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Miscellaneous - 22 BANNAN DRIVE 4/30/2018
F �/ Date ....... 97.7,...l.tl... .... ..... ... ... ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that _14- ............. 2 .................................................. has permission to perform ...... !��J.. ..... wiring in the building of ............. ................................................. at ...... ............ . North Andover, Mass. .............. /. Fee ... 5��Lic. No---�- ELgCTRICAL' INS �CTOT- ........ Check j 12 5 9 3 commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev- 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrica4Ins C), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Ii City or Town of: NORTH ANDOVER To thector ofWires: By this application the undersigned gives notice of his or her intention t erform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a build' g permit? Yes ❑ Telephone No. No [N (Check Appropriate Box) Purpose of Building Q AC, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters ,/) ,1 wf ,w tit- t-- lL Com letion of the following table may be waived by the in eeror o� wires. Arlacn aaalrionat aeum iJ Ue6trGCy yr — —q --u vy sn� +.• r� •�• ✓ -- Estimated Value of E ctrical Work: "^— (When required by municipal policy.) Work to Start:917 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 sa to theit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pain and enalties of per ry, that the inform tion on tl is a t tto true and comp FIRM NAME:. Z� LIC. NO./�"/ Licensee: U Signature LIC. NO.: -Ali (If applicable, enter " empt" in li ense nz ber line.) us. Tel. No.: Address: �dl Alt. Tel. No.: *Per M.G.L c. 1 7, s. 7-61, security wor requires epartment of Public a ety "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. P No. of Total No. of Recessed Luminaires No. of Ceii. Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency ig tingNo. BatteKy Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices He Number Tons KW "' No. of Waste Disposers talp De cSelf-Contained Detection Al Devices No. of Dishwashers Space/Area Heating KW Sp g Local ❑ Municipal ❑ Other Connection Heating Appliances KW Security Systems:Y Equivalent No. of Dryers No. of Devices or No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Arlacn aaalrionat aeum iJ Ue6trGCy yr — —q --u vy sn� +.• r� •�• ✓ -- Estimated Value of E ctrical Work: "^— (When required by municipal policy.) Work to Start:917 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 sa to theit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pain and enalties of per ry, that the inform tion on tl is a t tto true and comp FIRM NAME:. Z� LIC. NO./�"/ Licensee: U Signature LIC. NO.: -Ali (If applicable, enter " empt" in li ense nz ber line.) us. Tel. No.: Address: �dl Alt. Tel. No.: *Per M.G.L c. 1 7, s. 7-61, security wor requires epartment of Public a ety "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. r •�ty� ray r�s�-���y � ry� ry�•�y�� ��7-t �,r �,r r�c7- �•� �ry�, y� }� .nJR�i-1LJ-.[�.9.�.s.l1.gF3.G.�'+�,l,�U'�"� � .. � � • ^ 'assetl--� � �'a�Ieti--j � �2.eius�eetZo�xec�uiret�(�50.00)�[ � • aspetors' com rents: (�1�spectoxs'uignaiuxe��.o?iutaTs} ]ate _ . 3secl--[ 1 pectbxs' eornmepfs: Y'aReri•- (Xttspectoxs',�ignatuxe��.oinitials} WRACTXON- OMR.:' actoxs' coxnm.�rits: _ • 5 ' ioxs' minatuxe •• no initials) �nspecfio� date Pate 'asseci--�aile[i�Zteinseetioxtxeo�uixe($0.00)- [ �ri�ieetaxs' o eufs: . nsiectoxs',zgn e. �o' a s) Pate 'assetl--� � �'a�Ieti--j � �2.eius�eetZo�xec�uiret�(�50.00)�[ � • aspetors' com rents: (�1�spectoxs'uignaiuxe��.o?iutaTs} ]ate _ . 3secl--[ 1 pectbxs' eornmepfs: Y'aReri•- (Xttspectoxs',�ignatuxe��.oinitials} WRACTXON- OMR.:' actoxs' coxnm.�rits: _ • 5 ' ioxs' minatuxe •• no initials) �nspecfio� date Pate Fold, Then Detach Along All Perforations a� Division Location 2.2-, NJ No. Date 2, TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permi t Fee $U�00,n Foundation Permit Fee Other Permit Fee TOTAL $ Check # 9 �,� 27289 Building Inspector L. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page l - .• L ... S c -k w, edge ' PROPERTY OWNER Pant' 100 Year Old Structure yes, MAP NO''Q ik'PARGEL' ZONLN' G DISTIRICT: Histonc�Qistnct yes MachineShop Village yes, „ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building '% One family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septics :❑ V1/ell� ❑ Floodplain; 0 Wetlands ❑ WatershediDistrict Water/S:ev►Ier. DESCRIPTION OF WORK TO BE PEKrUKmtU: -►- ' l -z Identification Please OWNER: Name: _ � t.._ S c L -,", e CONTRACTOR Name: �L Print Clearly) Phone: ��1. 5M - 5-0 is Address: --C.v S ��- -`r tuv �.�►`-1,. b 1�^- - Supervisor=siConstruction'License: OS vR q Exp:_ Date: - b�Z,� t . Moine Impro ernent License:; Lol Y-"t`i Ezp. ARCHITECT/ENGINEER Phone: .z Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. f Total Project Cost: $ S-5 IyUD FEE: $ (D r Check No.: QW Receipt No.: 4 ✓ O NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund SlgnatureogentlOwne Si_gnature;ofcontractor, z Plans Submitted �_ Plans Waived Certified Plot Plan ❑ Stamped Plan ❑ Plans Submitted ❑ Plans Waived' Certified Plot Plan ❑ Stamped Plans ❑ I t TYPE_OF .SEWERAGE DISPOSAL �j Public Sewer ❑ Tanning/MassageBodyArt ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENT CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_.. Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit n DPW Tovv;� Engineer: Signature: -,? Located 3840s, ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no p.. Located at -124 Mair Street Fire Departinert•signatureldate ` COMMENTS Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 55,000.00 m $ - $ 660.00 Plumbing Fee $ 82.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 82.50 Total fees collected $ 925.00 22 Bannan Drive 585-14 on 2/11/2014 Remodel Kitchen and 1/2 Bath E J LU LL 0 m C t - O -LL .. aO' Ln U _ Ln 0 t.% a m. .. C '' 7- LL S 7 d' C U C LL . 0 LLI co G J. d - L 7 .0 W M LL- Oui ..- LIJ °• ~ W LU _ .. L 7 0 OC U a. i N - - LL O f.. LU Z. Q) to 7 K C LL W W LL ... - 1 m y N Ln y 0 i -14 O Ln C F--1 O w+ C Cc O cc W _ y Q E Q AZy rn .r c O _ V L to0 O' J N f0-0 c Aw;ccc�Q ��-E�o �moz :=No 0 rrnoo �• 3 L Q d z U) x n. (D •5 cn W O -0 w O O uj u. .2 as 0 ,rn c •�. O Lu EO � r V 0 V a) o� F v� CL °' 5 ;�- c rn .a o Ix— t � CLoU O Wa z z io0 E U w� .O U) x� � � V W C W J a Z W � Q O v O L F— G1 i • A�lj :2 O O �o G� Z w N C �• L O � � .Q —'C M N O Z '+ V. OCL v � Q � v O L F— • A�lj :2 O �o oC 0 w N a �• U O .Q —'C M N O Z '+ V. OCL v cn ss O J Q LLI LL„ O D Q m L Y ELU +O+ N 0 W Z Z m O 0_ m aTi 0 W CL In0 Z Z ME C a - _. O W d Z J U LU - U p d H Q L Z W C Q W W � LL N O Z ++ N D O O cc �a c 0 U) V E Q . � c 7 I E an • O C avow c a O ci L v to y •�, ” 3 as � 0 J 0 C4 y m �r c d y G1 o = > 0 • O c •tC)a • c 0 • ��• a� z , Q•y4-- - y O C 'sy3 Co c H L Q. 4 Q L c • CL •� I- O y y 2 m. W_ 'a 3- O O •O.,= O y +r uj:E r . W E c�.� � .a <•> Q. o m am 1U) > ;� c y � O 1- t 0 . � O 0 2 O m z Lw .W 6_L a CO w0 �v WW CL Z O W CL Co z CD0 CO W O E i O Z N Q� i O '- N 0 � m m o+ CD W o 0 cc O CL a CL a� Q OM r v_ J .O- O Z �. O ,QA V •� y cc ^� 4�: Kean .rp t y. Building Contractor Proposal To: Paul & Jean Schmiedel 22 Bannon Drive North Andover, Ma. 01845 From: Kevin Murphy cc: Date: 2/11/2014 Job: Kitchen Date of plans: 10/4/13 Architect Lucy Ross Location: Same Section 1- Work Schedule • 98 Forest Street • North Andover, MA 01845 • PH: 978-688-5335 • FAX: 978-688-7207 All Home improvement Contractors and Subcontractors engaged in tame improvement contras tirg, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and Status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108.(617)-727 8598 Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified hen: in writing contractor will begin work on or about 2/10/14. Barring Delay caused by circumstances beyond Contactors control, the work will be completed by 4/15/14. The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11- Warranty The Contractor warrants that the work fumished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section 111- Scope of Work Page 1 of 4 Kevin Murphy Building Contractor 98 Forest Sheet North Andover, MA 01845 PH: 978-688-533,5 FAX 97868a7207 General Page 2 of 4 Proposal is to renovate exisitng kitchen area, and update existing half bath. Building permit will be provided by contractor. Demolition Exisitng kitchen area will be completely gutted. Floors, walls, and ceiling will be removed. Existing half bath will have floor, vanity, and plumbing fixtures removed. Building Two new Harvey, all vinyl doublehung windows will be supplied and installed over sink. Other existing window in rear of kitchen area will be removed and filled in. All framing materials required for kitchen renovation will be supplied. Vinyl siding will be supplied and installed to match existing. No allowance has been made to change the size of any other openings / entryways to kitchen. Plumbing Plumbing required to renovate kitchen and half bath has been included. An allowance of $1700 has been included for plumbing fixtures ( $650 for kitchen sink, $600 for kitchen faucet, $250 for toilet, $200 for bath faucet) . No allowance has been made to relocate any plumbing fixtures. No allowance has been made for any gas piping. Electrical Electrical work required to renovate kitchen to code will be be provided. Eight recessed lights have been included. Any surface mounted fixtures to be supplied by owner, installed by contractor ( pendants, undercabinet lights etc ) . General layout to be approved by owner prior to rough. Existing thermostat will be relocated. Sub panel will be provided as required. No allowance has been made to upgrade existing electrical service. Heating/Air Conditioning Existing baseboard heat will be removed as required. Toekick ( under cabinet) forced hot water heating unit will be provided to properly heat kitchen area. No allowance has been made for any air conditioning. Insulation Existing kitchen area will be insulated to meet code. Plaster Kitchen will be blueboarded and skimcoat plastered. Walls will be smooth. Ceiling to match existing. Interior Trim/Doors Pre -primed interior trim will be supplied and installed to match existing. Cased openings will be replaced as required. No allowance has been made for any interior door units. Kitchen cabinets / bath vanity to be supplied by owner, installed by contractor. Countertops to be supplied / installed by vendor. Kevin Murphy Building Contractor 98 Forest street North Andover, MA 01845 PH: 97866135335 FAX 978-6887207 Painting Page 3 of 4 Interior painting will be provided. One coat of primer, and two coats of finish will be applied to all painted surfaces. Flooring Tile floors will be provided in kitchen and bath areas. Tile backsplash will be provided. An allowance of $6 per square foot has been included for file materials. Waste Removal All demolition / construction debris will be disposed of by contractor. • u V Kevin Murphy Building Contractor 98 Forest Street North Andover, MA 01845 PH: 9788888335 FAX 978888-7207 Section N - Price Schedule Total Page 4 of 4 We hereby propose to furnish material and labor—complete in Accordance with above specifications for the sum of .....................................$ 34,000 Payment to be made as follows: PercentagelItem Description Amount 1 Permit obtained $2000 2 Demolition complete $7000 3 Plasteiing complete $10,000 4 Cabinets/ trim installed $5000 5 Floors / paint complete $6000 6 Job 100% complete $4000 6 1$34,000. Notice: No agreement for Home improvement contracting work shall regrme a down payment (advance deposit) of more that one-third of the total contract pnoe of the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whici never is greater Contractor: Kevin Murphy 98 Forest Street No. Andover, MA 01845 Registration No: 101874 Section V - Acceptance Acceptance of Proposal — I have read this document and accept the prices, specifications, and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature �-PCIML . J10 Date 2 l o f Signature Date The Commonwealth of Massachusetts 01 Department of IndustriqlAccidints Office of Invesfigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name (Business/Organization/Individual): Utr/_U" City/State/Zip: 1,P_ Phone #: Sn V , Weie - 0 �3 5 Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with �_ 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).' have hired the sub -contractors �• `� Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 1311 Other comp. insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie 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. lam 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. #: VJL, wC `-t,-UL 'A6 —1 Expiration Date: —I� Job Site Address: Z2— � -�M' �r'L�`'� City/State/Zip: K/,,,. �� , �� U �� 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 tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: _ Date: Z,� l L t l y 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 #: ACOR F 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDo/YYYY) 7/17/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER., AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 CONTACT AME: Pr ac ND Ext: (978) 683-8073 1 AIC.No:(978) 683-3147 Aoess:sandi@mprobertsinsurance.com INSURER(S) aFFORDING COVERAGE_ NAIC9 INSURER A: PROVIDENCE MUTUAL INSURED KEVIN MURPHY BUILDING & REMODELING 169 BOXFORD STREET NORTH ANDOVER, MA 01845 INSURER B: MERCHANTS INSURANCE INSURER C: GUARD INSURANCE INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER RFVISinm N[ IMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE ADDLISUBRI msD Iwo I POLICY NUMBER POLICY FFF I MWDD POLICY EXP MM(DD/YYYY) LIMITS A X I COMMERCIAL GENERAL LUMILITY CLAIMS -MADE ® OCCUR BOPI068945 11/22/12 11/22/13 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 15,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � PECOT- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - CODdP/0P AG-, s 2,000,000 $ B AUTOMOBILE LIABILITY A ALLLL OWNED SCHEDULED AUTOS X AUTOS NON-OHIRED AUTOS AUT SEED MCA7013608 01/23,/13 01/23/14 COMBI ED SINGLE LIMIT Ea aaadent $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PR ) G $ Per accident) $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE CUP9145304 11/22/12 11/22/13 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION AND E&IPLOYEP,S' LIABIL(TY YIN PRIMpMFTNER/EcEctrrVEC OFFICEBEXCLUDED? (MandatoryIneunder E1 If DESCRIPTION OF OPERATIONS below NIA �C422467 07/01/13 07/01/14 OTH- X , STATUTE ER _ E.LEACH ACCIDENT $ 500,000 EL DISEASE -EA EMPLOYE $ 500,000 EL DISEASE -POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ncnrrrrnwrr rr�r nr.-. m I Vt$U-1U13 ACORD CORPORATION. All rights reserved. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD .•v�r.ari r rvr� TOWN OF NORTH ANDOVER BUILDING DEPT. NORTH. ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORRED REPRES A "-4*;; 1 m I Vt$U-1U13 ACORD CORPORATION. All rights reserved. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NL) i t5 anco DA I A — (tor department use D Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu,�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Buhding Permit Revised 2012 Location A A)/v 0 A.) No. -q Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 16 3 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING y, , * .;zea BUILDING PERMIT NUMBER: (� a DATE ISSUED: L ye ` Q3 SIGNATURE: ' Lj� Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 2Z AAILIV A,(l 0Zl 1IC- 1.2 Assessors Map and Parcel Number: 40d� Map Nu-0-Parcel Number uv:e i,- t 1.3 Zoning Zoning Information 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 Required Provided R red Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ IiECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record N�124 —22- uA-Q `tel vE Mo. Name (Print) Address for Service : I;-- 14A Sign re Telephone 42�� 8 Ss7 —0172- 2.2 Owner of Record: Aj Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: J d�� F Licensed Cgnstruction Supervisor: /C2 /f4VL- C-I Lk Ad rens (� �` ( 7,9 3 6 2 - `amu � i nature Telephone Not Applicable ❑ d Oq /,L/,-) License N tuber /` — ®2-- 3 Expiration Date 3.2 Registered Home Improvement Contractor �f Q ` Iy SG t S Not Applicable ❑ f © .AA Company Name oLt/ _ yG 043-3 %c-) 3-3 Registration f Nu me ber 2 00 A ss - Expiration Date SiduTelephone OU rn Z rn 'I I r SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 � 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ ti Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: f -e roc 'e is/A' L'C+o CQ �'4 10,6-4rF_A L4, r-ttiv44'- SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant (?FFICIAL IiSE ONLY 1. Building CO 3-500 (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection Total 1+2+3+4+5 ' 3 , ".rQ 0 Check Number CTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUR DING PERMIT Las Owner/Authorized Agent of subject property Hereby authorize Vok-,\_J 'M (T( to act on M 'n all ma relative to work authorized by this building permit app :31 1 �D� Si nature of Owner Date SECTION 7b owNMAuTHORIZED AGENT DECLARATION I, �v LL L, '4 4 /v( 6 t c.(i,`l r i ,ab r/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 o T/� Print e ,r 4pk /i, ZaU 3 Si na ire of<E w r/A ent Dat j NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TB/MERS 1 ST 2ND 3 SPAN llMIENSIONS OF SILLS DD, ENSIONS OF POSTS DINENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SITE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 03/28/2003 10:13AM THE HARTFORD PAGE 5 OF 5 ACORD,. CERTIFICATE OF LIABILITY INSURANCE T03-28-2003DATE PRODUCER PAYCHEX AGENCY, INC 210705 P:(877)287-1312 F:()- 308 FARMINGTON AVE FARMINGTON CT 06032 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED MORRETTI & SONS 85 SPOFFORD ST GEORGETOWN MA 01833 INSURERA: The Hartford Ins Group INSURER B: INSURER C: INSURER D: INSURER E: COVFRAGFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POI ICY NUMBER POLICYEEFECTIVE DATE IMMDD Y POLICVEXPIRATION DATE (MM/DD/YY LIMITS GENERAI 11AB11ITY EACH OCCURRENCE I $ FIRE DAMAGE IAny one Fire) $ COMMERCIAL GENERAL. LIABILITY CLAIMS MADE F1 OCCUR MED EXP (Any one ImN $ PERSONAL & ADV INJURY II GENERAL AGGREGATE S y GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S - PROPOUCYFACT 171 LOC r AUTOMORILE 11AB111TV COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY S ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY S HIRED AUTOS NON -OWNED AUTOS (Per accidem) PROPERTY DAMAGE S (Per accident) GARAGE LIABIL?Y AUTO ONLY - EA ACCIDENT S THAN EA ACC $ ANY AUTOOTHER AUTO ONLY: AGG S EXCESS IIABUITY EACH OCCURRENCE $ OCCUR r-1 CLAIMS MADE AGGREGATE $ 5 S DEDUCTIBLE S RETENTION I X WC STATU- OTH- WORKERS COMPENSA TION AND E.L. EACH ACCIDENT S 100,000 A EMPLOVERS'11ABIUlV 76 WEG KN1002 04/02/03 04/02/04 E.L. DISEASE - EA EMPLOYEE S 100,000 E.L. DISEASE - POLICY LIMIT S 5 0 0, 0 0 0 OTHER DESCRIPTION OF OPERATIONS( OCA TIONSVEHICLEN(EXCI UNIONS ADDED BY ENDORSEMEM/SPECTA1 PROVISIONS Those usual to the Insured's Operations. ATE HOLDER I I ADD17101VAL INSURED; TOWN OF NORTH ANDOVER 27 CHARLES STREET NORTH ANDOVER, MA 01845 CANCELLATION MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE XPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE (10 DAYS FOR NON-PAYMENT) TO THE CERTIFICATE IOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO )BLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR tEPRESENT AT IV ES. ACORD 25-S (7197) ° ACORD CORPORATION 1988 10 Moulton Street Georgetown, MA 01833 (978) 352-2641ph/fax HIC #108505 CSL #008147 MORET H & SONS JOHN A. MORETTI RESIDENTIAL BUILDERS JOAN C. MORETTI (978) 361-5050 mobile (978) 361-5049 mobile March 27, 2003 To: North Andover Building Department Re: Framing detail for replacement of window for Mike and Nancy Egan 22 Bannan Drive North Andover (978) 557-0172 Scope: The existing DH window (approx 2161'x4'6`] is to be removed and replaced with an Andersen picture window with Hankers. This is a first floor window in a wall that does not support floor load above, but does support roof load. 'kt S-n&s rA W W", O O; cau o w° a U) ° w C7 9 o � z w° to v E U w ° w c7 to w a o a U W W w°' C/)w a O C z C7 w�' w z a W w o z Cn v o o cn o :a c a :W � O � :a c ` O N ;� O r C A 1p A Ato Gf� E e C/). Z: �mcF CDW � V • y.+ n {tom, `O Z �►: o 0� o m cE ilk - y � co m � C a. Z Cr) h c '0 �:•O CIO O = ccc E® U : w :1— .00 v C•� h.:® Cf) `:.= g o C/5 cp `t c 0 C, m P -4.m r Cc, �Z 0 00cm 0 c HCOD O c O � �0. N m ♦0.• � O LU G e t e-. w Z 16- CJ cm "r ®tee O Vi .n ®'E 9 0 ® H •= o f 0 O Q Q V Z � C. Q y D � I cm C C Q.� H CD ,y c E m 0 CD CD 3� a2 Q Q L cc O a o- �a y � o.0-0 C CIOc D C Zts CD V y C M- CL _d 0 U) U) IrW w crw CO k BOARD OF BUILDING REGULATIONS . , Licerlse: UONS°PR(3CT(ON SUPERVISOR I _ Number: CS 008147 f 'I Birthdite: 11102/1942 izpires: '11J02I2003 Tr. no: 8931 tt t Restrictk 1.00. JOHN A MORETIT r/ i 10 MOULTON ST GEORGETOWN, MA 01833 Administrator' 3447 Date/C-�. -. /?-. - TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �4, This certifies that . ............................ (�Q has permission for gas installation . ......... in the builditigs of ... ............................... at ....... North Andover, Mass. Feeef�; Lic. No. all 1��IeS INSPEdToA WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N ASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING Type or print) NORTH ANDOVER, MASSACHUSETTS Date �Z/j#0 Building Locations L Z �3/�vt-'�e'�-. �� Permit Ll Amount S �. Owner's Name �� � New Renovation ❑ Replacement ❑ Plans Sub tied ❑ (Print or type) ` / /j Check one: Name "4- Corp Certificate Installing Company Address �� /2U,� t2 /L-` Li Partner. -)-,. v 14 tid ,, u.P✓z ✓ � 8 l P 1 Business Telephone L,=�FirmiCo. 1 Name of Licensed Plumber or Gas Fitter S�V 0-z—� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Lr No❑ if you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity F7Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1421 of the ✓lass. General Laws. and that my signature on this permit application waives this requirement. of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ I herebv 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 installatios pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Iviassachus erg .fate _s Code an hapter I of the G al Laws. By: Title Ciry/Town A-PPROVED (()Eric:- u�F !)Nl.YI Sienature of Lice:n�e'd Plumber Or Gas Fitter ❑Plumber ❑ Gas Fitter T icense -,7 umotr j ,,�fVI1S[�r �I---i Joumeyman �I (Print or type) ` / /j Check one: Name "4- Corp Certificate Installing Company Address �� /2U,� t2 /L-` Li Partner. -)-,. v 14 tid ,, u.P✓z ✓ � 8 l P 1 Business Telephone L,=�FirmiCo. 1 Name of Licensed Plumber or Gas Fitter S�V 0-z—� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Lr No❑ if you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity F7Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1421 of the ✓lass. General Laws. and that my signature on this permit application waives this requirement. of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ I herebv 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 installatios pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Iviassachus erg .fate _s Code an hapter I of the G al Laws. By: Title Ciry/Town A-PPROVED (()Eric:- u�F !)Nl.YI Sienature of Lice:n�e'd Plumber Or Gas Fitter ❑Plumber ❑ Gas Fitter T icense -,7 umotr j ,,�fVI1S[�r �I---i Joumeyman Date. (-,.e... N2 4480 TOWN OF NORTH ANDOVER 0 10.9 .0 PERMIT FOR PLUMBING U This certifies that ................ has permission to perform ................ plumbing in the buildings of .......................... at . ......... North Andover, Mass. old FeePib. . Lic. No ............... PIL Check # I— INSPECTOR WHITE� Applicant CANARY: Building Dept. PINK: Treasurer �. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) �i -N® LL AND O V Mass. Date a"O Permit #_ 4/ Z> Building Location ZZ 3y�4NOO,'J Owner's Name 11ne IWf c 9/1 EL 96, A r✓p 0 t/Q4,0—. M A 01 Pus Type of OccupancL S l D E Iv 1l r-1 L_ IN New ❑ Renovation ❑ Replacement ilk" Plans Submitted: Yes No ❑ FIXTURES Installing Company Name � o r iEez - SP (r r»,4 7 rQ e 0 Check one: Certificate Address C(: RC H mt4k) P J - ❑ Corporation + IV E % r -{l' c --A) Al A ❑ Partnership Business Telephone k1f Z -0117 7 1 perm/Co, Name of Licensed Plumberf'r3 r=;r? r fry SA,�v� rvl r4 �r4�r" INSURANCE COVERAGE: I have a current Iobility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Er No ❑ If you have checked yes, please /indicate the type coverage by checking the appropriate box. A liability insurance policy ld 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: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral laws. Title . re of Licensed lum r Type of License: Master � Journeymah ❑ City -Town APPROVED OFFICE USE ONLY) License Number �_3 5 I pp PA AM Installing Company Name � o r iEez - SP (r r»,4 7 rQ e 0 Check one: Certificate Address C(: RC H mt4k) P J - ❑ Corporation + IV E % r -{l' c --A) Al A ❑ Partnership Business Telephone k1f Z -0117 7 1 perm/Co, Name of Licensed Plumberf'r3 r=;r? r fry SA,�v� rvl r4 �r4�r" INSURANCE COVERAGE: I have a current Iobility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Er No ❑ If you have checked yes, please /indicate the type coverage by checking the appropriate box. A liability insurance policy ld 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: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral laws. Title . re of Licensed lum r Type of License: Master � Journeymah ❑ City -Town APPROVED OFFICE USE ONLY) License Number �_3 5 v z O I - m N N Z N m A O Z N Date. Nq 42 4 3 ,ORT)l TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING S'qCHUS This certifies thal ....... ............................. ihas permission toperform ... ............................ plumbing in the buildings of ........................ -at . zle-�:_ ` ......... North Andover, Mass. ...... ............... ......... PLUMBIN VN -T-OR / x ';;4C ;:ING �WTI' F e e 1-5 . L i c. N o. . lle'� WHITE Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFOI2M.APPLICATION FOR PL T TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS v Date Building Location taioZ � � �K% PW—Owners-Name 1 K -e 11t4ermit # J Amount Type of Occupancy "�S New❑ Renovation Replacement Plans Submitted Yes No 1WTYTTTR3i.0 (Print or type)pp Q p 1 ! Check one: Certificate Installing Company Name Qom, fa e, 0 C �% � 1 -rg ® Corp. Partner. Firm/Co. ` Name of Licensed Plumber. ��i� 1r�9�� a �i �:,y -F Insurance Coverage: Indicate th e of insurance coverage by checking the appropnate box: r Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance -- ignature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perforin der Permit Issued for this application will be in compliance with all pertinent provisions of the Massa etts State Plumbi g ode d C er 142 oiDthe General Laws. By: igna of LicenseFOUR, ype of Plumbing License e Title � Lf ? City/Town 77cense Num er Master Journeyman APPROVED (OFFICE USE ONLY __ • .r No MZI: all: I Now MMM MMMMOM 'Mom `3 D I -.-5-.M-WM--m...-...--m-� mfolume -----.--.m-.-M-...---M--- MM M mmmmmmmmm MMM ..• MMI iiiiii MMO iiimmmmm- MM MMMME (Print or type)pp Q p 1 ! Check one: Certificate Installing Company Name Qom, fa e, 0 C �% � 1 -rg ® Corp. Partner. Firm/Co. ` Name of Licensed Plumber. ��i� 1r�9�� a �i �:,y -F Insurance Coverage: Indicate th e of insurance coverage by checking the appropnate box: r Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance -- ignature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perforin der Permit Issued for this application will be in compliance with all pertinent provisions of the Massa etts State Plumbi g ode d C er 142 oiDthe General Laws. By: igna of LicenseFOUR, ype of Plumbing License e Title � Lf ? City/Town 77cense Num er Master Journeyman APPROVED (OFFICE USE ONLY __ Location No. V/ 01:5� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ C? Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3558 Building Inspector X67 Q , U) C O O U U Z LU lz ,1 C O N E" O .. Z OF, J O z N ti 1 C O O U U LU lz C Z OF, J O z N N C p ►�1 U U U c i ►� C ti 1 C O O U U LU C OF, J O z N C p ►�1 U U U c i ►� C C Z O O H H y U U U �y, :7 W to y cC] ❑ F•' tsl z a_ U U U ❑ G O ❑ O Z Z Z D O q U L < a z .0 U Z W U. O C o <w w(n `7 E.y C O O O O O o O U U U n O V z Z z 1� O H N W O in � S G ❑ G O cZ.l h �, G N G Z © H y ❑ ❑ q � v� c r ^h^am F�1 _ Or 11 z 0 z � w Z z � ^ z 2 � J ❑. �_ � ;c � z PC d; n 'a O G T Z ad U � N o O z V7 O N (� ❑ F z ._ F _1 l: t C U - z O w< z -I en W W u W W Z Z Z F—� O C C C_ "'� Z 7_ Z O -❑.1 G G Q ti 1 C O O U U The Commonwealth of Massachusetts Department of Industrial -Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print �7 f X Name: 1. 'r kc— Location: /O/ 1'Y4- se1hK, S� Cit/ ;�a 1/el�,. l� M� Phone 1# 7Z 62 l aI am a homeowner perrcrming all work myself. I am a sole proprietor and have no one working in any cupadb/ aI am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address City Phone 1: Insurance Co. Policy I Comcanv name: Phone "': Insurance Co. Police Failure to secure coverage as required under Section 25A or iMGL 152 can lead to the imoosiiion of criminal penalties of a fine up to 51,500.00 and/or one years' imorsenment as we!I as civil penalties in the form of a STOP WCRK ORCER and a rine cf (5100.00) a day against me. I understand that a copy of this statement .may be forwarded to the Office of Investigations of the CIA for coverage verification. I do hereby cert" u e painZed Pena , of pejury that the informaticn provided above is true and correct. Signature Date I2 —Z U Print name Phone m Offic:al use only do not write in this area to be completed by city or ,cwn emciai Cty or Tcwn Permit/Licensinc Building Dept ❑Check .d immediate response is required Contac.' Y Licensing Board ❑ Se!ectman's Office ❑ Health Department ❑ Other � _ — -- ✓/ie .�aavrw�.zue.�/,t! a��/�/%aa�sac�zuaeCta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number.,CS 065005 - i Birthdate A 1/15/1970 j Expires 11/15/2001 Tr. no: 9975 ',Restricted To: 00 BRIAN A LYNCH 101 HASELTINE ST HAVERHILL, MA 01835! Administrator r - Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r_ ip E L oc x p Ca x O w v V) O z z Qor G: G - 03 •Li O w '� O rx v G C u G a.. a p U W c7 �:, �b0 p C4 G w" � p W U U W to p 0G V S cn G w" p E., U z ~ C7 �b0 p C4 G ii w w Q k. C: w Z y F cn D cn c o O :oma O o U CD : d C CL) 'Q O O CD CD Ea CD (� ti m.e I E c V� 0 CD O W- as G_ m c E O CD a N h • "�'' O C v :2jW+/� v ai 'fl — O F-1 ;:4 C.) Cc m �:'= C C O 4.jQ. N� w U �Em C co 0 cm a' O L co C/) v ..,� o _c cm w .a AMID;. : CD m O VN O U �: M —Z o O O O CO C ydmc 'c C r 3m�0 m LLJ G rte. C 46►- v� m cv cv c O y L) ow 2 m omc g OGo 0 L- E 0., L O V CD CL CO) C 0 Cf) W W crw LLJ Cn