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Miscellaneous - 20 JOHNSON CIRCLE 4/30/2018
r 1 a J 100 Date .................................. INV NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACHUs� Thiscertifies that...................................................................../f................ . has permission to perforM,�*11 ..............................` ......••• wiring in the building of � .:..... f _L -41r".. ............................... at . c F...........!•�,�.° `- "... � ................... . North Andover, Mass. Fee..!_' ................ Lic. No, .37 '............ ................................................ ELEcmicAL MpEcm C� toy c 05/07 08:44 50.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 04e (ffvtnmvnwra1t4 of Maiwar4uoetto Office Use I nl Department of Public Safety Permit No. _ —3 Department BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 = Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 n (PLEASE PRINT IN INK OR TYPE L INFO ATION) Date City or Town of To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described beow. Location (Street & Number) s) U visciv Owner or Tenant Owner's Address b ��✓l Is this permit in conjunction with a buildin permit: Yes No ❑ (Check Appropriate Box) Purpose of Building eJYr Utility Authorization No. EXI_tino , _ .,p_ �Vo:ii; v.e.'ead 7 . ndgrG U� No. Ut IvieCer�, New Service Amps / _ Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Iq Location and Nature of Proposed Electrical Work fPCt�/%/%�J Ge / t�i�/C�f /yi i OTHER: INSURANCE COVERAGE: Pursuant the requirements of Massachusttes General Laws have a current Liability Insur e Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES NO ❑ If you have checked YE please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER❑ (Please Specify) ���/ _,7 t:�2 (Fxotratton Date) Estimated Value of Electrical Work $ Work to Start _ Signed under the FIRM NAME, Licensee Address 573 Ities of perj Inspection Date Requested Rough Fr(ial LIC. NO. 4 LIC. NO. 22 Bus. Tel. No. �SJ✓��� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.. Owner Agent (Please check one) Telephone No._ PERMIT FEE $ (Signature of Owner or Agent) a'f TOTAL No. of Lighting_Outlets No. of Hot Tubs No. of Transformers KVA A oveIn- No. of Lighting Fixtures Swimming Pool grnd. ❑ rnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. Heat Total Total No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices of Dish was lers Space/Area Heatin KW Municipal Local ❑ Connection ❑ Other .N1c,. No. of Dryers Heating Devices KW No. ot No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant the requirements of Massachusttes General Laws have a current Liability Insur e Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES NO ❑ If you have checked YE please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER❑ (Please Specify) ���/ _,7 t:�2 (Fxotratton Date) Estimated Value of Electrical Work $ Work to Start _ Signed under the FIRM NAME, Licensee Address 573 Ities of perj Inspection Date Requested Rough Fr(ial LIC. NO. 4 LIC. NO. 22 Bus. Tel. No. �SJ✓��� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.. Owner Agent (Please check one) Telephone No._ PERMIT FEE $ (Signature of Owner or Agent) a'f i Location �d 11 a W Cl J No. t _ Date 3,30-0)— TOWN '30-0j_.._ Check # l76 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: �,5 171 / DATE ISSUED: 3 SIGNATURE: Building CommissiZer—AgWtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: �y Lb o ffNS0 L2 1.2 Assessors Map and Parcel Number: ? �, SY- Map NumberParcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RcqLiired Provide Required Provided Reqaired Provided 1 1.7 Water Supply M.G.L.C.Q. 34) 1.3. Flood Zone Information: Public 0 Private 0 Zoae Outside Flood Zane 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSE[IP/AUTHORIZEDAGENT 1`'tr!Ct: Yee r,lp 2.1 Owner of Record _ Q `�_ G oiU b ��II �P� VC%tf Al C?Aj Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: ,-T�/,/ q 1—/,q -s ���id ./ 2 14S1,Lf)1k 6A rI./ Licensed Construction Supervisor: �3 3 11, ..A'061D �G� Address Sil(nafure v Telephone � J 7f - Not Applicable ❑ L. License Number 7 - /Date Expiration 3.2 Registered Home Improvement Contractor �� x(17 S ��L 1 GAJ:- IA-1�- a Tlpany Name /��� � •,<�-E'i� d�l/�Cr� �7 ? �JQ �! Not Applicable ❑ Registration Number -5C/,o -D Address Expiration Date Signature r Telephone SECTION 4 - WORKERS COMPENSATION (KG.L C 152 6 25cf6) 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 buildinig permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTIONS Description of Proposed Work check ss a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) (� Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OMCIAL USE ONLY ., I. 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 L as Owner/Authorized Agent of subject property Hereby authorize i��1 (�'� 7 �� C to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are Lrue and accurate, to the best of my knowledge and belief Print Name Si ture of Owner/Agent pate NO. OF STORIES 2 - SIZE BASEMENT OR SLAF3 SIZE OF FLOOR TIMBERS 1 sr 2 NU 3KD SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHI1kANEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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: (Location of Facility) signature of Pe it Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invats ggkns Boston, Mass. 02111 Waiters' C r penwUw Insurance Atiidavl Please Print Qft �� � IVA- Phone s 1 2 S- -6 C, DI am a homeowner perfomling all work myW. I am a sob proprietor and have no one working in any cape* i am an employer p vAdng workers' compensation for rry employees working on this job. Faiken to s=n eaverspe as re** -ed undo► Sedco 25A orMOL 152 can Iced Eo the knpaNbn d ak.ik pwmW= d,a fkw up to $1,500.00 andfar ane ymw imprbarrneet_an neal_•_cb&4=mbnlo fbeh= dA STAP VYOMDRDERmdA flew d.($1m.0q -mA" mgWW ma I understand that ■ copy of thla dd ment may be forwwdW to dw Office d InveNgedm d the DIA for covwW vw tcelon. l db hereby cw* under ft Pelnb end Pene<fke d ury dint -the kft" dm pour dbd &hove /s bun and coi Rten9turs � _ ` D Print name �J G F/iL ��Phone it 7J- official use only do not write in this area to be co MWAd by dty or town affidat' My or Town 0 Building DOW []Check F immedlele rosponae Is r@Pk dLtermft Board p selectman's Me contact Person: Phone 0 Health Department 0 Other 03/ /zoll1V .) Ii; t rns o©aai 00-6.98 P OIVIALLEY , Ilk, e 59" FINISHED DIM 27 3/4" CENTERLINE 1„ f OF RAIL 4 1/2" x 1/2" N I RUN CLR 3" MAX �-- 5" MAX ;o 2 4 1/4" s 4 n 11• m V Nto U I Oa g 04 53 1/2" CAB I 48" CLR _PAGE 03 I HAN DRAT L iv � SIDE cn Z a U s RECESSED PHONE BOX i NOTES: 1) DIMENSIONS ARE FOR I_EVEiF S CAB. 2) SHOW LOCATIONS OF C.O.Pd, HANDRAIL do ACCESSORIES IF DIFFERENT THAN SHOWN. 3) '—DIMENSION IS FOR CENTI RLINE OF STANDARD 36" DOOR. FOA OTHER SIZE, CONSULT FACTOR`. K-4/02/21105 07:50 5037983045 03/28/2003 17:Z0 FAX 3099238544 NrUv 0 RAIL SEE WALL X12 1/2" P OMALLEV RAILS NOTE (2) 12 1/2 1/2.' 0 I I I 4» D.s.G roL__28" __— R 1 R2 RAIL REACTIONS QY CgEACiLY (PER RAIL) 750# 950# Rt = 150 R1 = 175 R2 = 400 R2 = 450 PAGE 04 %w'_. " -. SEE NOTE (1) SEE NOTE (3) PROVIDE ADEQUAI t WALL SUPPORTS FOR T—RAIL, FASTENINGS. VERTICAL INTERVALS NOT TO EXCEED 10'0" (SECTION A—A). COMPLY TO ALL PERTINENT BUILDING CODES FOR HOISTWAY CONSTRUCTION AND FIRE RATING. HOISTWAY TO BE VERTICAL WITHIN 1/8" THROUGHOUT ENTIRE HEIGHT. RAIL BRACKET FRONT 22" 28" 32„ 34" NOTES: (1) TWO 2X 10'9 LAMINATED, SUPPORTED AND FASTENED BETWEEN TWO 20's RECESSED IN HOISTWAY WALL BEHIND THE SHEETROCK, (2) RAIL CENTERLINE CAN RE LOCATED ON THE HOISTWAY OVERYIEW DRAWING. sPEDESTAL CUP AND/OR DEAD END HrrCH MAY NOT BE ON ALL ( M pELS. SUGGESTED SACKING SHOWN ABOVE TO ANCHOR ELEVATOR RAIL BRACKETS. SHEET ROCK PEDESTAL BASE 03/02{2005 07:50 5087983048 ' 03/28%2005 1T:2.1 FAX 3099259344 *-DEALER IS RESPONSIBLE FOR INSURING THAT THE MACHINE SPACE LAYOUT AND THE MACHINE LOCATION MEET CODE REQUIREMENTS IMPOSED BY LOCAL AUTHORITY HAVING JURISDICTION" 7 1/2 MAIN UNE DISCONNECT & CAB UCHnNG mroNNECTS LIGHT SWITCH & RECEPTACLE P O9ALLE`r NWOV 48 _ - CONTROL BOX r -- SEE NOTE 2 1 111 4— L 9 WER UNIT CHT MIN. CLEAR SELF CLOSING, SELF LOCKING, ACCESS DOOR NOTES: 1) LOCAL, STATE, & NATIONAL. CODES MUST ALWAYS BE FOLLOWED 2) 3'-0 MINIMUM CLEARANCE IN FRONT OF THE CONTROL PANEL REQUIRED BY N.E.C. 3) DISCONNECT SWITCHES AND LIGHT SWITCH TO BE LOCA ED ON THE STRIKE SIDE OF THE MACHINE ROOM DOOR. 4) MAIN LINE DISCONNECT TO BE FUSED AND CAPABLE OF BEING LOCKEL IN THE OPEN POSITION, 5) CAB LIGHT DISCONNECT TO BE CAPABLE OF BEING LOCKED IN THE OPEN POSITION AND HAVING OVERCURRENT PROTECTION MEANS IN THE MACHINE ROOM, 5) THE PUMP UNIT SHOULD NOT BE OVER 40' AWAY FROM THE CYLINDER. PAGE 05 n **MAIN LINE DISCONNECT 8t CAB LIGHT DISCONNECT BY OTHERS" MANIN Udg DISCONNECI 3 POLES (1 FOR BATTERY LOWERING) AS. Ll xr 011.E MAIN Co TIROL B4X 24"H X 24"W X 8"R 35"H X 241"W X 12i"b NONE 1'3728 05 DHS 66 1 41- PHYSIOLIFT SHMEEN RESiOENCE 03/02/2005 0x:50 5087983048 03/2A,'200S 17:22 FAX 3098239544 I..---- 44 FRAME WIDTH �------� P OMALLEV ELEVATION 44r -- -- UFT 51pE To n a) PAGE 06 Uff SIDE w 1/2' SECTION A -A L V2* T 1 16/16 J 2 SECTION B --B CDP1000 DOOR PACKAGE 1- FIRE RATED DOOR 1 i/2 HR B LABEL 2-- FIRE RATED FRAME 3- ADJUSTABLE DELAY ACTION DOOR CLOSURE 4- GAL TYPE "N" INTERLOCK DHP100 5- GUMMY HANDLE OUTSIDE: W/BLANK PLATE INSIDE 5 t,Jrr HINGING OPTIONAL, ALL DIMENSIONS ARE NOMI E 1 s: c o •� m c C h O C O X11 - C.3 C3 'd,C7 d c A O �'6 •' E a me m D o qw: E c c � Woke.p i coo� c m c mN zZ H a:�3 .• c� C o A y �7; y� � ft J=2 C W _O N E .100 � mo sp acs CD • Ao s ==�CD ..r •. c p) c � c m �� 12 o cm�coc.o Qc m a- O C O = m m A O COD Z W O w' Z S vi CL c Z r o C.3 a ID g = .0 w �= F- t $ CZt.. m > M, R 42 v Pir Qr 5 C C O•— N� O V� O 'E m m CL C L m O d cmQ o C = -9O .0 12CL 0 O C z m 0 CL C.3 CIO O C C C C403 U) 19 W W 19 W U) o a a w H w w w w a �° w a a°' w ao cn o cn c o •� m c C h O C O X11 - C.3 C3 'd,C7 d c A O �'6 •' E a me m D o qw: E c c � Woke.p i coo� c m c mN zZ H a:�3 .• c� C o A y �7; y� � ft J=2 C W _O N E .100 � mo sp acs CD • Ao s ==�CD ..r •. c p) c � c m �� 12 o cm�coc.o Qc m a- O C O = m m A O COD Z W O w' Z S vi CL c Z r o C.3 a ID g = .0 w �= F- t $ CZt.. m > M, R 42 v Pir Qr 5 C C O•— N� O V� O 'E m m CL C L m O d cmQ o C = -9O .0 12CL 0 O C z m 0 CL C.3 CIO O C C C C403 U) 19 W W 19 W U) Location ' No. Date VA NORTN TOWN OF NORTH ANDOVER 10- � 9 Certificate of Occupancy $ ;�s ",••° • E<�' Building/Frame Permit Fee $ SCMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /a Check # 19 / .�- // —Building Inspect r ' 4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING 'I; e BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date —dtS SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: t-- z -C3 5 G� w ®rV C t YZ �---d 0 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'redProvided Re aired4 Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 Public ❑ Private 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT lis tur ic District: es O 2.1 Owner of Record boNc,�-t� S R�erN ,� 3ol y,, ow Ciade ti 4,-d cf'll t/" Name (Print) Address for Service %J Signa re7 S'3 Telephone ��5 2.2 Owner of Record: `Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ G-Gg-krio P c,+o vgvo Licensed Construction Supervisor. License Number Address � J�sna^f' `� Ci-7'00 1p"DSa ! �} �j Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone ou rn X Z O v rn O z rn 90 0 mn r v rn r _r Z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building rmit. Si ned affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check altapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: wo OrL G U .V t te 'C (00 t ti �� S , L ipP� t;fi-c)M. Ao0L 01 -c'005 'e y SRC'.TION 6 - F1.QT1MAT1P1N d"nNC'PU7T!'^rir►1wT i.�c..n.. Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by peniiit applicant - 1. Building a Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X ttl 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 l d v Check Number CF(`TrnN 7a nW?"ID A7TmrtA ■ ♦ I-- ----. ._ - .._.-.__.-.... ._a A ui, a.vPiCLL` Ir" WJILI'4 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT s Owner Authorized Agent of subject property Her y authorize 2liq wV 4 P�,Q w o to act on M be lf, in all a ers; ti w authorized by this building permit application. /v �2 — 0 S^ signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 11 as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/. Date t-. NO. OF STORIES SIZE BASEMENT OR SLAB t SIZE OF FLOOR TMERS 1 2 RD3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 at:,AD 4 N 5p v Ci -e 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Ovn�4� TP,vC, (AT I -L- d -S wr4 le k/oo 6 A I e 3 S c e rn Al, (Location of Facility) Fire Department Sign off AA Dumpster Permit o Signature o Permit Applicant Date OP IDC DATE (MM/DD/YYYY) AGORD CERTIFICATE OF LIABILITY INSURANCE CAPUA-2 03/10/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIOK ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Landmark - Insurance Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 398 Massachusetts Avenue North Andover MA 01845-4190 Phone:978-688-8829 Fax:978-975-3987 INSURED Capuano & Capuano Masonry Inc. 1 Silesia Court Lawrence MA 01841 COVERAGES INSURERS AFFORDING COVERAGE NAIC # INSURER A: Granite State Ins Co 23809 INSURER B: Preferred Mutual Insurance Co. 15024 INSURER C: INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING I ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH onl ICIFs nrr.PFrATF LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIV DATE MMIDD/YY POLICY EXPIRATION DATE MM/DDIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 PREMISES (Ea occurence) $ 50000 B X COMMERCIAL GENERAL LIABILITY CPP0110569674 MED EXP (Any one person) $ CLAIMS MADE X] OCCUR PERSONAL 8, ADV INJURY $ 500000 Business Owners 09/09/04 09/09/05 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2000000 POLICY PECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO _ BODILY INJURY $ ALL OWNED AUTOS (Per person) SCHEDULED AUTOS BODILY INJURY $ HIRED AUTOS (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR F-1 CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND TORY LIMITS ER E.L. EACH ACCIDENT $ A EMPLOYERS' LIABILITY ***SEE BELOW ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ If yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ***Workers' Compensation Certificate has been ordered and will be sent to you directly by Granite State Insurance Company. CERTIFICATE HOLDER I.AIVI.tLLAI1UIV Town of North Andover Department of Public Works 384 Osgood Street North Andover MA 01845 ACORD NORTH13 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Jul -20-05 05:38pIr, Fran -.41C (mark fns Agency Inc Massachusetts Avenue h Ardover, MA 01845 C puano & Capusno Masonry Inc. j 1 Fillbsia Court i L nce, MA 01841-0040 V$-318-6903 1' -BBI P.002/002 F-332 ,,,II,, J. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW COMPANY A GRANITE STATE INSURANCE COMPANY IS TO CERTIFY T'MAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR® NAMED ABOVE FOR POLICY PERIOD INDICATED, NOT WITHSTANDING ANY RBCUIREMENT, TERM OR CONDITION OF ANY C0,14TRAC7 OR OTHER UMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED THE CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE- TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN HAVE BEEN REDUCED BY PAID CLAIMS. LIABlUlY MA OPMOa OAT. C RTIFICATE HOLDER INER HEALTH i 48 JACKSON STREIrT M HLIEN. MA 018" 3MOULD ANY OP THE ABOVE O WCRIoED ?OL=ES BE CANCRLW BEPORR THE WRI,TM OATR TMEREpF, THE =VtNG COMPANYWtL EMMAYON TO NAIL to DAYS WAMN NOMCGIO THE MTIFIGIe MOLOER NAMED TO THE LEfT, BUT FAILURE TO MAIL SUCH NOTICE $WILL IIAM NO OOLIGATION OR LMILITY OF ANY KIND UPON THE CONFANY. ITS AGENTS OR REPIi WWA n%JES- AUTHORIZ.ED REPRESENTATIVE` �4. . C'p— Fps. •, ; �'• 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*********************** APPLICANT D 0 ei°y LOCATION: Assessor's Map Number SUBDIVISION STREET J©�NSOA) Ci'GLgle PHONE (i 79'66 7- -75-30 PARCEL LOT (S) ST. NUMBER ******************** OFFICIAL USE RECO,IOENDATIONS OF TQVMAGENTS: ATION ADMINISTRATOY DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm O H O z J h W � c o .O c O !� O y I C ca C.21 d ea W m C o m 1 r> E a xd y ;mac WW O c Z : _ o E c o� y D cm r m c E cog Ma VJ Cie +' cm c_ 10 C m O zoo co .0 y C4 W O •�" y o CD :=z o o► :moa m _O c�i y Z `O 000 CDn c Q i m C c S O a,- p N ~ +O•' y mei-- • N uiCOD w co .0 dt W C O W 'E 3 c=3o y 0:6 � o awm NNv �r ,am W O N W W 19 W U) v a U4 c3i o U p a 10- ° w a°' v U w a n: w a a w" t7 c� w" a rA O z cn cn h W � c o .O c O !� O y I C ca C.21 d ea W m C o m 1 r> E a xd y ;mac WW O c Z : _ o E c o� y D cm r m c E cog Ma VJ Cie +' cm c_ 10 C m O zoo co .0 y C4 W O •�" y o CD :=z o o► :moa m _O c�i y Z `O 000 CDn c Q i m C c S O a,- p N ~ +O•' y mei-- • N uiCOD w co .0 dt W C O W 'E 3 c=3o y 0:6 � o awm NNv �r ,am W O N W W 19 W U) 11M (I MLYWIV rvrAl"n yr 1V1tVXV1g1"L/J,..A 1 U�•••w �- �• •, DF.PARI39MOFPUBLJCSAFETY Permit No. 573 BOARDOFFMPREVPMONRDGUTATLONS5l aMI2.00 Ss - Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date*W� 3, U� Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) aO TOODIV Owner or Tenant Owner's Address 1?oNAC D ShAhe eN ,2n .TvL, N.) D 1v C1 pC t o � To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Brix) Purpose of Building _7NV %/4- Of 4 Cf1,4i/'Zirr FXOM / Sr7D v7 ` a)Q �Utility Authorization No. Existing Service AmpsVolts Overhead M Underground 1:3 No. of Meters New Service Amps Volts Overhead M Underground C3 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Ji 1jPC 3oA. o24%oi 47- o?CA /ZoU&Ae /V(pM"vt S -}- No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures / Swimming Pool Above 0 Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of SwMviaAW/ No. of Gas Burners FIRE ALARMS No. of Zones No, of Ranges No. of Air Cond. Total Tons No. of Detection and 'Jo. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local � Municipal r7 other No. of Dryers Heating Devices KW Connections f Water Heaters KW No. of No. of Sigm Bailasis ydro Massage Tuba No. of Motors Total HP L0. /S/?v voc7' ��e j,✓, LiGhT %t'/ 160TToH7 ri 6W f �eleOl�x/e ��`1�vci•�G Qw,PHteAO?d - �1' ez �/o^ SM _//�,/ (`egyil IZC411V"r 7odork� )u'. ruw"uurm xpmf=abuivuwduLmYuanaiawa nIkiWb%==Fb�k�C°�' arits��tialt luWat YES 10 NO E lkdvafidpoefafWW1D le0t� YESr2r r 1� ffyouhmdlad®dYES, plt=irtd *dierypecfcoverageby ON BOND p OTBM [3 Few**) P�'/�h'����/�r��C 11011,1) 8 /1y�o=_ () x4 s E � ValuedBx i DWimlimdt $ ( C �Da� � y FxW All it (4 /V T, S' , , yr -'t t; arc"/ c44_ Li=wNo. �L-aatsee 1)4 A VA/ i _ S rt , fieA /✓ sWgnaa><e ��� i'� Lit eNo .s>'111 e, Busr>essTd.No. 7 9 7J -J-4 f asNey<. M��yeti �� O�Pyy-'IJ-) AltTd.Na AffiWSKWRANCEWAVER;IamawarethattheLio wduesnothavetheinsutanoemreageoritsabsuMepvalaltasrequitedbyMamdinmCaleralLaws Iand that my sg rm cndis pang q#abm waivm this iagtmannt (Please check one) Owner Agent Telephone No. PERMIT FEE $ �� f Signature of Owner Of Agent Date... ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... 54......�...o...£a�1"".. z ..� a. ,P0e I1Ahas permission to perform......................................................r..r....C...,.�......'....�...... .. .. Ad wiring in the building of ..... A.. ............................................................... at .... c0f7. "..'! ar ' "� ... C1.. � .:.................. . North Andover, Mass. Fee .... . S . ... Lic. No. `r ��.7 ........ P 14 v �r?�i (/ ��t' rc, ELECTRICALINSPBCTOR Check # F. 3 iI JIM UUJVEY1U1Y YI'GfiL..1 11 V[' XV10LVIL'"L/01i11 u p DEPARTARMOFPURKSAFETY P .t No. 15-7 3 O BOARDOFFNEPREVEMONREGUT47701VS527C, Ml2W ��- Occupancy & Fees Checked I-2APHICATION FOR PE Aff TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4 31 0 - Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 0?0 TohNsml C ,PcLe Owner or Tenant TinNAL D S/hAhe t°N Owner's Address o20 .nkN�O ly ci/`c i e Is this permit in conjunction with a building permit: Yes [n No � (Check Appropriate Box) Purpose of Building -77Nf wt`_ liver CA411 L%rT K11;Xr11,f1Utility Authorization No. Existing Service Amps�Volts Overhead Underground ED No. of Meters New Service Amps I Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work lNlf[° 3t)A. aSloy06r %j) /e-wellFj', o70A /ZoyLi� Fr/� fOM�v[ S + No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures / Swimming Pool Above Below Generators KVA round round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch19660 / No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and _ No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local � Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP I s-AIYP- /-7p voce 4Ne �j✓` Zl6l? lit/ f,3vrvol Wrw 7` Aele,6. Ve lfy-, 61�f�/�h1e�, �a?OC`l>_"�V6 AX,EZ 25/- O h f-XVT/i�iG S�6 -/fi�� `�a� lzc;Aa;r Toao iiam cecovmr- Pawdbthetewimutsaf Nbssadwelts CalaalLaws I h aNe a a mert Litkb suR= PokY kdA 9 Q nV_J& 2 Y& CIS ComwarilsSul titanbal*Val at YES 121 NO IhaNesibrritWdvalidpafof9=lD he0>I= YES r"111) ff}euhawdeda:BYES,pkeindicatetheWofeaymgeby INSLRANCE L i / � BOND GRER �1�.� > Pr�`�r�rco�� � �7��y SZ&L§.� LiG� D* ^4 Estirrt*dValledEkcmcnlwak $ WodcbStatt 3,, D*Ra4eslad Rough • Z/, or Final All -it ( L T, jr/4'IT/C (tGrQ e 634 LimmNo.-0;i5A 6 7,711 Lioatsee signahae Busk=TdNo. as /i%N,ey <. Mei yew IVA O,P�y ALTe1Na YS/ lyfJ Ceee OWNEluSINSURANCEWAIVE2;IarlawaethattheLicawdoesnothawtheinsutalcewm*ailsabdaltdegnvaiataso4zedbyMasmdz>, mGaleallaws andthatmysiVrA ealdtispamrtapplicationwaivesfttec}itarta�t (Please check one) Owner M Agent Telephone No. PERMIT FEE $ signature of Owner or Agent Date..j. I 3 A ..... 41 TOWN OF NORTH ANDOVER �W 9 PERMIT FOR GAS INSTALLATION This certifies that . :."! .�... S !�%. ! .' "` ` .`..... /.. �. /. �- . . has permission for gas installation.. - A S S r (`! -e in the build'ngs of .. a.!10 N C 14 at . .... . G .... - . !N ........ Mrth Andover, Mass. Fee.?. U . Lic. No... 3 L.............. . GA INSPECTOR Check # f� 7992 FIXTIIRF.R MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: .121 U • MA. Date: / 1 Permit# Building Location: Z ll �'�or�.r-D*z-,, it/✓` Owners Name: 0-1 # lam C f� Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: 91*' Plans Submitted: Yes ❑ No ❑ FIXTIIRF.R INSURANCE COVERAGE: ir I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [L] No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent By checking this box ❑; I hereby certify that all of the details and information I. have submitted (or entered) reaardina this annlication 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 PertineAt provision of the Massachusetts State PlumbiqgCode and Chapter 142 of the Cyeneral Laws. Type of License: X �/ By [lumber t/1/-;- Title El Gas Fitter Slgnature of Licens&6 Plumber/Gas Fitter E; -Master City/Town ❑Journeyman License Number: APPROVED (OFFICE t1SF ONI VI ❑ LP Installer W LuCd Cd M F -L) W 0 (n x = fn CA m x (D Z J>. lX 1-- 0 W 0 LY '2 O W ~ w O N Z W > W w z 0 H m o Q 0 w = a 0 1- Q o W u� = H x > (J rn L) LZ W Z0 m J H N O Z —1 cn U' ILL N w x � W o W WW W LL LU Z 0 W >- Q "u it Q w Q m W O to Q> 0 Z 0 0 W F' z > z Z W H_ a t - V o a u_ 0 0 x x J 0 a fY E- >>> O SUB BSMT. BASEMENT 1 FLOOR 2 NoFLOOR 3 FLOOR 4 THIFLOOR 61H FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name: �% / ,S i�IVIW&� ��f- Check One Only Certificate # _�,% D� orporation Address: JJj) X 1S�LL / City/Town:—O-�,41/d IA—State: 4'' ✓� Business Tel: Fax: Sh-/" is ❑ Partnership WFirm/Company Name of Licensed Plumber/Gas Fitter: -e f/ -e &v,, ( INSURANCE COVERAGE: ir I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [L] No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent By checking this box ❑; I hereby certify that all of the details and information I. have submitted (or entered) reaardina this annlication 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 PertineAt provision of the Massachusetts State PlumbiqgCode and Chapter 142 of the Cyeneral Laws. Type of License: X �/ By [lumber t/1/-;- Title El Gas Fitter Slgnature of Licens&6 Plumber/Gas Fitter E; -Master City/Town ❑Journeyman License Number: APPROVED (OFFICE t1SF ONI VI ❑ LP Installer The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Piumbers Applicant Information Please Print Leg>lbiy ' Name (Business/Organizafion/Individual): (/� i �� t AL Address: dk —S Cl/ City/State/Zip:_ ! (! %�iw�(�_1 Iru �� Phone #: 7 Z v Are you an employer? Check the appropriate box: 1. I am a employer with 4. ElI am a general contractor and I employees (full and/orp-time).*• art have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub=contractors have working for me in any capacity. workerscomp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] 3. ❑ .I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' COMP. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other �.%-� ,►h,«; T —�-.:.r••-•.••• •••••• ..,::...c n :�v:. rl uic:::� �:5J rlll U!!L CIIC SCCLIOII t1e.oW Showing r�elr wci'itw ' compo sa-don policy inform,'�oa. Homeowners who submit 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 their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address:_ City/State/Zip 7j/ .v} 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 herebycer�und the pains a#d penalties ffper pry that the information provided above is true and correct 01LLLMUM ' v -� - Date: � ! l 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 CIerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector 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 luCal 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 certifictes) of anies (LLC) or Limited Liability partna insurance. Limited Liability Comperships (LLP) with no employees other than the members or partners,. are not required to carry workers' compensation insurance. ]fan 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 retwvm,e4 , the city or tov L , .., that the appuca ion for the pec .ait of hcense is being mq'aested, not the Departr'.ent 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/lice' nse 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 £ndustrial Accidents 0Mee of Investigations 60:0 Washington Street Boston, MA. 02111 Tel. # 617-727-4900 ext 4,06 or 1-8.77 MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.rnass..govfdia 50 Date. , I Vto- : . -•��30 TOWN OF NORTH ANDOVER �c PERMIT FOR PLUMBING SSA�MUS� This certifies that ....111 ` 7 * /+... . has permission to perform .t��. P. 4.e I.)( ........... plumbing in the buildings of .6 ?4 A<C.�..................... . at. 1,0...� �^^�>.. CA . .. , h A over, Mass. Fee 3.7,. Sv . Lic. No. ...� �a . ........ PLUMBIN NSPec Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS oDate Building Location �" � /� p�'y1�w9..V� iy�tr. Ap, Permit # -- Owner (3--,K C 4 Amount New [—] Renovation ❑ Replacement 13 Ti yv'ry m,lmo Plans Submitted Yes ❑ No (Print or type) / Check one: Certificate Installing Co parry NameY . -� . i S�' / �/v'�k C 4,14 _Corp. Address. � � � lS Partner. Business Telephone (q -1 ❑ Firm/Co. Name of Licensed Plumber: 5t -t -(.-e- �–/,% e Insurance Covera e• Indicate the type of insurance coverage checking the appropriate box: Liability insurance policy c�, Other type of indemnity ❑ Bond Insurance Waiver: L the undersigned, have been made awarethat the licensee of this application does not have any one of the above three insurance lgnflture Owner ❑ ❑ Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above best of my knowledge and that all plumbing work an talla ' p ormed Ider permit compliance w hall pertine�bpr�Osions of the Mas�etts =bin de and Cha D (OFFICE USE ONLY >ptrcation are true and accurate to the owed fvhis application will be in er W of the General Laws. Type of Plumbing License rcense MET= MasterEr � Journeyman ❑ r-� The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub=contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other —.-rr..-..••• •.•••• •.•,....:.:.:,v:. r. i w LbL UML) IJU CUL @e SC=on be ne, Shetymg T.�.^.e2r compmsatlon policy info^. atiom i Homeowners who submit 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 their workers' comp. policy information. I am an employer that is providing workers' compensation information. insurance for my employees Below is the policy 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct Sian at ire: Date 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): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing, 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 aparhnents 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 than 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 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 Investigations 600 Washington Street Boston, IMA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Revised 5-26-05 Fax # 617-727-7749 mm— .mass-govfdia Date .... �1............................i / Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............v. 6.4 .......... !"�................................. has permission to perform ....../ Q ................................................. wiring in the building of .................. g11T ,# wL'...................................... ....................... ...... . North Andover, Mass. s" Fee ...r'c�'.�............ Lic. No. 5f`' ........ ! . ................. ELECTRICAL INSPE R Check # 10584 Commonwealth of Massachusetts Official Use only Permit No. Department of Fire Services G e 9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code E , 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Insp cto of Wires: By this application the undersigned gives notice of his orher ' tention to perform the electrical work described below. Location (Street & Number) Z0 b Ih 5LM r)&Ao Owner or Tenant i>I Ih!" rL.9wIC4 Telephone No. Owner's Address Is this permit in conjunction with a buil 'ng per 't? Yes No ❑ (Check Appropriate Box) Purpose of Building 97Vk<1 Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the_following table may be waived by 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 ❑In- 1:1o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Total Number Tons ... ... .. ..I KW ...................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securityy Nof 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: r� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o El ctrical Work: (When required by municipal policy.) Work to Start: {� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C V RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insura including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in forc nd has exhibited proof of same to the pe it issuinAofflice. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the iWndp ltie f perjury zat tAcia formation on this application is t ea d complete FIRM NAME: (/ LA LIC. NO. Licensee: �>IMVM Signature ! LIC. NO.: (If applicable, ent npt"jj� tlic e n mber ine.) Bus. Tel. No.: Address: V d�lVA Alt. Tel No.: *Per M.G.L c. 147, s. 57-61, security work re ires 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 fequired bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE: $ Signature Telephone No. ..j a,t AA PZ7 r-