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HomeMy WebLinkAboutMiscellaneous - 227 GRANVILLE LANE 4/30/2018 (2) 227 GRANVILLE LANE 2101106.60065"0000.0 �I I � LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 February 12, 2015 Building Commissioner/Inspector of Buildings North Andover, MA 01845-4903 Board of Health/Board of Selectmen North Andover, MA 01845-4903 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: Rena & James Chace, Jr Loss Location: 227 Granville Lane North Andover, MA 01845-4903 Policy Number: HN007477 Date of Loss: 02/12/2015 Cause of Loss: Water LA File Number: MA-2-25867 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Amanda Williams Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 9857 Date... Of t.oa oT e,MO a� ,•� - a� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;�SSACMUz v This certifies that jU PS f;,�E q� � �e-/�>1Z has permission to perform .................... ............f�......................................... wiring in the building of........ z~ .................. ................................................... t L L = . .North Andover,Mass. JI-D 60 1-37y7-8 Fee..................... Lic.No.............. ............... . . .. LECI'RICAL INSPECTOR l Check # 4-3 7 Date... ..2L5 .e5— ....... ....... ... .......... 'AORT" TOWN OF NORTH ANDOVER 0 I- p PERMIT FOR WIRING CHU This certifies that ..........C'.........� ye.................................................... has permission to perform ............A-r ..................................... wiring in the building of..............Ix...('11W'5 ......................................... at.... c2.7...PXM.1/�L�..//I/......... . ,North Andover,Mass. Fee..;?,�� Lic.No.&fk 7.............. *Z!-�l.......... ................... N**S*P**E* Check # 65a6 Commonwealth of Massachusetts t"►���." tin'` ' Permit No. ;` _ ►;.a Department of Fire Services r' ()ccupanc; and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev,9 o; b APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Al •.%ork to tk rcrfnniled in accordance t%ith the\la-,.,achumms Fhxtric.d lode i\lF ),i?'(AIR 12J00 WLE.ISE PRIAT 1XIAK OR TFPE.ILL 1.`'�OR.11.1TION) Date: y•—a2G—oG City or Town of: /1/. 4141 �t)E1L Tn the hi.�l�ecvor of ll•lres: 13y This applicatitut the umdersi,ned�iws notice of Itis or her intention to perform the electrical work described below. Location(Street&Number) GleaydylltC LN 4A1,1aL1f/Z S`�g (honerorTenant c /-4/zE 4sF Telephone No.6,K 50' 3/2' Owner's Address Q.-i 7 G AJO tlE_ LAI ry• 1-211! dyez_ Is this permit in conjunction with a building permit? Yes !Q' No ❑ (Check Appropriate Box) Purpose of Building S F// Ltility Authorization No. Existing Service GD Amps e2�/_9Yd Volts Overhead❑ Undgrd❑ No.of Nleters New Service Amps / Volts Overhead❑ Ltndgrd❑ No.of Meters Number or Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wg� I Con•lerir,rt u/th, 'idlun;ut•Irrhlr olui he itaiv,d!1t.fit lus:traor u/rt;. No.of Recessed LuminairesNa of Feil:Susp.(Paddle}Fans o.u uta :w �a Transformers KVA No.of Luminaire Outlets 3 No.of Hot Tubs Generators KVA No,of Luminaires Swimming Pool ,% v :e ❑ n- ❑ o.o mergeney Lighting lrud. •rnd. Battca [tits_ No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS Yo.of Zones No.of Switches No.of Gas Burners : o.of tection an Initiating Devices No.of Ranges No.of Air Cond. Tuns ;Tl No.of Alerting Devices No.of Waste Disposers eat Pump Nom r Tons KW o.of Self-Contained Totals: :Detectioni.klerting Devices No,of Dishwashers Space/Area Heating KWmaIE] Municipal [IOther Connection a.„_ .-. .---•_.- No:of Dryers Heating Appliances KW Security S stems:* No,of Devices or Equivalent No.of ater KW o.of u.of Data Wiring: Heaters _ Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs � No.of Motors Total tip I e ecummunicathms.V Wag: No.of Devices or Equivalent OTHER: O),6 el-f_ " j _, tltrn:h .,Ll;nunu:Jrr.tit,t.!c�.rrd,.:r.ta rr.fmrtf!., rhe h,�pr,.t..r. 1'. F_tim:ued 1':duc u'Electrical 1York: _ (W lwn required by municipal policy.) 1 Work to Start: 7 _U�L � Inspections to be requested in accordance with \tEC Rule lel,and ripon.complction. INSLRANCE COVERAGE: U less waived by the owner.no pt-mit for the performance of electrical work may issue unit•, the licenser prw lrtes proof of li:;bilit� insurance including"complctcd operation'cotcragc or its substantial cqui%alvnt- ht. vndcr•.i..ned certitir> that-alch coy:rr;e i•.in t6rcc.and has c.hibited pnnrt of-,avis to the I`crmir i::.aim: tittice. t I Ilii K OM.': INS[ R.1VI 3t;�;t) ❑ r.i tFll:R ❑ l:;hrcit�.: ! ,•nijr, ureter jbe nrr>rrs n1 pe::uiRb•.c.#'perjury, +all!be-'reformed%cru.ar tris ,lyr!icariurr.s•erre ntal.a •.pt tr•. 9.29 G/7_ °. 1 6y•t µµN.r .�.r,r :+N�17• ;rte. ---_�-�� ii1[S.TCI. "1!.•�.�� - lddress: d /`36/ZES�cno� 4 2/�Gc�/Zf/yU /`d/� 11t. rel. ."Security System Contractor Liter+sc requircd for this work;if appl.te.rble.oitct•the hceasr nombcr heir: OkNNER'S INSL°RANCE 1 RIVER: I am aware that the Licenstc deet•••Ara hen•,•the liability insurance r:•a�:r,r_e n�rntall� icyuired by law. By my :•mature bcicw,l hcr%+y waive this,require it m. lam the(,heck one)❑owner ❑ounce':,•tezur, Uw mer;.1;ent —�—� P :1goature F'R.LI1T PF'F• S 8 15 T M j U 03 9 hip ".1.7jV I i4A&S' f %fir )1 0 0' city owl two MAO Nth Jim eft aid!tit!C9;.qnlj Jr. 110.uo, f.mumn I bNOMY W AN t e B 1-tgtf;Ij di,t lin: t- o -; "hwMix i .o/ roy" 0'unit i'e11111 1, -Pi `1A V wi u u P a INA him/ Hrl 4- d" roll WAH W 77-- I, a.7;1 i" Al.I./._E I- a-tJ j,.I n. 1•Wit i.;rt ;ii! '.i ih mi i 1 a on" 1 'Al It jP ,11, f 1:'J.+: kp; ahnn.i .4d ,mis"Y' j 0`` C'ommonwea&o f Mamac`Zumtb Official Use Only i c ? a(JeParEmen�o��ire�ervice� Permit No. Occupancy and Fee Checked i� BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /2-/2 S Z(� City or Town of: N6127-# ,9i 06 VEF, To the Ins ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Z2—r7 C.�2AAVI L-LE I-AN-r Owner or Tenant KE /.j/.� Telephone No.;50$-88 7--yk(04/ Owner's Address 227 ak,4/)LJ/1-LF L4AA9— Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No,of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: AIVD Ziv,D FwoZ 1,3,47,qo6rM Pac -/-0 Di4A4,+#F til Com letion ofthefollowing table may be waived by the Inspector of Wires. No,of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS JNo.of Zones No.of Switches No.of Gas Burners o.of eteng D and Initiatin Devices No.of Ranges Na.of Air Cond. Tota Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No,of Self-Contained p Totals: •.••••.......•••.••.•...• Detection/Alerting Devices I No.of Dishwashers Space/Area Heating KW Local Municipal El El Other Connection No.of Dryers Heating Appliances K`4, Security Systems:* y No.of Devices or Equivalent f' No,of Water K`,`, No.of o.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: H y g 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 cov rage 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 informationon this application is true and complete. FIRM NAME: LIC.NO.: Licensee: CHR/,sraPrVF,e P. IUA,0.5- Signature - LIC.NO.: /3 =� (If applicable, enter "exempt 'in the license number line.) Bus.Tel.No.:!778-90Y-Z89q Address: ' EOW/AI A ilF_ NJ�?NIJ�/�I MW Dt f�/��1 Alt.Tel.No.:9 78-6 SS- *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 Signature Telephone No. PERMIT FEE: $ { e �, f r r� �, Y �� h The Contmonlvealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Rashington Street Boston, MA 02111 wrvfv.,nass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 7 EyGulAf RV9- City/State/Zip:li)6- /lU f1J gA ,glsilel Phone#:_q 7S, ,geld.- Zgq q- Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am demployer with 4. ❑ I atm a general contractor and I 6. ❑ New construction employees (full and/or part-titre).* have hired the sub-contractors 2.[9 I am a sole proprietor or partner- listed on the attached sheet. T Remodeling NZ ship and have no employees ' liese 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 required.] officers have exercised their .10. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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' 13.❑ Other comp. insurance required.] *Any applicant that checks box Ht must also fill out the section below showing their workers'compensation policy information: f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContraclors that check this box must attached an additional sheet showing the name of the subcontractors 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: g7,C Policy#or Self-his. Lic. M pol le–y-,5f- G%200/15 20 Expiration Date: 6 Job SiteAddress:_2—,Z7 6kgA1111LL c L/\/ N,,4Alpoy6/Z q—City/State/Zip:N0�7/f ANll�d t��1Z MSF 131.�'�a� y 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 fitie 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 tinder the pains;Inddpwnalties of perjury that the information provided aboveis true and correctS� tlue�/�aA �` _ Date: 1z1z__Y1i.d .Phone#: 78 — 90 y- 2 P 9 Oficial use only. Do not write in this area,to be completed by cio,or town official. City or Town: Perrnit/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: P1ione M Date. . ��� . . 8821 NOR7q �. �h oo� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING i SSACMUS� This certifies that �. . . . . . . . � r . .: . . . . . . . . . . . . . has permission to perform . . . . . ., .�.<.� �:�.�' �! ° ` plumbing in the buildings of .f-. . . . . . . . . . . . . . . . . . . . . at . . 7. . . ? .'! No h Andover, Mass. Fee.l/.7 ' Lie. No.. . . . . . . . . .�. . . . P UMBING INSPECTOR Check # 1 << MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Q ,Mass. Date 20jj_ Permit# Building Locationjo Owner's Name ,E y, Owner Tei# Type of Occupancy New ❑ Renovation ❑ Replacement Plan Submitted: Yes ❑ No ❑ FIXTURES z � � a y a O > LU y � �1 y �F, F v5 pC a 0W d 3 O A 3 y p+ d A aC A fi a A. 0 d w U d a oda � o a a 3 x H0 UB-BSMT BASEMENT ls`FLOOR 2ND FLOOR j— RD FLOOR 471 •r -5TH FLOOR 6m FLOOR 7-FIQOR TH FLOOR Installing Company Name W2. Uy Check one: Certificate ❑Corporation U I AO LM , N► ` 14 o l`n`1 � ❑Partnership Business Telephone# ?(�j"3 ®� ❑Firm/Co. Name of Licensed PlumberE_ #��(��5� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 94— No ❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. A liability insurance policy 0/ 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 ElSignature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the G e S. By Title a (��-- S' re of Licensed P ber Type of License:Master ❑ Journeyman City/Town APPROVED(OFFICE USE ONLY) License Number The Commonwealth of Massachusetts t _ Department of Industrial Accidents _ Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AUlicant Information ` Please Print Legibiy Name(Business/Organization/Individual): R(,,(( -(::7� ^l� b�,(}`� Address: City/State/Zip: 1�1 Com{-IUCJO I Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1 a employer with_ 4. [] I am a general contractor and 1 employees(full and/or part-time). have hired the sub-contractors 6. F1 New construction 2.[1 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' insurance.: 9. []Building addition comp.[No workers' comp.insurance P• required.] 5. F] We are a corporation and its 10.F-1 Electrical repairs or additions 3•❑ I am a homeowner doing all work officers have exercised their I IZPlumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: ­7zn-P(, c f` trr_ L a� C�} Policy#or Self-ins.Lic.#: Expiration Date: / C) j Job Site Address:YO��7 mot LL - City/State/Zip:_�ll _• AO Q`�-wlj MA p(mob r 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage eraga verifcation. Ido hereby certify under a 'ns and penalties of perjury that the information provide above is true and correct. Si afore Date: - Phone#: �, C, f Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• �9 7478 f� z /f Q � Date.. �`.: �,`. . ...... .. p0RTh 3? �` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SSACHUSE • .6/• .r. �T. '. This certifies that ! . . � .�� G. .`. : . . . . . . . . . . . . . . . has permission for gas installation . . u . . . . . . . . . . . . . . . . . . . . 1' in the buildings of . Gtr r-�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . ��. `�!!�.�. . .`. . . . . North Andover, Mass. �v Fee. S. . . Lic. No.. . .y . ..' . �`�... .. .---. . . . . AS INSPECTOR Check# MASSACHUSC'TIS UNIFORM APPLICATON POR PERMIT TO DO GAS FTITING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS l Building Locations a g, ` � ��!/� Permit# Amount$ Owner's Name New Renovation Replacement a Plans Submitted � w w w v CA z co z c a a M w v a ' Az s o m 3 a 101 > aI IF SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR {' 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Cmc one: Certificate Installing Company Name_ T 11/4 G L O A-4 /���/ {■�![ Corp. Address r' d d X S 7 aZ ❑ Partner. 4-4w4efvre Al *.q le C/Z Business Telephon9 So Y ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 7L/v,K I,s X94//a erg ej INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked,L,please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type ofindemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not.have the Insurance coverage required by Chapter 142 ofthe 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 ofthe details and information I have submitted(or entered)in above application.are true and accurate to the. best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code an Chapter 142 ofthe General Laws. �- 69 0_e� Signature ofLicensed Plumber Or Gas Fitter By. ® Title Plumber A Y Q 33 City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman �L Date . . . . .. . . . ".O RT:'�, TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING 'SSACHU$ por— This certifies that . . . '..j" 4--tt-& .. . . .!. . . . . . . has permission to perform �....,....<-. . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . at . . North Andover, Mass. Fee/4— . .�Li�c. /3 ? r / / . . .R. . . . . . . . �PLUMel,,' NSPECTO Check # C! 6928 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_M Mm_ , MA. Date: I 1 i 10 Permit# _ Building Location:JA7 Lrmut 'L Owners Name:UAkc 6 Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration: Renovation: Replacement: Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED SYSTEMS a Uj lZQ2� p G 2 d W z Z d: Z Q Q Z .'� Yaf W W ct o '� o a z Wm � a z to aLU Y 3 C 3 W0 W H r Q z OC = W W 3 W Q m m D D = Y > >3 w O p 4 ac Q Q H u oac 5 w � o SUB BSMT. 8,ASEMENT 1 FLOOR Z FLOOR 3V FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR H -44--, Check One Only Certificate# Installing Company Name: � Y�� ❑Corporation Address: /1% City/Town: 1 wr i State: " ❑Partnership Business Tel• 97f ax:to F� ❑Firm/Company Name of Licensed Plumber: OA I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title lumber Sign ure of Licins Plumber- City/Town Master APPROVED OFFICE USE OMLY Journeyman Lice se Number: _Z1 :225:7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations •' 600 Washington Street 1 Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers r Aoalicant Infarmatian Please Print Lezebly Name(BusineWOrganization/Individual): b V X rvV I Address: City/State/Zips: i4Phone#: �— Are you an employer?Check the appropriate box: Type of project(required): 1.Q 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. []New construction Wloyees(full and/or part-time).* have hired the sub-contractors 2. a sole proprietor or partner. listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp. insurance. g, (] Building addition [No workers'comp.insurance 5. [3 We are a corporation and its 10❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGI. 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' comp. insurance required.] 1ther *Any applicant that checks boil#1 must also Ml 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 subcontractors and their workers'comp,policy information. I am an employer that is providing workers'conVensadon 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 a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information providedro e is true and correct Si a Date: l Phone#: Z� 00kial use only. Do not write in this area,to be completed by city or town ofJIcial City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 7445 Date.� ,��........... NORTh pf 1 ao ,e,ti0 TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION SACHUSE� f� This certifies that . ., '!� . . . ���1�� .js . . . . . . . . . . . . . . . has permission for gas installation . . . .7.�. .j� . . . . . . . . . . . . . . . . . . . in the buildings of . �.`' It. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . `. . . . .. . . ., orth_Andover, Mass. Fee. �?�.�. Lic. No.. '0. . . . . . . . �-! `�,-1. . . . . GAS INSPECTOR Check# It MA%ACMSEMUWORMAPPUCATONFORPEWOUTODOCAS G (Type or print) Date NORTH ANDOVER,C�C J� �MASSACHUSETTS /� Building Locations _ RA�// �`J� - 4 Permit# Amount$ Owner's Name C C � New Renovation Replacement Plans Submitted v1 y U W C p� an p w A C G O z E O Z d w zdzx W w cW7 W rN� IwAw x O x w � it A C7 UU a > A C F O SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD. FLOOR 4TH. FLOOR 5TH . FLOOR v) 6TH . FLOOR 7TH . FLOOR 8TH. FLOOR (Print or type) r / C�k one: Certificate Installing Company Name �/�� 1� � 5� Corp. Address L Q Partner. ULY/' usiness a ep one 79—,S SA—11 1 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No O If you have checked, es,plf4e indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 13 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 13 Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S t G ode and Chapter 142 of the General Laws. By: Signature of Li erased Plumber Or Gas Fitter Title Plumber City/Town Gas Fitter License NUMbet'�`—� Master APPROVED(OFFICE USE ONLY) Journeyman MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location � v� Owners Name Permit# Amount %{ 2— Type T e of Occupancy- New ccu anc New Renovation 0 Replacement Plans Submitted Yes No FIXTURES Q > w U a w w w �" ccnnx a 0-0 -t04 a w o f 3 A x A W A )-4> x z p w 3 a a Q H A °a � s�>M BAS vUgr >srFLOOR MMM 3M Him 4M HfM 5M HBM 01HDM 7M MOOR 9M lit (Print or type) Check e: j� Certificate Installing Company Name w,�l Corp. Address Partner. km Business Te ep one () ', 13 ID Firm/Co. Name of Licensed Plumber: �\ v, Sir Insurance Coverage: Indicate theXvpe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above apPliolation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe d for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code er 142 of the General Laws. By: Signature Of icense um Title Ty ie of Plumbing License City/Town License lNum5er Master Journeyman ❑ APPROVED(OFFICE USE ONLY Date... . .. ..../ .©. ..... NORTH pf 3= �' TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION ` y9SSCHUSEtty ' This certifies that . . rt!'`~^''. . . . 6�. has permission for gas installation . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at a�. . . . . . . . . . . . ? .rte , North.Andover, Mass. Lic. No..� `cg . . . . . . . �. . . . . . . . GAS INSP,E�OR Check# i 5534 ),(IASSACHLSKM LN1FORNI APPUCATON FOR PERM TO DO GAS Fr1TDJG (T)pe or print) Date NORTH ANDOVER,NIASSAC USETTS Building Locations `^ G - Permit# Amount$ .3 yl� Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted U t� D M F x Mr F O a ; F oa U cry F p F SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) y Cl a e: Certific to In, aping Company j l Name b� ��`t Corp. Address ❑ Partner. .rn� Business lelephone ;-3 67 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ICM ;�1b INSURAINCE COVERAGE Check on I have a current liability Insurance po icy or it's substantial equivalent. Yes Noll If you have checked yes,plte the type coverage by checking the appropriate box. ease ind' a Liability insurance policy Other type of indemnity ❑ Bond ❑ Ow ner'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 ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing .work and installations performed under Permit Isef or this application will be in ,;cmpliance with all pertinent provisions of the Massachusetts State Gas Code and C ere General Laws. 44 Signature of Lic s lumber Or Gas Fitter By. ® Plumber J��f 'ride _ Cit)/Town Fitter Licenge :Numver faster ,APPROVED,OFFICE USE ONLY Journeyman STRUCTURAL SYSTEMS, INC. 16 HAVERHILL STREET o ANDOVER, MASSACHUSETTS 01810.3000 phone 978.623.0000 fax 978.623.0088 STRUCTURAL AFFIDAVIT To the Building Commissioner of the town of North Andover, MA In accordance with Section 116.0 of MA State Building Code We certify that to the best of our knowledge, information and belief, the steel erection at 227 Granville Lane has been completed in accordance with the requirements of the Massachusetts State Building Code and calculations dated March 6, 2006 by Structural Systems, Inc. OFq O JAY H. BMW c o STRUCTURAL NO.344233 ` a Fcr s ��� ay rown, P.E. `�ssION Lt��`N MA Reg. No. 34338 STRUCTURAL SYSTEMS, INC. 16 Haverhill Street Andover, MA 01810.3000 April 26, 2006 Then personally appeared the above named Jay H. Brown and made oath that the above statement by him is true. Before me, April 26, 2006 Notary Public My commission expires 12-29-11