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HomeMy WebLinkAboutMiscellaneous - 21 JOHNSON CIRCLE 4/30/2018Date..,.///-�. . (......... ORTN 16 TOWN OF NORTHANDOVER • PERMIT FORA S INSTALLATION S SACH This certifies that has permission for gas installation ... ,/ ................... in the buildings of .. n ... r!: f e.< ...................... at . J..1.. A P/ ;s : North Andover, Mass. r� Fee. v..... Lic. NoJ. ........ GAS INSPECTOR Check # 7 S S C 1;/ :117 Inspection of Gasfitting MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) L r 1 f C�f3��7^, Mass. Datel$ 6 Permit #t Building Location 1 _��n5on Ur Owner's NameJat'Y, `ginlug 11-6 1 � 06;,6 Type of Occupancy G New ❑ Renovation ❑ Replacements Pians Submitted: Yes❑ No ❑ Installing Company Name Check one: Certificate Addre s Ct Corporation 2.1P P f VP fYIl)� O�2 4S7 O Partnership Business Telephone '%�`/— a�9' 35,3(Q, 0 Firm/Co. Name of Licensed Plumber or Gas Fitter _.Sf-e vee C% til INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes i No 0 If you have the ed yg, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy * Other type of Indemnity ❑ 1Bond ❑ 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 Cwner's Agent Owner ❑ Agent O 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. BY T e of license. _ Plumber !gnature oficense Plumber or as Fitter Title ase M 1,3 /o Master License Number Cit /Town Journeyman N N a w ul N N Y +J Z a vi N 0 a In w ¢ o O1 0 - x W X 0 u d arC z a O Fs Y K m H r y u°Ci o b a c rr W W 0 W z C S ¢ H W O C W f' W i xcc N 0 Z f- a Z w J F- d Z }. .- W 'r"' W i N O> m Z LL O F � V w J O W x q W> a W .C. Z d 3 a< O O w > a a O W �- 0 ¢ x O c7 t u. a a 0 u W. a 1- SUB—BSMT. BASEMENT 1ST FLOOR. 2140 FLOOR 9R0 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLoofi 8TH FLOOR Installing Company Name Check one: Certificate Addre s Ct Corporation 2.1P P f VP fYIl)� O�2 4S7 O Partnership Business Telephone '%�`/— a�9' 35,3(Q, 0 Firm/Co. Name of Licensed Plumber or Gas Fitter _.Sf-e vee C% til INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes i No 0 If you have the ed yg, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy * Other type of Indemnity ❑ 1Bond ❑ 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 Cwner's Agent Owner ❑ Agent O 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. BY T e of license. _ Plumber !gnature oficense Plumber or as Fitter Title ase M 1,3 /o Master License Number Cit /Town Journeyman , R x . C. r ID , O Date. .. �.. G. �... . ,A°RTp E 1 ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ! !.:.. 1�. !�. ? .. `.' ................ . has permission for gas installation .. �-� . �... r'�0.` ......... in the buildings of ..,�!-?.r`�.�'�." ..................... at .. ...:� c�..... f .. ` ... .1. ... , North Andover, Mass. Fee. .. . Lic. No.. Y.0 a !... ... .--,. GASINSPECTOR Check # ;? G U 6112 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Prim or 'Type) Z . & j,Maas. Date �E7 , Zak— . Permit x Building Location g% J o Al) So N Ci Je Owner's Name p Owner TeU D r%93 a Type of Occupancy S/_/)CpU /f L/ New ❑ Renovation ❑ ✓Replacrment D Plan Submitted: Yea ❑ No d� FIXTURES Installing Company Name. ;lel f/ ��7 � �_ - a c Check one: Certificate Address !q0 So (_)7_H InPI N ST ❑ Corporation %}%t l) DL67 N MR • 0 VI7;0 ❑ Partnership Business Telephone q % ) Aa -3 — /30,/ % )(Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: have a currerri liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 if you have ed n}, please Indicate the type coverage by chocking the appropriate box A biabiaty insurance pocky * Other type of hrdemnity 0 gond 0 OWNER'S INSURANCE WAIVER: I am aware that the Iloensee don rat We the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit appkdm wo1vu this requkement Check one: Owner 0 Agent 0 Slonature of Owner or Owner's Aoent knowledge and that an plumbing work and Instanstlorts perfomled under Bte pe rtinent proyWons of the Massachusetts f3tate Gas Code and Chapter 142 of By Type of Ucense: ,►- Trtie-Gas -Plumber fitter 02. blaster City/Town • ,Journeyman APPROVED (OFFICE USE ONLY) a s a WE IMP, Installing Company Name. ;lel f/ ��7 � �_ - a c Check one: Certificate Address !q0 So (_)7_H InPI N ST ❑ Corporation %}%t l) DL67 N MR • 0 VI7;0 ❑ Partnership Business Telephone q % ) Aa -3 — /30,/ % )(Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: have a currerri liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 if you have ed n}, please Indicate the type coverage by chocking the appropriate box A biabiaty insurance pocky * Other type of hrdemnity 0 gond 0 OWNER'S INSURANCE WAIVER: I am aware that the Iloensee don rat We the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit appkdm wo1vu this requkement Check one: Owner 0 Agent 0 Slonature of Owner or Owner's Aoent knowledge and that an plumbing work and Instanstlorts perfomled under Bte pe rtinent proyWons of the Massachusetts f3tate Gas Code and Chapter 142 of By Type of Ucense: ,►- Trtie-Gas -Plumber fitter 02. blaster City/Town • ,Journeyman APPROVED (OFFICE USE ONLY) d)m above applICO t are a aria accurate to the boat of my i mit Issued for this,appn ! u will aria with an i he Sign re of Uoensed Plum AA Itter Ucerse Number 4 Qy 1 :C,d17- ,MM ' ��, y V S A�.I U:SE DIVISION OF I'll OF ESSI ON AL LICENSURE IN PLUMiS}�rNG""'FITTERS i LICENSED' J1O.0 E :GASFITTE ; To ' 'MICHAEL B N • '►"t' 1.6 .N.ICHOL V 'LYNN. °n�; 2-,37.18 2.9163 " r commo W 4 TH CF MgbS4 , NUSETTS .., 'DIVISION OF PROFESSIONAL LICE NSURE IN PLUMBEfS ' AND G3ASFITTEIE RS OCENSED AS:AN���P•�-GAS INSTALL ise�>ptF,ndlta8 To 14 I C H A E L A -S '"S.R 16 NICHOL'S „I�V� 1. YN N `e.'•k1�1`�•, a / "62-3718 933 0.01T0� !' 259162 �y V V 4 A'.I h Wyman bearamce Agency Inc . 1S Gfaat St. leverly, KA 01915 Sagan zgbin ONLY AND,CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, WS CERTIRCATE DOES NOT AMEND, EXTEND OR E'CONERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL 0 INSURES Kichual A. Brymm DIA: c/o TIS, Inc. 140 S. Wain St. Kiddltoo, MA 01949 wISuRERA: National Grange Iasaranae Co. 14739, w18uItERik wraulaERC . waeuRERo WSURER E: ' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITMSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, TME INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREEI IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PMD'CCAN& �h 2 TY►E OF INSURANCE _ POLICY NUMSER E uwrl GENERAL LIABILITY TID 11/01/2006 11/Ol/ZOOT EACH OCCURRENCE Z COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED f CLAW MADE � OCCUR MEDEXP.V'MTIMIIIn, I f Low A PERSONAL A ADV HAIRY f 1000 GENERAL AGOREGATE f E O00 OENL AGGREGATE MtlTAPPLES PER PRODUCTS • COMPIDP AGO f 'j 000 POUC► IPRO,ECT LOC Al MA LIABILITY COMBINED p MW LMR S ANY AUTO ALL OW RED AUTOS ODDLY INJURY SCHEDULED AUTOS ( PIS) f HIRED AUTOS BODILY INJURY NONOWNEDALROS (PK 4 f PROPERTY f 1 �tDAMAGE GARAGE LlAlIlLrrY AUTO ONLY- EA ACCIDENT f ANY AUTO OTHER TiMN EA ACC f —E� AUTO ONLY: AGO f EXCESSA MBRELLALIABRdTY EACH OCCURRENCE f OCCUR CLAMS MADE AGGREGATE ! f I DEDUCTIBLE f RETENTION S f woRxERs COM►ERtATTON AND W A EMPL.OYERr LWLJTY - ILL EACH ACCIDENT f ANYPROPRIETORIPARTNEMF,XECUTNE OFFICER/MEMBER EXCLUDED? EL DISEASE •EAE f I M. OMaDe woft EL DISEASE • POLICY LMTT f SPECIAL PROVISIONS Dhow OTHER I � 1111 { leSCRIPT" OF OPERATIONS I LOCATIONS / VENICLEB I EXCLUSION' ADM BY IN am 18"CIAL PROYIEgNE ------------ BM U ANY OP THE ASM DnMED PMJM tt CANCELLm EJ1TNM TM EXPEIATTON OATt TMEREOR TM MUM EWURER WILL ENDEAVOR TO W& !� DAYS IMIW= NOTICE TO TM COMPICATI MOLDER NAMES TO TM LEPi, SLIT PNLURE TO MNL EIICM NOTICE SHALL MIPOEt NO oELJGATIO11 OR LLAtaJTY For Information Only AUTMGRm011MPRtfENTATTVt 4CORD 25 (2001/OS) OACORD CORPORATION 1999 'DF created with pdfFactory Pro trial version www.odffactory.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information PhsavA 1)rvn+ T amAlkh Name 1Pzqr7r Address: qo v7H &1}1 City/State/Zip: i/! 1 b17Z.,C. 10� 1& . 6/ `�y y Phone #: q7& - 77 q � a 76 0 Are yo an employer? Check tIwAppropriate boz: Type of project (required): 1. • I am a employer with — 4. Q I am a general contractor and I 6 Q Nom, construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet t 7. 21emodeling ship and have no employees These, sub -contractors have 8. Q Demolition working for me in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑Building addition required) officers have exercised their 10.❑Electrical repairs or additions 3. Q I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, -§1(4), and we have no 12•Q Roof repairs insurance required.] t employees. [No workers' 13.Q Other comp insurance required.] 1%uy appucuat um cnecra box #1 must also frill 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 on additional sheet showing the name of the sub.contraetors snd their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name:-.PPPZ,-'-l / WY/11 -4N �i SUP1) C.5 &�w>c C� . Policy # or Self -ins. Lic. #: GV C. � � 4 3 q q (p Expiration Date: ID Job Site Address: City/State/Zip: Attach a copy of the workers' compensation polity 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 imprisomnaent, 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 penaUesofpeLrjuury that the information provided above is true and correct Si hire: Di Official use only. Do not write.in this area, to be completed by city or town officid City or Town: Per nWUcense # 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 #• 7346 Date.. ? �. �� ...... . 17 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ..Y y This certifies that ... ... .. ' .. ... ..... / ............. . has permission for gas installation ... pG .�. .. f l � ........... in the buildings of ..rJ? �?� �. ......................... . at .... ... �'.` �. J..L7 ....� Nrth Andover, Mass. Fee...:. Lic. No. !.) U?. ?.. ...1. , AS INSPECTOR Check # �' t J NIASSACHliSETTS L1UMNI APPLICAMN FOR PER1tiIlT TO DO GAS FITTING (Type or print) Date 6 ^�P6— /Q NORTH ANDOVER, MASSACHUSETTS Building Locations JO�Nh Sion Circ (f Permit # Muc ty\ `t \ k3�oywe r t --t4, Owner's NameAmount $ Akxr- . & k nee - New © Renovation ❑ Replacement ❑ Plans Submitted 11 (Print o01,lL.So � OL. Name Check one: Certificate Installing Company n Corp. Name of Licensed Plumber or Gas Fitter ,\ 1 C (A ! f ,�� ✓L Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 11 No 13 If you have checked yes, please i cite 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 reyuirement. , Check one: Signature of Owner or Owner's Agent Owner .,vy --y u—' un vl we ucLuua iuiu 1111W IMMU11 111ILVC SUUr u for enierea) in above appllcatlon are true and accurate to the - hest of nn knowledge and that all plumbing work and insta . Ions rfo • c:d im I r Prrmit Issued for this application will be in compliance with all pertinent provisions of the Massach ;ctts St: ('odc)riyYChapter 142 of the General Laws. By: Title Ci tyiTo wn APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter PILIIl1bl;C 06� MGas Fitter Llccnse r rn er � Master ourneyman w V Z x w z ° W rx d a W Z z F F v� a � w w F a 'o ? a a z o 0 A o H 3 a SUB-BASEi�t ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4T II. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR R 8TH. FLOOR (Print o01,lL.So � OL. Name Check one: Certificate Installing Company n Corp. Name of Licensed Plumber or Gas Fitter ,\ 1 C (A ! f ,�� ✓L Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 11 No 13 If you have checked yes, please i cite 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 reyuirement. , Check one: Signature of Owner or Owner's Agent Owner .,vy --y u—' un vl we ucLuua iuiu 1111W IMMU11 111ILVC SUUr u for enierea) in above appllcatlon are true and accurate to the - hest of nn knowledge and that all plumbing work and insta . Ions rfo • c:d im I r Prrmit Issued for this application will be in compliance with all pertinent provisions of the Massach ;ctts St: ('odc)riyYChapter 142 of the General Laws. By: Title Ci tyiTo wn APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter PILIIl1bl;C 06� MGas Fitter Llccnse r rn er � Master ourneyman - 960 ill Date.... . �—..� �. zo. IV "`° '• " TOWN OF NORTH ANDOVER A PERMIT FOR WIRING This certifies that � �.�", /J./ � Ul Lid ................. PP ......................................... has permission to perform ............v�-- X ..................... wiring in'the building of ........... T... 1�,....................................... at ............... .................... 'orth Andover, Mass. Fee..... °---. Lic. No..��cf................. /...�yrG .... L� EL CTRICALINSPECTOR; ` Check # 7 , O 44 cd ~ oo o° ti a a O () roa�r ..q0., W O O]4 ca[� 41 o o Ej cq q O cd H .UO O •a' O V•i � 40 •-�'" .-� w d � � c� _ ami r*'i� r�i N G P C O O N N cUC ON( -'u q 2 N q v' 2.8 y42 -9 o ' "y+ 421 b N q 40 b U a �. •E", +U, 0 � � o c. ... cm a ° — cn w �,, O b y f+1 O �" N b ch a7 O r" bD 'd •3q �ao� ° �pUc`den U ° vi m q q 3° C g G O y W +�+.' v ti A N w d Y .O O ti q ' odd C w b OC o U b C ,sC q-, '� 'o o A G U � `RJ' aqi G. 0 o „ o o c 4°.5 ccl 2 U "b NDN N N �" U O U ° U y ° NUy y W y�J �W o 3 ti 7 b0 i+ o,0 -S qo W ^, �b•y 3 q � oou„•• iC 7 N N t w xo12.�k a W R• W7 s N ao W U 4i •� CO w tL' 'O h M „" O ti U ° .n U O .fir +-+ N. .' �' N U N O O W U O N ... 0 N Wy N N Wl. O au 0 R. 0 O cd ," r i.ufn►nu►►wCa►a►► w ria��ac.►►u�c�w Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co e (NEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: UiJ4 22, V 10 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesotice of his or her intention to perform the electrical work described below. Location (Street &Number) �i r Q Lt ,t� iJ J1 ✓u I Owner or Tenant I m . CA Q, 1 1' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Rr No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service IVO Amps _Volts Overhead ❑ Undgrd u No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1a4�� LZo (foo Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. F1Baotter . o Emergency Lighting Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ..................................... Tons.......... ........... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and enalties ofperjury, that t/te information o �Iication is true and complete. FIRM NAME: lA `o7 LIC. NO.: o-?� Licensee: j L.") Signature LIC. NO.: o� 2 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.9%F /S Address:' 56 t:;4" f, Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department o ublic 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 Owner/Agent PERMIT FEE. $ Signature Telephone No. -'t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M,4 02111 4 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ) Please Print Legibly Name (Business/Organization/Individual): �a `-4 � Address: 4�y rp livrnt-A00yi City/State/Zip: _(9 tr1w TL+ Phone #: C p �- f l �Y - 6io?v Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[ lectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip.-- Attach ity/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 cert fll q d�r th e andpenalties ofperjury that the information provided above is true and correct. Phone #: � %k zy. --6011_21 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 Phone 1 200 Date /.�f .r........ . 40RTH TOWN OF NORTH ANDOVER pyj.eo ,e1ti0 PERMIT FOR GAS INSTALLATION r A CU N This certifies that has permission for gas installation ...R.:.1.3 .................. in the buildings of . .,., , , , , , , , , M �. at `......... , Nolth Andover, Mases al Fee Lic. No..//. .. ... ; . . AS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTtNG (Print or Type) c NORTH ANDOVER Mass. Date 1iuilding Location %, I ��.i r l�ld��6 Permit # 10( Owners Name • 'i !1 • New '7 RenovationReplacement Plans Submitted D FIXT(JQrC (Print or Type) Installing Company Name d Address t:5'7 U4VAI u.— 'Ve> Business Telephone: ( S2C �) 42L Name of Licensed Plumber or Gas Fitter Check one: Certificate Q Corp. Partner. Firm/Co. Insurance Coverage: Indicate t!ie type of insurance! coverage by checking the appropriate box: Liability insurance policy = Other type of indemnity D Bond 0 Insurance Waiver: 1, the undersicned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. W W ct N tr .0ul us us Z -C C C O= O Z r aC m (A W r t W (. yt o. W y 4 m (13 W% v ut to w< Q O o us O ? U. h- U _ul� -.i f- W 2 d W G t Y• N 0 O Z W O ca '- C .d1 0 _C LL G h C 1 U G� y O C 1W O BASEMEXT I I I I I I I I I ZST FLOOR I I I I I I I I f (I I I I I 2ND FLOOR I I I I I I I I I I I I I ( I I I I 3Rn FLOOR I ( I I I I I ( ( I I I I I I I I I I 4TH FLOOR I I I I I I I I I I ( I I 5TH FLOOR ( I ( I I I I I I I I I 6TH FLOOR I I I I TTH FLOOR I I I I I I I I I I STHFLOOR I ( I I (Print or Type) Installing Company Name d Address t:5'7 U4VAI u.— 'Ve> Business Telephone: ( S2C �) 42L Name of Licensed Plumber or Gas Fitter Check one: Certificate Q Corp. Partner. Firm/Co. Insurance Coverage: Indicate t!ie type of insurance! coverage by checking the appropriate box: Liability insurance policy = Other type of indemnity D Bond 0 Insurance Waiver: 1, the undersicned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent El I hcteby certify that all of (he details and information i have submitted (or entered) in above application are true and accurate to the best of my knowlcdge and that zU plumbing work and taraLLations perforated under Pt:rmit iuucd for this application will be in compliance ahl pettlnmt Provisions of the Massachusetts State Cas Code and Cuptet 24. of tho General Laws. By TYE LICEN — ber �' Title t—'5itter Signature of L ensed City/Town- ter Pler��r Gasfitter Journeyman APPROVED (OFFICE USE ONLY) 0 License Number Location No. i,� Date TOWN OF NORTH ANDOVER p Certificate of Occupancy $ ey /C) Building/Frame Permit Fee $ �'�s''••°''<�' sACMUSE Foundation Permit Fee $ Other Permit Fee $ r Sewer Connection Fee $ Water Connection Fee $ ,. TOTAL $ t c N-WKg3 10:03 10 .00 Fa1D Building Inspector niv Piffi is Works Location - - No. Date NORTH TOWN OF NORTH ANDOVER • • OR O� n Certificate of Occupancy $ �° . Building/Frame Permit Fee $ ,; sACMuSE Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ;l �# Building Inspector My Pnhlin VU^,L,c 2 n IlVn� - vz, zz N v_' n 3i aLn ra ti y y z z O �D m �� — O y z ^ X T. �, C ^1 C C o r. J ✓' .�rm 'mCA z w C ,'� ►y V 5 n� � Z 9 z Z awl y'n C z 7 Z G > R W y in A f c Ym n � y Z O Z .� Cy m Z m a CA W 77 'rf A a CA OP A D z > D z z L fl1 a Ch Z z rt : F m O CD z m ;1i Q 1 J y 3 m Z O � Z P = r� .nom T 7 a CD n s j• Et O z 0 a c� IlVn� - vz, zz N v_' n 3i aLn ra ti y y z z O �D m �� — O y z ^ X �, ^1 C m o m ✓' z C rn i� n� � Z � O c iX � � Z O .� Cy � Z m a z a CA OP A D z > D z z x - a m ;1i Q 1 J IlVn� O �D m — O o � � c a z a ;1i Q 1 J Z � a IlVn� V The Commonwealth of Massachusetts t_ Department of IndmtrialAcciden4y 011iceo//~#ANos 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit name: Mike Antoon Construction fecafion: 20 Johnson Circle city North Andover, MA 01845 phone # 978 687-7530 0 I am a homeowner performing all work myself. p I am a sole proprietor and have no one working in any capacity ® I am an employer providing workers' compensation for my employees working on this job. tLx name: Mike Antoon Construction. 14 Bearse Ave. Methuen, MA 018443409#, 978-688-6272 phoneinsurance co. The Maryland, Commercial Group. nolicv # TC8 00957854.66 1 am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: �omparw name - city: phone #• _. men—wa on � nnlinv il:�.' � .•. 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 S1.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 it day against me. t 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 is true and correct. 4/9/98 # 978 688-6272 official use only do not write in this area to be completed by city or town official _ city or town: permitAicense __ []Building Department OtAcensing Board - - i] check irimmediate response is required OSelectmen's Office 01-1ealth Department contact person: phone #; []Other (mild 3195 PJAi b t BE • t 42 w a I p n CD O E O Z p„ O y Q C CD I CC h Q O h O O 'E m m CD ow L- 93- _H CD O� �3 .o O O Q O L m O d a-0 cc v�cC CO c V C. O CD c Z CD CL c C Q. CO2 Q� . c y- o O W a CD c O W a Cd W � ,..� C� w a �.e O CH O_ Q i w � c9i C Oa c w° m G U w a ;� a w W •a W -�y w � .c 00 C2 w W4c rA z cn u cn BE • t 42 w a I p n CD O E O Z p„ O y Q C CD I CC h Q O h O O 'E m m CD ow L- 93- _H CD O� �3 .o O O Q O L m O d a-0 cc v�cC CO c V C. O CD c Z CD CL c C Q. CO2 Q� . c y- o CD c C� �.e O CH O_ C VV .Q � CL r- 43 C 0 cl 0 Ea I o CE �_ IL%ECLy c O O c -cc CD ft-. E 0 M, CD 3 N _C m ' = C V N � Em o :•m o CLS m o c oQ cn N _ G C O Cl N O c Z O co CO` aO C : N _ `om 3 N � amo N D W C m•O'~ •N ev F:. W .n a.J c -o V . y Z e ` Qw f~� O� O_� ... O = O BE • t 42 w a I p n CD O E O Z p„ O y Q C CD I CC h Q O h O O 'E m m CD ow L- 93- _H CD O� �3 .o O O Q O L m O d a-0 cc v�cC CO c V C. O CD c Z CD CL c C Q. CO2 Q� 6 Respond to Andover Office Joseph A. Millimet Retired William J. Murphy O(Counsel J.M. McDonough, III *Richard G. Asoian Paul C. Remus Andrew D. Dunn *Mark E. Tully David H. Bames George R. Moore *Susan V Duprey. Donald E. Gardner Daniel J. Callaghan *Frederick J. Coolbroth *Steven Cohen *Aaron A. Gilman Nancy V. Sisemoore Robert C. Dewhirst *Richard E. Mills Newton H. Kershaw, Jr. *Karen S. McGinley Donald A. Burns Steven E. Grill Ovide M. Lamontagne Thomas Quarles, Jr. Paul L. Salafia Mark T Broth *Nicholas Forgione Eric G. Falkenham *Robert W. Lavoie Nelson A. Raust Charles T Giacopelli Camille Holton Di Croce *Mark J. Sampson *Jon B. Sparkman Ana R. Mullikin Ronald D. Ciotti Diane Murphy Quinlan *Melinda S. Gehris *John R. Blake, Jr. Alexander J. Walker, Jr. *Linda L. Mesler *Patrick G. Sullivan Margaret A. O'Brien *Michael Dana Rosen *Dyana J. Crahan *Patrick C. McHugh *John P. Sherman David P. Eby Scott W. Ellison Bret D. Gifford Jennifer Shea Moeckel Charles R. Powell, III *Michael E. Kushnir *Kevin G. Collimore *Julie A. Dascoli Thomas F Irwin *Daniel E. Will Matthew H. Benson Donna M. Head James W. Seeman Kristin Kohler Joelle G. Collins *Matthew R. Johnson Patricia M. McGrath Patti R. Kfoury, Jr. DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION eATTORNEYs AT LAW June 16, 1998 Town Building Inspector North Andover Building Department 146 Main Street No. Andover, MA 01845 Re: The Chatsons, 127 Bridle Path Road, North Andover, MA Dear Sir/Madam: Please be advised that this office represents the Chatsons who reside at 127 Bridle Path Road, North Andover, Massachusetts. In May, 1998, the Chatsons obtained a building permit for renovations made on their home. The Chatsons initially hired Michael Antoon, d/b/a Mike Antoon Construction, to perform this work: Please be advised that the Chatsons terminated Mr. Antoon's performance on June 10, 1998. Should you have any questions or comments, please do not hesitate to contact me. /dmm cc: Drs. George and Kim Chatson \\atg\vol l \common\mj s\letters\noanbui I. doc *Admitted in Massachusetts. Very truly yours, Mark J. Sampson 12 Essex Street P.O. Box 39 Andover, MA 01810 Tel: 978-475-9100 781-942-0932 Fax: 978-470-0618 Victory Park 111 Amherst Street P.O. Box 719 Manchester, NH 03105 Tel: 603.669.1000 Fax: 603-669-8547 ,•re,.m,1 ;.� 1�;.1. ;.� tirl,r P t,,,nn r,;n, „III. t1.;ma• oo."o i:. `L,cc 6,1111.,n n.r.rt. Ik,ch,nt •K;. I•. v,i E. \LII. TcOt •. ....I ,, :I'., :IIS .i•,.. Ci� L.;v,nc �., u1.1 �.unl•"�n •L,n P �I,ukn,.,n `I'dhk,n •\L.�,.,ci P.m., K"•cn d t' EF, \C' Ell ;>„n I' ,Jm; nl Iitl)11 1'ti .1 Nl—k,[ !..",.:. rP ,„,n, ill „I E. K—hmr •\r, ,�,� ,.Ahn,.,re h,,m- F. Irn,n ,u 1 E. \'t'',II \L,r,hc•., H. P n -n !,,.nn., \I. lic.,d '\r,nnn K,•I)I,r ,-01c U C"11m, c,. R L,hm,m DEVINE, MILLIMET & BRANCH PktIPIiSSI()N 11.:�SStlt;l \1'111\ 0 ATTOkNH S AC 1, 111 June 16, 1998 Town Building Inspector North Andover Building DepVment 146 Main Street No. Andover, MA 01845 Re: The Chatsons. 1?7 Bridle Path Road, North Andover. MA Dear Sir/Madam: Please be advised that this office represents the Chatsons who reside at 1?7 Bridle Path Road, North Andover, Massachusetts. In May, 1998, the Chatsons obtained a building permit for renovations made on their home. The Chatsons initially hired Michael Ar:toon, d/b/a Mike Antoon Construction, to perform this work. Please be advised that the Chatsons terminated Mr. Antoon's performance on June 10, 1998. Should you have any questions or comments, please do not hesitate to contact me. /d, -nm cc: Drs. George and Kim Chatson \\atg\vol I \common\mjs\letters\noanbuil.doc Very truly yours, Vim• Marl,- J. Sarni sorl 11'. ts'ci Strect P.O. N,.x ?9 Tel: u78.475.9"'O 731-94=•O'i12 Fax: 978-470-06 IS Victory Pad: I11 Arnhem ``crccc P.O. Box 119 \1wichom. NH 0310 Tel: c)03 -6b9- ICC'0 Fax: 603-669-6347 •' r Electrical Inspector North Andover Building Department 146 Main Street North Andover, MA 01845 Re: The Chatsons, 127 Bridle Path, North Andover, MA Dear Sir/Madam: Please be advised that Michael Antoon and all other subcontractors hired by him have been dismissed effective June 10, 1998. This includes but is not limited to Gil Paradis, an electrician. Please see attached letter sent to building inspector dated June 16, 1998. Should you have any questions or comments, please contact Mark J. Sampson, Esquire at Devine, Millimet and Branch in Andover. cc: Mark J. Sampson Sincer ly, Ki Jerlee E. Chatson, M.D. 1� 51- q9 9& m w MR •.�C O• W 0! O O V LU a a V WZ Z Z Ru _, t N Ix d L w MR •.�C h O• t h 4.5 h L H .!2 V E COL. � c s c c n Q! > -v 0 j E a •� V .� O C C 3 O o m C) E .c c u o C o CL. � o w H a o G V "= O F z L S: N 4 cn v a.w c. z o bb 41 +� ° .b : WD U 'O b.0 �• cd •o i� 2c-) a to ( o si, oW x �' N a� j7 W oCd z U o O x U .d N C t. ° H a ° ° +� a O .c a ° .�a > L H .!2 V E COL. � c s c c n Q! > -v 0 j E a •� V .� O C C 3 O o m C) E .c c u o C o CL. � o w H a o G V "= O F z v PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP NO. I LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK PAGE ZONE SUB DIV. LOT NO. 1 1I 1 LOCATION PURPOSE OF BUILDING/c1 eV OWNER'S NAME N NO. OF STORIES SIZ / OWNER'S ADDRESS t, • Cti� i BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND SPAN �— _ / 3RD ), r r BUILDER'S NAME JLA� rS .�} /y, /- q DISTANCE TO NEAREST BALDING (�t / U' DIMENSIONS OF SILLS DISTANCE FROM STREET /�<t�G "' "" POSTS DISTANCE FROM LOT LINES — SIDES / /' 0 REAR "" GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW 't SIZE OF FOOTING 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 INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE JILED SIGNAT R�.FO NER OR UTHORI D AGENT F E E PERMIT GRANTED y 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER ✓SQ. FT. EST. BLDG. COST PER ROOM -9iMW PERMIT NO. /3 d' (%• 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR 'NV-ld 101d S30b'1d3bl SIH1 'a3SOdWIM3df1S '013 'S30VEI -V0 'S3H3H0d H-LIM 'SONIa11f19 d0 SNOISN3WIa lOt/X3 aNV S3N11 101 W021d 30NVJLSI(3 aNV 101d0SNOISN3WIa 1:)VX3 AAOHS-LsnW N01103S SIHl Z L AONvd (1000 L 0210:)3t JNla1ina ONIIV3H ON P'£ I 01 DIMID313 —1 P"L 1, W.9 110 SWOOV d0 'ON L SVJ Sd31V3H IINn 9.I.H 1NVIOVd JNINOI110NOD MIV MOdVA NO M.I.M IOH _ 38311VM 000M 'SIO: g 'SW9 1331S WV31S 'NMnl MIV IOH 03JMO4 3DVNMn1 SS3l3dld _ 'S10J 'S 'SW9 89SWIl lslor 000M ONIIV3H L L II 9NIWV8d 9 OOVO 3111 Mooll 3111 S38n1X11 N8300W ONIJOOM IIOS M3MOHS 11V1S JN19Wnld ON 13AVMJ 8 MVI 31VIS NNIS N3HD11N S30NIHS DOOM A801VAV1 S310NIHS 11VHdSV 13SOlD 831VM 03HSIVId V 13M9WJ ('Xld L) 'WN 131101 OMVSNVW XI1 E) HIV9 dIH 319Vo CJN18WOld OL 100a 5 �-I 3MOI 3daS Mood WHIM 3WV81 NO 3NO1S ABNOSVW NO 3NO1S N19 M30NIJ NO 'DNO: _I MOoll 7 'S81S DIIIV 3WVM1 NO NJI89 AMNOSVW NO NDIM9 — _E E � _ l _ 9 3111 'HdSV 3WVdJ NO o::n1S AMNOSVW NO O:Jn1S ON101S '1M3A NOVJWOD — `JN10IS SO1S39SV 0.Nk(J"H ON101S 11VHdSV H18V3 S310NIHS 000M lS0a 3138DNOD o9dOlo SHOOld 6 II 511VM b NIHD11N NM300W S3DVld 3811 V38V DI11V 'NH V3MV .1.W.9 'NIJ WOOM 0V3H 1.WA ON 7c `h 7, llnl V3MV INMMS E E _ L — _ — _ 9 NI1Nn llVM AMO M313Vld SM3ld O.MOMVH 3NO1S NO NDIM9 3NId 'N.19 3138DN0: 3138:NOD HSINid 101HUNl 9 NOIIVONnOd Z NOIlonNISN00 S1N3WIMVdV _I S3DI110 A11WV1 *wnw 53180!s A11WV1 DONIS Z L AONvd (1000 L 0210:)3t JNla1ina