HWA!!R, wroOT . . !r tho t..n tno ria ardarsed. IS waw WAIM to the Urm end aondkbm at 00 FO}k Y. PWWft MW r Mft IM eddoraelMnL A ablwuW on thh woftft do" "t "Mm rt btt to � ceWtl! to WdW M a" of Web g mwoum Hws W"m AW-cY\ Mm (978M3162 (�aai�•2fi 36 Maw$"* AV16 fie+► up 018a . llaiotk bRadhM MIgad Am bmumvt n+euRep . 8tsva� Car' '� •• - DU VC Piuvokq as l "*q 12 Conoco SL me 018" COV6RA6 CERTOWA E li11MSM- t rMOW AdB R; THIS IS ro cr Y1iA7 S MMM BE OW "AVE em! tssu� TO Tto m8ow mudo Aam pm Trr POLICY PERIOD WWATM NaiwtrMANDW W REQUOMANt. TMt* on ODNDMK OF AW 000TlUCT OR arwR aocrAre+T " AM= TO MUCH nub CWtpCAYb WY 09 {SSD OR MAY PIRTA N,. TIM 94&QAWA AFFMW W AY THE POW68 MCAWD wee 10 sum,t = TO AU TM! tsRAM f.M.t 904 Iwo OMMOM OF *UCM Pl7i Gft UMMS $MOM MAY HAVE 09EN REOtM By PAID WA rmcwoew*Alo .: uwrta 1 UAW4 tY t o oo, �a�w�t+•�eeLjDom c aAov. A : A 03JoMI3 03f2mio ,0opi, 2,000100. 1-mc"oG s Au+oaoeee weemr UMZb%4411 forme Awrw+ra - e0�>owwRvaurv■.oM c 71 WCLYIIIAMIV(i0'N�90rIQ ' 1dItFA MVOs e 1 �1Mt e.M r A GmmWyy OIOTiVR L MNF WE7033NA � •� 1 �InrTloworo►upNn��r.ncn710�w11t�e06sf fAe�NA�►o1a,MQNIw1.lOb+�T�eol»M,A,MwewM.whlt�iw0 ►MteUaWn eno moo* d pkmt*v w4 heaft vquOram. 1 CERTWIFAT9 jVLPl1R T r..�~ •"..". Town of M4rth Andover Dula/IscY+aF at �tmLtc�su aao,Q Buil4smg Dept 706 ne~Mv DATA Wm WILL u o4Alm w wcroAVAM WFM TMG POMP PM)MMa, 169'0' -oagood 8t - BuildLng 20, suite 2.36 Nor h .>Andovearr ice. 01845 ,1140 a 1SSe, Ap Won COWMTM. Ari ASND. r+werm ACRO 26 rmlo�.osi TM ACM neo *t h4a am r+ &Wa me*& of ACM Date ...,1 ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... .l ..... C /C has permission to perform .......t//� ...J,d .... wiring in the building of ................S.I..I..F.. / r at ...... .��....`/! W.......!..... �1........................................... orth Andover, Mass,, Fee.....? :7e ................ Lic. No. ............................ .�!.. s�..- .. ........ �.......... CTRICAL INSPECT_OR� Check # -3J Z' I `� pt k-, 2 Iq I - /�� 14 (.omrrwnweaf o/Vamal"ffi Official Use Only 2, rartrnent o1 ire Jervice3 PermitNo. (r—i Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. I/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 9MR2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1� / F / 41 City or Town -of AhkIV,q,1.1Wi/&—)'� To the Inspe tori of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address No. Is this permit in conjunction with a building permit? Yes No ❑ (Ch . pproprtateBox) � Purpose of Building Utility Authorization No. 1 % -.43215 Existing Service /UP Amps / Volts Overhead 0 Undgrd ❑ No. of Meters / 1 New Service 2,&-0 Amps / Volts Overhead Undgrd ❑ No. of Meters / Number of Feeders and Ampacity No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g Location and Nature of Proposed Electrical Work: Heat Pump Totals:I Number Tons KW No. of Self -Contained Detection/Alerting Devices Completion of the folimpine table may be waived In, the Inspector of Wires. No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ ln- ❑ d rad at o Units Emergency Lighting Butte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals:I Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Loral ❑ Municipal ❑ Other Connection No of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water. KW Heaters No. of No. of Ballasts Data Willing: No. of Devices or Equivalent No. hydromassage Bathtubs —signs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this ap lication ' true and complete FIRM NAME: DAV 1 PL I - E L T RI CAL— Cod j I P /�C"" LIC. NO.: Licensee: p A\J i t'7 14466 AP, Signature LIC. NO.: i il G to � fp f applicable, enter "exempt" in the license mrmber line) Bus. Tel No. -9 Address: i '7 t L lY! C! ? i i`� �2�1 i Ni7L' �l iZ 1 1 fit` �' Alt. TeL No. -.!J 19 -I 7 5 - 73ff *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. 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, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE.- $ Signature Telephone No. The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST City/State/Zip: NORTH ANDOVER, MA 01845 Phone #: 978-682-6262 Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 8 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other ELECTRICAL CONTACTING *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. * *If,the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy # or Self. -ins. Li,. # 9353694 Expiration Date: MARCH 1, 2015 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 iWance coverage verification. I do hereby certify, under ��a n f perjury that the information provided a ovee�iis true and correct. ii srnatnre T�atP a �/L 7'" V Phone #: !el -f — &2-- &� 2 -- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Date ....... •a���v—�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..................:�,d:..�!.�........' .�G / has permission to perform ...................t� tlC,,,,,, , wiring in the building of ..................., at ................./.' ...... Y U........?6...........................•, North Andover, Mass. J Fee.S... S .... '.%...... Lic. No. ! t—l�'1� 6 ii �..!�...... �1 �C,ECTRICAL SPECTOR Check # 3 49'?"D R,,,k , S/-, , /-/ y 0, rtas o-tr � - 2- -)- / 4 PIL", IN C ommonwea& ol'Namaclu, Ib Official Use Only aUeParbwnt o f -7ire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS [Rev. Occupancy and Fee Checked 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: a :2// City or Town - of:,� To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) % 9 VOOI46 ep Owner or Tenant /44Q,� 4 1-12- ly 46eFL Telephone No. Owner's Address Is this permit in conjunction with a building permit? , Yes i9l No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A,1 /k;Z1y No. of Meters No. of Meters Comoletion ofthe following tahle may he wniwed by the Inenertnr of Wire -c No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above 1:1In- ❑ rnd. rnd. o. o Emergency Lighting BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMSNo. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number _ . ._ _._.._ Tons __.--------_-_- KW ------._....----- No. o elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [I Connection E] Omer Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 4S5,6tC /�•ctc2 �><iifrtMc�si Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this app tion ' true and complete FIRM NAME: DAV l p E LIF & T R I GA i._. GUN TR AC i LIC. NO.: Licensee: D A\1 i 17 1446?6 t4 Signature _ IC. NO.:! 11 Cj b 3 (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No -9 78 -- Address: r 7 13� 1.. M ON 7` 67- iyRM 4Npvy i2 h"r o Alt. Tel. No.•q I6 --375 - r-y3q *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. 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 a ent. Owner/Agent Signature Telephone No.PERMIT FEE: $ 0 The Commonwealth of Massachusetts" Department oflndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST City/State/Zip: NORTH ANDOVER, MA 01845 Phone #: 978-682-6262 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 8 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]** 4. ❑, We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail. 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11.❑ Health Care 12. other ELECTRICAL CONTACTING *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy # or Self -ins. Lic. # 9353694 Expiration Date: MARCH 1, 2015 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 Inyestigations of the DIA for insVw*e coverage verification. I do hereby certify, under th ai a p rls of perjury that the information provided above is true and correct. Phone #: 1 % G�z � 7./ Z— Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: www.mass.gov/dia Phone #• This certifies that ......... P. PkA r. . .44.d . ........ has permission to perform..�. i ................. plumbing in the buildings of .. ...U:...p...... • ............. 3 at . � C1... ........ • . • ... , North Andover, Mass. Fee.. _.... Lic. No.�.. .. . I45-7� PLUMBING INSPECTOR Check # 61 v� � - �4 vy�- -)I3o1I3 Q MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# (��� JOBSITE ADDRESS /1�//�//(?_!��!—� OWNER'S NAME POWNER ADDRESS (,/1 �r fZ 1 TEL jy �_yFAX_- TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: 211 PLANS SUBMITTED: YES NOF( FIXTURES Z FLOOR- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ._.__I I ___I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEMI I DEDICATED GREASE SYSTEM __I DEDICATED GRAY WATER SYSTEM I I I {-_._._. I _... .__f i I _.._._ J .__...._I I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER �! _ _.-._I f ► l ......___I _.-__-_i .-_-.._.._( _____.. -..-..._J __.__.I ..-._.__.__.l .___-._ __.__-( .. _....I _ _I ___ _....) FLOOR/AREA DRAIN n_I _...__..._.1 _..__I INTERCEPTOR (INTERIOR) R _..._i _-___--._f_.._..__ KITCHEN SINK _ l _ ---_-__.f ! ___--� i _.__. J { --.- -__1 I _.___..._! _ ........... l —__f LAVATORY ! .._._._..-.-1 ._ ..._.._( -__._..1 _.__.__-} ... _.... l ROOF DRAIN SHOWER STALL —JSERVICE / MOP SINK (__. 1 ( i P ! _ ._._._l ..._._.._f I __....__s _ _I I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _..I OTHER __j i _! INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, YES NO - OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY [711 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT _I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and c rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEj LICENSE # ! SIGNATURE „/ _ , , MP d JP P CORPORATIONFA #=PARTNERSHIP D#= ? LLC i COMPANY NAMEe-1 /J��,�.y �r/6 ADDRESS CITY 1`.CYV, �- ...............I STATE �ZIP G�/ �, j TEL % l - FA/X �/�°'1?I EMAIL %�C�f� / ii .. � � CELL —� � �. �.�� c.../C � T _ . --... _. _ _._ o o z y ❑d W IL 40> w LU The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ml n print Y .Pulhl, Name (Business/Organization/Individual): —,I'P C Address: �� n City/State/Zip:, %/CcNya W e1SYY Phone #: 14"V -XI" Are you an employer? Check the appropriate box: 4. ❑ I am a general contractor and I 1. ❑ I am a employer with mployees (full and/or part-time).* have Hired the sub -contractors 2, '1 am a sole proprietor or partner- listed on the attached sheet.These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. 5. ❑ We are a c6rporation and its [No workers' comp. insurance officers have exercised their required.] 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 employees. [No workers' insurance required.] i comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ['emodeling 8. ❑ Demolition 9. [-]Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date'. Job Site Address: City/StatelZip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage a equiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a of a fine up to $1,500.00 and/o/one"year e violator.s Be advised that a copy of this statement nt, as well as civil penalties in the a be forwaP. rded dedoo the ORK �ffiEe of d a fine of up to $250.00 a day a a th Investigations of the D r insurance coverage verification. I do hereby thepains and penalties of perjury that the information provided above i tru and correct. Phone # Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person; Phone 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 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 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. 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 ofMassachusefts Department of Industrial .Accidents Offiioe of Investigations 600 Washington Street Boston., NIA. 02111 Tel, # 617-727-4.900 ext 406 or 1-8.77:MASSAFB Revised 5-26-05 Fax # 617-727-7749 WW-mass,govfdia COMMONWEALTH 0:F M1fiSSACHUS� TTS iR l LICENSED AS A MASTERI PLUMBER i ISSUES THE ABOVE LICENSE TO: StT,=VEN !' CARR €. 12 CONCORD ST < L f :METONEN NA 01844-14:C. ]:366 05/01/14 164478 Date ...... 7:....3.. /—... �3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / ...........................1-^............................................... has permission to perform ...............-�' ..................................................... wiring in the building of ............... 8�C ........................................................................................ at .....�..... E...V x'1..1.1 eV.��....North Andover, Mass. Fee . .... Lic. No. r-- EL CTRICAL INSPECTOR Check # Z -Q t175b M �Oa� �aav a officiat use only FermiiNo. L BOARD OF FIRE PREVEpMc)N REGULATIONS CWcupawy and Fee Checked (tet APPLICATION FOR PERMIT TO PERFORIN ELECOMnTRICAL WORK Ail, tobuis �dw tcode (PL UwPR8&-W�OJtMEAUWFORWTj0 �? CM jz� Gity or Tows oe .� Date.— $Y this applicatitmdzemad grm entice ofba or ?'a rhelnsp�ctor of FPtt�r: �' to pima the oiectrieai wtxic dcscnbed brow. Location (Street do Number)--tt-a� OwnerorTenant Owner's Address Tetephoee No. is ti& permit in eonjaatlim mlffi a buWft panYes purpose of Balubg 0- No ❑ ( e* Apprepriatt: Itox) Uiiiity AutharhaUon M. Bing Service Amps ! Wits Overhead uodgrd ❑ No, ofMeters N� S�e 1. -AMP -AMP I Yoits Number of Feeders and Ampaeity Overhead ❑ undgra ❑ fto. of Meters Location and Nature of Praposed Electrical Work: r—,,.. _ _ ..5_ . _ 'A _ . ofRecessed Luvahmim No. ofQ!L-Susl► (Pad1110 Fms table be xgivadArthehopwaro 3�rret - o. of T %umiuOutletsOutletsormers ana /NO. ofnot Tubs TransfOf XVA Gemeratom KVA of Luminaires Fao! p e. of Recepba k ounds / o. of on Bnr"m ALARMS Na of Zones of Switches .3 Na, of Gas Bwam o. am of RangesDear _ ofAirCmtd. Tom m NaofAhwfmg Dvrim of Waste mposces m' Totata: of Dimers - Area Heating ger Devises D ©tom of Dryers r $Appliances o ateri{W Heaters o. of o. Ballasts No. of or ent Data WhI ag: laydrOIR2sSagellatidubs No of motors Total HP Nm of Devices or t I -. __ - ns Edwated Valu: of Eleckr at Work •- S wsaraaaa Guam9� orasr by the taspectarof F_r wb& to Start: �ud by mmucgW Polley) darts to bcicq=W in jwi& MEC jb& Ig, and upon comp etion. i1NSDRANOC'UYi#SAGM UM10S;vdw4byftomw: � permit fm the p ofetegricai vroric may issue wiles tate lit proyidas pnaofof ► kcluating a •, Or its sabstant+al Ott. t�atsm a cavetsge is is fang and Iasi p���lb &pmt issuing oEfiee. i7ie CHECK UNE: I1vSUI(ANCE �{ BOND [] Qi�R p ESpe�) I M10, corder fire pahzr andpenahft ofpliuy, a ar}arnmfirm art fkii is free acrd aatngrte ft FdRM NAME: t7�1 t i7 cL r %T`,�' C�}L C.�tiT' .}Z til ifs : ' LIC. NO t,ICeBSee: (�il4t%' E%!lb(a _ — llrapplaaW ewe► eaA+�t"ur lf�e%+erts£ ime c - G NQ•� f i 1j& 3 Address:�jl, �$�.Tei.iliso.�`ll *Per M-G.L er I47, s.57-61, secaft�c tofPobfic Alt: TeL No.: 16 7 3 -.:5-73 f OWNSR'S Il1TSiJItANt WAIIM- I am sumsUQ that (fie does rrrdkm the m • BYMysigaambgow, l hxbgwaiee hs f amthAgente{ p'&y� po829L Sipaturi TelephoneNo. P�FEE: `a The Commonwealth of Afazachusd& Print Form Dgptfinent of1ff&0M&.4cefifin& Of x t0fbM*&*nr 1 Congress siiree ,�aitelDll t== 1-7 Boston 1Y1A 02-1.1¢20.17 wWw NMU4W/W7ff Workers' Compensation Insurance Affidavit: Bugden/Con#aradors/FIedriciaus&b tubers nlicant Information Please Print Lm7bk Name (Business/C Mm&afl fi dMd.0: DAVID ELECTRICAL CON RACE NG LLC Address. 87 BR M014T ST NORTH ANDOVEK MA- 0184.5 Phone #- 978-882-6262 Arra am employer? Check tlieappropriate bate 1.21 I am aemployeawith 7 4� 0 I am ageneral contractor and I empkWcw (fid and/or part -ti m)_# . have hired the subixonactors 20 iaraaS0%pTgNiftrorparbW- shiipand have no employees wortamg for mein myc4mcilcy_ tmo wodawe comp 3. ❑ I amuohonaeownwdvmg an work nWsei£ [No mod me comp hmnance requred.] T fisted onftaftched sib These sub-cxmhactors have employees and have workere comp_ ce-'. 5. 0 Vle area cmpora#ion and its oven; have exercised their right oi: eacemption Per MGL c-152, §1(4), and we bave no employees- [No wwk ae Type of project (requiraW 6. C3 New cooftuciion 7. ❑ RemodeEmg 8_ [l Demolition 9 ❑ BuRdmgadditian 10-0 EiectEicairepairs oraddi ions I1.0 Pk mbmg'WHRs or additions 12.0 Roofmp*s 13 -fl Other--- - *Any WlicantdWd=ksbm-91mustatsofill"theswuonbelowshmmthewwodm&�Tnlm,irdacmauor J HomwWUMwho subtttitthisaffidavit iFM Ig &W am doingall lana thm hire oulsidecor&actm mustSub=anew affWavit ucdiratine soca 'Conka0b= that dm* this baunistaUacbed an additiond shmtsbawiag&emameofthe and stM'Vvhcd=ror int &ose eshave MW*ees- ifdt--SWX=tracwmh—employeMtkymu puvdethw waskets' comp- Policy mnnber. i con a Toyer thaiispsnridmgworkers' comm bLuamre formy employees. Belowis the in�oain� pnGcy mrdlrrbszte lusur'ance Company Name: THE HARTFORD Policy # or Self -ins. Lie.#: UU WEC 018293 Expiration Date: MARCH 1, 201* Job SiteAdaress: Z I AAL4 A city/staftaip: )(L 4t -,,c 01fel Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration daft). Failure to secure coverage as required under Section 25A of MGL e.152 cart lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year hWr'wnment, as well as civil Penalties in the feral of a STOP WORK ORDER and a fine of up to $250.00 a day against a violator. Be advised that a copy of ft sWement Investigations_of tate DIA verification- Ido erification_ ' be forwarded to the Office of I do he�ebycer8. fy of t&�ihe " or�onpab9ve is brae quad caorrecL Phone#- WU-bUZ-6262 Fcsal ust onik Dao nOiWrifein db �q IV hCe v by cs€y or#oavra q@FdaL City erTewn: bsuingAnthm* {cane en* Permit cense # Ila" 6. Otherof Heabb 2. BtnWmgDqmtneat 3 CiLyfrown Clerk 4 Elertnc-i h-VeCIM' 5- Plmnbing Iuspertor CoatactPersen: Picone #: .� I : .0' N2 I Date................................. (0' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that./% 0111:• Use 0 Permit No. y4 1 , �l�e C�ommonwe�lt� of �ttt���chu�ett8 11tptlrtment of Vublic lhifttg Occupancy b Fee Check 9190 peeve blank) BOARD OF FIRS PREVENTION REGULATIONS 527 CMR 12.'00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date . 10/8199 City or Town of NORTH ANDOVER To the inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 19 YOUNG ROAD O r or Tenant T.ORRAINE KANELOS kelt• (978) 685-9399 Owner's Address Is this permit in conjunction with at building permit: Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _J _volts Overhead ❑ Undgmd ❑ No. of Meters Now Service _ Amps _J Volts Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Ttformers Total ans KVA No. of Lighting FixturesAbove In - Swimming Pool gmd. ❑ gmd. ❑ Oeneratoa . KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Somers fiery Units No. of Switch Outtilts No. of Gas Sumer$ FIRE ALARMS No. of Zones Tow No. of Detection and No. of Ranges Cond. No. of Air Con tons Initiating Devices . ' No. of Olaposats Heat Total No.a Pumps Tons Tbtal KW No. a Sounding Devices . No. of soft Convened No. a Dishwashers Heating KW OetsctionlSounding Devices No. of Dryers Heating DrAoss KW Munici Local ❑ Connection ❑ Other No. of No. of �n�TURGLAR MARM No. of Water Heaters KW Sign Ballasts No. Hydro Massage Tube No. of Motors Tbtal HP f OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws 1 have a current Liability Insurance Policy Including Completed Operations Coverage or Its substantial equNralen4 YES G NO O I have submitted valid proof of acme to the Office. YES O NO O It you have checked YES, please Indicate the type of coverage by checking the appropriate box. INSURANCE Q BOND. O OTHER O (Please SP*dM (Expiration Date) Estimated Value of E�y�lcal Wbrk s 124.00 10/1/99 Final 10/5/99 Work to Start Inspection Date Requested: Rough Signed under the Penalties Of penury: 1731G, FIRM NAME LIC. NO. Llceneee 11nnal d A Arnnlrn Signature LIC. NO.. 123= Sus. Tel. No. (2r0�) 741-4008 Address 111 Morse Street.Norwood,MA - Alt• •til. No. OWNER'S INSURANCE WAIVER. I am ewer* that the Licensee 00@4 not hive Insurance coverage or Its substantial equivalent as rem qulred by Massachusetts General Laws. and that my signature on thio perrnit application waives this r*qulrement. Owner Ag!nt (Please chock one) 35.00 (Signature of Ownor or X96110 Telephone No. PERMIT FEE i ti.gSA'f Date. y. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. .. °.-'1"'..:.. �-�-7• .......... . has permission to perform .......... • . plumbing in the buildings of ................ at !. i..... .... �� " , North Andover, Mass. ( Fee./6 . i .... Lic. No.'�.` ...... ...%- R`::`�r..� M8 / PLU1 G INSPECTOR Check # 5214 t. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) �- NORTH ANDOVER, MASSACHUSETTS Date Building Location 0 P Uf1S R.0 Owners Name long+*A, -r 1-14,0/e 1v.S Permit # 2 Amount ,(5—`p Type of Occupancy /J iv e f/i',vr, New ❑ Renovation Replacement Plans Submitted Yes 11No Im FIXTURES (Print or type) Check one: Installing Company Name �/�}//�,� ,9� /�Lyrr► %T i`vC/ ❑ Corp. Address �O �d� S�� ❑ Partner 92 ,�, 6 F5 9So y ❑ Firm/Co. Name of Licensed Plumber. Ti., 06, /yk-2 A/ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity ❑ Bond Certificate 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 in compliance with all pertinent provisions of the Massachusetts State nbing Code and Chapter 142 of the General Laws. (APPROVED (OFFICE USE ONLY Type of Plumbing License ay,e33' icense um er Master ❑ Joumeyman ,/ J9 2- ,— Date..................... TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION This certifies that ... `.:..... ... "....... '.`.... "........ . Chas permission for gas installation ..........'.:................ . in the buildings of....:.....:�tQ-'......................... . L � � at .! ... c ` `-^"'' .. ��.:.............. . North Andover, Mass. Fee.: ..r.... L c No.: .......... . GAS_INSPECTOR c Check # 4 ') 10 M %ACHUSErIS UNIFORMAPPLICATONFOR PERMTr TO DO GAS FrrDNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations yO(1AJ ! j 2 Q - Permit # �(,o Amount $ ° Loe.(i 4,w A-4AIelas Owner's Name New ❑ Renovation 11 Replacement El Plans Submitted (Print or type)O?�N � j�� �� �� Ch❑eck one: Certificate Installing Company Name G Address P D - 6 d Y— Ste% Partner. W2 e -/cc n'I O !Business Teep one f7 X 6;'S-y5;-,vY Firm/Co. Name of Licensed Plumber or Gas Fitter %wt k INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No If you have checked }_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity1:1 Bond13 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 Agent 13 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 in compliance with all pertinent provisions of the Massachusetts State Gas Code pd Chapter 142 of the General Laws. By: Title City/Town APPROVED (OMCE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber 1� zflr,?3 Gas Fitter License Number OMaster ® Journeyman a vl 0> w C x a o ww F Z F W UUG x z W W vF A a 0a A aO FO O SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6 T H. F L O O R 7TH. FLOOR STH. FLOOR (Print or type)O?�N � j�� �� �� Ch❑eck one: Certificate Installing Company Name G Address P D - 6 d Y— Ste% Partner. W2 e -/cc n'I O !Business Teep one f7 X 6;'S-y5;-,vY Firm/Co. Name of Licensed Plumber or Gas Fitter %wt k INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No If you have checked }_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity1:1 Bond13 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 Agent 13 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 in compliance with all pertinent provisions of the Massachusetts State Gas Code pd Chapter 142 of the General Laws. By: Title City/Town APPROVED (OMCE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber 1� zflr,?3 Gas Fitter License Number OMaster ® Journeyman Date.... j.io ,e °VO TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. __ ,�r.�1� J .. _ 1.�.1 J ,j has permission for gas installation.//f�llr/ in the buildings of at G���I� �?...... ....... North Andover, Mass, Fee.Lic. No..w�L�t.. .......................... It Check # l -J /-/—Al 5 015 GAS INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date Z 6 110V Permit #��� G MOM Building Location. i y r0 (A 0(-,T RD owner's Name kANELos L Type of Occupancy kt S 1 OC_ &J1 Jfi L New ❑ Renovation ❑ Replacete��r Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68.7-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have aYesrenat liability Insurancepolicy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X( Other type of Indemnity ❑ Bond ❑ 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 ❑ Signature of Owner or Owner's Agent hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and aocur to to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpiiance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ i BY Type of License: Plumber Signature of Lioemnse Plum r or Gas Title Gasfitter Master License Number City/Town Journeyman O IC S . ONL r - v Y • Y • mom NONE •• ■�������������������r�■ son moon Q. IRS Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68.7-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have aYesrenat liability Insurancepolicy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X( Other type of Indemnity ❑ Bond ❑ 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 ❑ Signature of Owner or Owner's Agent hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and aocur to to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpiiance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ i BY Type of License: Plumber Signature of Lioemnse Plum r or Gas Title Gasfitter Master License Number City/Town Journeyman O IC S . ONL r - Z ' O F v w a N _Z N N w cr n O CL n z• t- t - LL N Q J n x 0 O a N F a F- U- � 9L ¢ W w n z O 0.Q cc J O 0 0 U. n d 0 0 -' w w a Q m U }, � r a «s a a w � ul � X P. N� .. ..'ice •�.. . ,...lh- .t��-w` % t ♦. zI Q z. LL �a i 1 Location U ' No. 1-1`10 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ -f Check # �sf 6379 'i Building Inspeo& a - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING :4er (?isl _. Usie`Qul ... BUILDING PERMIT NUMBER: ��� DATE ISSUED: _� D Q SIGNATURE: Ilk Building Commissioner/I for uildiAgs Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel umber 1.3 Zoning Information: ' j a� U—I Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided 0 76-7 ,s 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for S rvice Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Ct I, K-i4L �M Licensed Construction Supervisor: i f��� w (�lJ�/U�� Address I t`r Signature ! Telephone Not Applicable ❑ License Number D2 J Q'IS Expiration Date 3.2 egistered Hom mpr _ enf Contractor Not Applicable ❑ Company Name Lq 1 W r i at' ^ ,> '1 Registration Number �y i�'` Expiration Date Address I_In Si ! Tele hone MU rn X Z O j� W SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506) 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 ..... K No ....... ❑ SECTION 5 Descri tion of Proposed Work(check all a licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: fEODW MOD 9POL DE9�:: ) a X ( PO C S avvve SL,? -e p�(6tn0A. w��� I`( Kac cDeCL<_ 80+- k A d\- -1-t!5' S h r t A) (L -i-00 Z�e A R C. _ �� c s� r w� r,A-) I \-( SECTION 6 - ESTIMATED CONSTRUCTION COSTS Itern 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 3 Plumbing Building Permit fee (a) X (b) 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 I, 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 OWNE IZED AGENT CLARATION as Ownqvgthorized A f 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 I XX 11 V IV Pri e b ...+0 SiaELure of O /erAijar Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1y� `D, FORM U - LOT 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION p *****r*^******** APPLICANT / o r I'� "e- (0#-40 0 S PHONE 9/2 f — (� d J " g 3 9 C/ LOCATION: Assessor's Map Number (0 PARCEL SUBDIVISION , n LOT (S) STREET 0 0 'V Co P,,,,JX71 ST. NUMBER / ************************************OFFICIAL USE ONLY******************************* ENDATIONS OF CONSERVATION COMME TOWN PLANNER i COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS AGENTS: TOR DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE_ Revised 9197 im MORTGAGE INSPECTION PLAN 5 PLAN 4 Bi SED ON A Twp gJ"=- N.r. � p 15 TO BE USED FOR F/OKTGK:1n pURppy6,S ONLY rnE fOFtE. T}rz OFF.�6Ts i s_SaA WIV SifGt1LO NOT BS U66 1 GSMLA PROPERTY LMIGS. .r.. C 5 5 E X COUNTY DEED REFERENCE: PLAN REFERENCE: v PLAN OF LAND PL NO. ;3jgM�15_ PIN 6K G PL_8KPL CERT. No. o B ._ NORTH ANDDVEP-1 i r,treny CerUty that the existing structures are located appruxirnately ea shown and 'ire nit in vlcdauon or the zoning by taws at the time of construction or are ei PREPARED FOR: `r Orn V+iiatiin onton ement action under, Chapter440A Section 7 of the Nil=. ie.a.Laws. The structures are located in Zone. C- ocording to the fufloMng E M to rrrdp. Note: Zone C represents arsaa of minkf>ei nodding. FLOOD HAZARD COMMUNITY NO 250096 BOUNDARY MAP NO EFFECTIVE LIL- �"a_ SCALE IN.=20 FEET BAILLIE & COMPANY LAND SURVEYING & RESEARCH 33 HOWARD STREET READING, MA. 01867 PHONE: (781) 844-2767 FAX: (781) 944-15112 _' U U i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: MekV - DQ &�j'ZWJU Cd t,)t(2�-Yi- S TIMJ Address . Ll City: Phone Company name: Address City: Phone #: ?:�-- F-? 01 )� U 1� —112 -- Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment.as_v&U-as_ciOl.penattiesin.2heinrmda-STOP WORK_ORDER.aad_a fine _of.($11i(?M)2-day against.me, I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under theAains and Signature. Print name WLI 1 of perjury that the information provided above is true and correct. Date�3 Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing El Building Dept EJ Check if immediate response is required 0 Licensing Board F-1 Selectman's Office Contact person: Phone #. ❑ Health Department Ej Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: -DOMP (Location of Facility) SigAeofrmitApplicant 1. Date NOTE: Demolition permit from the Town of !North Andover must be obtained for this project through. the Office of the Building Inspector 04/04/2003 09:43 6179238315 AA&K DBA Ea PO Box 2057 Woburn MA 018 Name I Address Lorraine Kamice 19 Young Rd. North Andover, MA 978-685-9399 CONSTRUCTION, INC. stern Construction 845 Phone g 781-938-5229 Fax # 781.938-5229 PAGE 02 Estimate Daft Fstlmate 9 4/2/2003 160 slanature * Maatoraerd and Vi gladly accepted *All roofmg enlinau arc based on rmmNing up to two(2) layers, unlcna xtatad otherwise o tm gout roof ie 'ng rvrerovod, ?tease reananbct to cover mod or move any valuables In your site Pape 1 Description Total I --Remove entire 1: ack porch (including steps, tailings, framing,ete...) 2—Dig now foto to deep holes as needed for new footings for new stairs, tailings, and deck 3 --Install new mu tubes in new holes 4 --Fill new Sona to with concrete (additional footings are to be installed as needed for support of a futarc ja ZU22i) ; 5 --Mata Il new re treated framing for riew stairs and new deck 6 --Install now prei ium treated floor joists for new deck 7—Install new stee hangeas on new floorjoists B --Install now ure treated stringers for new stairs 9 --hate it new pleaa treated posts as needed for new stairs, deck, and railings 10 --install new 1 x fir flooring on new f Dor joists 114natall new 1 x Fir flooring an new stringers 12 --Install new firing as needed for new tailings on new stairs and new dock 13–Install new squ re fir balusters on newrailing framing 14-4natell rtew cern ry form as needed for new oothorete bottom step 15—Fill new form concrete 16 -Remove tem Form 17 --Install new p e treated framing as rreedat for new lattice under new deck 18—Install new vi lattice on new lattice framing 19 --Install new . ad pine trim around new lattice as needed 20—install new fra ing as needed for new privacy lattice on right side of new deck 21 --install new lattice on new &amihtg 22—Install now dings around new privacy lattice u needed 23—Install now tae treated filming as needed for new seas on left side ofnexk dock. 244nstall new l x fir flooring.9n naw flaming for seats 25 --New seats atae be installed on boat sides of stairs for new deck Initial deposit due at lime gf contrnct signing. Thank YOU. Total slanature * Maatoraerd and Vi gladly accepted *All roofmg enlinau arc based on rmmNing up to two(2) layers, unlcna xtatad otherwise o tm gout roof ie 'ng rvrerovod, ?tease reananbct to cover mod or move any valuables In your site Pape 1 04/04/2003 09:43 6179238315 PAGE 03 • � r i `AA & K DBA Ea PO Box 2057 Woburn MA 018E NSTRUCTIONN, INC. n Construction Phon! * 781-938-5229 57 Fax# 781-938-5229 Name / Address Lamlipe Kanolaa 19 Young Rd. North Andover, MA 01845 978.685-9399 26. Apptox size of 27. -The steps for w the now seats being 2"ew stairs are be aMox 7 feet of 29—Remove all job 30—Eastern COMM at Signature _ • Maeu.'trsrd and Via *All roofing aatimata •VAM your rmf is b Estimate Date Estimate # 4/2/2003 160 Description Total w deck is 22 feet (along the house) by 14 feet (off the house) deck are to be built on the left side of tate deck and be =eased in the new deck with ilt on both sides of the new stairs_ w built in the middle of the left side of the dock. (the middle of the new stairs is to house) aced debris ion is responsible for all necessary permits 11,000.00 YOU- ) I Tia! $11,000.00 g1aNy aaceptod _ im aro bawd do �a a mncmbcr to covEr anup to twok2) d, r mow any ova bice in your attic ng n:rttbvod, p Page 2 t -r-r------r---F- I I I -Y - -t _....... -- I r - I I I I jH ICi? I f �- , i 1 I I- I ._-. � --- -.-F-+-F - --- � N Insurance Adjustment Service, Inc. 139 Billerica Road, Unit A-1 Chelmsford, MA 01.824 (978) 256-3334 Fax (978) 256-3354 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 313 Date: March 26, 2010 TO: Board of Health/Building Inspector RE: Insured: Lorraine Kanelos Property Address: 19 Young Rd. North Andover, MA Date of Loss: 3/13/2010 I TM OF N" ANtX APS , � ZQ1Q Policy Number: XM8752 Type of Loss: Wind and water damage to dwelling. File or Claim Number: 61359 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Tim Martino Adjuster x135 tmartino@insadjserv.com h 0O z e 1 1 �¢ d O w uo u $ w v cn a U) o w A W o w o a: v 'c U co w" 0 w o �L coa a w o a U w o w c� c w" x 0 z d C7 o r� cz c w z w A w CL w CQ z cn v Q o cn LLI am E� U co v E � CD i :m Z a (�►►��ti-�� O CO) C/) � I Cm CD y O =p cD C/) Z1. z 'E m m Q Q CL co � O .CD F� (/) w L '' z M O o. W 0 cv C/) ci W 'a o W W Z a y Q � C C C CA 0 a ui Q Cl) LLJ C/) CCW w w Lij Cn N o as c o � C N Cc O O A � C.3� o w am Nmc qb o r1�o� m I E a Q sCD O. OO 4� y E r o � s CM m c fti E � • CL y !p Cf�CD � mJ y c ? cc o _:• E m L- a� � S m : y m ; 0,6 '_= O � C" • y V:acc , m .%eA*eca C, y O '� Z o tipd C Q i ` m c m� 3 O = ~ m O �" N O y O H CL=C 30- o,y Z O V 23 O cm O m c C* G O -5 O = CA0 y •a O =tea. -m>0 E� U co v E � CD i :m Z a (�►►��ti-�� O CO) C/) � I Cm CD y O =p cD C/) Z1. z 'E m m Q Q CL co � O .CD F� (/) w L '' z M O o. W 0 cv C/) ci W 'a o W W Z a y Q � C C C CA 0 a ui Q Cl) LLJ C/) CCW w w Lij Cn N 06/14/2011 10:00 FAX 19787412012 HASERUICES Department of Public Health & Department of Labor NOTIFICATION OF DELEADING WORK `li ;+ �` lAll sections of this form must be completed in order to comply with %X �,the notification requirements of M.G.L. C.111§197, ' .b 454 CMR 22,00 and 105 CMR 460.000, as most recently amended Contractor performing project Christopher Zorzy License a DC000440 Exp, Date 04111/2012 Lead Paint Inspector Christopher Maraeic Date of inspection 03/2112011 License # NUR -2006 Exp, Date Street Address 19 Young'Road ` ___ Apt. Number Cit *-Northt` ndover,MA—__-� Zip 01$45 Property Owner Matthew Gabree Address 19 Young Road, North Andover, MA 01845 Telephone Number 646-239-0027 Deleading Method:j]✓ Wet/Dry Scraping ❑ Heat Gun []Liquid Enenpsulant ❑Deatolition ❑ Caustics Replacement ❑Covering 0 Other If "Other" selected, please explain Check one; Dwelling is multi -family Start Date 07/20/2011 Single-family Other = Completion Date 07/22/2011 When will work be done: AM X PM X (Specify times on site) Weekends? Project Supervisor Name Willie Woods License 0 DS003534 Exp. Dote 10-19-2011 Worker's Compensation Policy Number 0243MOl5UB Carrier Traveler's in case of emergency contact Christopher ZOrZy 1'el. #_9! 78 1 741-0424 (Contractor's Representative) 002/003 alt, The undersigned hereby states, under the pains and penalties of perjury, that he/she has rend and understood the Commonwealth of Massachusetts Delesding regulations, 454 CMR 22.00, and the Lead Poisoning Prevention and Control Regulations, 105 CMR 460.000, and that the information contained in this notification is true and cornctito the lyrist of his/her knowledge And belief. Company Name A&A Services, Inc. Address 115 North Street, Salem, MA 01970 Telephone plumber 978-741-0424 OVER -4 06/14/2011 10:00 FAX 18787412012 A&ASERVICES Page 2 of 2 2003/003 In accordance with Massachusetts General Laws C-111 §197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(s) of removal or covering of paint, plaster or other accessible materials containing dangerous levels of lead is to be provided and most be received by the Foliowing agencies, at least M (10 ) days prior to the beginning of deleading, NOTI'lt+XCATIONS MAY BE FAXED, 1. Department of Labor, Lead Program, Division of Occupationai Safety 19 Staniford Street, I">Floor, Boston, MA 02114 FAX; 617-626-6965 2. Director, Childhood Lead Poisoning Prevention Program Department of Public Health, Oonovittl Healtb Building, 5 )[ mdolph Street, Canton, MA 02021 FAX: 781-774-6700 3. Occupants of dwelling unit 4. All other occupants of the residential premises, if any S. Local Board of Health/Code Enforcement Agency 6. Massachusetts Historical Commission (if promises are listed on the State Register of Historic 220 Morrissey Blvd. Places, this notification must be made upon receipt of an Boston, MA 02202 Order to Correct Violations or at least 30 days prior to FAX (617) 727-5128 Initiating preventive deleading) NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED - INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT. (If owner or unlicensed owner's agent will be performing low-risk deleading work, complete the following); Property Owner Agent(s) Address Telephone Number C___j - I certify that I have complied with the training requirements of the Cemmonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations. 105 CMR 460.175, for owner/agent low-risk abatement and containment. I further certify that I or my agent will be performing the following low-risk activities (I have circled all that apply): applying liquid eneapsulant capping baseboards removing doors, cabinet doors, shutters applying exterior vinyl siding covering surfaces I certify that all the information contained in this notification is true and correct to the best of my knowledge and belief. Date Signed Revised 1212007