HomeMy WebLinkAboutMiscellaneous - 200 BLUE RIDGE ROAD 4/30/2018I
Date.. . .... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.......
................................................ ......................
has permission to perform 57r/vj? ... 107 .... 1.71 ?q7aZ ....................
10 wiring in the building of ..... [.UM'/YA ... ........................................
;?::at --,;,2Ad ....... 61ki ..... .................... 9 Mrth Andover, Mass.
Fee ... 3-r ...... Lic. No..... ...... , 50.•ELE CAL IN PECSOR
Check #
96t.-4
V
Commonwealth of Massachusetts Official Use Qn1Y
Department of Fire S Perm"
No.�
Services
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07) nP.AVP hl�"irl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (IC), 527 CMR 12.00
(PLEASE PRINT IIV M OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER ro(o 1/7)By this application the undersigned gives notice of his or her intention to perform the Inspector
electrical work abed below.
Location (Street & Number) o26o &ue ,O,d _ XCI
Owner or TenantillU 11, ;O STy iN
Telephone No.
Owner's Address Si4tit-
Is this permit in conjunction with a building permit? Yes ❑ No
Purpose of Building❑ (Check Appropriate Box)
N (I Le �� M � � u � Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und d
�' ❑ No. of Meters
New Service Amps _ / Volts Overhead
❑ Undgrd ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
QST 6y
win table may be waived bYv the Inspector of Wires.
No. of Total
Transformers KVA
Generators /oZ- KVA
o. o mergency g
❑ Batte Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Alerting Devices
-.. No. of Self -Contained
Detection/Alertin Devices
Local ❑ Municipal
Connection Other
Security Systems:*
No. of Devices or E uivalent
Data Wiring:
No. of Devices or Rnn;ooto„�
No. of Devices or
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start(When required by municipal policy.)
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 issui: 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 ❑ O'ER
❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: -�- 0oMbe E%e'ilr I eA I Se v-
Licensee: �SA LIC. NO.: Z26& yM
�����• a Signator LIC. NO.:
(If applicable, enter "exempt " in the license number line.) e-&8,620--,
Address: 1-161" 2u �I l��ytie� Bus. Tel. No.: Ca367�-�/
*Per M.G.L c. 147, s. 57-61, security work requires D ty ,�„ Alf. Tel. No.:
37 -
Alt g s - �� 7TI
OWNER'S INSURANCE WAIVER: I am aware that the Licens e does noSaft have the liabili Lic. No.
required by law. By my signature below, I hereby waive this requirement. I am the check one insurance coverage normally
Owner/Agent ( ) ❑owner owner's agent
Signature
Telephone No. PERMIT FEE. S
Completion of the
No. of Recessed Luminaires
No. of Ceil.-Sus g►. (Paddle) Fans
No. of Luminaire Outlets
No. of Hot Tubs
No. of Luminaires
Swimming Pool Above �_
d ❑
of Receptacle Outlets
. n
No. of Oil Burners
of Switches
FNo.
No. of Gas Burners
f Ranges
No. of Air Cond. Tom
No. of Waste Disposers
Tons
Heat Pump Number Tons 1
Totals: _
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances KW
No. of Water
Heaters KW
No. of No. of
Si s Ballasts
No. Hydromassage Bathtubs
No. of Motors Total HP
win table may be waived bYv the Inspector of Wires.
No. of Total
Transformers KVA
Generators /oZ- KVA
o. o mergency g
❑ Batte Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Alerting Devices
-.. No. of Self -Contained
Detection/Alertin Devices
Local ❑ Municipal
Connection Other
Security Systems:*
No. of Devices or E uivalent
Data Wiring:
No. of Devices or Rnn;ooto„�
No. of Devices or
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start(When required by municipal policy.)
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 issui: 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 ❑ O'ER
❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: -�- 0oMbe E%e'ilr I eA I Se v-
Licensee: �SA LIC. NO.: Z26& yM
�����• a Signator LIC. NO.:
(If applicable, enter "exempt " in the license number line.) e-&8,620--,
Address: 1-161" 2u �I l��ytie� Bus. Tel. No.: Ca367�-�/
*Per M.G.L c. 147, s. 57-61, security work requires D ty ,�„ Alf. Tel. No.:
37 -
Alt g s - �� 7TI
OWNER'S INSURANCE WAIVER: I am aware that the Licens e does noSaft have the liabili Lic. No.
required by law. By my signature below, I hereby waive this requirement. I am the check one insurance coverage normally
Owner/Agent ( ) ❑owner owner's agent
Signature
Telephone No. PERMIT FEE. S
iltii+� /
Mia
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 ff'oshine ton Street
Boston, MA 02111
' www-massgov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
33icant Information
Name (Business/organization/individual):
Address:
. 1
V •er,,j 0 /tl led
City/,State/Zip,*-,4M 7.ersT-
I Ser✓,.
Phone #:_�o3 %%a-
Are you an employer? Check.the appropriatebox:
1 • EB -11 am a employer with 4, ❑ I
_(
am a general contractor and I
employees (full and/or pari -time).*
2.E3 I am .a.sole proprietor or
have hired the sub -contractors
Iisted
partner.
ship and have no employees
on the attached sheet $
These sub -contractors have
working for melt any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required-]
3. ❑ I am a homeowner doing
officers have exercised their
all work
TYself. [No -workers' comp.
right of exemption per MGL
C. 152, § 1(4),'and we have no
insurance required.] t
.employees. [No workers'
comp. insurance re "lied
Type of proles (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
l0-1SZiecb ical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof-
9 ) 13•0 Other
`Any applicant that
checks bo g t must also fill out the section below showing their workers' bompensstion policy mfotmation
t homeownwho submit this affidavit indicating they are doine connectors must submit a new afndavit indi
;Cotttrcntors that check this box g all work end then hire outside must attached an additional sheashowing. the numof the sub,cone+a .+ Fs.�er x __ cahag such
I ant an employer that is.Pmirfdtng workers' con ertsadon ' "N pol;�s' iniarnraticrn.
information. P u7surance for my employees: Below is the policy. and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date: 1.2 - /7 - //
Job Site Address:_oir�r, 1,1�_e r rc�
City/state/Zip: rt/
Attach a copy of the workers' eontpeusation policy declaration page (showing the policy Dumber and expiration date
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal enalties of
fine up to $1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a f
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 fine
Investigations of the DlA for insurance coverage verification.
I do here"c i0nder the pains
�c3 P �a-ai9
jienaitla of perjwy that the information provided above is itue and cotre,
Date
00icW use only. Do not write in this. area, to be completed b or town o ,
y �' ff
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/'iown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:
Phone #:
Date . 00/4........ .
of °A TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
s _ _
9
This certifies that /................ .
has permission for. gas installation ....... t .........
in the buildings of ..t�I?.� ................................
at 2.62 <,... � l (°' J. ..........\., North Andover, Mass.
Fee.Lic. No./P!.% ?.... .... .........
GAS INSPECTOR � ?
Check # ye
7262
le
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
ES iLa r u Owner's Name
New ❑ Renovation Replacement ® Plans Submitted
Date /9 — It -o
Permit #
Amount $
(Print or type) Check one: Certificate Installing Company
Name --L4 0 ae- @ iC U � Corp.
Address 0 k '% 5 01— '
Partner.
usmess a ep one 7�_ S`- t/ Fhm/Co.
Name of Licensed Plumber or Gas Fitter
V
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes r1 -_J No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy E^ 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent E3
1 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 St Gas Code ann Char J�92 of the General Lawj
1
Title
City/Town
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Q Plumber A15) f `
E3Gas Fitter icense um er
—_ aster
oJourneyman
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SUB-BASEM ENT
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B A S E M ENT
1ST. FLOOR
2N'D. FLOOR
3RD. FLO 0
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
-
8TH. FLOOR
(Print or type) Check one: Certificate Installing Company
Name --L4 0 ae- @ iC U � Corp.
Address 0 k '% 5 01— '
Partner.
usmess a ep one 7�_ S`- t/ Fhm/Co.
Name of Licensed Plumber or Gas Fitter
V
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes r1 -_J No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy E^ 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent E3
1 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 St Gas Code ann Char J�92 of the General Lawj
1
Title
City/Town
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Q Plumber A15) f `
E3Gas Fitter icense um er
—_ aster
oJourneyman
Mf
The Commonwealth of Massachusetts
Department o f Industrial Accidents
Office of Fnvestigations
600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leai<bIy
Name (Business/Organiza6on/Individual):
Address: P
City/State/Zip: n ,�� ro �5o�%Phone #:
Are you an employer? Check the appropriate box:
1X I am a employer with g
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole
have hired the sub -contractors
listed
proprietor or partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
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. ❑ Electrical repairs or additions
11cErPlumbing repairs or additions
12.0 Roof repairs
13.❑ Other
t HUw. ine secnon oe+on+ sn^S W g their e+ort-= compeneynfo.�at:ousation noli
moeowners who submit this affidavit indicating they are doing all work and then hire outsidmust submit a new affidavit indicating such.
Contractors that check this box must e contractors attached an additional sheet showing the name of the sub -contractors and their workers, comp. policy information.
l am an employer that is providing workers' compensation
information. insurance for my employees Below is the police and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: C�06�
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.
Ido hereby certify under th�ipainsInd�enalties ofperjury that the information provided above is true and correct
n ii
i*;In
—
tone #:
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town: Permit/License #
Issuing Authority (circle one):
L 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 ox- 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 mainte=nance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested I , not the Depa=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 pemmittlicense 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 perxnits 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 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, MA 02111
Tel. # 617-72.7-4900 exg406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-72.7-7749
viww.mass-gov/dla
Date.....?.... &.. .U...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .........................L...../1p... :rl ....:...
has permission to perform .......... 4Tf?`4.
wiring in the building of ...... ,!�. 5-7—E< [./ ...............................................
a®D ' ���1 fiE .GnD ,
at ................. North Andover, Mass.
Fee. -5P ... . -:.... Lic. No. .............. .......... ... ...............
`' �� ELECTRICAL IN6E R
Check # -3-:5
JL
Commonwealth of Massachusetts
Official Use Only
kipDepartment of Fire Services FPer=milNo. C1� r7BOARD OF FIRE PREVENTION REGULATIONS pancy and Fee Checked
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 WINK OR TYPE ALL INFORMAT1019 Date:
City or Town of: NORTH ANDOVER 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) p:?C�0 R1jI /"-;7, _j,_ ' -. /
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes
Purpose of Building N El No (Check Appropriate Box)
t.U-t Utility Authorization No.
Existing Service Xjups / Volts Ove ead
❑ Undgrd ❑ No. of Meters
New Service Amps / _Volts Overhead
❑ Undgrd ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: -. I
Completion Of thSALOWing table may be waived lVhe Ins ector of Wires.
No. of Recessed Luminaires No. of Ceil.-Susp, (Paddle) Fans o. of Total
No. of Luminaire Outlets
No. of Luminaires
M
eceptacle Outletsitchesangesaste DisposersishwashersryersaterHeaters KWomassage Bathtubs
No. of Hot Tubs Generators KVA
Swimming Pool Above In- o. o III it ig g
d• d• Batte Units
No. of Oil Burners FIRE ALARMS No, of Zones
No. of Gas Burners No. -of Detection and
Initiating Devices
No. of Air
Con
Total
Tons No. of Alerting Devices
_ _
Space/Area Heating KW
Heating Appliances KW
Ballasts.
No. of Motors Total HP
tecuon/Alerting Devices
:al ❑Mumcipal
Connection ❑ Other
urity Systems:
No. of Devices or Equivalent
:a Wiring:
No. of Devices or Equivalent
ecommumcattons Wiring:
No. of Devices or Eanivalpnt
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
INSURANC
Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion.
E 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 covera a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER
❑ (Specify:)
I certify, under thepains and penalties of pe{qury, that the information on this application is true and complete.
FIRM NAME:
Licensee:l J LIC. NO.: v7 G
Signature
(If applicable, enter exempt " in the license number line) � • NO.: _3
Address: v fy e,4 M ej Bus. Tel. No.: 3t; ��-oz/9
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: �� Lich• No.
�7J � ��
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
Signature Telephone No. PERMIT FEE: $
The Commonwealth of Massachusetts
Department of £ndustrial Accidents
Office of Lnvesiigations
600 Washington Street
Boston, M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/C
3plicant Information ontractors/Electricians/Plumbers
Name (Business/Ctganizabmvindividual):
Address:
City/Sate/ZiP:— AM � e iU LI g 3 p,3 ,
Phone #:hn
Are you an employer , Check the appropriate box:
l . Eam a employer with -42�� 4. ❑ I am a general contractor and I
2. ❑employees (full and/or part-time).* have hired the sub -contractors
I am a. sole proprietor or partner- listed on the attached sheet t
ship and have no employees These suitecontractors have
working for me m any capacity.
[No workers' comp. insurance 5.
required]
3. ❑ .I am a homeowner doing all work
myself. [No workers' comp.
Insurance required.] t
workers' comp. insurance.
❑ 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 recrui 4
'Amry zp-Dh:zat that chec> . box #1 must also M. uat the Sectio^ heeoa' saon W_
Homeowners who submit this afnda ti u'Mic-m-s' cor__
Type of project (required):
6- ❑ Neve construction
7. ❑ Remodeling
E. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.7 Roof repairs
13.❑ Other
vrt Indreatmg th-.,
+Ca?` Som^ a: wcre and �' r _ W aca
mractors that cheat this box must attached an additional sheet showing the �m lure outside con�cta ;dug submit a new aiiidavit indi Sting such.
name of the sub -contractors and their workers' comn. policy information•
I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #.-
Expiration Date: Z I (o
Sob Site Address: o?OC� U
Attach a copy of the workers' compensa on policy declaration ave shov►^C� /State/Zrp. �(/ p,t/of�,� M,�
he
Failure to se^ure coverage as required under Section 25A ofMGL F 152ranlead to the impoolicy sition expiration date).
fine up to $17500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDS and a fine
penalties of a
of up to $250.00 a day against the violator. Be advised that a campy of this statement maybe forwarded to the office DE a
Investigations of the DIA for insurance coverage verification
Ido here certify�u�err"the pains ar enalties of perjury th"t the information provided above is true and correct
Signature:
y
Phone #: 03 (� —
Official use only. Do not write in this area, to be completed
by city or town ofJacwl
Cit3, or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. Citv/TOwn Clerk 4. Eiectrical Inspector 5. Plumbin.,
6. Other b inspector
Contact Person:
Phone #:
Date..: �2 .......... .......
-.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... --e,�
............. ... .. .
...................
has permission to perform .... ........
wiring in the building of ...... . ..........................................
'J2
at ........ North Andover, Mass.
Fee ................. Lic. Nozl�kw�,-� ............. ... . ...........
t�AL'I"'S i
Ad 'ELEMM INSP R
Check # R 7A S-
7752
�-� Commonwealth of Massachusetts
Pemiit No. %7..5
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 9/05j 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: lol.2 q�o %
City or Town of: A10.✓f/I To theInspec or of Wires:
By this application the undersigned gives notice of his or her intention toI erform the electrical work described below.
Location (Street &Number)_' _200
Owner or Tenant /11,4-4/ -4,0 �5- i,;, Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No El___ (Check Appropriate Box)
Purpose of Building /]§y.) ,- Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd El
New Service Amps / Volts Overhead ❑ UndgrdEl
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: W�&1
.zv s � L -c Co c1-5 no,;- c., -v A
Completion o%the folloivin.Q table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers MIA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. grnd.
o. of Emergency tg t trg
Battery Units
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:
I Number
ITons
K\V_
No. of Self -Contained
Detection/Alerting Devices
--
_
-
No. of Dishwashers
Space/Area Heating KW
1.No.
Local ❑ Cor nMuntecp on El Other
of Dryers
Heating Appliances KW
Security Systems:*
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 E uivalent
OTHER:
Attach additional detail iifdesired. 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 proofof same to the permit issuing office. .
CHECKONE: INSURANCE O—BOND ❑ OTHER ❑ (Specify:) General Liability 12/31/07
I certify, under thepains and penalties ojperjury, that the information on this application is true and complete.
FIRM NAME: Boissonneault Electric Corp. LIC. NO.: 11823A
Licensee: /1/O/tw ✓0,a .9,k.,,,4;ryv&�—Signatur ���_--—LIC:NO.• „�yLyU
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.:( 978)'41;4-0383
Address: 19 Chuck Drive, Unit #6, Dracut, MA 01826 Alt.Tel.No.- 978 458-9977
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee floes 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 o
Signature Telephone No. PERMIT FEE: $,3
Date ... —./ (.-) ....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... (.".I .... �!r . ��.
....................................
has permission to perform ... ........................
wiring in the building of ............ -57 7,/. ...........................................
North Andover, Mass.
Fee Lic. No...3��. , . .....
......... .. ............. 1�'*'9'i1",;I,.;,;,3-ve
V -EU&rRiCALINSPECTOR/
Check it Z 1 6 2-
A
96U 0,
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. %;d
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECT
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
WORK
(PLEASE PRWflV W OR TYPE ALL INFORMATIO
City or Town of. NORTH ANDOVER Date:_ ) --3 p.— /0
By this application the undersigned gives notice of his or her intention to peTo the rform the inspector
of Wires:
below.
Location (Street &Number) `o�p� '5 �V L 1 r �1c�
Owner or Tenan SU
Owner's Address G
Telephone N
Is this permit in conjunction with a building permit? Yes
Pt urpose of Building 1 L No E] (Check Appropriate Box)
C Utility Authorization No.dbl,Q_2�.�,�
Existing Serviced s lav l
�P at Volts Overhead ❑ Undgrd� No. of Meters a"'
Am
New Service /
Ps Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work;3; AcC
---------------
No. of Recessed Luminaires ,3
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water
Heaters IW
No. Hydromassage Bathtubs
c,om [etion o the ollowin
No. of CeiL-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑ In-
No.
n No. of oil Burners
No. of Gas Burners
NO- of Air Cond. –off
.?ASCD
table maybe waived by the
Generators KVA
ALARMS, INo. of Zones
of Alerting Devices
Totals: I
_"__ 1" ._
�No. of Self-C—Ontaine
Detection/Ale rtin L
Pace/Area Heating
IOW
Local ❑ Municipal
A
,eating Appliances
KW
Conner '01
Security Systems:*
o. of
o. of
No. of Devices or
Si s
Ballasts,
Data Wiring:
No. of Devices or
o. of Motors
Total HP
Telecommunications
No. of Devices or
❑ Other
Estimated Value of Electrical Work: aav�' Attach additional detail if desired, oras required by the Inspector of Wires.
Work to Start (When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVE GE: Unless waived by the owner no
the licensee provides proof of liabilityPermit for the performance of electrical work may issue unless
undersigned insurance including completed operation" coverage or its substantial equivalent. The
fined 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. enalkes o
p /PmlurJ', that the information on th
FIRM NAME; is application is true and complete.
Licensee: LIC. NO.:
—� I �'�C Signature
(If applicable enter exempt to the license numb r line.) LIC. NO.:
1z:
Address: � Bus. Tel. No.: -"
*Per M.G.L c. 147, s. 57-61, security work re Z s D , o to _
OWNER'S INSURANCE W q ePmtrnent o Public Saf Alt Tel. No.:
AIVER: I am aware that the Licensee does no have,thelIiabili Lic. No.
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner
normally
Owner/Agent
Signature ❑owner's agent.
Telephone No. PER1IIjT'
The Commonwealth of Alassachuse&S
Department of'.fndus&W Accidents
t '• !
Office Investigations
gations
600 N7ashington Street
Boston, MA 02111
c j
Workers' www.massgov/dia .
Compensation Insurance Affidavit: Builders/Contractors/Eiectriciatts/Plambe
rs
ADRlicant Information
Narri (Business/0rgmi2,6,n/Individual):
Address: /YI /Inde 1, n,I /I
City/State/Zig:
ME
Phone #:. %— 9ciD
Are you an employer? Cheek the a
ppmpriate box:
1 • ❑ I am a employer with 4, ❑ I am a general conJh
end I
_
Type of project (required):'
employees (full and/or part-time).*
2.
have hired the a&ctors
6. ❑ New construction
am .a.sole proprietor or partner-
ship and have no employees
listed on the attachet =
7. ❑ Remodeling
working for me .in any capacity.
These sub-contractve
worker' ins.
g' Q Demolition
[No workers'comp, insurance
comp.
5. ❑ We are a corporatioits
9• Q Building addition
3. Qrequired.]
I am a homeowner do'
mg all work
Officers have exercieir
right of eXemption L
10•Q Electrical repairs or additions
rgyself. []Jo workers'comp.
c. 15insurancerequired
2, § 1(4),'and we no•emPjoyees.
I I.❑ Plumbing repairs or additions
] i
[No wor12
Q Roof repairs
appiicsnt that Comp• insarance:req] 13.0 Other
checks boS'! I must also lin out the section below showing their workers' compensation policy infotmatioa
t �OT1GO" °era who submit this affidavit indicating they are doing a!i w°
�Cantractons ey ��
��{ h6s outside con
that check this box rause atmohed a,, add aai shirt Showing,�0m must submit a new affidavit inditeting such.
thcrri<me of the sub.crrgctvrs mad ft_� .
•
Poliq, ininnnation.
P am an employer that is m '
p . �dng:warkers• cnmpensatiasi �nsrrranreformy. e
information. mplolre= fidlow it the Policy
Insurance Company Name:
aed job site
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/state/Zip.
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration datee
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to $1;500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER penalties of a
Of up to $250.00 a day against. the violator. Be advised that a copy of this statement may be forwarded to the Office o� a fine
investigations of the DIA for insurance coverage venin"cation.
I do _
Date..�/...m ./d .....
TOWN OF NORTH ANDOVER
vow
PERMIT FOR GAS INSTALLATION
o 71'0 It
This certifies that`(/ t
has permission for gas installation ..C7 �it!�, q!r` lz
in the buildings of ,,% U C.!... .. :".. ................ .
at t�:........ North Andover, Mass.
Fee:,Lic. No.. .�L . /.�3d.�� �z
GAS INSPECTOR
Check # �a
Ti bl
r
MASSACHUSETTS UNUORM APPLICATON FOR PERMIT TO DO GAS FMING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date- / —`6 / b
Building Locations P -i Permit #
Wo r j4 v-vj y V^ Amount $
�►"Z Owner's Namey d � � 5• r
New Renovation❑ Replacement 1:1Plans. Submitted r�c�11
(Print or
EG I %
Address Ito G/9*,4r— C :—L l ti 1), .,,,c J—, (. 11.
Check one: Certificate Installing Company
❑ Corp.
Partner.
® Firm/Co.
Name of Licensed Plumber or Gas Fitter
1 -
INSURANCE COVERAGE Check one
I have a current liability Insurance policy or, it's substantial equivalent. Yes No
�
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy®Other type of indemnity on
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
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 S as Code and Chapter 142 of t `�Cneral Laws.
By:
Title
City/Town
IAPPROVED (OFFICE USE ONLY)
Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fid
License Number
v�
ro
w
w
o
o
z
F
w
z
w
x
z
�"
a
p
o°O
A
>
w
�'
H
z
a
w
w
0
w
H
wrA
`~
z
a
a
rreqq
z
o
z
o
in
x
o
x
3
a
U
a
>
SUB -BASEMENT
O
C7
A
a
O
B A S E M ENT
1ST. FLO O R --
2ND. FLOOR
LOOR3RD.
3 R D .FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. - FLOOR
(Print or
EG I %
Address Ito G/9*,4r— C :—L l ti 1), .,,,c J—, (. 11.
Check one: Certificate Installing Company
❑ Corp.
Partner.
® Firm/Co.
Name of Licensed Plumber or Gas Fitter
1 -
INSURANCE COVERAGE Check one
I have a current liability Insurance policy or, it's substantial equivalent. Yes No
�
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy®Other type of indemnity on
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
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 S as Code and Chapter 142 of t `�Cneral Laws.
By:
Title
City/Town
IAPPROVED (OFFICE USE ONLY)
Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fid
License Number
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
nniiennt Tnfnv-..,.,"__
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. ❑ 1 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. workers' comp. insurance.
[No 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.]
*A -Y applicant that checks bux #1 must also iill out the section below shot. i^.�* -heir ,.,,.kers- c l
e '-.�. t. �...�.� ompensation policy info Wation.
t 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 poli information.
I an employer that is providing workers' compensation
information. utsurance for my employees. Below is the policy and job site
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
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.❑ Roof repairs
13.❑ Other
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
Laic.:
Lone #:
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 Clerk 4. Electrical Inspector S. Plumhinu fn-.......
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, §25CM 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 ...turned 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
provided to
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be 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 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 Investiggatdons
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5 -26 -OS cA1Wu1.maSs..c,ov/dia
Location
No.
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ `r
Building/Frame Permit Fee $ U �`
/y /il,
Foundation Permit Feel' $ �
*? Other Permit Fee $ +l
Sewer Connection Fee $ f - 1
�Y.
'Mater Connection Fee $
v ;
Building Inspector
Div. Public Works
Location
No. Z
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee ='
Other Permit Fee $
IJ � 'IeZU9C91on Fee $
V1(�tmPnnection Fee
TOTAL I
Building Inspector
( l /l Div. Public Works
PEF\iIT NO. !' '
4",
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. / 1IAIV 17 6V/ PAGE 1 J
AP KVO.
ZONE
LOT NO. , 1
SUB DIV. LOT NO. z
1
2RECORD OF OWNERSHIP IDATE
n
(,,. oue1-,+2 De -v. �ppp- �1(JJJ wj
BOOK
12 VA(
'PAGE
LOCATIONC O �� \ �U
J U
) 4
PURPOSE OF BUILDING
_ �-i 1>ekQ
1 ✓��I
OWNER'S NAME pq O�1//O
/��
NO. OF STORIES l SIZE 30 X CD
OWNER'S ADDRESS ADDRESS T R O llC...� l.l.(P C.� 12
4-
l.(�j�t►1.�,�'t)
l
`
IV
�• 1�.�'tc[1)llL
BASEMENT OR SLAB
Q�ARCHITECT'S NAME
O�F2 !?
i
!/� ,fz
t
IZE OF FLOOR TIMBERS 1ST •L 2ND 'j,,, I 1'113.. 3RD
2 x D
O
BUILDER'S NAMEp AT, yv% -
-e J'
1J-----1., fp
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET 4� D
" POSTS X12« L C` l.. O o tV l s
G
DISTANCE FROM LOT LINES —SIDES 1+0 REAR
O
GIRDERS C.{- X 12. l.. c..w.� ✓��� G
AREA OF LOT ' .ir C l e- FRONTAGE
IL -O
HEIGHT OF FOUNDATION -7 1/2 THICKNESS lo
IS BUILDING NEW yes
l
SIZE OF FOOTING z x /O « X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY (AS•Ona2
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND /
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 1
`Y
/ e C
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER -4 e -
IS BUILDING CONNECTED TO NATURAL GAS LINE t� �S
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS i - 3
INSTRUCTIONS
330 I l l Vk ase
05.3 j 8
3 PROPERTY INFORMATION
LAND COST jnO
EST. BLDLL
PAGE 2 FILL OUT SECTIONS 1 - 12 PERMIT FOR FOUNDATION ONLY
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDINWEGULATED BY PARA: 114.8-5. B.C.
ATTACHED GARAGES MUST CONFORM TO STATE FIRE
nREeGrUCLATIO/7S �_
PLANS MUST BE FILED AND FEE P�� APPROVED BY BUILDING{IBSpF�T�Q•
DATE FILED '�'/�" I/�/1 3 / • / r
_
IGNATURE OF OWNER OR AUTHORIZED AGENT
1 FEE
PERMIT GRANTED
m 19
,.,AUG. PERMIT FE'
LESS FDA FEF �' / o o
DUE FSE PMM 0 q sd . 0
CONTR. TEL.
CONTR. LIC.
m -- 3 1
G. COST/ c� /O
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
o• `
• r
1
9NIIV3H ON —I Pic I Atl
31813313 PUL
410 SWOON 10 'ON L
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3WVM3 NO >13189
AMN SVW NO N3169
S30NIHS DOOM
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9
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FORM U
TOWN OF NORTH ANDOVER ��
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP /0 `T" 6
SUBDIVISION LOT(S) al-(
PERMANENT ADDRESS (ASSIGN D BY D.P.W.
STREET 's.�iq/f,)�/�'b
APPLICANT PHONE
DATE OF APPLICATION
TOWN USE BELOW THIS LINE
PLANNING OARD
DATE APPROVED
TOWN PLANNER DATE REJECTED
CONSERVATION COMMISSION
CONSERVATION ADMIN.
c3�
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATERT CONNECTIONS
FIRE DEPT.d C
DATE APPROVED'
DATE REJECTED
DATE APPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTION
DATE��
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
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CknTIFUCATE
O & OCCUPANCY
Town of North Andover
Building Permit Number 191
Date AUGUST 14, 1991
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 200 BLUE RIDGE ROAD (Lot #21)
MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3 -CAR GAR. IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE 9UILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
/2 ytttec '.6.'6ryOL
CERTIFICATE ISSUED TO PARM DEVELOPMENT
lt� 4 ROACH CIRCLE
ADDRESS No:'_Read' n
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QDN.11lD P`y(y
LSSA C HU SES . �e
Building Inspector �)
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o AMERICAN CLAIMS SERVICE
MULTI-LINE ADJUSTERS
BUILDING COMMISSIONER OR BOARD OF HEALTH OR
INSPECTOR OF BUILDINGS BOARD OF SELECTMAN
120 Main St.
N. Andover, MA 01845
RE: INSURED: Ned Epstein
PROPERTY ADDRESS: 200 Blue Ridge Rd., N. Andover, MA
POLICY NUMBER: H004001882
LOSS OF: 5/17/02, Water around chimney
FILE/CLAIM NUMBER 22693 PD
NA TI NAL
ASSOCIATION
INDEPENDENT
INSURANCE
DIUSTERy
DEDI A TO ,w([
Claim has been made involving loss, damage or destruction of the
above -captioned property, which may either exceed $1,000.00 or
cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable. If any notice under Massachusetts General Laws,
Chapter 139, Section 3B is appropriate, please direct it to the
attention of the writer and include a reference to the captioned
insured, location, policy number, date of loss and claim file
number.
Craig Gillespie
Claims Representative
On this date, I caused copies of this notice to be sent to the
persons named above at the addresses indicated above by first
class mail.
Unless we hear from you within the next 10 days, we will not be
obligated to pay any portion of this claim to you.
May 17, 2002
Date
7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940
TELEPHONE (781) 245-9516 • FAX: (781) 245-1077