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Home My WebLink AboutMiscellaneous - 23 FIELDSTONE COURT 4/30/2018 l" m G i Date,314... (,a....... aF r.".'tia TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS�CHUS� This certifies that.................: ::--'......v has permission to perform.....(e. `. -..... � .............. plumbing in the buildings of .......................................CQI( LCQ `� tc � -............................................ at.a(; z .r'-�.¢...I2,.-fi..t. s -4C ; North Andover, Mass. Fee....... -. ....Lic. No. �. �� ................................................................................. �1 PLUMBING INSPECTOR Check# t�2— v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY bj��MMA DATE _ ( PERMIT# JOBSITE ADDRESS y�� c e et.��l O#ES E POWNER ADDRESS hG <' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINTPLANS SUBMITTED: YES Q NO CLEARLY NEW: I RENOVATION:© REPLACEMENT: FIXTURES Z FLOOR-� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 4 ( ____ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM E DEDICATED GASIOILISAND SYSTEM l _. 6 --JE DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I - - -- DEDICATED WATER RECYCLE SYSTEM I __._-__J DISHWASHER 1 .-- .-__._-- __ ._�E—__—J ( __..J I .___-_-( _- _____-( ._—._f -____ ______1 __.._._�) .-_--.� ..__....__ __.._ __...._I DRINKING FOUNTAIN FOOD DISPOSER I ..___I ___.__� ---.__.( ------- FLOOR/AREA DRAIN -_-.__FLOORIAREADRAIN INTERCEPTOR(INTERIOR) [ ___._I -.--J KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK ! _-__--j TOILET JRINAL _...___I .�__l J. WASHING MACHINE CONNECTION 1 ! ___ _ _ _ I r— WATER HEATER ALL TYPES I w1 WATER PIPING - I ---- --I OTHER i ---i INSURANCE COVERAGE: 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�/ OTHER TYPE OF INDEMNITY BOND Q 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to st of my knowled and that all plumbing work and installations performed under the permit issued for this application will be in compliance w all mo e vision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME cu _ LICENSE# SIG AT ��11 IMP JPQ CORPORATIONS]J#=PARTNERSHIPS]#®LLC �J COMPANY NAME� � f ADDRESS CITY STATE �/�- _� ZIP TEL FAX --� [:='I CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINPECTION NOTES Yes No f� r � THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street,Suite 100 " Boston,MA 02114-2017 www mass.gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organization/Individual): Address: City/State/Zip: l Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I ama em foyer with employees(full and/or part-time).* 7. ❑New construction 2, am a sole proprietor,or partnership and have no employees working for me in 8. ❑Remodeling any capacity.(No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. - 12. umbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who 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 the policy and job site information. Insurance Company Name: , InYeo' Policy#or Self-ins.Lie. V Expiration Date: Job Site Address.. p!� —, 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 tl ai and ae perF Haat the information provided 960vels true and correct. Si nature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: lJ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation'policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY �l�t MA DATE / I PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS .- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINTPLANS SUBMITTED: YES fl NO - CLEARLY NEW: E.I. RENOVATION:© REPLACEMENT: FIXTURES-1 FLOOR, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I I 1 ---1 -- DEDICATED SPECIAL WASTE SYSTEM _. _ I .--- - ---_' -- __-_ -_�j DEDICATED GASIOIL/SAND SYSTEM -_ f . _____.1 - -- _._I --- -- DEDICATED GREASE SYSTEM — 6 -¢ — I I -_-J ---JJ' DEDICATED GRAY WATER SYSTEM 1 _ _ _I ___� I __..._ __.__. ..._ 1 --- . I I _ _.__.I ._! _ ....EH DEDICATED WATER RECYCLE SYSTEM { __.__.1 .__..__I ____- _..�_ -- DISHWASHER 1 __. _.__J _____I -. f - _� ._ _J __.__ _.._..1 DRINKING FOUNTAIN FOOD DISPOSER I ..___1 __..__. ___-_--( _.. ( .. f ------__1 FLOORIAREADRAIN —__--1L___.1 INTERCEPTOR(INTERIOR) 1 E-73 _( __._i �___� ___I __..� ._.._� ..__.._. I ._.__-..1 KITCHEN SINK I _ .___1 __._I j _____I _JF 11 LAVATORY I _ __1 ____J ......_1 .___._1 ___--1 ___._.I _._._J ______f .___1 ROOF DRAIN 1 __ ___J �1 __1 _1 ._�J _____I ._.__.1 ___ SHOWER STALL I ._._. 1 r...__._1 _ -- SERVICE/MOP SINK l ___ I ___.__I _.___I ____._f ___J __ f TOILET URINAL __. I - I. _._._1 __— I —__1 ..-- -_I ___..__ ___ ____.!F-7--7-7 3 .___._l WASHING MACHINE CONNECTION I s ___1 .___ _.._._. -_._.__ m_J _ _—__1 WATER HEATER ALL TYPES I _ WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch:142. YES .-. NO __; IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF-COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L�� OTHER TYPE OF INDEMNITY EE BOND 0 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 AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur best of my e and that all plumbing work and installations performed under the permit issued for this application will be in complian all Pe ' nt p ovisi he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME f!1 �/ l kICENSE# G ATURE Mp JP Q CORPORATION�]J# PARTNERSHIPD# ;LLC COMPANY NAME ADDRESS —1 _ CITY 7�� _ __..-_I STATE ®ZIP L Lt_ / �f/� FAX —�CELL��EMAIL ----------_._.._I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INPECT OdOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES f The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am.a.employer with employees(full and/or part-time).* 7. [:]New construction 2.F]I am a sole proprietor,or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'compAnsurance required.]t �]4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed.on the attached sheet. ❑ - 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . x 1. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractors)name(s),addresses)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents fok confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE ( PERMIT# I I CITY . JOBSITE ADDRESS WNER' NAME POWNERADDRESS d TELL ��FAX -j1 TYPE OR ' OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PPUNT PLANS SUBMITTED: YES® NO CLEARLY NEW: RENOVATION:® REPLACEMENT: FIXTURES 1 FLOOR- BATHTUB BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 I BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER i DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN 1 __.__ _.__� ___( _.. _� ( _".__. ____._J _ _f 17771 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL I ._.____i SERVICE 1 MOP SINK I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE: I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _. 0 _-; IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q 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 �[�I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an c to the best of mn nth e and that all plumbing work and installations performed under the permit issued for this application will be in compli a ith al (Massachusetts State Plumbing Code and Chapter 142 of he General Laws. PLUMBER'S NAME f or - I LICENSE# s SIGNATUR MP a jp�( CORPORATION�]J# PARTNERSHIP Q#®LLC COMPANY NAME ADDRESS CITY _ _..,._I STATE M G_I ZIP ��/�'�r� it TEL I FAX _I CELL EMAIL-- -- - -- I -------- - -- -- --- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL IN ECTIO VOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r : Clx The Commonwealth ofMassachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia > Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check&e appropriate box: Type of project(required): 1.❑lam a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor,or partnership and have no employees working for me in 8. Fj Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.-insurance required.]t 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.E]Plumbing repairs or additions 5. I am a general contractor anI have d hired the sub-contractors on tors listed the attached sheet. ❑ # 13.E]Roof repairs These s4-contractors have employees and have workers'comp.insurance. 6.F1We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ` of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the'boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should•enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia c <:-OMMONW ALT OF MAS ACH S ' S ' 1BOARd fl ?Ll!hr3ERS D GASE��TLfweNSE I S ti U x:;5..'3 H F F 0=L04d I i�C LLMB A.: JOtJ...... MAN rr 1 #� R A3lAt v �'1l�L.f�r�' 1 y. l2 ,`rfs� 9l�11c.: J 6 RUTH CIRCCE 0 i -12 0 ' IL ; ti� : OMMONWF,.ALTH OF M4S�. H11$ETTSY SGAP"F . PLUMB64 AND GAS:F..:IaT F#'S`>'` I SSU:E THE F 0L'�OW[:NG>,:L_IC a �: JSEO AS A MASTER, P•LL ER ROAM -C HOLMEs 6 RUTH 'G I R I 32-89 24-4 4 Date...J..�n Z � ....... iC 79 ' r" TOWN OF NORTH ANDOVER oF,,..o ,•.'tic PERMIT FOR PLUMBING 4 $B�cHUg� #This certifies that............................. al has permission to perform.. .r: .. ...r. ............................................... plumbing in the buildings of...Wu .v2, '.� ,:.. . !. Y' .................... at.....a...........�'l.P Lck.�tiVa.2. . ............' North Andover, Mass. Fee �-�......................Lic. No. .... 1.Y ................. ................................................................................. PLUMBING INSPECTOR Check it ",. � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK It CITY MA DATE PERMIT# �' JOBSITE ADDRESS _ \ OWNER'S NAME POWNER ADDRESS _ TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: �' PLANS SUBMITTED: YES Q NO FIXTURES 7. FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i _ ( . _l ! ( ( - ..._1 ( ._._ ._( ( _ .. ! y. ( �n CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! ___11___-J .,__._-_,J _A_j, DEDICATED GREASE SYSTEM .......... f ( _I DEDICATED GRAY WATER SYSTEM f _—AL DEDICATED WATER RECYCLE SYSTEM ( 1. ._ ( f _..�_J _.._. .! ( I . ( . ...__._I DISHWASHER DRINKING FOUNTAIN [.-I .._....._! FOOD DISPOSER FLOOR/AREA DRAIN ( __..1 _-_-__► _---_.� _.. _ i _( __..___-� _,___1 .__...._.( __ _._.J .__._._( _ ._..( ..__.__1 I -_____I INTERCEPTOR(INTERIOR) KITCHEN SINK ( _ _.._.( —t --- ( -( _....- ---_.f .- __( ._ ..._► --( -( . .. . .I ._._._ { I - LAVATORY ROOF DRAIN f _____� __.___I .__—f ___-_ _..l ___-•' -_-.__ f ._.._ ..___. . ...__._( .... _I __.__J �I ___.-_ SHOWER STALL SERVICE/MOP SINK ._.__( —TI _.___-( ._.—__f -_-_._-1 TOILET _.c1 ( -----� f: I ( -----� URINAL _-- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES s _ �— WATEN PIPING i OTHER _._,.� Tf _ .�-� .-._ � --_.---� � ' ' ----__ + ( INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ... IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a-" OTHER TYPE OF INDEMNITY El BOND Ej 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 LO AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat a best of m nowl and that all plumbing work and installations performed under the permit issued for this application will be in compliance it Pertin t provi ' n o e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# lob' ._- i S N RE MP 0'--`JP D_I CORPORATION Rl# j PARTNERSHIP # _ !LLC M COMPANY NAME ADDRESS _ f cam_ CITY L_ ,/,cyf ��- - -- _ STATE ZIP �-- E TEL _ FAXj CELL ; EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAMNSDECTIbN NOTES, Yes No J THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r r t ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM,\GAS FITTING WORK 6 The Commonwealth of Massachusetts Depa,,tmentoflndustrzqlAccidents OffIce of Investigations 600 Washington.Sheet Boston,MA.02111 www.rnass gov/dia V rkers' CompensaizonInsurance Afidavi :SuilerslContxacfortl/Eleciease Print Le bX A lieani Xnformaiion - Name,(Businesslftanizationffndividual): Address: City/Slate/Zip: 1 `„ ` " 1 l� Phone#:__ _ • w v Type of project(required): Are you an employer?Check the appropriate box: enexal contractor and I to ex with 4. I am a g &. El New construction 1• I am a p y -- have hired sub-contractors e oyees(full and/or part-time), 7. [1 Remodeling listed on the attached sheet.� $ El Demolition 2. I am a sole proprietor or partn" These sub-contractors have ship and:have,no employees workers'comp.insurance. 9. []$uilding addition working forme in any capacity. [No workers' comp.insurance 5. F1 we are a corporation audits officers have exercised their 10.[1 Electrical repairs or additions required.] right of exemption per MGL 1.7.0 Plumbmgrepairs or additions 3.[] I am a homeowner doing all work ins�rancerequired.]i Roof repairs c. 152,§1(4),andwehaveno 12,[] myself.LKo workers comp. ' employees.[No wore 13.[]Other comp.insurance required.] xAny applicant that checks box#I must alsdi atinu thee sere doing all wok nd hen hiw sho'Ningtheir re outside contractors must submit a new affidavit indicating such. i'Homeownerswhosubmit this affidavrtm g Y tContractors that checkthis box mast attached n additional sheet showing he name of the sub-contractors and their Workers'camp.policy information. 'compensation insurance for my employees. Below is the policy and job site X am an employer that is pYoviding workers information. . Insurance Company Name:. ExpirationDate: Policy 0 or Self-ins.Lic.9. City/State/Zip:' rob Site Address: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as regu3redunder Section SSW of as civil enalties in the form imposition 0.152 can load to the a STOP WORK ORDER and a free fine up to$1,500.00 and/or ones-year imprisonment, p of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA-for insur coverage vex atio - X do hereby certify u ' r e�ai a e f nary t t the information provided ova zs rue and correct. - Date: f Signature: Phone#: Official use only. Do not write in iliis area,to he completed by city or town official. II' City or Town: Perminicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Date..... "�..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r g$�CHUg� This certifies that ............. `.....-.............✓.4-P......f..:...�1 v1.��.�......��.�...� has permission for gas installation .... in the buildings of...... u � , .'. ..��.,.:.-" ..C. ................................ at... ......:. 1..P�cQSn: -... -}' ................, North Andover,Mass. Fee 2. ..- Lic. No. 8 e M ...... ......................... ..................................................................... GASINSPECTOR Check# �y7 . UC7 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I -/l/' MA DATE PERMIT# JOBSITE ADDRESS O ER'S AME OWNER ADDRESSTEL FAX L TYPE OR i OCCUPANCY TYPE COMMERCIALEDUCATIONAL PRINT �) �] RESIDENTIAL --- CLEARLY NEW:El RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES F___jj NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER —�I . ._.. .-.._ __. I I _ =J . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �. _ (IV fI[�! - _ _. I_ . _jL_j 1. OVEN POOL HEATERS nR_I - �� - s_—E—_ -_. 1 ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER AER f FE INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES JJNO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 0 AGENT �I) SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac rat a best of m n W edg and that all plumbing work and installations performed under the permit issued for this application will be in compliance t P n pr v' on th ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME w� tr s�LICENSE# SIGNAT RE MP MGF El JP 0 JGF a LPGI M CORPORATION©# PARTNERSHIP®#=LLC E]# � COMPANY NAMES �" � _ ADDRESS CITY ( STATE=ZIP JTEL FAX CELL 3�� MAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES s • is ./ v 1/22/2015 Division of Professional Licensure:License Search i The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov r Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................................................................................................................................................................................................................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name: ADAM C. HOLMES REFERENCES& HAVERHILL, MA RELATED INFO NEW SEARCH I Disclaimer Regarding **This Licensee has additional Licenses, click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS Ft GASFITTERS License Type: MASTER PLUMBER More... License Number: 15685 Status: CURRENT f Expiration Date: 5/1/2016 Issue Date: 3/18/2010 Exam Date: 3/18/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday,January 22,2015 at 11:34:28 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http:/Aicense.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type_plass=_M&license number=000015685&color=&Ib=PL 1/1 Date.... ........................... to TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ss,CHU /1 ,Q7 ............................................... This certifies that,.,.,..,.,............................. ....................... .......... has permission for gas instal ti .........;wle.. el...................................... IA.) I inthe buildin s of............................;.....r ........................................................................... North Andover, Mass. at..... CP 7�Te-lds-�-e. ...................... Fee,3�e ***;��***********'**"*"*"*"*'*""'**************'*"*"*, , .......... Lic. No. 2(o,75-3... ..................................................................... ......... ............ ... ... GASINSPECTOR Check# 3717 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � leo � CITY / ty- MA DATE S PERMIT# ow JOBSITE ADDRESS OW ER'S NAME P/ r GOWNER ADDRESS Y, TE AXI TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL[ - PRINT CLEARLY NEW:[1 RENOVATION:[l REPLACEMENT:Ej-' PLANS SUBMITTED: YES 0 N09— APPLIANCES Z FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE C _. - . . l, �. . .. . _ _ . DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR (� __ _.� �— — I _ _ —1- FURNACE GENERATOR GRILLE .- - -. --- r-- .. _�-. _. �---- INFRARED HEATER --- LABORATORY COCKS MAKEUP AIR UNIT I I-,. _.II -I OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST =='I. - = . I I _ =I - UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER 0 HER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES 19-NO Ej IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate est of my k ge and that all plumbing work and installations performed under the permit issued for this application will be in compliance a e . ro 'sio he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GAS_ITTER NAME LICENSE# VSIGNATURE MP Rr MGF[j JP fj JGF LPGI COR—PO-R�A�TION Ell#E:=PARTNERSHIP 0#=LLC E]#=..._ :_,..._.JI COMPANY NAME:Ij�_ -�- -II ADDRESS _ -- - - —_ CITY _ _ _ _-� STATE ZIPTEL ZAA I FAX��— CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTUR Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts F Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA.02114-2017 o�< www.mass.gov/dia ODM SV�V Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbexs. TO BE FILED WITH THE PERMITTING AUTHORTl:'Y. licant Information Please Print L_ --Y AP Name(Business/Organizationftdividual): Address: City/State/Zip: Phone#: zY, Are you an employer?Check ttie appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. Q N&O'donstriiotion 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remo delitig any capacity.[No workers'comp.insurance required.] 9. Q Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.] 10 Q Building addition 4.Q I am a homeowner and will be,hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation e sole I1.[]Electrical insurance or arrepairs or additiops proprietors with no employees. 12.Q Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13%Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. ave no employees.[No workers'comp.insurance required.] 152,§1(4),and we h *Any applicant that checks bbk#1 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 U' s box must attached an additional sheet showing the name of the sub-contractors and state whether or not(hose 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 insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:. Expiration Date: rob 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 MGL e.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert fy under the pains andpenalties ofperjury that the information provided above is true and correct. Date: Signature: Phone#: Official use only. Do not write in this area,to he completed by city or town of lcial City or Town- Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 0 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of Wo, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver"or trustee of n individual,partnership,association or other legal entity,employing employees.•However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage requiked." Additionally,MGL chapter 152,§25C(1)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is b eing requested,not the Department of Industrial-Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insura'nc'e license number on the appropriate line. City or Town Offiicials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write•"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASS.AFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia MONWEgLTH OF MAHUSETT Q QOM • Bt}Af��QF PLUMBCRW AND GASB 1T £f5 HE FOL�OWP'NG':`LiC� ENSE>. ;.'<: : VU ED AS A MSTER.�P,LLMfBE71, l21 Q d C HGLMES 1 b RUTH. Rf' AA 01832-69�� 01; n c::.:. 2424 4 fi COMMONWEALTH OF M ►SSACHUS :,TTS::;:;::,_:.;:,: • • - • • . , J BOAR. OF PLLM3E3?;S" +ANG UASFLTfCRS': 1 SSvR.$ THE F0 LOW ! CENSE, L A JDUR;N:EYMAN -L ; a �f t `�< \ a Qisr HOLMES wj � ��} Ez 15 La 6 RUTH C ItCL E ver', `� W {,��iEPHII.:i A 018 AVE I HpRTp °;• •° "o TOWN OF NORTH ANDOVER A PERMIT FOR PLUMBING ol ,SSAcmus This certifies thatr r f' G `. . . . . �. y : . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . G plumbing in the buildings of . UA-0.0.�.P.�.!`.f.... . . . . . . . . . . . . . . . . . at . . .? `. . . .j !- (. d .F�. . . . . . . . . . . . . . .. North Andover, Mass. Fee.l.?. . . . .Lic. No.4o). ?. . . PLUMBING INSPECTOR Check # 8031 MASSACHUSETTS UNIFORM AppLICATION FOR PERMIT " . (Type or print) TO DO PLUMBING. NORTH ANDOVER,MASSACHUSETTS Building Location f0,6 '�U Owners Narne Date "i Permit# a / T e of Occu ari Amount _ ?= New Renovation E3 Replacement Plans Submitted Yes ❑ No ❑ FIX"MRES 0 0 a U r IST>� zaNDM smK_0CP, � R I , (Print or type) -} Installing Company Name Check one: Certificate f . ��/,)(Address , r- Corp' \ El Partner. \0 usmess elephone ita Name of Licensed Plumber: Insurance Coveraee: Indicate the insurance coverage by check- ---------- Lability insurance policy Other covertypeoage my clic g the appropriate box: ty � Bond Insurance Waiver. I, the undersigned,have been made aware that three insurance the licensee of this application does not have any one of the above Signature E3Owner ❑ Agent I hereby certify that all of the details and information I have submitt best of my knowledge and that all plumbing work and installations m (or to m above application are true and accurate to the compliance with all pertinent provisions of the Massachusetts p edPernut Is ed f s application will be in =B3, ino ° to -of the General Laws. ignaeure of l..icensType of Plumbing License � — NLY License vum°er Master ❑ Journeyman �/ Date. . . .. e./c.g.. .. NORTH TOWN OF NORTH ANDOVER • : ; -.z ; PERMIT FOR GAS INSTALLATION . y SAC NUSEtS _ This certifies that . . . .P . . . . . .f (-e.. . . . . . . . . . . . has permission for gas installation . . .+� :-. . . .i .n . - . . . in the buildings of . L.V.U. . . . . . . . . . . . . . . . . . . . . . . . . at Ay. 6-r.'L.A.&1 r.�. . . . . . . . . . . , North Andover, Mass. Fee. . Lic. No.. .1: ?. �1 ...�- r,- . . . . . . GAS INSPECTOR Check# 6743 MASSACHUSE'T'TS UNIFORM APPUCATON FOR PERMIT TO DO GAS FPITING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS ; Building Loqations Permit# 3 Owner's Name Amount S New Renovation Replacement Plans Submitted a W CrA w y C4 C C z O W o ° o z U > w > w z o z W o 'SUB -BASEMENT 3 O `� OU C > p d F IL BASEM ENT 1ST. FLOOR 2N D . FLOOR 3RD . FLOOR 4TH . FLOOR FFLOOR LOOR LOOR LOOR (Print or type} Name Check one: Certificate Installing Company Corp. . Address Partner. usmess a ep one �1rm Co. Name of Licensed Plumber'or Gas Fitter C INSURANCE COVERAGE 1 have a current liability Insurance,policy or it's substantial equivalent. Check one: If you have checked please iodic a cove Yes ID No[ Liability insurance otic -type rage by checking the appropriate box. policy Other type of indemnity D Bond 13 Owner's Insurance Waiver. I.am aware that the licensee does-- s not the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13 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 performe under P it Issued for this appl' on will be in compliance with all pertinent provisions of the Massachusetts State Gas e h _142 of the Laws. By: Signature of Licensed Plumber Or Gas Fitter Title 1:3 Plumber City/Town,. [3 Gas Fitter License urn er _ 0 Master APPROVED(OFFICE USE oNt rl � rneyman 4 i �. Date...... Q ..-/� O.6 ... NORTH °t�„`°:•�"° TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING tl •O��r�° ��'� ,SSACMUSE� ' This certifies that ............ .........1 ................. has permission to perform ' /el.9y4a'.../.!!� wiring in the building of... Z-> .0F.-.....P,-AA e, ........................ at...J.U.r......../0.5,R- .......... ,North Andover,Mass. � em .. C --- Y /t!lrFee... ..""' Lic.No. ............ERICAL .!... INSPECTW C Check # ASO !1 6923 4\1_ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0 Z-5 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 08/02/2006 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 20 Fieldstone Ct. Owner or Tenant Wood Ridge Homes Telephone No. 978-423-7867 Owner's Address 10 Wood Ridge Drive,North Andover,MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Residence 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: Installed Contactor for Court Light, Installed Ballasts in Office t Completion of the following table may be waived by the Inspector of Wires. t No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. E] rnd. E] Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts 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. 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 X BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains andpenalties ofperjury,that the information on this applic tion is true and complete. FIRM NAME: Landers Electrical Co.,Inc. LIC.NO.: A5912 Licensee: Terrence J. Landers,Vice-President Signatur LIC.NO.: 9743 (If applicable, enter "exempt"in the license number line.) 7 Bus.Tel.No.: 978-686-3828 Address: 1000 Osgood Street,North Andover,MA 01845 Alt.Tel.No.: 978-686-3829 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 FPERMIT FEE. $20.00 Signature Telephone No. Date.... 0 (0 . . ..................... 'AORTof TOWN OF NORTH ANDOVER to PERMIT FOR WIRING SS CHU This certifies that ............ C- has permission to perform ....i��. ............... ............ wiring in the building of.....Wcov. .. .....1.0!& ................. at...... ...........Cr......,North Andover,Mass. ...... ......... O Fee.... Lic.No..4.T.W.2�.?17................ . .. .. . . .. ............I ..... ........ ....... 62�� , • ELECTRICAL INSPECTOR 7 Check # 6 ' v8 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. L�74_g BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked U19- [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 08/02/2006 City or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 20 Fieldstone Ct. Owner or Tenant Wood Ridge Homes Telephone No. 978-423-7867 Owner's Address 10 Wood Ridge Drive,North Andover,MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Residence Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters a Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install 220 Outlet and Wiring for A/C to box Completion o the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- F-1o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump N 1KW No.of Self-Contained ............................... ....................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection e No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: e Heaters Si ns Ballasts 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. 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 X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Landers Electrical Co.,Inc. LIC.NO.: A5912 Licensee: Terrence J.Landers,Vice-President Signature -LIC.NO.: 9743 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-686-3828 Address: 1000 Osgood Street,North Andover,MA 01845 Alt.Tel.No.: 978-686-3829 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 a ent. Owner/Agent PERMIT FEE. $20.00 Signature Telephone No. Date................-................7 f HORTM 1 ``°-i': o- TOWN OF NORTH ANDOVER FO A PERMIT FOR WIRING A I ,. ,SSACNUS� This certifies that ....... !;.r..;R , ............eAee/......................... has permission to perform ..... 'f / �. ....... wiring in the building of...Wa�A fit. f= Wo FS................. ... !9 F�6n T(�s2 at.......�..................................�.............................. ,North Andover,Mass. free.... ��...�.. Lic.No.f 5^9�2-.......... . �4*�'G. i ELECTRICAL INSPECTOR Check # � �� 65 3 , Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. (175 BOARD BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 03/08/2006 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 20 Fieldstone Owner or Tenant Wood Ridge Homes Telephone No. 978-423-7867 Owner's Address 10 Wood Ridge Drive,North Andover MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Residence Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters r New Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Removed ceiling fan,installed ceiling fixture Completion of thefiollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o mergency �g mg rnd. rnd. Batte 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 No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of Devices or Equivalent KW No.of No.of Data Wiring: Heaters Si ns Ballasts 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. 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 X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains andpenalties of perjury,that the thi informon application is true and complete. al FIRM NAME: Landers Electrical Co.,Inc. LIC.NO.: A5912 Licensee: Terrence J.Landers,Vice-President Signature LIC.NO.: 9743 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-686-3828 Address: 1000 Osgood Street,North Andover MA 01845 Alt.Tel.No.: 978-686-3829 OWNER'S INSURANCE WAIVER: I am aware that tot have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ ownerhe Licensee does n ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $20.00 NORT1� �J�JOE,•��io s 1ti0 10- 9 sAkCHU�t� HEALTH DEPARTMENT Complaintllnvestigation Intake Report - Taken by: Date of Report: Time: Category/Ty e of Complaint: Address/Location of Incident: Name Person Reorrting: Phone Number: . ( or (W): folat24/ Phone Number: (Cell):Name of Alleged Phone Number of Alleged Violator: 9 Complaint et 'Is: C Recommended corrective action to be taken: Immediate corrective action to be taken: A To be Investigated by: Title: Date Scheduled for Investigation: Date Submitted for Data Entry: Date Entered: la� CCL /7-41� c Air 7 � s r 0 �'l2' �-o-�d�urr� oc; 0 oCg ,¢�� a�,c�c, ,�.a.�c r- Ca.2-P ywo-�-cD`1(ieu'-e- sL `�� r�-rt!,�-t ,co,�;r�., Hca �.e!!zh^� to ,L�e.eaf!'cE o-we(.v-z ,�-ZP�r.et �.� .ao�a.cZ`� PS � � �z , UJ � Gj� �J"'cuyi, 3eo6 ' � /� � �� X�Z t �e � � e � �� f � "o ��l /1�y � � �� YI^n-E fv2 �" evl b�i-�( 66 , E 94<c/ A y � u'� � �� ,e�� 1��a- -�d,_ ,to_�a �zax` i 4u ��t � � '7' Q ' ,, ,arc �� c'��rz«P --e�l.�.�y 7r,�� Date. . . . . . . . . . . . . HORT#1 . • TOWN OF NORTH ANDOVER a ' PERMIT FOR PLUMBING • o _ ,E �► •O+,r.°.A`,fig ,SSACMUS� This certifies that . . ' has permission to perform : plumJJbing_i 'the�build.ings of at� . . . . . . . r .�I.. . .. , North Andover, Mass. Fee:3tel, ,�) �j"� / . �' t! . .Lic. Noo,:,5 , . r . . l� PLUMBING INSPECTOR Check # �` 4-'� 6388 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Locatio ob!1) Owners Name /de '?,e,.)P Permit# Amount Type of Occupancy New 0 Renovation 1:1 Replacement [ 4 . 11 1:1 Plans Submitted Yes No FIXTURES Cr SL IRM MAW M FIOOR M FLOCK IM FDXR 4M FUM 5M Hf CR 6II�FIOQt 7M HCM 9M FLOCK (Print or type) Check one: Certificate Installing Company Name - [:] Corp. Addr ss < <��-2 �� S��T � Partner. usmess a ep one —cV 61 Firm/Co. Name of Licensed Plumber: '�V(//lj L,yiLSon Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ,m 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 ubmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing wo�sachuse install 'ons rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the s S Plu ng o nd Chapter 142 of the General Laws. BySignature of LAcenseu Type of Plumbing License Title �6 3/ City/Town 7.end NumDer Master El Journeyman Mf APPROVED(OFFICE USE ONLY Location r-�r) 4 -�-��-e-., No. c 2,2 8 Date �oRT� TOWN OF NORTH ANDOVER o? � .• 0 • • Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNust Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #676 Building Insp for i The Commonwealth of Massachusetts State Board of Building Regulations and . TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code 780 CMR APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OF OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number. Q Date Issued: _ O a Signature: ( Q 1 Building Commissioner for of Btdidings Date (� SECTION 1-SITE INFORMATION 1.1 Property Address: Irt 1.2 Assessors Map and Parcel Number: Cou Map Number Parcel Naber O� 1.3 Zoning imation: 1.4 Property Dimensions: information: �J Lot Area(sq) Frontage(ft) ZoningDistrict Use 1.6 Building Setback R Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 water Supply 9kiG.LC.40.4§S4i 1.3. Flood Zone InformRion: 1.9 Sew Disposal System: Public Private O zOOe rl Outside Flood Zone Q Municipal� On Site Disposal System r 2.1 Owner of Record '4.1OCA R e 1-6vne5 .1? Name(Print) Address: 1 cjoccth' t oL Q 12 d ee- Signature Telephone 9-7 W1 -7093 2.2 Authorized Age.N cLM (3 I d r Name(Print �-.o Q Address 3 w t,11l2s �� c�nl a(^d� W Signature V, �T 1 Telephone p CO W 011(40? SF.C1'ION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 000 CUBIC FEET OF ENCLOSED SPACE 3.1 Licensed Construction Supervisor: Not Applicable Q Licensed Construction Supervisor: License Number O33 (4-1 Addres�s� t.e)( I I t Q w15 fed l CL V-L d Expiration Date 15 200 Signature Telephone o y (D 2� 3.2 Regi�Ho a ent Cogrtractor` Not Applicable Q ct Company Name t Registration Number ' 01u Address Expiration Data l I (CL'A d t �-T FI � 1- 50 (a 2-0 Signature Telephone 60 g Revised 1997 JMC SECTION 6-DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction Q Existing Building Re airs Alterations Addition Q Accessory Bldg. Q Demolition Other Q Specify Brief Description of Proposed: 4ctbW5, o-P^t- S - T S l r✓1 5. 26 y109- SECTION 7-USE GROUP AND CONSTRUCTION TYPE USE GROUP Check asapplicable) CONSTRUCTION TYPE A Assembly A-1 A-2 A-3 IA Q A-4 A-5 1B Q B Business El 2A Q E Educational Q 2B Q F Facto Q F-1 F-2 2C Q H lEgh Hazard Q 3A Q I Institutional Q 1-1 I-2 1-3 3B Q M Mercantile 4 13 R Residential 13 R-1 R-2 R-3 SA Q S Storage Q S-1 S-2 5B Q U Utility Q Specify: M Mixed Use Specify: S Special Q Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: ♦ Existing Hazard Index 780 CMR 34 Propose Hazard Index 780 CMR 34 SECTION 8-Building Height and Area BUILDING AREA Existing ifapplicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9-STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION I Oa-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> I ,As Owner of subject property hereby authori -77 477.4 i)cl P G to act on my behalf,in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION l Ob-OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date SECTION 11 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to Official Use Only be completed b permit applicant 1. Building (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of O Q D Construction from 6 3. Plumbing Building Permit Fee(a)x(b) 4. Mechanical AC 5. Fire Protection 6. Total= 1+2+3+4+5 Check Number .�,� - - •i�7y j000iWi1041K�6R1(Ii•q�� Q�iuE6�d i; ✓/tiSOARp QF_Q14I)j °RF4�U1,ATI0N3 i 1.1csnse: CONSTRUCTION SUPERVISOR , 5 #; NumbQR 033843 BI -1955 i �t ki Tr.no: 19350 JOHN T HAFFE 3 WILLIAMS RO WAYLAND, MA 01! �?'` Administrator 1 f y, SECTION 4 WORKERS'COMPENSATION INSURANCE AFFIDAVIT[M.G.L.c.152 §25C(6)] Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No SECTION S- PROFFESSIONAL DESIGN AND CONSTRUMOIR SERVICES-FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 3 000 C.F.OF ENCLOSED SPA 5.1 Registered Architect: No Applicable Name(Registrant): Address Registration Number Expiration Date Signature Telephone 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name): Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone 5.3 General Contractor Not Applicable Company Name: Responsible in Charge of Construction Address Signature Telephone tl�Ri i ASc7 1 The Commonwealth of,' ;as saGhusetts ' ` cclde • Department of Indunts•>si� ��: . • • Office of inVOM1 ations g, . a 600 Washingtoh,. et Boston, Miss. ' 02111 Workers' Compensation Insurance Affidavit 1 N Name: i:00cQ rt 121 e. Hayne-s Location: ©od R L old e- City: IU o r't'e A nd,o ve r rVLA phone# ❑ I am a homeowner performing all work myself, ❑ 1 am sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: f 4�e13u i(du-2 In c- Address: 4 3 U T l u^ s R- City: 4-{A(CL r*KA (5 ('7'Z tf phone# S Insurance co. V-nooiL�r kcrv,-? policy# Wcb? �T 1 3 3-O =w i2-)S'-o ❑ I am sole proprietor, general contractor,or homeowner,(clrcle one) and have hired the contractors listed below who have the following workers'compensation policies: Company name: Address: City: Dhone# Insurance co. policy# Company name: Address: + City: iphone# Insurance co. policy# Failure,to secure coverage a=. @qt heo uiidef Section;;.5A of MC3L';1 2:caj�`''ha .'toah4'.(trip itiori of criminal penalties'of a fine up to$1,500.00 and/or one years imprisonment as well as•olvll penalties in the form of a sTOP WORK;ORD,E,q'and.a fidkof$100.00 a day against me. I understand that at copy of this statement may be forwarded to the'office of Investigations of the DIA for.average verification. i do hereby certify under the pains and penalties of pejury that the 1nforrriag0i3Orov�ded above is true and correct. Signature Date Print name PtiOPe# 50�co ZD Cl t to 8 Official use only doY of write in this area to be completed by'city o�1 vyn official . .City or.town: mlit/llcense# ❑Building Department r4:�1�,.4 ❑Licensing Board ❑check if.Immediate response is required : ,a{„r; ❑Selectmen's Office: ;' ❑Health Department coptad person: One:# ❑Other Zff.,, 7�r (• J J { t { } U+� rttj tL } ::s.::�f .� .d Y,., .1.. t. ..e! �i. ..:,ZI Y tY.•+,tt�u:: 11:2iw ' � '»�'f.:t. •'�H:+.. ... ... .. .. r . .,...; .a^ -'11y•.•p,,:,r. .,..r.::,..- .n'H^.5'�y4fJ:.•T`•4iiYr !\•� •:y,'Pw'd+N:. 7'&-;:r..Sai "i:• ��' . .,y 't, jr, � Y j { 57,1 t'sdi , ,. �� .< 1 f �''t•'•�tt}r�y��'1. 7uh F}MS G i 6 . Board of-Building Regulations and Standards x VW4 One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration I Registration: 108945 Type: Private Corporation Expiration: 8/27/2004 J. T. HAFFEY BUILDERS John Haffey 3 Williams Rd -- ---- ---------------- - ---- Wayland, MA 01778 — Update Address and return card.Mark reason for change. E F_' Address —' Renewal Emolovment '—_1 Lost Card } Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: T Board of Building Regulations and Standards Registration: 108945 One Ashburton Place Rm 1301 Expiration: 8/27/2004 Boston,Ma.02108 Type: Private Corporation J.T. HAFFEY BUILDERS John Haffey 3 Williams Rd � Wayland, MA 01778 � y Administrator valid without signature r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: FCL uy-)-�O�, m et ss — (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NORTH own of Andover No. ,� � dover, Mass., C1 -01 do 3 ORATED P Pa`t�5 S H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.... 0 . .......... 1 �• YV�! s �dFoundation ............................... .........................................� � n rPIAC� has permission to erect.... ... ............................... buildings on..o�d�o? 1 e�� Rough to be occupied as...... 1 Ar W N 0 s .* Chimney ..............ry......p.........................Zel provided that the person acceptor f�s permit shall in eve respect conform to .. of the application on file in Fin al this office, and to the provisions of the Codes and By La relating to a Inspection, Alteration and Construction of Buildings in the Town of North Andover. oZ 3 �Q 6 aO PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR G Rough .......... .... ... ... ................... ............................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. 356 Date. .. ��.. .r'�. . ... .. %ORTN TOWN OF NORTH ANDOVER pf 4� a° ,e 1ti0 0 °� � pp PERMIT FOR GAS INSTALLATION SACHUSEt This certifies that . . . . . .`.�. . . . . . %. . .. . . . . . . . . . . . . . . . . has permission for gas installation in the buildings of . . . . . . . . . . . . . at I. . . . . . . .. , North Andover, Mass. Fee .,. . :. . . . Lic. No.! . . . . . . . . . . . •GAS INSFECTOA WHITE:Applicant CANARY: Building Dept. PINK:Treasurer s > MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT T GAS FITTING T Type or print) Date NORTH ANQOVER, SSACHUSETTS Building Location,; � ° ✓ `�"' � � Q Permit# Amount S Owner's Vame � 1p e) ., En r New❑ Renovation ❑ ReplacementAT Plans Submitted ❑ 1 Le W C6 Cn C Z Cn n L n z :� C L z W W Z =t %r z ` : n Z C 7 m C n t w zji SUB -GASE .M ENT BASE ,vt ENT 1ST. F L 0 0 R 2V D . FLOG R 3RD . FLOOR 4'r It . F L O G R 5•r 11 . FLOGR 6T H . F L O O R 7T It . FLOOR 3T 11 . FLOG R SSI l (Print o ) n l/ Check one: Certificate Installing Company �14 Name �/LJ (� ❑ Corp. e �J Address C G`✓ ❑ Partner. � 07 I Business Telephone — -7 ❑ Firm/Co. 1 Name of Licensed Plumber or Gas Fitter YXjk / INSURANCE COVERAGE Check n I have a current liability Insura cepolicy or it's substantial equivalpnt. Yes No❑ f If you have c�iecked ves,pleas i icate the type coverage by checking the appropriate box Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. aware that the licensee does not have the Insurance coverage required by Chapter 142 of the I Mass. General Laws,and t at my signature on this permit application waives this requirement. Check one: Shmature of Owner or Owner's AgentOwne ❑ Agent ❑ i hereby certify that all of the details and information I have submi (or n Lermit ove application are true and accurate to the best of my knowledge and that all plumbing work and instailatio (slued f pp Ic will be in compliance with all pertinent provisions of theMa achusetts St Gas eer 14 the General Laws. Bv: Signature icensed Plumber 0) as Fitt Title Plumber City/Town 4Gas Fitter License NumDe, Nl'aster APPROVED(UFrICE USE ONLY) �Journevman BUILDING PERMIT No DTH qti TOWN OF NORTH ANDOVER �? 4`.'' APPLICATION FOR PLAN EXAMINATION ° : Permit NO: Date Received pDAATEG•�' Q �SSACHUS�� Date Issued: I o / IMPORTANT: Applicant must complete all items on this page LOCATION Lt( dG7 �"' (Wovdf-214e hovw--3) ��P,rint PROPERTY OWNER (42, :�e, ' t�1 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition � Two or more family Industrial Alteration l.� No. of units: OR- Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer j2km ` 4E� IPTION OF WORK TO BE PREFORMED: Identification. Please Type or Print Clearly) OWNER: Name: ��)�aIi� ,2 9d`^'�`� Phone: � J Address: � ( 0 do4 k `Q r I , V`e CONTRACTOR Name: �av( � Phone: L C 6 �7q5 J Address: L/,�Ly A y n�-J �" )( 1 4 1�y V M C FC/ 1 d Supervisor's Construction License: —Exp.p. Date: Home Improvement License Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �� 00 FEE: $ I LN 2– Check Check No.: �f ff Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access tothe anty fund Signature of Agent/Owner Signature of contracto Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art 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 COMMENTS 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: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 NOTES and DATA– For department use) i ❑ Notified for pickup - Date ......................................---........_......................................._....... .-.....__............................_._............._................................................................................._—.-...._...--------------.-----------------------------------------............................................._.._._....__......... . Doc.Building Permit Revised 2008 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Application Revised 2.2008 Location No. � Date NORT1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 10e4 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector 0'V�"M of NORTH Andover . 0 No. 19/ 77 = _ CS 0 dover, Mass., LAKE COCHICHEWIC OA?ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............. ....... Foundation has permission to erect............... buildings on ....49Y..... .....idds Tz to be occupied as........ ............... ....................................... Rough W Chimney ..A................................................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU S 11" TS Rough .................................................................. ......... Service BUILDING INSPEC R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and- Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. -� The Commonwealth ofNlassaehusetts Department o Ind 1.6 .J� ustrial Accidents office Of Investigations 1W 600 r ri r as inogton Street Boston� , Mt1 02111 + w�'-mass.gov/dig Workers' Compensation Insurance.Affiday.it: guilders/Contractors/Eleetridians/Plumbers Aa Iicant Information Please Print Legibly Name (Business/Organization/individual): TUU l 6 j�-o (to Address: City/State/Zip: 4M JO vt V VVW Phone#:� Are you an employer?Check the appropriate box: 1• am a employer with 3 4. ❑ I am a general contractor and I . F7. of project(required): 2.❑ employees(full and/or part-time).' have hired the sub-contractors New construction I am a sole proprietor or partner- listed on, the attached sheet $ Remodeling. ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. insurance. ' ❑ Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition 3.❑ required] officers have exised.their 10-❑Electrical repairs oradditions I am a homeowner doing all work eroright of exemption per MGL 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. cI52 ons . , §1(4),and we have no 12+❑ insurance required.] t employees. [No.workers' Roof repairs comp, insurance required] 13•❑ Other t*Any applicant.that checks box#1.must also fill out the section below showing their workers'compensation pofic}r information. �. t'1nn1CUWner£WllQ SUbntll.tl!!S&,,LId6.N11 IniitCflitEY.,tiiei'arc%(i Eli'?i+;;r;;&tid th=n him otiifiiC pens tion nnliL l infor a tion arjlllaV XCcntractors that chcol;this box must attached an addifional nr sheet showing tie name f o.the sub-c0„tractors and their workers'romp.policy inrormation. t am an employer that is proviafin;workers'compensatiotz insurance for 'a to ees. Below is the oft in formation mP Y policy and job site Insurance Company Name: i Ca of 1 e)A 4 o-v Policy#or Self-.ins. Lic.#: W Q ( Expiration Date: .lob Site Address: � �� I C (�1'1t�i C LA/C}�j� �l r e- �jY►Ze� City/State/Zip: M41'.'r M q 0/,t/5 Attach a copy of the workers' compensation policy declaration page(showing the policy Dumber 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 one in e to S250.00 o 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 veriftcati.on. I do hereby cerlify under a Paine and penalties n�fper u � . .1 rJ that the information provided above is true and correct Signature: Phones#: �(� �l�? O fficial only. Do not write in this area, to be completed by city or town ofcial Cityn: Permit/License# hority(circle one): Heattb 2. Building Department 3. City/Town Clerk 4. Electrical Inspector5. Piumbirtg Inspector son: Phone#: Information C .nd Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empioyees. Pursuant to this statute,an employee is defined.as "...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and includirr.g the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maint.-nance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state o r local licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence wr compliance witb the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit compl-etely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensafion insurance. If an LLC or LLP does have _ employees, a policy is required. Be advised that this afn-davit may be submitted to.the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffidavit should be:returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the nix-nber:listed belavr. Self-insu;ed companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the-affidavit is complete and printed legibly. The Department has provideda space at the bottom of the affidavit for you to fill out in the event the Office of-investigations has to contact you regarding the applicant. Please be sure to fill in the permitAicense number which will be used as a reference number.' In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or Iicenses. A new affidavit must be filled out each year. Mfhere a home owner or citizen is obtaining a licens—_ or permit not related to any business or commercial venture (i.e. a.dog license or permit to burnleaves etc.)said person is NOT required to complete this affidavit. The'Offrce of Investigations would like to thank you.in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fay, number: The Comrnonwe8:lth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston; MA G21 11 Tel. 4 617-727-4900 e rt 406 or 1-877-MASSAFE Revised 5-2645 Fax 4 617-72.7-7749 VAM—mass.gov/dia NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: _ 2 Z11e(�- is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant j'e Date i f Bo>� Constnictibn$u{ wisor Lic6*w t ire C5 1 X21 B�rthc�te��q!1/19�59 F .;^. �•y. . ROstrit�t� 1¢ DAVID P GULEZIAN 428 PLEASANT '�' ei M M-. t A N ANbOVER,MA 61& e Iolssaoner ;I s� 142" 30" —36° 30" 30" 3 391# _ — _� 7FE i 5EE 3 12 2�toI � .77 � ' I W3630BUTT -- }} yl W3030BUTT I N 1530 W3018 l I N = B12L (Y B12R 24.DISHW 11 Ilji i B30 i i 0 GAS—RANGE00 w i — �t co w w Cj w w w w I v i i N f .... c rn N i I 4 I r i I i ® FINE �I C i I ff t ! I /3102008 11:55 FAX 1 978 888 5350 8acDonald I Pangione I®vozluu� ACaR . CERTIFICATE OF LIABILITY INSURANCE ;�1 FROM TICS CEJVV=TE IS NOW AS A MATTER OF INFORMATIDN MacDonald&Pangione Insurance Agency,Ing. ONLY AND CONFERS NO ROM UPON THE CgRTWICATE P.O. BOX 428 HOLDER. THIS COMATE DOES NOT AMEND EXTEND OR ALTER THE CMMWE AFFORDED BY THE WLk& N9.0w. 104 Main Stnmt Nodh Andover,MA 01645 INUMERS AFFOMWO COVERAGE NAIC s " D G ConVac g,Inc nA 428 Plesssnt St #mRm e gmft 1 Insuran©e rdpgM N Andover,MIA 01846 wou m Q i weuag+v WGUM L COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISStIEfl TO THE INSURED NAWD ABOVE FOR THE PO=PERIOD INDICATED.NOTwMiSTANDWO ANY REQUIREMENT.TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MGM THIS CWnFrATE NAY BE ISSUED OR MAY PERTAIN.THE 11MRANCE AFFORDED BY THE POLICIES DESCRIED lEr816 SIAIECT TO ALL THE TERNS,M ICLUSI NS AND CONWONS OF SUCH POLICIES.AGORMATE LIMrM SHOWN MAY HAVE BEEN REDUCED BY RAID CS.Aws. tNsf1AVWL PyLKYW mETi YOIIxY m Sys A smam LLummm atcHocG1dum-wpomleu I 1 .000M qw.GeNotALUAeam DGpending 07/18108 07/18/09 + CLAW MAGE 10 acmm Woew em s 5,000. 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