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Home My WebLink AboutMiscellaneous - 202 GREAT POND ROAD 4/30/2018Date ....4 "113 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....),. ... &.......6-. /,e. CI..................... ..... ........ .............. has permission to perform ... .. .....Se .............. ... .... .�:7/ ...... ......... .. ................. airing in the building of ....... . .............................................. at ..... ......... North Andover, M ' ' North . Andover, 73-3 Pee. ........ ................... Lic. No...... ............ ....... I'll, ......... . ..... ..... .... E�C'MC�AL �NECM Check #2 r -54I Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official �Use �Only Permit No. Occupancy and Fee Checked u� [Rev. 1/071 (leave blank)N 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 W INK OR TYPE ALL INFORMATION) Date: 113 City or Town oh 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) „2 �r eA j 12,6 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes [-I-- Purpose of BuildingfS��cr7►r� - Existing Service 0o Amps /pp / oeTlp Volts New S Amps Volts Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead � Undgrd ❑ No. of Meters 1— Overhea Number of Feeders and Ampacity js-, f. ; - 17I -el . Location and Nature of Proposed Electrical Work: af:se-me-*r- 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 `3 Swimming Pool Above/❑ In- ❑ r d: rnd. o. o me ncy Lighting Battery its No. of Receptacle Outlets No. of Oil Bur rs FIRE ALARMS No. of Zones No. of Switches No. of Gasiurliers No. of Detection n / Initiatin De ices No. of Ranges No Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Torts r`" " KW ."""......'"....... No. of,Self-Contained Deteetion/Alerting Devices No. of Dishwashers Space/Area Hea ' g KW Local El Municipal �ther Connection No. of Dryer Heating A lances KW Security Systems:Y No. of Dev' s or Equivalent No. of Wafer KW eaters No. of No. of r ns Ballasts Data Wir' : No Devices or E uivalent Hydromassage Bathtubs o. of Motors Total HP Teje ommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 666' (When required by municipal policy.) Work to Start: S" 3 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: INSURA=NCE [✓)' BOND ❑ OTHER ❑ (Specify:) I certify, under the gins and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. LIC. NO.: '({07331-' 1 i Licensee: �� l y,/ Signature LIC. NO.: 160 33, 0 (If applicable, enter 11xempt', in the license number line) Bus. Tel. No.! 17PI - li / - y63/ Address: 4J Nf/ 43,F 7,2- Alt. Tel. No.: 603 -1-94? -631'3c' *Per M.G.L c. 147, S. 57-61, security work requires Department of'Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 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 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 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 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 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 Coxa moRwealth of Massachusetts Department of ludustrial .Accidents Office of Investigations 600 Washington Street: Boston, MA 02111 Tei, # 617-727-4900 ext 406 or 1.-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 www-Mass.govldia -.tOMM6N7W EALTH OF MASSACHUSETTS., ELECTRICIANS ECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN. ISSUES THE ABOVE LICENSE TO: - RONALD D DE13OW .P. 0 - BOX 112 10 r - SANBORNvILLE NVI 038-12-011, 3 40733 E 07/31/13r-, + _� , � _ . 8859 10011 OF �.10RT/� qti O „m Date .� fT� i -9 ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING rV� This certifies that ..... �J` S� P .e 1'0 4-D A' has permission to perform ... . .....�..... ..... e,-. plumbing in the b i,�s o ding'� � �- ............... . c)7 Q at ........... . , North Andover, Mass. Fee . ! ..ham— ... Lic. No. Z 3 ... .. ................. ... r PLUMBING INSPECTOR Check # i6 (P .�e 6&13-1-s VV\- 643-lh--5 �a\_ a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ IL _ems _ _ I MA DATE _,33 PERMIT # v� I A JOBSITE ADDRESS dD 2 (' �, —OWNER'S NAME - POWNER ADDRESS (TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL-N- PRINT CLEARLY NEW, RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES © NO 01 FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _- -__+I _ _-_ DEDICATED GREASE SYSTEM 1 -A. _J l 1 _._.� I _ .._.__1 1 I ______I f —J _. _..__.( _I= DEDICATED GRAY WATER SYSTEM I __...._._E DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ..__ _. E __.__ .I FOOD DISPOSER € - -i .... - -f - - € { - € _ .i FLOOR /AREA DRAIN 1 _..__._1 _► ___.___( J INTERCEPTOR INTERIOR _-__._- _I ___.--i KITCHEN SINK _..-_-_( _______I _-____.I _ .. __I LAVATORY --I --_ l--_._..J ....__._. ---{ - -1 _._.__..I .._.._J .---� -- I ----'l --....� --f- --- ---� ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URIN L WAJfiING MACHINE CONNECTION WATER HEATER ALL TYPES WAT•ERPIPING € r` _ _._._..1 __:._ .....► OTHER _ .....-._------� I J f ! INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYJ�J-- OTHER TYPE OF INDEMNITY 0 BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER —I AGENT J i SIGNATURE OF OWNER OR AGENT � t hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli a with al ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /1(1Gd�-oma T LICENSE # � SIGNATURE mpla- JP U CORPORATION R#=PARTNERSHIP PI #LLC _f COMPANY COMPANY NAMEADDRESS qw - CITY—STATE /j j ZIP TEL p FAX ___ _ CELL EMAIL H O O H U W a W o� z y w pCl) w � w a o w � W 3 0 0 a w a U J a o. Cd x W LL W H O O H � U W a \ z z a a I � ' a t The Commonwealth of Massachusetts 07 Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #:, Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 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.] Type of project (required): 6. ❑ New construction 7. F] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie: #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration 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 certtfy under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town offlcial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, 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 0ffice 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 Commonwealth, of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 Tel, # 617-7274900 ext 406 or 1-877rMASSAFF, Revised 5-26-05 Fax # 617-727-7749 ww.naass,goV as COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: BRUCE 'A STEELE . I F� 86 POND .ST +� i7,i BILLERICA MA 01821-1226 i 12348 05/01/14 .172423 r PERMIT FOR GAS INSTALLATION This certifies that..! I� . f.. ! ..' j..........�! .� ... has permission for gas insta ation . P.N�'.�.� ........ . in the buildings of . �' 0h . . � Lam---. at .. ab' -I' ��.('e ..�`^^ P North Andover, Mass. . !� Fee�p ... Lic. No.� '.?!�................ . 'heck 4 8711 GASINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY MA DATE iPERMIT# 4 • JOBSITE ADDRESS OWNER'S NAMES/p GOWNER ADDRESS_ FAX _ ) TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES 0 NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER -- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE (- _ M -_I— FRYOLATOR ( FURNACE GENERATOR -- O GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UIVENTED ROOM HEATER IL L WATER HEATER I O' HER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _ 0 [�( IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG NECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY -__ OTHER TYPE INDEMNITY E] BOND Q/ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the this Massachusetts General Laws, and that my signature on this permit application waives requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT �n he by 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 1 A all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provisi of the _ KA�chusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # SIGNATURE (� MP 0 MGF 0 JP 0 JGF __ LPGI 0 CORPORATION 0# PARTNERSHIP ©#= LLC 0# COMPANY NAME: g� . _ ---_! ::]ADDRESS --! ► f+�lc, - - CITY STATE ZIP5rjTELF 60 LC, FAX �-� CELL -- ---.._ EMAIL w H °z 0 H U a w 0 o El a z o yEl W } H W H °z a ft w 3 v� a w W5 > a a O LU L w LU w N a o a d a a rA U �"y J F, a CL a � w s w LL rA H zz o ° ry H U W Ina 4 °a r r y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): M61 e/ Address: City/State/Zip: �,�� ,� IWI g925F, Phone #•_ Are you an employer? Check the appropriate box: LEETam 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. ❑ 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.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 1211 Roof repairs 13.gko'ther offs IIS t'/T/1 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ire 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 information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. V . , Insurance Company Policy # or Self -ins. Lic. #: V Expiration Date: Job Site Address: q0,2 6i4 PdA PSG/ ` City/State/Zip: O✓Lf� 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 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. 1 do hereby certify under the pains andpgnalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone 1 i Information and instructions • . Massachusetts General Laws chapter 152 requires all employers to provide "workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, 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 ladustrial Accldents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877rMASSA.FB Revised 5-26-05 Fax # 617-727-7749 www-mass.govaa n GENERATOK %� DATE: 5- O- i3 LOCATION: Z. ---.s 2 - C, rY.A.J,- 'Pv-NL- " OWNERS NAME: GENERATOR kw Za NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS"' CONTRACTOR:(,p„,._. PHONE NUMBER: ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: "'ZONING DISTRICT: PZ,4Nur,,c' .14..p1Ialeo✓a-L, "'CONSERVATION APPROVA X NOTES l.- NORTH ARROW TAKEN FROM L.C.C. 33537 D. 2. BOOK/PAGE AND PLAN REFERENCES ARE FROM ESSEX ' fF (NORTH) REGISTRY OF DEEDS LOCATED IN LAWRENCE, Mf SB10H (FND) i N/F 112 FOX HILL ROAD 19 23 43 W REALTY TRUST ;90.00' (TIE) L.C. BK.86/PG.293 32.7' 1- \-SB/Dt (FND) R=25.00' / — L=38.97' CH=35.14' N64'02'37"W N70'53'39 "E 194.99' GATE BAY WINDOW o N `CONCRETE x= PATIO W/ QN N INGROUND POOLL PRO OSED 21 'x 14 7,a w o O 1 ST ADDITION (AREA -294-+ S.F.) I m 114.5' EXISTING WOOD DECK & STEPS , y CHIMNEY (TO BE' R4ZED)' " 126.4 % GATE Q GATE + SHED v C GAZEBO c TOWN OF NORTH ANDOVER ASSESSORS MAP 37C, LOT 24 AREA=35,067+ S.F. (0.81 4- AC.) k 110.30" S71' 18 00"W ~� 70.00' _ 74-59S GREA T POND Ido ' D (PUBLIC - VARIABLE WIDTH) t North Andover MIMAP May 13, 2013 Interstates — Interstate — Major Roads Horizontal Datum: MA Slaleplane Coordinate System, Datum NAD83, Roads Meters Data Sources: The data for this map was produced by Merrimack 14ORT11 Valley Planning Commission (MVPC) using data provided by the Town of C r Easements i'9C 1,', Of r� North Andover. Additional data provided by the Executive Once of E3 MVPC Boundary j `<< .� O0 Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary Parcels F b ANIMMW♦ definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING t THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY i s + # OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT • o •r # ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 'tsACHUSEt 1"=94ft •�° North Andover MIMAP May 13, 2013 9 F.OKWLI_ RD 037rC 6 R2 ac-oo2s � 037:.-000 102 FO (HILI -RD� 037sC- x N�A�• �Rl 105 FOXHILL,RE 11—OXHIL'L/RD - ' 037..-p0 . :: :•:: -;. Yater Protection .:.. - 180 REAYPOND RD 'LUL GREAT/POND 03a.0-0023 0/ /� 170 GREATiP ND R/ 1110371r-0 0/ �✓i� o / a 7s •-0 s - r tauo t 037.C-0D t 7.0 Z o3a.c-Dais o37:C�02 -- Rail Line ': Wetlands Zoning I " Busine s 1 District Interstates Exempt Lands — Interstate Busine s 2 District Horizontal Datum: MA Staleplane Coordinate System, Datum NAD83, — Major Roads Q Busine M Busine s 3 District s 4 District AORTIJ Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of Roads L r Easements Q Genera O Planne ' Business District Of �L�D '�� Commercial Dev 4 r•• O ? • O North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this ma is P ❑ MVPC Boundary C3 Municipal Boundary Garrido 0 Garrido D Corrido Induslri Development Dist •; L Development Dist O A Development Dist �" p t 11 District • for planning purposes Doty. It may not be adequate for legal boundary y definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY Zoning Overlay BAdull Entertainment� ©Downtown Overlay District :.Induslri Q Induslri Q Induslri 12 District s � � 13 District • e I S District �+ �. + OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF C3 Historic District 0 Water Protection Reside Residei ce 1 District 'll °•�rx° .��-.� 2 Dislricl 7S tt THIS INFORMATION ❑ Parcels n Ronde ce ce 3 District SAC Hydrographic Featuresde 1" = 94 ft • ede ce 4 District ce 6 Dislricl Streams TTT de %'—ge ce 6 District esidential District GENERATOR APPLICATION DATE: 6111�11y LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL L-, Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. (i I The page above has been generated by the Division of Professional Licensure web server on Tuesday, May 28, 2013 at 2:39:16 PM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ.asp?board_code=GF&type class=_J&li... 5/28/2013 LICENSEEMore... i i� i Name:MARK T. MENARD i i REFERENCES & LONDONDERRY, NH j RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Licensing Board: PLUMBERS ti GASFITTERS Glossary License Type: JOURNEYMAN GASFITTER i Glossary of License Status License Number: 5095 Codes Status: CURRENT More... I Expiration Date: 5/1/2014 Issue Date: 8/9/2011 Exam Date: 8/9/2011 j School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. (i I The page above has been generated by the Division of Professional Licensure web server on Tuesday, May 28, 2013 at 2:39:16 PM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ.asp?board_code=GF&type class=_J&li... 5/28/2013 Zz 6✓e.� P�� G_OMMONWEALTH OF MASSACHUSETTS E PL-IMBERS AND GASFITTERS LiCEN�.ED JOUriNEYMAN GASFITTER ISSUES THE ABOVE LICENSE TO: j F MARK T ;IENARD 2.0 GRENI .R BL 09 LONDONDER EN NH 03053-2364 5095 05/(G1/14 150310 l ' i i S i Date...............................2, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ............. U�1.1 1 %!'�'%�...L ..!..... has permission to perform ................ C ...............4:! uC-7-LC—SS.................. wiring in the building of ......................................................................... p/` t .. ............! �4 ... ..i��.1....*LEiCTRic;AL orth Andover, Mass. Fee ...7��....—..�—.. Lic. No J��. �O �� ........ INSPE R Check #- 10864 Official Use only Commonwealth of Massachusetts a , Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 91[Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASEPRINT.W.INK OR TYPEALL INFORMATION) Date: 5'-30'1X City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or he 'ntention to erform the electrical work described below. Location (Street &N,jiruber)�a1 Owner or Tenant 1JC t t, a Cdr p f : Telephone No. Owner's Address Is this permit in conjunction with auilding ermit? Yes ❑ No (Check Appropriate Box) Purpose of Building si t4 G i !'r ^#-c 14/ G GcJt N G Utility Authorization No. Existing Service Amps 160 hZVO-VOlts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: INo. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges f No. of Waste Disposers tC swc of Ceil: Susp. (Paddle) Fans of Hot Tubs Swimming Pool t,.uore ❑ grnd. No. of Oil Burners No. of Gas Burners vo. of Air Cond. Ta !able maybe waived by the Ins ector o Wires. No. of Total Transformers KVA Generators KVA ❑ 1w. vi r mergency iagaung Battery Units FIRE ALARMS No, of Zones No. of Detection and InitiatinLy Devices No. of Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection [I Other No. of Dryers Heating Appliances Ku' Security Systems:x No. of WaterNo. ofDevices orE uivalent Heaters KW No. of No. of Data Wiring: Signs Ballasts No. Hydromassage Bathtubs INo. of Motors Total HP Telecommunications Wiringg: IOTHER. No of Devices orEauivalent y, Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �. ! C3� d �""' (When required by municipal policy.) Work to Start: S^36 ' t 9L- 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 9 BOND ❑ OTHER ❑ (Specify:) I certify, under thins and penalties of perjury,thn_f the information on this application is true and coil) ptete. �,t, Xe N QAri S LIC. NO.: V� %� J Licensee: AM L'3 �puy0 jy Signature LIC. NO.: (Ifapplicable, ae ter " xempt" in the licaa �sse numb line.) Bus. Tel. No.; ' )d Address: _6 -oW t Lc- .Cp , o frrk NA 6 r J Alt. Tel. No.: 'Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ JUJe+tI,m4�.�H�{��ltJ�C{T��ilpP,lylAl�l�1y®N.-S. E CTR^.U.'lS.C.UCSCJ.OJ.BWORT.- . X017 7 P CTION V ;. '�ssetl [ +'aileB--[ e-znspeetion xequix xfor0.00) � [ �iaspectoxs' coxnmeJats: , (i! ns -o eefiore sicnature - )RO mtjals) Pale �'asse�i-- p`aiteti-•Z) � �teinspeciioxtxec�uirecl ($54.40)-• [ � . Inspectors' comment (tris&ctors' bignature •- n initials) date 31 UNMR IROUND MR) CTZON. Z'assed ate-xnspaction requirea ($60.00) � [ Impectoxs' comments: cinspectoxs, Signature •-no Htfals) Pate 4 MMMON•- fit ICER: � I DMAM CA VOID NATITONA:6 GN DI, NAM: Passed--[) I'ailed—[e-inspectionxequiretl($50A0)�[ ) Inspectbxs' eoxnmep�is: . (Xnspectors' plgnature - io Wtials) bate . �. ��TIICTXON -• OT�1EA: - 'assecl--[) failed-•[ )- 'ate-inspeciionrecluiz'e�($50.00)�[ � - aspectoxs' colAments: • S ' �wsgectoxs' ignatoxe no initials} Date Doi R 7 AQ19.RE TO BE MMED YOTASD EEFT OSI' 91TE F TM AREA TO BE INSTEC7E`.ED 19 NOT ACCESSIOEEAM ARE INSPECTION OF $50.00IN TO BE CMRM- . SIX The Commonwealth of Massachusetts Department ofIndustriglAccitlents Office of Investigations qV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)'s-n M es 9-, E+V `C t?,,_! AA. 3 't-- 1� Address: 6S LCWz cC_ _�O . City/State/Zip: `y' vj*k�- ' / .4 • d )68 y Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ T am a general contractor and T employees (full and/orpart-time).* have lured the sub -contractors 2. 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. I [No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 3111 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.] i employees. [No workers' comp. insurance required.) Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition -i 9. ❑ Building addition 10. [1 Electrical repairs or additions 11.[] Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they &ie 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 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:. I Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DTA. for insurance coverage verification. Ido 11ereby cert under t7�p �/,%H.c nHd enalties ofperjury that the inform ation pro vided above is true and correct. S Date: 2 d 3 Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. CitylTown CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Informati®n and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written" An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso be sure to sign and date the affidavit. The affidavit should be retumed 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 ofMassachusetts Depaftent of Zndustdal Accidents Office of Investigations 600 Washington Stxoet Boston} MA, 02111 Tel, # 61.7-727-4900 at 406 or 1.-877,MASS.AFE Revised 5-26-05 Fax # 617,4727-7749 www-mass,gov/d is f NORTH 1 F 9 '�i °•art° •�,�� CMUSE� Date.....r-.L..- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....�...... 5!"f...!v has permission to perform ............ l!..!?i...................................... wiring in the building of ................ ............ ee-0................................................ at ....69O.Z. / ! �a'�......f� North Andover, Mass. Fee .... ^ Lic. No. �A4 729 ..............6'W"i ..... E ECTRICAL INSPECTOR Check # 3� 3O 88� 11 "I'\ Commonwealth of Massachusetts Official Use Only kUlIVi Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07) (1Pavr r,i�.,v� 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 PRINTIN NK OR TYPEALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of fires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ue,-T PbN D Owner or Tenant C HAAXLe1 QeZjb (Vo6e Telephone No. Owner's Address r20 a r�PAT ��A) tQQ Is this permit in conjunction with a building permit? Yes Purpose of Building CV X 14 _SyA1R17DM Existing Service 200 Amps Zo / a t Volts New Service Amps / Volts Number of Feeders and.Ampacity No Ll (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd No, of Meters / Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Wj41q S111V .400M No. of Recessed Luminaires of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Ceil.-Susp. (Paddle) F No. of Hot Tubs 3 Swimming Pool Ahove ❑ d. 7 No. of on Burners No. of Gas Burners No. of Air Cond. To To Heat Pump Number ons No. of Dishwashers I Space/Area Heating KW No. of Dryers Heating Appliances No. of Water KW No. of o. o Heaters Signs Ballas No. Hydromassage Bathtubs OTHER: No. of Motors Total 'the ollowin table may be waived b the Ins ector of Wi ans f res. No. of Total Transformers KVA Generators KVA In- d. � o. o mergency g Batte Units FIRE ALARMS No. of Zones No. of Detection and Ini satin Devices nsl No. of Alerting Devices KW No. of Self -Contained Deteetion/Alertin Devices �� ❑ Municipal ❑Other Connection KW Security Systems:* No. of Devices or Equivalent is Data Wiring: No. of Devices or E uivalent HP Telecommunications Wiring. No. of Devices or E uiv dent Attach additional detail f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy Work to Stark Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 cove ge 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: D .i LIC. NO.: ,& Licensee: �/Q�� C jja��,j Signature (If applicable, enter "exempt " in thelicense number line.) LIC. NO.: Address: c2 /II A. �% r Bus. Tel. *Per M.G.L c. 147, s. 57-61, security work requires D artment of Public Safety "S" License: �� L cl. No. OWNER'S 9 7 - t'"//.,y OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ m Z,3�c 7-l7-a?/� Ll k J+" k - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t , www.mms govIdia . Workers, Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers policant rnfnrmaiinn Name Address: M City/,State/Zip:_ 4�A_l.��/''f/� Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with _._ 4. ❑ 12111 a general contractor and I employees ploys (full and/or part-time).* have hired the sub -contractors 2. am a.sole proprietor or partner- ship and have no employees listed on the attached sheet $ These sub -contractors have working for me .in any capacity. [No workers' comp, insurance workers' comp. insurance. 5. El We are a corporation and its required.) 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.) t employees. [No workers' COMP. insurance required_] LI Type o project (required): 6. Type construction 7. Q Remodeling 8. Q Demolition 9. ❑ Building addition 10.Q Electrical repairs or additions I I .(] Plumbing repairs or additions 12.[] Roof repairs 13-M Other 'Any applicant that checks box'>i` I must also fill out the section below showing their workers' compensation p o ley mfonnetiotL t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside comrac $Cortbactors that check this box must attached an additional sheet showing tors must submit a new affidavit indicating such the name of the sub -contractors and their wortoss' comp, policy information. 14M an employer that is providing:workers' compensation insurancefor my employees; Belo informaion. w is the policy and job site Insurance Company Name: Policy # or Self -in L' # Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci under the pains nnd penalties of perjury that the information provided above is true and correct -- 7 , J_t lJ. ,, , _ ficial use only. Do not write in this area, to he 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 #: k Information and Instructions � Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associatiori 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not requiredto cavy workers' compensation insurance. If 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 numberlisted 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 "lob 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, r please do not hesitate to give us a call. The Department's address, telephone and fax number: v The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 102111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.nmass.gov/dia U 0. 4 r •sy4= • i North Shore & Southern New Hampshire 17 Malcolm Hoyt Drive Newb MA 01950 Office:ce: (97 (978) 462-5822 '�• • ,r•, • a DESIGN GROUP Facsimile: (978) 462-5823 ENGINEER'S FIELD REPORT TO: CHARLES R. DELLA CROCE FROM: DANIEL W. SMITH SUBJECT: 202 GREAT POND ROAD 2.0 Engineer observed that Contractor was in the process of completing or has TSDG JOB N0145-08 CONTRACTOR: RENES CUSTOM CARPENTRY DATE: MAY 26, 2009 WEATHER: CLEAR (± 58° F, SUNNY) CC: BUILDING INSPECTOR, RENE'S CUSTOM CARPENTRY, AND PROJECT FILE Work in progress observed: 1.0 Engineer arrived on job site at approximately 09:30 am and toured the project site with Contractor. 2.0 Engineer observed that Contractor was in the process of completing or has completed the following structural items: 2.1 Demolition A. Current percent complete = 100% 2.2 Foundations A. Current percent complete = 100% 2.3 Concrete A. Current percent complete = 100% 2.4 Masonry 19 Of ilq. A. N/A 2.5 Structural Steel o� KENNETH DENNISON N A. N/A STRUCTURAL NO. 8669 Western Region Office 1000 Quail Street, Suite 290 Newport Beach, CA 92660 Office: (949) 622-0417 'CSDG # 145-08 Pagel of 2 I 2.6 Wood A. Current percent complete = 99% (Structural Framing) B. Engineer observed that knee braces are still to be installed. C. Engineer observed that deck framing has been changed to all 2X8 instead of 2X10 joists and 2X12 beams. 2.7 Facade A. Current percent complete = 0% 2.8 Miscellaneous A. None Structural items above observed by Engineer at time of site visit, except as noted otherwise, were in conformance with the construction documents prepared by TerraSearch Design Group. Except as noted otherwise above, Engineer takes no exception to work in process or completed at time of site visit. 3.0 Engineer discussed with Contractor the following items: A. None 4.0 Photo record was taken see photo log attached. 5.0 Engineer completed tour of work in progress and left job site at approximately 10:00 am. KENNETH DENNISON STRUCTURAL NO. 8669 202 Great Pond Road TSDG # 145-08 Engineer's Field Report North Andover, MA May 26, 2009 Page 2 of 2 1 �4 ,x•9;3'" ti 4 i Vzz -49w— DESIGN GROUP PHOTO LOG North Shore & Southern New Hampshire 17 Malcolm Hoyt Drive Newburyport, MA 01950 Office: (978) 462-5822 Facsimile: (978) 462-5823 202 Great Pond Road North Andover, MA 01845 Date: May 26, 2009 @ 09:30 am Western Region Office 1000 Quail Street, Suite 290 Newport Beach, CA 92660 Office: (949) 622-0417 Picture No. 1 — New addition east elevation. TSDG # 145-08 Page 1 of 7 .s Picture No. 2 — Column/beam connection (knee brace missing) Picture No. 3 — 2x8 deck framing (instead of 2x10 and 2x12) 202 Great Pond Road TSDG # 145-08 Photo Log North Andover, MA May 26, 2009 Page 2 of 7 Picture No. 4 — Gable end view of framing Picture No. 5 — End of ledger 202 Great Pond Road TSDG # 145-08 Photo Log North Andover, MA May 26, 2009 Page 3 of 7 Picture No. 6 — Center floor beam connection to ledger Picture No. 7 — Center floor beam connection to beam 202 Great Pond Road North Andover, MA TSDG # 145-08 Page 4 of 7 Photo Log May 26, 2009 Picture No. 8 — Roof framing Picture No. 9 — Roof/gable end framing 202 Great Pond Road TSDG # 145-08 Photo Log North Andover, MA May 26, 2009 Page 5 of 7 Picture No. 10 — Ridge beam connection into wall of house k._ Picture No. 11 — Roof edge beam/rafter/stud wall connection (north side) 202 Great Pond Road TSDG # 145-08 Photo Log North Andover, MA May 26, 2009 Page 6 of 7 �ff S , I Picture No. 12 — Edge beam/rafter/stud wall connection (south side) ./00 Picture No. 13 — Roof waterproofing as flashing joint connection 202 Great Pond Road North Andover, MA Photo Log May 26, 2009 l2tcation moo. r Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ y Qp0_ tOeomit Fee $ 'Sewer Connection Fee $ Water Connection Fee $ ptf , TOT„,� $ ' lei G° N°, NO Building Inspector Div. Public Works Fp ERMMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. /PAGE 1 MAP 4.40. , LOT NO. 2 RECORD OF OWNERSHIP '.DATE BOOK '.PAGE ZONE SUB DIV. LOT NO.I OCATION PURPOSE OF BUILDING op -Z r R 0 / V" l! x r OWNER'S NAME !7O'O[ .fi?PAT {L� L�JNO / OQ lrCq NO. OF STORIES SIZE OWNER'S ADDRESS Li o \ BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST 2ND 3RD BUILDER'S NAME �J) SPAN STANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET (,94L+ l POSTS DISTANCE FROM LOT LINES — SIDES REAR " " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION -! u THICKNESS 11 IS BUILDING NEW V10.. SIZE OF FOOTING �yir X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 INSTRUCTIONS A ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING r ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS T PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR /DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT F E E OWNER TEL. 0 PERMIT GRANTED CONTR. TEL. #_. 19 CONTR. LIC. # 3 PROPERTY INFORMATION LAND COST /EST. BLDG. COST 3-b"3 0 :EST. BLDG. COST PER SQ. FT. r-• EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN ew 4 & BUILDIN INSPECTOR BUILDING RECORD i OCCUPANCY 12 SINGLE FAMILY I STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA '/ 1/2 1/1 FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ CONCRETE EARTH HARD\!✓'D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY ATTIC STIRS. & FLOOR BRICK ON FRAME I_ CONC. OR CINDER ELK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBRELMANSARD A TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL A'M'T 2nd _ 3rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 1st q A o� i LL o o m cz � z u z m L 0' a: C E U ii Q z u z J a L a m ii 99 0 z a u W L 3` ¢ V m c ii u W C6 ? L m ii W � oc m Y CO) H .y E L IL O Le CL I' u ,V ca to c cc 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: (L11101 cka,� 1� LOCATION: Assessor's Map Number 3-7 C Phone 6 �- � -- �--5/(, Parcel Subdivision Lot s ) /.5- Street � _a Dcd 11/-2 PST St. Number a o ************************Official Use Only************************ REC DAT ONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Health Agent Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date MORTGAGE INSPECT/ON PLAN AT 202 GREAT POND ROAD NOR TH ANDOVER, MA. N0. ESSEX REGISTRY OF DEEDS.'LAND COURT BK. 62 PG.265 CER TIF/ED TO. FIRS T ESSEX SA NGSOBANK 7D SCALE.' / "= 50' DATE,' OCTOBER /9, /99/ /94.99 r n I WOOD y -SHED p LOT /5 L=3B.9j I � a- //0.30 70.00 _ GREAT POND R04D NOTES.. /) DO NOT USE OFFSETS TO ESTABLISH PROPERTY LINES OR TO ERECT ANY STRUCTURE. o A 2)PROPERTY LINES ARE DETERMINED FROM COMP/LED#35 INFORMATION INFORMATION TO BE USED FOR MORTGAGE PURPOSES ONLY. CERTIFICATIONS.' BASED ON MY KNOWLEDGE, INFORMATION AND BEL/EF, / HEREBY CERTIFY THAT THE PERMANENT STRUCTURES INDICATED ARE LOCATED ON THE GRGUJND APPROXIMATELY AS SHOWN AND ARE CONFORMING TO THE ZONING SETBACK RECUIREMENTS OF THE TOWN OF NO. ANDOVER WHEN CONSTRUCTED AND THAT THE PARCEL SHOWN IS NOT LOCATED /N A FLOOD HAZARD ZONE AS PER FEMA. MAP, - COMMUN/TY NO. 250098 EFFECTIVE DATE.' 06-15-83 ZONE.' C JOHN ABAG/S B ASSOCIATES, PROFESSIONAL LAND SURVEYORS 137 CHANDLER ROAD, ANDOVER, MA. (508)688-4899 NO. P 124 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... .................... has permission for gas installationL-4,.t:4 .............. in the buildings of . C-. 1Z (). (, r_.. at e2. /?,q North Andover, Mass. Fee. Lic. No. ASINSPECTOR Check# Zt/y/�- MASSACHUSE LTM% FORMAl" FOR PERNIlT To Do GAS FfrMG (Type or print) Date NOV NORTH ANDOVER, MASSACH SETT Building Locations 6 121~ j z�kv_ %2 i Permit # ZI 9 3 J Amount $ tri Owner's Name New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ U vl U H x x o f H a o a o z as rn F OF •, a 9 4 i, ch q GCWh F z C O G V C 0 0 0 00 0 0 1 -.--2 U 94 SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type)/I�� rr ,,,^, �y� one: Certificate Installing Company Name ryz pgiyr / S W �� ChecCorp. Address ly s%�"'�%% %�Z' d X t/� ❑ Partner. ❑ Firm/Co. ne;nPCc P. P.i) nne �J i Name of Licensed Plumber or Gas FitterL�- INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [3No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submittedAr entered) in above application are true and a curate to the best of my knowledge and that all plumbing work and installations ormed under Pe t Issued for this applicat' compliance with all pertinent provisions of the Massachusetts S G Code and Chapter 142 of G neral s. / y: _ I (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber��-�— Gas Fitter (cense Number ❑ Master ❑ Journeyman a i Location No. '-/ Date NORTH TOWN OF NORTH ANDOVER A ' Certificate Occupancy $ of Building/Frame Permit Fee s�cwus $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i C� Check # / /✓ I '" ! /. ! , Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: /� DATE ISSUED: �— SIGNATURE: / Building Commisslner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: moaL1.7 1.2 Assessors Map and Parcel Number: Map Number Parcel Num A9 ' A A(© V /w �,`, !y f: 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R red Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record R«S E A�A 14 C ROCZ a o 2 ai 44r Roxo RD Name (Print) Address for Service: a 3- rgnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: S'T,e�/°s��E�C/ A ?-E Licensed Construction Supervisor: ,Address �f /T — 3 7a / Signatur Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home provement Contrac r Not Applicable ❑ Companyp0ame Registration Number Address 3 ` �` �J Expiration Date Si natur Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2: Workers Compensation Insurance affidavit must be completed and submitted in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) this application. Failure to provide this affidavit will result Alterations(s) K r I Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant , OFFICIAI, USEONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X bbl 4 Mechanical HVAC 5 Fire Protection 5 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby au Drize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST2 ND3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , Boston, Mass. 02111 Workers' Compensation Insurance Affidavit a3 aam a homeow6r performing all work myself. aI am a sole proprietor and have no one working in any capacity = I am an employer providing workers' compensation for my employees working on this job. Company name: at) T,5 9,0W S' %- a G _ Address A) /4 i6A1_b ST 0 City' Phone #: 3110_2 / V 3 J_ Insurance Co. Policy # Company name: Address City Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjuryA9t the information provided above is true and correct. Date ?, 1,, 6D Print name 3J Official use only do not write in this area to be completed by city or town official' Building Dept ❑Check if immediate response is required Building Dept p Licensing Board p Selectman's Office Contact person: Phone #: I] Health Department 0 Other FORM WORKMAN'S COMPENSATION ;1/ce i�ont�ra{�nu�<z�li a� L �irri,u�cirrts�s ; BOARD OF BUILDING REGULATIONS { _icense: CONSTRUCTION SUPERVISOR Number: CS 017853 Birthdate: 06/24/1931 Expires: 06/2412002 Tr. no: 27914 Restricted To: Uu STEPHEN R COTE �,,�r�'�~ '• 468 WATER ST (� HAVERHILL, MA 01830 Administrator r �' HOME IMPROVEMENT CONTRACTOR _ Registration 102306 Expiration 111/02 Type: OBA COTE COMST CO. Stephen Cote 10 APPLETON ST. �M—''RATO� Haverhill MA 01932 ;1/ce i�ont�ra{�nu�<z�li a� L �irri,u�cirrts�s ; BOARD OF BUILDING REGULATIONS { _icense: CONSTRUCTION SUPERVISOR Number: CS 017853 Birthdate: 06/24/1931 Expires: 06/2412002 Tr. no: 27914 Restricted To: Uu STEPHEN R COTE �,,�r�'�~ '• 468 WATER ST (� HAVERHILL, MA 01830 Administrator 0 a C w O w co cn O z 1-� w c2 u Cd x a 0 � HI jii w :d w" � 0 H � ►rl aG ch Cd w oW. BP p �G w" H w cn 0 c/) �Eo •cam o o f Pt Cy c CL C :o m c ;= O ' o � EQ� • L rm+ C =rt/ : *"Co v O c O r ♦ �c m c 0 0 3 =y o c m N CCo N O O r1 *"mE N y �, m o c' H � � c c Ha ID ac= � :CHo'Qq m o. d$ CM a F- m : y m c .E- 15 - c C a m m=3 N _ a ,... o co ev = m W CO -0 '0 w r C CCD � •N ar O c Z LU cm C. .m COOa = A C Js i y'O F. fil 1 y MCD E CD CL CD O CD r.7 0 CD 3� L CL cmQ C cc O O Z 5 CDCLCO2 C rM1 0 ui vJ w W ccW U) N2 /' 4 65 Date .... ....... t ,10 " TOWN OF NORTH ANDOVER 0 I -A PERMIT FOR WIRING 4L This certifies that•........................................... /;"nl .......... . .. ....... ..................... has permission to perform............................................................................. wiring in the building of .... ......... ....................... ........................................... at ..................... ...................... ........................ ,North,Andover, Mass. Fee �. 77� ............... Lic. No............... .......... .1 .............................................. %-.-, ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer T1iEC0Aff10NW j LTH0 r M4MCWJS •777 Office Use only DEPARTME7VT0FPUBLICS4FM Permit No. BOARD 0FMEPREVEM0NREGLE4T10AS527CMR 12DO ' Occupancy &Fees Checked APPUCATION FOR PERMU TO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 a"M 12:00 ;7,1P ^ �� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) S Date Town of North Andover �t�c� Sal / To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes [—] No ® (Check Appropriate Box) Purpose of Building �' -1,3 1 e f-v�rvt f I y Utility Authorization No. Existing Service0'®CD Ampsd}' /07- Volts Overhead Underground � No. of Meters New Service Amps / Volts Overhead ® 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 Transformers Total KVA No. of Lighting Fixtures 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 Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices LocalMunicipal Other No. of Dryers Heating Devices KW Connections ® 4o. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER Insur=Caeraga Rraat1oIhetagtmemrCdMmmduq&G=rJLaws Ihawaa etLiabiltyknm=Pohcyutdt&gC Tpide Ca awcrilsstksurtialmovAui YES In NO F Ihawstbmttadvandpoofof=netotheOffix YES FJ NO r7 If}wha%edrdWYES, p1mseudr*thetMxofwmaWbydn:atg& WSURANCE ® BOND OTHER CC -At (r`rbt l EViEltim Dai Estirechical Walk $ WakioSlat hq)ectionD*Rtgxsted Ro# FiIal Liom9ee Gam- 1J�'A/ -,,e T� Lioa>SeNa �8''al / &wmTd % 6tg "3 94 - `16 -AP Q (II Z ��t J T{� ' \ f JW r :T r I \� r V C 4' % V 'j w�fl --70 J a- AIL TeL Na OWNED,SMJRAMMWANER;Iamawateth�theI dognot Canal Lam a ndiatmyWu�sernftpan Wpke onwaiAsthism*mianalt (Please check one) Owner ® Agent Telephone No. PERMIT FEE n - -'I• , J- , J ........ ..1,1....... "aoTOWN OF NORTH ANDOVER P PERMIT FOR WIRING This certifies that ....!� .. ' .................................................... ......... has permission to perform .......... - / .............................. wiring in the building of . :..... •......................................................... n - �— % .-- .t. North Andover Mass. Fee ... .....' ...... Lic. Naq %!,7.. .. �1 : ^ <.:......... ..... �. ELECTRICAL INSPECMR 05/27/99 11.39 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N Dile &mmonwettlo of 41flaggar4alieftS f3epartment of Public =%ttfetg BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use �n� Permit No. Y Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00�fG (PLEASE PRINT IN INK 0 TY AL INFORMATION) Date �2 ()' % / City or Town of To the Inspector of Wires: The udersigned applies for a permit to perform tl?$ electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes El No (Check Appropriate Box) Purpose of Building !t ml LC E&&:4JP—C—S )D6&Z LUtility Authorization ., No. Existing Service V� Amps � oits Overhead ❑ Undgrnd Po.No. of Meters (`mow Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity ,Q /- Location and Nature of Proposed Electrical Work / / l L— No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. / Total tons Initiating Devices No. of Sounding Devices No. of Self Contained No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local❑ Municipal ❑ Other Connection No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER INSURANCE COVERAGE: Pursuant to the requirements of M sachusetts general Laws I have a current Liability Insurance Policy including Comp! ed Operations Coverage or its substantial equivalent. YES NO G I have submitted valid roof of same to the Office. YES NO C1 If you have checked YES, please indicate the type of coverage by checking the ap r nate box./ INSURANCE BOND ❑ OTHER ❑ (Please Specify) j (Expira ' n Date) Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Rough Signed under the Penalties rlury: / FIRM NAME G T Licensee ��'� '�T—Signature Address OWNER' quired bl _ (Please check one) Final _ Telephone No. PERMIT FEE $ 145400 (Signature of Owner or Agent) x-6565 /� AJ PO/( A,,VJe, 146 Mq iN Sq-