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Miscellaneous - 201 DALE STREET 4/30/2018 (2)
ei Date ....... t...1.cil l.6 ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... t CAD. �� } UR- �' C, ................:................................................................................. has permission to perform .... t . t._- �►�'4.. VD -Ai wiringin the building of............................................................................................................... at ...`-e North Andover, Mass. .........................../.....,............, ) . / Fee.....'.......... Lic. No. .`........!� ...l.�l..1.'`` ................ ELECTRICAL INSPECTOR Check #10 �5o t 0 Commonwealth of Massachusetts urnmai use uniy Department of Fire Services Permit No. Occupancy and Fee Checked kip BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leaveblank 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 July 6, 2015 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 201 Dale St. Owner or Tenant Mark Aude Telephone No 978-283-2299 Owner's Address 201 Dale St. Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Residential Utility Authorization No Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Electrical associated with A/C handler upgrade 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- ❑ rnd. grnd. o. of 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number .... ............................................. I J. ........... KW KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security m f Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: _ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work 400 (When required by municipal policy.) Work to Start 7/7/15 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Roy Spittle Associates LIC. NO.: Licensee: Nicolo Taormina Signature i( , ��n.ti,,,� LIC. NO.: 14918 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-283-2299 Address: 5 Heritage Way, Gloucester MA 01930 Alt. Tel. No.: *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 does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: SS Signature Telephone No. c J bi yvlyar, 1. L. The Commonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Naine (Business/Organization/Individual): Roy Spittle Associates Address: 5 Heritage Way City/State/Zip: Gloucester, MA 01930 Phone #: 978-283-2299 Are you an employer? Check the appropriate box: 1.0 I am a employer with 25 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. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ 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 10.9 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box # 1 must also fill out the section below showing their workers' compensationolic _ I p y information. 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 boa must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, the}, must provide their workers' comp. policy number. I mi employer that is providing information. workers' compensation insurance for my employees. Below is the policy and job site Insurance Company Name: A.I.M. Mutual Insurance Company Policy # or Self -ins. Lic. #: WMZ-800-8006575-2014A Job Site Address: ao 1 -64. /,,— 5-f = Expiration Date: 9/11/15 City/State/Zip: North Andover, MA 01845 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 a #: 9782832299 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 7/ 6/ice Contact Person: Phone #: C. VJ Date. I. � ......... TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION � 6� w l- l This certifies that Jle.............. . has permission for mechanical installation . J.'.-. ZINC ............... in the buildings of ..... . :.0 �- .......................... . r at .. ..I.... ` `.�. , North Andover, Mass. Fee.' . Lic. No.. !.�: �.. .......................... GASINSPECTOR n WHITE: Applicant +^ i CANARY: Building Dept. PINK: Treasurer t ''t r, At k Commonwealth of Massachusetts Sheet Metal Permit Date: Estimated Job Cost: Plans Submitted: YES NO 1' Business License # Uo-5- l Permit it �" I4 Permit Fee: $ NfU-W- ® Plans Reviewed: YES NO i Applicant License # Business Information: Property Owner / Job Location Information: Name: ��%� �f /T1f4_ �'i��f�.,C, Name: g, Street:(, f �t f���� Street:4 !� City/Town: $GJ�cLi Nf O � City/Town: N , �oC�-e2 /A a� %��5�^'�� Telephone: Telephone: 1 Photo I.D. required / Copy of Photo I.D. attached: YES V' NO Building Type: Residential: 1-2 family V Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft.��over 35,000 cu. ft. Sheet metal work to be completed: HVAC V Metal Roofing New Work: Renovation: __z Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: *t INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch.112 Yes m No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy V Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 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 Agent By checking this box hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date Progress Inspections Comments Final Inspection Inspector Signature of Permit Approval Comments (S Signature of Licensee License Number: Check at www.mass.clov/dpl Type of License: By 92 aster Title ❑ Master -Restricted Cityrrown ❑Journeyperson Permit # ❑Jo urn eyp erson-Restricted Fee $ Inspector Signature of Permit Approval Comments (S Signature of Licensee License Number: Check at www.mass.clov/dpl The Commonwealth of Massachusetts Department of Industrial Accidents Office Oflnvestfgafi0ns 600 Washington Street, 7"hFloor -T;�,, <-/ Boston, Mass. 02111 '7 Workers' Compensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors ApAlicant information: Please PRINT legibly name: address: �F� JIAC -bcCue City state U I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑ I am a sole proprietor and have no one working in any capacity. �y ❑ Building Addition Im am an employer providing workers' compensation for my employees working on this job. uk- SCLC- tC phone #: insurance co. ITS Ir`�fr/%��r' /rlG,t/�4 f 6 policy# WC 060.0,'A /:g" T� ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: City: phone #: insurance co. policy # company name: city: phone #• insurance co. oolicv # Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/ol one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certifjY n r the pains Print name of perjury that the information provided above is trate and correct. Date -C. official use only do not write in this area to be completed by city or town official city or town: ❑ check if immediate response is required contact person: (revised Sept. 2007) rte # permit/license # ❑Building Department ❑Licensing Board ❑Selectmen's Office ❑Health Department phone #; ❑Other CERT IFiiiiICATE OF LIABILITY INSURANC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO DATE (MM/DD/YYYy) CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COV 4/24/2015 4ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN T REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. RIGHTS UPON THE CERTIFICATE HOLDER. THIS COVERAGE AFFORDED BY THE POLICIES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the otic HE ISSUING INSURERS , the terms and conditions of the policy, certain policies may require an endorsement. A statem () AUTHORIZED P y(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to N CT certificate holder in lieu of such endorsement(s). ent on this certificate does not confer rights to c the PRODUCER Boynton Insurance Agency NAME: Boynton Insurance 72 River Park Street PHONE . (781) 449-6786 FAX E-MAILinfo@boyntonins .COM A/C No : (781) 999-4269 ADDRESS: Needham INSURED MA 02494 INSURER S AFFORDING COVERAGE INSURERA:Hayle sville Preferred Ins Co NAIC # Morris Heating & Air Conditioning Inc INSURER B. -Harleysville Worcester 35696 INSURER c:H 56 Mitchell Road 6182 arle sville Mutual Inc Co INSURER D: 14168 Ipswich MA 01938-1219 INSURER E ' OVERAGES INSURER F : � THIS IS TO CERTIFY THAT THE POL C EgTOFI NSTE URANNUMBER:: STED BELOW HAVE BEEN ISSUED TO THE I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC REVISION NUMBER: CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID INSURED NAMED ABOVE FOR THE POLICY PERIOD INSR UMENT WITH RESPECT ALL WHICH THIS I LTR RIBED HEREIN IS SUBJECT TO ALL THE TERMS, TYPE OF INSURANCE ADDL SUBR CLAIMS. GENERAL LIABILITY IN WV POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYy MMA D X COMMERCIAL GENERAL LIABILITY LIMITS AEACH OCCURRENCE $ 1,000,00 4 CLAIMS -MADE [Z OCCUR DAMAGE TO RENTED X FormCG0001 (12/07) PREMISES Ea occurrence $ 100,00( PPOOOOOO16803T /1/2015MED EXP (Any one person) $ /1/2016 10,00( GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY $ 1 , 000, 0 0( POLICY X PRO- GENERAL AGGREGATE $ 2, 000, 00( AUTOMOBILE LIABILITY LOC PRODUCTS - COMP/OPAGG $ 2, 000. 00( A ANY AUTO LE $ ALL COMINED SINGLIMIT OWNED X SCHEDULED Ea acBcident AUTOS1 000 00( X AUTOS AOOO00016802T BODILY INJURY (Per person) $ HIRED AUTOS X NON -OWNED /1/2015 /1/2016 I AUTOS BODILY INJURY (Per accident) $ X UMBRELLA LIAR X PerOa cdentDAMAGE $ OCCUR B EXCESS LIAR $ CLAIMS -MADE 000000168047EACH OCCURRENCE $ 2,000,000 DED X RETENTION 10,00 /1/2015 /1/2016 WORKERS COMPENSATION AGGREGATE $ 2, 000, 000 AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE WC STAT $ OFFICER/MEMBER EXCLUDED? X OTH- (Mandatory in NH) N N /A If yes, describe under C00000019816TE.L. EACH ACCIDENT $ DESCRIPTION OF OPERATIONS below /1/2015 /1/2016 500, 000 E.L. DISEASE - EA EMPLOYE $ � 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 `I DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) f I I A SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Evidence Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25 (2010/05) S Denneno CISR/JPM INS095/9rnnn5im — -- Th, Annan .,�..,o ..,a h�� pro +e.orl ©1988-2010 e'ACORD CORPORATION. All rights reserved. ` `r. OISfnIH� SA ;U IIA _ 4. ISSN 99END NONE 4d NUMBER _ 072-p� 49 S4885727 't �'1 46 P• 2,4 �,.µµ�1y09 : J DOB.• :.I 07-23195 N1A9SA�fAS8:.. U REST.- 15 SEX .M 4 •• 310 MAIN ST u72a 1e54, DUNSTABLE, MA 01827-1803 5 DD07-21-2014Rev07.15-2009 a .. +.wrightsoft- Load Short Form Entire House Project Information For: Aude residence 201 Dale Street, North Andover, MA 01845 Job: Date: Jun 15, 2015 By: Design Information Htg Clg Infiltration Outside db (°F) 2 88 Method Simplified Inside db (°F) 70 75 Construction quality Average Design TD (°F) 68 13 Fireplaces 1 (Average) Daily range - L ' Inside humidity (%) 50 50 Moisture difference (gr/Ib) 50 28 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 Btuh 0 Btuh 0 OF 1400 cfm 0.021 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Lennox Trade Cond XC21 Coil CBX32MV AH R I ref 5991265 Efficiency Sensible cooling Latent cooling Total coding Actual air flow Air flow factor Static pressure Load sensible heat ratio 18 SEER 0 Btuh 0 Btuh 0 Btuh 1400 cfm 0.035 cfm/Btuh 0 in H2O 0.90 672 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) Let side of home 672 16039 9949 343 344 Main Area of home 1303 35683 23390 764 808 Back Right Wing 361 13671 7194 293 248 Entire House d 2336 65393 40534 1400 1400 Other equip loads 0 0 Equip. @ 0.93 RSM 37534 Latent cooling 4439 r—TeIn I nnnc Cc0n0 A4n70 4Ann 4nnn Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. .` Wr 1 htsoft ` 2015 -Jul -07 09:52:08 9 Right -Suite® Universal 2015 15.0.02 RSU03051 Page 1 ,4CCA ...t Scans\Mist Scans\WrightSoft Projects\Aude.rup Calc = MJ8 Front Door faces: NE 367 Date...��1�� ........ Com... ,—�Iryd TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION D s 1 1 Ni n This certifies that ....... n..... has permission for mechanical installation . V P � !. � \- A- ... . i in the buildings�of ... ^. .............. at . ........; �°'` .:. ! ......... North Andover, Mass. Fee.�)r .:.. Lic. No.!..JK.... ......................... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer C �'(�!L -W- 1 l° ICS 1 TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 NORTH ANDOVER MA 01845 FURNACES, BOILERS, ROOF TOP UNITS, AIR CONDITIONERS, EMERGENCY GENEREATORS Date: jdr 3e 2� The undersigned applies for a permit to install the following at: Location 06 C v- ISO Owner of premises KdLQ (--t' t AaN e Au- & Address.201 Da (-e 5fpe-el— Name of mechanic {6J A' VAddress '�- Building occupied forte/ , ¢Q.y-e AC a Material of building � wo v a Kind of fuel Q6(.(( i�D �s ' Chimne L5 No. Of flues Size ell Chimney Thickness Lining If steel stack location Diameter Heig DESCRIPTION OF HEATING APPARATUS Kind of heater H /2,0 how many A? make • BTU In j Location in building i3a < Protected against fire as required_ l nr How protected Make See the State Code (Pertaining to Chimneys, Smokestacks and Heating Apparatus) ROOF TOP UNITS OR EMERGENCY GENERATORS No . Dimension Length Wdth Height Location of buildi how supported Size of roof timbers Material of roof timbers Span of roof timbers Distance on center Protected against fire as required How protected AIR CONDITIONS Kind of apparatus 41- laK make �P'��`%x [r HVAC FORM REVISED 11.04 The Commonwealth of Massachusetts Department of Industrial Accidents Office oflmresbgabens 1 =_ 600 Washington Street, 7rh Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: Bu_ ilding/PlumbingDectrical Contractors Applicant information: L, n Please PRINT legibly -- - -_� name: V iAc>e2 5 C A,�CD( �/2 cc -IV lot -6� W Q C 1 5 address: L�-6 t-st. tCLe ll NQ J city l.3(CL� state Ii�Y v ziP76( 5N phone# LJ 1 am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel 1❑ I am a sole proprietor and have no one working in anyacity. _ T ❑ Building Addition _ T am an employer providing workers' compensation for my employees working on this job. city: a�2,-J t'CLk Gt phone #• insurance co. V/T�<lt�sfst/il�t� ldtGiB� � f nolicv # WC dad ot0o A'a'l'l T ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: companv name: address: city: phone # insurance co. olic # k -- companv name: address: city: phone # insurance co. otic # jAttach additional sheet ,if necessary Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify n�r the pains Print name of perjury that the information provided above is true and correct. - Date Phone # 3 3 K2— official use only do not write in this area to be completed by city or town official city or town: permittlicense # ❑Building Department El check Board check if immediate response is required ❑Selectmen's Office contact person: phone #; ❑Health Department (revised Sept. 2003) ❑Other ACRO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/ 4/24/2015015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Boynton Insurance Agency 72 River Park Street Needham MA 02494 CONTACT Boynton Insurance PHONE (781)449-6786 F� No: (781)449-4269 ADDRIESS, info@boyntonins . com INSURERS AFFORDING COVERAGE NAIC # INSURER A:Harle sville Preferred Ins Co 35696 INSURED Morris Heating & Air Conditioning Inc 56 Mitchell Road Ipswich MA 01938-1219 INSURER B:Harle sville Worcester 26182 INSURER C:Harle sville Mutual Inc Co 14168 INSURER D: INSURER E: INSURER F: rnvEDAr_ce rFRTIGIrATF NI IMRFR- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 PREMISES Ea occurrence)$ MED EXP (Any one-person) $ 10,000 A CLAIMS -MADE Fx_1 OCCUR PERSONAL &ADV INJURY $ 1,000,000 X Form CG0001 (12/07) SPP00000016803T /1/2015 /1/2016 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 $ POLICY X PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED F;X_l SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOSX AUTOS RAOOO00016802T /1/2015 /1/2016 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 B EXCESS LIAB CLAIMS -MADE CMB00000016804T /1/2015 /1/2016 DED I X I RETENTION$ 10,00 $ C WORKERS COMPENSATION X C WSTATUS OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBEREXCLUDED? (Mandatory in NH) N/A C00000019816T /1/2015 /1/2016 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Evidence Of Insurance AUTHORIZED REPRESENTATIVE S Denneno CISR/JPM ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 (gmnn,;� m Thn ArnRrl name 7nr1 Inn^ =rn-ie4ororl mnr4c of Arnon y�t1-. ♦ �.��..�� PSA 9a ENO 4d NUMBER ,.� 07 SI-2014 ;NONE S48857271 x 8 BOB.- `. MAREUISS- i2 REST_. 15 SE%.IVI 1HG; Drys B--,', fit' f Y` lip, 4L�HLW 'pAUI . i o7 zanesi"'J . 0 310 MAIN ST DUNSTABLE, MA 01827-1803 " . 5 DD 07-21-2014 Rev 07.15-2009 y_� Load Short Form Job: - wrightsoW Date: Jun 15, 2015 Entire House By: For: Aude residence 201 Dale Street, North Andover, MA 01845 Design Information Htg Clg Infiltration Outside db (°F) 2 88 Method Simplified Inside db (°F) 70 75 Construction quality Average Design TD (°F) 68 13 Fireplaces 1 (Average) Daily range - L Inside humidity (%) 50 50 Moisture difference (gr/Ib) 50 28 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 Btuh 0 Btuh 0 OF 1400 cfm 0.021 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Lennox Trade Cond XC21 Coil CBX32MV AHRI ref 5991265 Efficiency Sensible cooling Latent cooling Total coding Actual air flow Air flow factor Static pressure Load sensible heat ratio 18 SEER 0 Btuh 0 Btuh 0 Btuh 1400 cfm 0.035 cfm/Btuh 0 in H2O 0.90 672 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) Let side of home 672 16039 _ 9949 343 344 Main Area of home 1303 35683 23390 764 808 Back Right Wing 361 13671 7194 293 248 Entire House d 2336 65393 40534 1400 1400 Other equip loads 0 0 Equip. @ 0..93 RSM 37534 Latent cooling 4439 T. -.Tel n nooc ccono A1n72 1Ann IAOO V I /1L0 GJJV JJJJJ T Zvi v — I Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2015 -Jul -07 09:52:08 ^— + wrilghtSOW Right -Suite® Universal 2015 15.0.02 RSU03051 Page 1 ACCK ...t Scans\Misc Scans\WrightSoft Projects\Aude.rup Calc = MJ8 Front Door faces: NE Date .. . � U.1. ...k'15 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................... � � Qr1 '..... e............................................................. has permission to perforni,3 r....�................`2,/ P � 5S ................................................... wiring in the building of............................e— -................................................... Zai 11 Cj -.�- .............. 0 '-S .............. at ...............................................�........................................ ...O orth Andover, M s. UD ` Ii1 �`ee....... Lic. No .............. ........... ECTOR ELECTRICALINSP Check # ld � n� Cs t Off cial .0 a Only ConUyw►Lcvaalth p� madsae"iid ccyy�� Permit No, ! V ..UePar� o� �ira �arvkae Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev, 11071 teaveblank APPLICATIONFOR PERMIT dance h ERMITthe TMassachusetts Electrical � OPERFORMELode �ECTRICALaWORK All work to be perform i Date (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) /a To the Insp ctor of Wires: City or Town of:� By this application the undersigned gives nottce o his o h intention to perform the electrical work described below., Location (Street & Number) 20/ 7Jr'/e. S� Telephone No. Owner or Tenant Owner's Address (Check Appropriate Box) with a bullding.permit? Yes ® No Is this permit -in codjunction Utility Authorization No. Purpose of Building Vo]ts Overhead ❑ Undgrd � No, of Meters Existing Service Amps No, of Meters New Service AmpsVolts Overhead❑ Und rd g ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No, of Recessed Luminaires No, of Luminalre Outlets No. of Luminaires Na, of Receptacle Outlets No, of Switches No. of Ranges No, of Waste Disposers No, of Dishwashers No. of Dryers o. o Rer KW Heaters —_ 'Hydromassage Batbtubs Com letion o the oil owin table m be waived b the Ipso{cator No, of Cell.-Susp, (Paddle) Fans 0.0 Transformers KVA No. of Hot Tubs Generators KVA Swimming Pool gr n3 e ❑ - 0 _ No, o mergency Lighting Batte V Units FIRE ALARMS Na...of. Zones No. of Oil Burners No, of Detection an No. of Gas Burners Initigin. Devices o a No, of Alerting Devices No..of Air. Cond. Tons Space/Area Heating KW Heating Appliances KW oo o, o Siens Ballasts No. of Motors Total HP Local ❑ Data Wiring: No. of Devices or or L tXa [] Other a uivalent � OTHER: xnach additionaldetail if desired, or as.requirea When required by municipal policy,) Estim0 ated Value of Electrical Work: ��( 9 Work to Start: Inspections. to be requested In accordfor the ance iterfME an el of elects cal wok may issue unless INSURANCE CO RAGE:.1 Jniess. �vafijed by the owner, no p p . E the licensee provides proof of"liability, ifisin'ance includitig "completed gpexatioa" o'v6rage or its substantial equivalent. The force, and has exhibi epoof of same to the permit issuing office,. undersigned certifies that such coverage is in ND .❑ OTHER ❑ (Specify:) CHECK ONE: INSURANCE BOND er u that the Information --on this application is true and complete, 1 cert, under the,pains and penalties o p % n� LIC. NO,: FIRM NAME: e / % 1? LIC. N 0,: Signature l-^zZ Licensee: Bus, Tel, No.: (yapplicable, enter "exempt" in the license number. ine.) Alt, Tel, No,:' Address: work re vires Department of Public Safety "S" License: Lic, No, *Per M.G.L. c. 147, s, 57-61, security q �0,1his re nsre does I am the (check one) ❑ ownerOWNER°S INSURANCE "4YAIYER: 1� aware that eb waivett e Licgnsee does.not have the liability insurance coverage norma y required by law, By my signature below, I he Y PERMIT -P Owner/Agent Telephone No. gignature O CA IV -e -I s _-47 1. s The Commonwealth ofMassachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): %��jg/�—✓ . Address:_ - City/State/Zip:_ x Cw z: � OAK Phone #: ?7 % Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ T am a em to er with 4. ❑ T am a general contractor and I ' - p y 6. [] New construction employees (full and/or part-time),* have hired the sub -contractors 2.X Tam a sole proprietor or partner- listed on the attached sheet, z 7 E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g, E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. F1 Plumbingrepairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12,❑ Roofrepairs insurance required.] t employees. [No workers'. 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submitthis affidavit indicating they Ric doing all work and then hire outside contractors must submit anew affidavit indicating such. rContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job .site information. Insurance Company Name:. e S , . 2 b /I— x e cz� - - Policy 4 or Self -ins. Lic. #: _ Expiration Date: lob 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 requiredunder Section 25A ofMGL 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 DTA for insurance coverage verification. -Ido hereby cerci under the pains andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone M Information and Instruction's 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 ofhire,• express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials -Please be sure that -the affidavit is-completeY lete-andpp rinted leg ihl: TheDe adinenfhas rovided a s ace at the bofiom p p- P ----- of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The 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 Cmmonwoa Ith oassarliusPtts DeparUxzeut ofladuMal .Accidents O fAce of Inyestigations 600 Wasbiugtm Stzeet Boston, MA, 02111 Tool, # 6X7..727-4900 at 406 ox 1:- 87WASSA.B., Revised 5-26-05 Fax # 617-727-7749 Date. 'rot 4, o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . W! , '/ .. �i'' c �, r Ile ..... , , has permission to perform ..... ......................... ,plumbing in the buildings of .. ... ne T ................ at ................................ , North Andover, Mass. Fee ,..... Lic. No. �. �. �.. ..l. }- .".,.......... . j PLUMBING INSPECTOR Check # > al 4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New rl Renovation (Print or type) Installing Company Name Address N of Replacement 11 FIXTURES Date Permit # Amount Plans Submitted Yes ❑ No ❑ Check one: Certificate ❑ Corp. 0 Partner. 11 Firm/Co. Name of Licensed Plumber: _� Insurance Coverage: Indicate the pe of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner❑ El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By: igna ure ot Licen—s-e-aum er Title Type of Plumbing License City/Town icense IN um er Master ❑ Journeyman ❑ APPROVED (OFFICE USE ONLY r 6154 Date....(. ..2.................... f HOR7M � ° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ........................................................... �!G ................................. has permission to perform ........ /1. T l a w ........................................ wiring in the building of ................ c................................................... at ........... 5�............................ North Andover, Mass. a Fee..l/b...... Lic. No. ............. 20E ...................... . ............ ..... ...... ELECTRICALINSPECTOR 1 q Check # rV0 DORNBE 'OBPl1BMSAF6/Y _ l'rxmit No. to Z . BOAMO�FFBPBPREYFIVIWRF�ULgg7Ig1 M7aaaw Occupmy 3 Feet Checked A.PPUCATTONFOR PERMTITO PERFORMELECTRICAL p WORK ALL WORK TO BE FERPORMED BY ACCORDANCE WITH THE MAssACHUSSTS ELBcm :AL CODE, 527 CMR 12:00 l (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perforin the electrical work described below. Location (Street d Owner or Tenant 's AAA- Ownerress `.-• is this permit in conjunction with a building permit Yes o (Check A ) PProP� Boa Purpose of Building V � 9. t Existing Service Amps Volt) New Service Amp��/ olts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Na of Liahtiry Pico No. of Receptacb Ou No. of Switch Ontteu No. of Rw%m No. of Dispoub No. of Dishwuhms No. of Dryms No. of Water Neaten No. Hydro Manage 7 eG r C Utility Authorization No. OverheadUnderground 0 No. of Meters Overhead Underpound C3 No. of Meteni l�o�s BNtery FIRE ALARMS No: of Debwm and loidad% DrAm No. Of SMURM Na of Sam Co�dDeHoea Local Conrrectiom No. of Zones b OTHER • 4 u h - n �l a ` husixeQNam a Pt1o<rrltbbetec}snrnbafMarsd>tserlGamlLawa e M orbateds WapV U NOQ I�giliemdondpioddaaablre�on Y) 4 ayouhwatbdedY@4�PL�id�lte d type oaerrgby MiA�FZrWMD e,*f e"' -M wakioSm a �" j l // dvaliedEb �� It�"Ir syredurtd,r Pnnlbdpajtry. E MNANffi % Li=WNa :6;Zr9 Sivan 7 �r7�7 (�� ! ( l(� h fJ , 4 e r �' �� 1� &aasTMNa fA 3 - fir : — I awr�xsn�ttArlc�wAlvE�,Ianaweethrcit�I� AtT�,Na a ardthetrrp�sgnesaeandispmit�piasimvrr>�hestinwheatat � o� ° Uzq*dbY eebCff0WL " (Please check one) Owner Q Ageat ' Telephone No. pMWr FEE 1 Jim LUIMMUP /1'L flu n Vr irir1a]M%,1JvLa.i i L2 DEPAWMENT FPUNKSOM Y Permit No. BDARDOFFJREPREVffMWRFX,i LVnVS aR12-W Occupancy & Fee Checked -� APPUCA77ONFOR PERAIIT'TO PERF RMELECTRICAL WORK S ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSAC ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform,ttheelectrical work de ribed below. Location (Street & Number) a0l a/c $`/- Owner or Tenant man ((- Nud c , Owner's Address is this permit in conjunction with a building permit: Yes [!I -No [:3 (Check Appropriate Box) Purpose of Building r e`"O d `t I Utility Authorization No. Existing Service Amps olts Overhead Underground No. of Meters New Service Amps....L.V olts Overhead Im Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work C c No. of Lighting Outlets , No. of Hot Tubs No. of Trmstornrcn Total KVA No. of Lighting Fixtures 3 Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bomer FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. TOW Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Device No. of Sounding Device No. of Dishwasher Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local 0 Municipal Other No. of Dryer Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Ballads No. Hydro Massage Tuba No. of Motor Total HP OTHER - b&zff=Covwp RzuaiDlhewq*e nawCfMessechl ftCk IedLSWa Ihmeaa=tLieb*is>raraePOL-Yid*gCmT#Eff7 alssut>�rrialec}ivaist YIsS E' NO M It>awaftrsWdvai WdGf9=lD lead YM r)cuhmdrd1zdYE5,ph=1rtddeQtetypecfaraageby 'dladargdle bac BCND C MMER Bk*"DAe EMm*dVaheofE1wWcdWak $ r0l�IDDSW� / / � Fill �Per�afpoW.-r,� ao Ia u C f l,clr / f // CCJJ/ Lioarr�Na o w+ � s /Z &I doe- %� � 1 N Btlsk=Tad.Na A]LTdNa 33b.20E (03- Y37- 59,27 Ge % ys?- 6,233 'SMJRANCEWANMIamawaedNidleLimwdoesmtharetheiaua=aNaWarilsagivahtasmWWbyNb=d>t mG=dLam IysgA=ondisp=iw*etimwaiwwdlit;mgi M01 check one) Owner � Agent Telephone No. PERMIT FEE 3 69 /r- 6 lr,- eg e- 6— l Ll --os— 1z- 13—C dr�- 3 __ le'4!� f T NORTH 0 Date f/3;�G." TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .�%�� .. C%/t-:� has permission to perform ... At -A .(. s . (r.'l!�................... plumbing in the buildings of ..l%,... c- r% ....................... at ...,2/....0/-/. i- -t ............... e- Andover, Mass. Fee. J. r ... Lic. No./. ........... �% ... ^ ..... . PLUMBING INSPECTOR Check # c , s 67u0 P 14 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location of New Renovation Replacement Plans Submitted Yes ❑ No ❑ (Print or type) ofd g Check one: Certificate Installing Company Name arr n a l?o ❑ Corp. Address r� �17/1' ��¢� L Partner. Business Telephone 3 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy 0 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature I Owner ❑ Agent 1-1 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 tate PlumbinWCodea d Chapter 142 of the General Laws. By: =ignarure o 1cense um er aalrm' Title � T pe o�f Plumbing License City/Town icense um er Master [T Journeyman 1:1APPROVED (OFFICE USE ONLY n--1 1' i i ; ------------ MMM ---MMMMM --- . ,. • MMMMMWMNN=MMMM0MMMMMM���� MMMMMMMMM MM (Print or type) ofd g Check one: Certificate Installing Company Name arr n a l?o ❑ Corp. Address r� �17/1' ��¢� L Partner. Business Telephone 3 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy 0 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature I Owner ❑ Agent 1-1 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 tate PlumbinWCodea d Chapter 142 of the General Laws. By: =ignarure o 1cense um er aalrm' Title � T pe o�f Plumbing License City/Town icense um er Master [T Journeyman 1:1APPROVED (OFFICE USE ONLY n--1 I Location_ s No. - Date ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ IV Check # i 31 Building Inspector TOWN OF NORTH ANDOVER BUILDING.DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: � l DD SIGNATURE: Building Commissioner/1IjisRector of Buildings Date SECTION 1 -SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: or 0c4e -r 69 8 23 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Res; de, la S.2 2, ! _3 Zoning District ProposedUse Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 3 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Zone 1.8 Sewerage Disposal System: � Public a Private ❑ Outside Flood Zone 8" Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT i ' toric IS rIC : Yes No 2.1 Owner of Record N At- I C 9v c>I e o/ Aodf sT Name (Print) Address for Service : Signature Telephone 5/c ,9`t Gk h " e- 2.2 Owner df Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ SO J, ot.� Licensed Construction Supervisor: S n 73 3/ License Number c/ on �/r,,, ee rr /,/ 0-7 o S,? Address (,o--3 y3%—,,Q%%h Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Sc otf- Jr (, l/ Company Name Registration Number 9 C�f.`�¢�'.-t %Lal � oytc��h d--�� ti Address 2 If _11� 0.3 — Expiration Date Signature 107 Telephone v rn A t SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 §„ 25c(6) Workers Compensation Insurance affidavit must be completed and submitted, with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: 0.. MCw A On ac,& y -F FY'Si.�• I SECTION 6 - ESTIMATED CONSTRUCTION COSTS i Item Estimated Cost (Dollar) to be Completed by permit applicant _ OFFiCIA USE E)NLY 1. Building 9rO O G.6 . 2 G (a) Building Permit Fee Multiplier 2 Electrical o'f V (b) Estimated Total Cost of Construction 3 Plumbing / (j p 0 0 Building Permit fee (a) x (b) _ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+59-1y, 00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, / as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION I, —,.\ C 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 S Cart Print Name SiNature of Owner ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TDABERS 1ST 2 ND 3 SPAN DEMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING C014NECTED TO NATURAL GAS LINE • ALO . F � 1 .L._ Town of NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT p/Ss v� PERMIT NO.: PROJECT: 01 y�'O?c� Lt/3�y 8a1-� Ibd DATE: �/911S e9_ UNIT NO.: FLOOR: z Vlfilfd6: r4 BUILDING NO.:00/ REMARKS: c Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector - Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector -Electrical - final Plumbing and/or gas - final Other: -ate: Date: Date: Inspector Inspector Inspector 'ire Dept - I burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of O # Inspector Inspector Inspector -orm 1996 A&I.n P— ana_7nnn __ 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 K AT LOCATION: Assessor's Map Number SUBDIVISION STREET .4-, 6 / lP OFFICIAL USE ONLY PHONE &03 y3 �7- 9 `i', O PARCEL LOT (S) ST. NUMBER 9 O 1 TION A15MINISTRATOR DATE APPROVED T tr- DATE REJECTED TOWN PLANNIM �" DATE APPROVED &66LIO-7— DATE REJECTED c� /��'tG�� r�f..,� v►.�C�� _,^ COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT VIRE DEPARTMENT DUMPSTER PERMIT RECEIVED BY BUILDING INSPECTOR DATE FORM U - Revised 6.05 JMC �?y 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: oT 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: Fire Department Sign off Dumpster Permit Si ature of Permit Applicant 0 or, os Date ..s: a.vrssnsursFVV Usn Uf iviassacnuserts Department of Industrial Accidents Office of Investigations 600 Washington Street r Boston, MA .02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 'I Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): (' n n in'yc Address:___2 6 r: -FF','rt Rai City/State/Zip: 4464 Q30l�one #: t/� 7 9 e//p Are you an employer? Check the appropriate box: 121 am a employer with 4. 1:11 am a general contractor and I employee's (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet I 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.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' COMP. insurance required.] "Any applicant that checks box # 1 must also fill out the section below showing the;, w k 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 T Homeowners who submit this affidavit indicating they am doing all work and then hieoutstide msa ors must submtonnt a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' ccmtp, policy information I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 6(/ # (7 93_•� l�� Expiration Date: Job Site Address:_ 9 O 1 G\ e S?— City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy Dumber d 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 the pains andpenalties ofperjury that the information provided above is true and correct. Oficial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/Llcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Insnectnr 6. Other I - Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employ on in the service ® another under any cong to provide workers' compensation for tracet of hire w , Pursuant ' this statute, an employee is defined as ...every P� express or implied, oral or written." An employer is defined as an individual, partnership, association, corporation or other legal entity, or any ooor�more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the of the or the owner of a dwelling house having not more than three apartments cencdwho onstructioneorthrepa�ir work on such adwelling house nt dwelling house of another who employs persons to 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 rt your situation and, if necessary, supply sub-contractors) name(s), address(es) and phone numbers) 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 advised that this affidavit may be submitted to the Department of Industrial employees, a policy is required. itso be sure to sign and date the affidavit. The Accidents for confirmation of insurance pli coverage. n forthepermit or license is being requested, not the Department of should be returned to the city or town that the apph P Industrial Accidents. should you have anyyquestions tthe cumber the sted below. w or if ySelf ou are companies should enter their compensation policy, please call the Dep 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 b ato of the affidavit for you to fill out in the event m the Office of Investigations has to contact you regarding the app applicant er. in addition, an Please be sure to fill in the p r lie numb a h willgiven yeae used r, need only submit a reference one affidavit indicating current that must submit multiple pe app writeuld policy information (if necessary) and under "offib cite stamped or mararkhed by the city or town may be provided to the or town)." A copy of the affidavit that has be officially stamped 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, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LAPOSCI DATE (MMIDD/YYYY) 05/19/05 2RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE "canto Insurance - Salem 224 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TYPE OF INSURANCE Salem NH 03079 Phone:603-890-6439 Fax:603-890-6521 INSURERS AFFORDING COVERAGE MAIC# NSURED INSURER A: INSURER B: GENERAL LIABILITY INSURER C: Scott Lapointe 9 Griffin RCI Londonderry NH 03053 INSURER D: INSURER E: "AVFRA [1.Fr. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 511 _TR A00, NSR TYPE OF INSURANCE POLICY NUMBER DATE D DATE MMIDDIYY LIMITS GENERAL LIABILITY b EACH OCCURRENCEEa PREMISES (Ea occurence) $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE r] OCCUR MED EXP (Any one person) $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO- El LOC JECT I AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea aeddent) S BODILY INJURY (Par person) $ 1 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS - PROPERTY DAMAGE $ (Per accident) I i GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC $ AUTO IRANY AUTO ONLY: AGG $ EXCESStUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND OTH$ ITORY LIMITS I I ER EMPLOYERS! LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER(MEMBER EXCLUDED? WC731S325698023 12/20/04 12/2.O:i!05 E.L. EACH ACCIDENT $ 100000 EL. DISEASE- EA EMPLOYEE $ 100000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 421-0151 CERTIFICATE TOWNAND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN NOTICE TO THE CERTir CATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town of Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Andover Building Department 36 Bartlett Street REPRESENTATNES. Andover MA 01810 AUTHORIZED REPRESENTAYIVL- ACORD 25 (2001108) 0 ACORD CORPORATION 1988 Y SCOTT E. GILEAS, P.L.S. CRANK S GILES) P.L.S. 50 DEER vMADOW ROAD NORTH ANDOVER, MA 01845 www.FrankGilesSurvey@aubi.COM TEL. (978) 683-2645 (978) 683-3924 SURVEYING LAND PLANNING CONSULTING October 9, 2004 TO: Town of North Andover FROM: Frank S. Giles, P.L.S. j RE: Letter of verification LOCATION: Map 37B, Parcel 23 AUDE, MARK S. & STEPHANIE N. 201 DALE STREET NORTH ANDOVER, MA 01845 deed 6983 pg. 324 1, Frank Giles, have observed an encOmpassing perimeter area of 400 feet 201 Dale Street The area, is free from wetland vegetation. The proposed addition to 201 Dale shall not cause any substantial impact to the water quality. ' Please feel free to call us for any questions you may have! Sincerely, ,fir Frank S. Giles, P. . . M tv `moo m c G y co:, C �' O : Ci 10JCCU V. m u Q fluO imy ,N �` �► 3 cmM " •' o ?v E O y _y c OEm Amo - n" CD 4D COC •; �0 C c �mg co1.2 o 2 0` C Z m � O TQC O W C Co�� m w ` LL •a mw cw .... LU W— CA w� Z E C3 ID o z y a ���= s A _ CD CL3� Al 5 G w' U O 0 MI h w C�7 O a L z CD o c 0 ICD CM y O — CD ca m m W cc w C aft W 0 0 o L eov o m W a cm y =3 Cc W Q .a o CD �zm , V � 0. .y D zw9 o A Gc a00 �v+ Uwa w" `moo m c G y co:, C �' O : Ci 10JCCU V. m u Q fluO imy ,N �` �► 3 cmM " •' o ?v E O y _y c OEm Amo - n" CD 4D COC •; �0 C c �mg co1.2 o 2 0` C Z m � O TQC O W C Co�� m w ` LL •a mw cw .... LU W— CA w� Z E C3 ID o z y a ���= s A _ CD CL3� Al 5 G w' U O 0 MI h w C�7 O L z CD o c ICD CM y O — CD ca m m W cc w C aft W 0 0 o L eov o m W a cm y =3 Cc W Q .a o CD �zm , V � 0. .y D ZONING DISTRICT Rl SUBJECT PROPERTY Map 37B, Parcel 23 AUDE, MARK S. & STEPHANIE N. 201 DALE STREET NORTH ANDOVER, MA 01845 deed 6983 pg. 324 SEE PLAN#2100 (N.E.R.D.) goo' OLD FLAG y #F-4 r °/ 3 t % WETLAND MAP 37.13-0024 TIMMONS 203-205 DALE ST ,I,%, - 3 ,�i�b,SSZt S ob tTj ~= 00 �z d FLAG #A -I MAP 3713, PARCEL 22 SALVETTI, AUGUSTINE J GRACE R SALVETTI 185 DALE STREET PLOT PLAN OF LAND LOCATION #A-3 201 DALE STREET RTH ANDOVER, MA DRAWN FOR MARK AUDE MAP 37.B-0024 TIMMONS 203-205 DALE ST z U I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING 00 BY LAWS OF NORTH ANDOVER, MA. AT THE TIME OF CONSTRUCTION. THE OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. CACLIENTS\AUDE \PLOT PLAN.DRG LOCUS a SITE DEVAL L PATRICK GOVERNOR JOHN W_ POLANOWICZ SECRETARY CHERYL SARTLETT, RN COMMISSIONER The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 ADVISORY REGARDING POTLUCK EVENTS RE: Implementation of Chapter 230 of the Acts of 2014, "An Act Relative to Potluck Events" DATE: October 2014 On August 5, 2014, An Act Relative to Potluck Events was signed into law. Under certain conditions, the law exempts food brought to a potluck event from regulation by the Department of Public Health (DPH) or by any local board of health (LBOH). To implement the law, DPH is providing guidance to LBOHs. Under Chapter 230 of the Acts of 2014, all the following conditions must be met for the event to be considered a "potluck event": • People must be gathered to share food at the event; • no compensation may be provided for bringing food to the event; • the event is sponsored by a group of individuals or by a religious, charitable or nonprofit organization; • the event may not be conducted for commercial purposes, but money may be collected to support the religious, charitable or nonprofit organization; and • the participants at the event must be informed that neither the food nor the facilities have been inspected by the state or by a local public health agency. A business establishment dealing in the sale of food may not sponsor a potluck event. Additionally, food from a potluck event shall not be brought into the kitchen of a business establishment dealing in the sale of food. If all of these qualifications are met, the event constitutes a "potluck event' under Massachusetts law and food brought to the event for consumption is exempt from regulation by DPH or by an LBOH. It is important to note that under the law, participants at the event must be informed that neither the food nor the facilities have been inspected by the state or by a local public health agency for the event to qualify as a "potluck event" and be exempt from regulation DPH or by any LBOH. Participants do not have to be members of the sponsoring organization for the event to be considered a "potluck event." DPH also notes that the most commonly -reported food preparation practices that contribute to food borne illness are improper holding temperatures, poor personal hygiene, inadequate cooking, contaminated equipment, and food from unsafe sources. For additional information on food safety, organizations looking to conduct potluck events may wish to consult the USDA's publication "Cooking for Groups: A Volunteer's Guide to Food Safety," available at: http•/Iwww fsis usda gov/wps/nortal/fsis/topics/food-safety-education/get-answers/food-safety-fact- sheets/safe-food-handlin cooking for-groups-a-volunteers-Qvide-tafood-safety/CT Indexl_- Session Laws: Chapter 230 of the Acts of 2014 Acts 2014 Chapter 230 AN ACT RELATIVE TO POTLUCK EVENTS Page 1 of 1 Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same as follows: Chapter 94 of the General Laws is hereby amended by inserting after section 328 the following section: - Section 328A. For the purposes of this section, "potluck event" shall mean an event that meets all of the following conditions: (1) people are gathered to share food at the event; (2) there is no compensation provided to people for bringing food to the event; (3) the event is not conducted for commercial purposes; and (4) the participants at the event shall be informed that neither the food nor the facilities have been inspected by the state or a local public health department. Notwithstanding any general or special law to the contrary, neither the department of public health nor any local board of health shall regulate the serving of food that is brought to a potluck event sponsored by a group of individuals or by a religious, charitable or nonprofit organization by individuals attending the potluck event for consumption at the potluck event. Individuals who are not members of the group or organization sponsoring the potluck event may attend the potluck event and consume the food at the event. A business establishment dealing in the sale of food items shall not sponsor a potluck event. Potluck event food shall not be brought into the kitchen of a business establishment dealing in the sale of food. Approved, August 5, 2014. 1.++..... //«....1....:..1..+...........-./7- —... 10,,,.,..--T ..._...! A ..a../nr%I A rn–'— n /ten inn t A U72Zli-uL 15:5a kAA Ula air 333U NORTHERN ASSOC + ARTHURRGILLIGAN 40001/001 _ MORTGAGE INSPECTION PLAN 401 SOUTHBROADWAY,LAWREE R EHMA.0 843 35202 TIE (9 85 837-3TES 335 FAX:(978) 337-3336 MORTGAC+OR: MARK E 5TEPhANIF AUDr DPED ".F": . 4323 / 241 LOCATION: 201 DALC 5TK=T PLAN REF: #2 100 CITY,5TATE: NORTH ANDOVER MA. 5CALE: 1 "-40' DATE: JULY 25,2002 JOB; 202;07073 LOT 0 2 13. 4' DALE STREET CERTIFIED TO: WA5MINGTON MUTUAL BANK Flood hazard Zone has been dCtzrmined by scale ands not necessarily accurate.Until definitive plans are issued by MUD and/or a vertical control survey 15 performed,precise elevations cannot be determined. rvo:C rnvy rnortyap9 Inrpastwn uar 1-30"t rw an,aha lt�eu6a �rWied y u nQi�in.t Tl�Y—y! d", si�sWdttnnpp et mr �rvattan R6 P� `�-ad J OHN diem grin d - emd .ftitd an, ahs,an ap,s{1Yaau pr --in# dstawtrwaiie nae to }�r�epa.�if% n lkka eri�saaa ew "finrotwn and Z baeW—at hftf-, aawww. andof walk amt ether eewt of ..mrd and jmaerp *wor athar 94VpAie. 96— �e>eei,taa. fna w, w" noweeWs-AitY1brdomaDar .eouLri+.D ha*l aarldniiaxa ►yY auLyorw WAar he% eke said raortyayse and tta —ipw in aomwabion vAtl: tta pryMad--ttasaw JW�tng t> —id rtwtyapen i'hw m t➢is avrddnc. ilk the T«knieol SYandarda J6� Ye ht f lm-. Insta,Cwna w ado}aad by the Moaemkelraltr Board eJ ibryiat news of AeJtrne..a1 t"st iara and land Sw�sy *60 CMP. dos. If stain 0= iu my 7_1kss4ona1 WT"wn [Mt 1ha wrvotvroa aho— eanfb_ W&A Ow latad xMir p Aa.iaantot dtm~i&nal srebuk retaprreiit fAv at eha ilwu of a ,ii veti*n cr toempt under praviriaw.s of AML 041 40—A Seo. 7. t, Pro /House ie nw —.Mad Hwe,d G = Jia/g� w 11% a Rood nneart Arra rmsfwn in iwmffi9 nt to datarmim Baal lYarmd. Aad Ar"ard ddter"LOW6 jh N iatgt %load lnrvaanca Batt Lhv rat._. �-a-93 Earn 3l•U�,eSNh©F'j DA 4,5:7 � r S, 4 J/ q Date........ j ./... .�.9 NORTI♦ 3?0 ;<�`".:•'4 a TOWN OF NORTH ANDOVER ' p PERMIT FOR WIRING This certifies that .......I.) !.r...�. �= ......f.0 // ' T.r .. ............................ has permission to perform .............: { r � wi^ in the building of ' ............................. at r. ;� ............ f� ,North Ando er, as3� I I7 Lic. Noll �O v l �........ ........>�� �. Fee.. .... .... ............ .... ..........�.�. ELECTRICALINSPECTOR Check # ?� V _)o Js�t= COmmonwea& of Vj aldac1zu4e1b aCJe,oartnien� o�.}ire �ervices BOARD OF FIRE PREVENTION REGULATIONS 0" clal Use Only Permit No. Occupancy and Fee Use (Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (iiMEC), 527 CMR 12.00 (PLE:ISEPRINTININK OR TYPE.ILL INl''ORLI,117OiV) Date: yr�rrjrc o City or 'Town of: /Un To the I/ I es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Ll Owner or Tenant l; Q 7 / Telephone No. Owner's Address Is this perutii ill conjunction with a building permit? Yes ❑ No (Check appropriate Bo.-,) Purliose of Buildings (f (.� Utility authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of tlIeters New Service Anips / Volts Overhead ❑ Ulidgrd ❑ No. of Meters. Number of Feeders and Ampacity Location and Nature of Proposed Electrical York: Lu I oe-e r- - Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is fit force, and has exhibited proofofsame to'the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) 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. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIIUNINAiIIE: Buddy. Electric Inc LIC. NO: 12017-1 Licensee: Vincent B. Landers JR Siguatur.e L1C.N0. 23684 E (If applicable, enter"ercntpi"inthelicense number line.) Bus.Tel.No.:975-4 55 Address: 24 Colgate Dr T4+ _ And nypr� MR4a n1Alt. Tel. No.: rm OWNER'S INSURaCE WAIVER: I aaware that the Licensee does not have the liability insurance coverage normally required by law. B\' Illy signature below, I hereby waive this requirement. I am the (check otic) Elowner ❑owner's atent. Owner/Agentr Signature TCICphUiIC NU, P%:RaIIT FL•E: � �•••- ••_ ,-•.,.,,.g <uure Ilia), oc n•arved ov 1/10 /its ector o%Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Falls No. of 'Total Transformers KVA No. of Lighting Outlets No. of I -lot Tubs Generators KVA No. of Lighting Fixtures Stiiimming Pool .o bove ❑ Ili- ❑ 1 0.0 mergency Ig ltnlg rtrd. rnd. Batte Units No. of Receptacle Outlets No. of Oil BurnersFIRE ALARlNIS No. of Zones No. of Switches No. of Gas Burners No. of lletection and Iuitiating Devices No. of Ranges No. of Air Cond. TotTons No. of Alerting Devices No. of Waste Disposers Heat Puurp Number Tons -- KW --+' No. of Self -Contained Totals: Detectiotl/Alertino Devices No. of Dishisashers Space/Area ?;•seating XW Local Itilunicipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems: No. of Devices or E uivalent No. of Nater Heaters KWSmits 1V o. of No. of Ballasts t;ata'r'Jiriug: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of lIOtors Total IIP Telecommunications V1 irulg: _I Nc. of llevices or E uivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is fit force, and has exhibited proofofsame to'the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) 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. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIIUNINAiIIE: Buddy. Electric Inc LIC. NO: 12017-1 Licensee: Vincent B. Landers JR Siguatur.e L1C.N0. 23684 E (If applicable, enter"ercntpi"inthelicense number line.) Bus.Tel.No.:975-4 55 Address: 24 Colgate Dr T4+ _ And nypr� MR4a n1Alt. Tel. No.: rm OWNER'S INSURaCE WAIVER: I aaware that the Licensee does not have the liability insurance coverage normally required by law. B\' Illy signature below, I hereby waive this requirement. I am the (check otic) Elowner ❑owner's atent. Owner/Agentr Signature TCICphUiIC NU, P%:RaIIT FL•E: � Date. o? - Ca a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ''This certifies that ��. `... '..4`O � N� r has permission to perform � 6 Lk Clow � t' -e U-VtiAU 1-- P P •• plumbing in the buildings of . Q V" : ...................... at ... ......� p �..... .�............ , North Andover, Mass. Fee. a ..Lic. No.(9��.! . .. • �tO2Z. /�(l PLUMB NG INSPECTOR Check # CPS H 5446 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ll ' Date ���'L d+��2 Building Location Q/ i9% S Owners Name or)- 41 Permit # Amount Type of Occupancy iz t—S New M Renovation M Replacement ® Plans Submitted Yes E] No El (Print or type) Check one: Certificate Installing Company Name (r /�iJ� lel /�� Corp. G Address 0 0 �'d >'r MdN ST ❑ Partner. L "9,k/ Business Te epone 7 g f 4 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ID Other type of indemnity © Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance P Signature Owner ❑ Agent ❑ I l greby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumb'Ing Code and Chapter 142 of the General Laws. By: igna ure or Ocensea dumber Type of Plumbing License Title 1, "z City/Town cense um er Master ❑ Journeyman APPROVED (OFFICE USE ONLY i' i i i111�------------------------- ' ,D o -----------------------EMS -- no (Print or type) Check one: Certificate Installing Company Name (r /�iJ� lel /�� Corp. G Address 0 0 �'d >'r MdN ST ❑ Partner. L "9,k/ Business Te epone 7 g f 4 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ID Other type of indemnity © Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance P Signature Owner ❑ Agent ❑ I l greby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumb'Ing Code and Chapter 142 of the General Laws. By: igna ure or Ocensea dumber Type of Plumbing License Title 1, "z City/Town cense um er Master ❑ Journeyman APPROVED (OFFICE USE ONLY 4 Location A No. Y, Date 40wrN 14 TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ •,ssAGNUSEt'�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Ila oe- Check # ✓ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATL OR DEMOLISH A ONE OR TWO FAMILY DWELLING M& , BUMDING PERMIT NUMBER: DATE ISSUED: 7- ©S� SIGNATURE: Building Commissirner/IngWor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: A- ► A j1 37,52Y-X/ ;Z /-3 ` 4 `r Zoning District se Lot Area Fronts $ 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Regaired Provide Required Provided ReqWred Provided 1:5,2, 3/ ` 1.7 Wats Suyply NLG.L.C.40. § 54) I.S. Flood Zone Infomsuion: 1.8 3ewera6e Disposal System Zero O.. Flood Z. ff Municipal i� On Site Disposal System ❑ Public Private ❑ SECTION 2 - PROPERTY OWNERSElIP/AUTHORIZED AGENT 1.77;1 ic; lct(!Ct: N633 P,10 2.1 Owner of Record Ma rK !; £ 6-feD%a n, e -11 Rude 2 O/ � ST Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Sistnature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ C- ,:L , Licensed Construction Supervisor: C S 07-13/6 License Number Gad kQft dtiAer rtn Al � 0.306-3 1 G j Address 71(,/b(0 ,,,zr Ag� 603 — 51Q Expiration ate Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ .�UIIT I ���o � ,t >�� _ K-19 4- Company Name Registration Number ' Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 g 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this in the denial of the issuance of the bu4mt permit. Signed affidavit Attached Yes ...... Air No ....... 0 SECTION S Description of Proposed Work (check A anWfim le n New Construction ❑ Accessory Bldg. ❑ Failure to provide Existing Building kr .I Repair(s) ❑ 1 Alterations(s) 0 I Addition ❑ Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: I SF.rnm 6 - RSTIMATRD CnNCTRTTCTinN VncTQ Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY ,.: 1. Building S-0 S:Z ' .9y (a) Building Permit Fee Multiplier 2 Electrical �'? p (b) Estimated Total Cost of Construction 3 Plumbing 00 Building Permit fee (a) x (b) ' 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 (0 , 9 V Check Number aL' %- 11vL'1 i m v n LIIl.' ll Av i n%Jnxz A Y lVLI i V nJL %-VD rLA l,Ell W HEP1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, cl CV;6 t T, L a po; / /e ,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 � n Signature ot�ent Date NO. OF STORIES SI BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 b7. 2 3Ra SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION TurrTrut~ec X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W 600 Washington Street Boston, MA 02111 '°�M s •�� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): K– '�_0 0A3_7 fVC.7'/Q-X Address: �'l c� �. F�'v� 4 City/State/Zip: 1 n,., ,Q, d 03 0.53 -Phone #: (, 0J '% 3 7- 9 %yy Are you an employer? Check the appropriate box: 1. Er am a employer with �1,— 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. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [:1 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [:1 Electrical repairs or additions 11. F-1 Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infoTniation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: l�rne�,'rari tytterna�i��sa�/ r�o,✓� Lie. Policy # or Self -ins. Lic. #: C.c! c 7 31 S •3,� ,� 9 XQ2 3 Expiration Date:1.9,1,2 Job Site Address: 9 0 0-1e 3y' il/.City/State/Zip: (j4 yam" 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 riprisonment, 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 andpenalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of ab 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 iepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that.the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple 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, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia 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 I 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: -4—Signdfure of Permit • • �z 6/ 05— rDate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ACQRD,. CERTIFICATE OF LIABILITY INSURANCE OPID DATE (MM/DD/YYYY) KATCO-1 06 07 05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Santo Insurance - Salem HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 224 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem NH 03079 GENERAL LIABILITY Phone: 603-890-6439 Fax:603-890-6521 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: American International Group INSURER B: INSURERC: K A T Construction, DBA 9 Griffin Road Londonderry NH 03053 INSURER D: INSURER E: MED EXP (Any one person) $ COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY MM/DD/W N LIMITS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY EACH OCCURRENCE $ PREMISES (Ea occurence) $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE F -I OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ PC POLICY RO El LOC JET AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ A COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE WC6932743 12/28/04 12/28/05 TATWORKERS TORY LIMITS ER E.L. EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE $ 100000 E.L. DISEASE - POLICY LIMIT $ 500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS (;ERTIFIGATE HOLDER rANCFI I ATInM TOWNNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 400 Osgood St REPRESENTATIVES. North Andover MA 01845 AUTHORIZED REPRESENTATIVE James A Santo M%,%jrcu co kcuvuva) © ACORD CORPORATION 1988 Aude 3/4 bathroom Total Price and Quantity Page # 1 Item Code Oty Unit Price Phase 1 Bedroom 1 Bedroom 1 Base Dimensions: 8'0" L x 36" W x 8'0" H Division: 01 Plans and Permits BUILDING PERMIT (AVERAGE AMT FOR U. S.) Building permit fee, based on total amount of job. EA = Total job PER $1,000 = Per $1,000 of total job cost (contractor's cost) or job price (price to customer). Building Permit Fee Based on $ per 1,000 01.009. .0 $M Division: 02 Site Preparation CONCRETE SLAB Break up existing slab in bathroom with pneumatic tool and haul rubble outside to grade Concrete slab removal 4" 02.011. 5.0 SF CONCRETE SAWING Cut concrete with gas concrete saw, per inch deep Concrete sawing slab 02.051. 2.0 LF CERAMIC TILE FLOOR Remove ceramic tile Ceramic tile flooring removal, mastic 02.305. 28.0 SF CEILING COVERING Remove ceiling covering from ceiling joists Gypsum drywall ceiling tear -out 02.317. 32.0 SF INSULATION Remove insulation from open wall or Aude 314 bathroom Total Price and Quantity Page # 2 Item Code Qty Unit Price ceiling , Insulation batt removal 02.323. 64.0 SF INTERIOR WALL Remove wall coverings, Interior wall removal, drywall 02.324. 192.0 LF BATHROOM PLUMBING Disconnect, remove and cap Water closet removal 02.407. 1.0 EA SWITCHES, OUTLETS Remove switch or duplex outlet 02.426. 1.0 EA Remove bathroom fan 02.428. 1.0 EA Remove baseboard heating system 02.437. 2.0 LF BATHROOM CABINETS Remove wood or steel cabinets -- base, wall or island bathroom cabinet removel 02.505. 5.0 LF COUNTERTOP Remove countertop from base cabinet (NOT including disconnect) Countertop removal 02.506. 5.0 LF BASEBOARD Remove baseboard and shoe moulding, up to 1" x 8" baseboard Baseboard removal 02.507. 15.0 LF Division: 14 Plumbing VENT Aude 314 bathroom Total Price and Quantity Page # 3 Item Code Qty Unit Price Run new vent through existing roof 14.010. 10.0 LF WATER CLOSET 1 or 2 -piece floor mounted water closet within 5 feet of existing stack. White 2 -piece water closet 14.102. 1.0 EA BATHROOM SINK Rough and install bathroom sink within 5 feet from existing stack, including faucet, spray and two strainers. Intall bathroom sink 14.300. 1.0 EA Division: 15 Heating and Cooling DRAIN SYSTEM Drain system, disconnect and cap off radiator, fill system. Drain system 15.017. 1.0 EA TOE -SPACE HEATER Install toe -space heater under vanity or kitchen cabinet, 1250 watt heating element, remote switch and outlet included Install toe -space heater 15.233. 1.0 EA Division: 16 Electrical DUPLEX OUTLETS Duplex outlets 16.100. 2.0 EA GFIC Ground fault breaker 16.109. 1.0 EA Aude 3/4 bathroom Total Price and Quantity Page # 4 Item Code Qty Unit Price SWITCH Single -pole switch FIXTURE OUTLET Ceiling or wall fixture outlet (in addition to cost of fixture and switch) Ceiling Fixture BATHROOM FANS Exhaust fan and light in bathroom, incl. switch. fan unit supplied by clients Bathroom fan & light Division: 17 Insulation FIBERGLASS BLANKET Stapled to open framing or laid flat between ceiling joists on installed drywall Kraftback one face R-30 10" insulation Unfaced R-13 3 1/2" insulation Division: 18 Interior Walls GYPSUM DRYWALL ON NEW WALL -COMPLETE JOB Up to 300 SF of wall, nailed, or screwed into studs or furring, taped, finished and sanded 3 coats EA = Each job (NOT each sheet) Gypsum drywall new work up to 300 SF Division: 19 Ceiling Covering GYPSUM DRYWALL ON NEW CEILING Up to 300 SF ceiling, nailed or screwed to joists or furring, nailed, taped, finished and sanded, 3 coats. 16.115. 1.0 EA 16.120. 1.0 EA 16.203. 1.0 EA 17.017. 32.0 SF 17.033. 64.0 SF 18.000. 1.0 EA Aude 3/4 bathroom Total Price and Quantity Page # 5 Item Code Qty Unit Price EA = Each job (NOT each sheet) Gypsum drywall new work up to 300 SF 19.000. 1.0 EA Division: 20 Millwork, Trim PRE -HUNG DOOR Interior 1-3/8" door Stain grade jamb 2 sides casing Privacy lock @ $10 Pine, 6 Panel 3-0 x 6-8 pine six panel interior door 20.535. 1.0 EA Division: 22 Specialties MEDICINE CABINET Recessed cabinet with hinged window glass mirror door, overall size 16" x 22" Medicine cabinet 22.000. 1.0 EA GRAB BAR Stainless steel grab bar, 1-1/4" diameter, straight, with anchor plates. 24" grab bar 22.011. 1.0 EA Division: 23 Floor Covering CERAMIC TILE FLOOR Install ceramic tile on bathroom, kitchen, laundry room or foyer floor Thin set mortar Set ceramic tile, grout and seal with silicone Ceramic tile floor @ $4.00 23.222. 32.0 SF Division: 25 Clean-up DEMOLITION Removal of debris from demolition work, loading masonry, plaster, lumber Aude 3/4 bathroom Total Price and Quantity Page # 6 Item Code QW Unit Price and other tear -out debris - load dumpster from building by hand and haul to dumping ground estimated for one 15 yd dumpsters aditional dumpsters will be charged @$425.00 per dumpster. SF = Floor area of building Debris Removal 25.010. 1.0 EA Phase Total: 7,369.98 Grand Total: 7,369.98 K -A - T Construction 9 Griffin Rd. Londonderry, NH 03053 (603) 437-9440 To: Mark & Stephanie Aude 201 Dale R. N. Andover MA 01845 Job description Completely demolish the 3/4 bathroom down to the existing studs Remodel it according to the plans supplied by the clients & to the specification supplied with this proposal. This estimate is based on current material and labor coats A# material used will be in accordance to the job specifications enclosed. This proposal may with drawn by us if not accepted within 30 days Please sign and return with your 5% deposit of $368.00 please make checks payable to Scott LaPointe, Total estimated cost Accepted Accepted by $7369.98 ,5—dadate K, 7 ' 0,5— da te te J t;pard or u / BuiidingRe I HOME iMP �ulations and Standardsa Registration: CONTRACTOR Expiration; 129364 811312005 Type: DBA Scott LaPointe 9GRIFFIN RD Londonderry NFI03053 AdrryjnistraYOr ✓4 .� BOgRD 2``��a� license: CO 's SU" -DI IG efrtUmber• CS ST Ru071 pN SU ERVISO NS hdate: 071061193318 R Expires: ss 9 COTTJ GRIppINLA Restricted 00 X6/2006 Tr. no; 28j1 LO BOND RD O/NTF 2 ERRY NH 03053 C Comms_, ��J °ner I(A m m m OC 7x0 CO) F, C CO) .0 A06CD Z O O CL ato o p CL c �d CD O CA O O COD 'O d d CO) CO) O y d 0 O CD A y� Co CO) 0 CD O CD C C M10 C m o — « a Q ce = r c0Sa y m �m n z�CL�' m c B 0. ozm �' T �m—CL o m ,a m m o y r4 0 IE ?m m = > oma: p m a7sl = o en c m� 'b r a W. o o = r. : :• m : Cn m Cnm CV, v C 3m mq l"f O ti d d .� cn cosc y b �• CD yam? rn CT Lm t - n Z Er 1 cn z y� o cn o ro' C o m O G C ? O O OR.cp o M M v i 0=3 O C Date. G - IV: .4$—. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. 3'-�. �:�... �- Vis-- ...".� ...... . has permission to perform ....= -) ��-. �� ............... plumbing in the buildings of ... ................... .... ................. .North Andover, Mass. Fe�<G...... Lir. No......� .. .%�� ` PLUMB';W /4NSPECTOR Check !t �� i0 6lot 89 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New 0 Renovation (Print or type) Installing Company Name Address Name of Licensed Plumber: Insurance Coverage: Indicate the Liability insurance policy Owners N of l ance coverage Dy cnecxj Other type of indemnity TION FOR PERMIT TO DO PLUMBING Date X,, - /G- as— Permit # e" 4 Amount &6 Plans Submitted YesNo Check one: Certificate ❑ Corp. ElPartner. Firm/Co. ate box: Bond 14 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 1:1 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 Stat lumbing Co( agLhapte 142 of thg,03eneral Laws. BY igna ure orilcenseu riumoer Type of Plumbing License Title 3 �� City/Town icensL�Q3ie n e� Master Journeyman ❑ APPROVED (OFFICE USE ONLY Date..!`.............................. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that Ge ,t/� ....�...................P................................ ........... has permission to perform ��r 1? wQ,W;,. r .11............ pe pe j........ ..... wiringinthe building of. ,�.�. ........ .................................... -S .............. . North Andover, Mass. Fee. . Ga...... Lic. No .............. ...... ...�................... ....... . . ......... ELECTRICAL INSPECTOR Check # 5b4z JIM L UJMV1Uly "rA s .a n Ur Jrtrsa,,riL,,avaa.l i J --••• � -, DeWMEYrOFPUBLKSAFE7Y Permit No. BOARDOFFLR R&MM70NRB9JLW0NS27(,1 V 1Z - Occupancy & Fees Checked APPUCATTONFOR PERNffTO PERF�STSMELECrRICALCODF,ELECMCA.L WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHU 527 CMR 12:00 LO-S (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) / Date Town of North Andover The undersigned applies for a permit to perform the electrical Location (Street & Number) ao l W, below. To the Inspector of Wires: Owner or Tenant Ala^ !< N v d e - Owner's Address . 4- ` Is this permit in conjunction with a building permit: Yes [!:rNo (Check Appropriate Box) l Purpose of Building �� 1 ` r r—VJr( Utility Authorization No. Existing Service Amps Volts Overhead a Underground No. of Meters New Service Amps olts Overhead Im Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Trsnafortners Total KVA No. of Lighting Fixtures 3 Swimming Pool' Above Below Generators KVA ground El ground rell No. of Receptacle Outlets No. of Oil Humero No. of Emergency Lighting Battery Units No. of switch Outlets No. of Gas Homers 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 Puma 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 a No. of Water Heaters KW No. of No. of signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP e OTHER• klsulanceCoveage Ptmaneltbdrwgt>se xMcfMasss t=ftC=adIam •� . a AWN . F itssl>bs�tndaleg hwfflt YES � NO ffymbmc1ied®dM131=eirlcaledmetypeofa mWby EtirnatedVakmeofEkcb3cd Wade $ WodcbStat �,� � Final SignedurciathePtr�a-palow — / J FMMNA.ME ! U� 't o �a e L �rcTr i LimseNa Lioaasee` o m s /Z� i tld�� �� �' 33b -10E / Q�..�l . 1or /�/lf a3as 3 F>t�i='te1Na �3- 5137' 5'f27%r Add AltTt Na & a y3? -&33 OWMVSMRANCEWAIVER;IanawaeftdieLioereedDesmthmdleirlumlxeorne cri5Rkd3 givalnastec}mrtedby (3erlaWLam andthatmysaecndisperilffic damwardimsm#mni (Please check one) Owner M Agent a Telephone No. PERMIT FEE S Signatu or Owner