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Home My WebLink AboutMiscellaneous - 233 MAIN STREET 4/30/2018 -233 MAIN STREET 210/031.0-0003-0000.0 J i I i AdvancedAdjustment Service, Inc. Property and Lia6i(ityAdjusters 60 Cottage Street, Easthampton, WA 01027 Phone: 413-282-0150 Fad 413-527-5144 Toll Free: 800-791-5432 September 4, 2016 Building Commissioner or Inspector of Buildings c/o Town Offices North Andover, MA 01845 NOTIFICATION UNDER M. G. L.c. 139, §3B Re: Insured: Markey, Donald&Carol Policy#: HP3031143 Date of Loss: 08/31/2016 Type of Loss: Water damage Our File: 16-09006-OOP38 Loss Loc.: 233 Main St.,North Andover,MA 01845 To Whom It May Concern: Advanced Adjustment Service, Inc., is the independent adjuster retained by Bay State Insurance Co. to investigate and adjust the captioned claim for damage to a building or other structure at the property listed above. Pursuant to M. G. L. c. 139, §3B, Bay State Insurance Co. hereby notifies you that payment of $1,000.00 or more may be made in connection with the captioned claim. If the city/town intends to initiate proceedings under M. G. L. c. 139, §3A; c. 143, §9, or c. 111, §127B,please forward the notice required under M. G. L. c. 139, §3B, to my attention within the time provided under that statute. Sincerely, Je an t. 2204 Advanced Adjustment Service, Inc. cc: Bay State Insurance Co. JHJs Location Z J 'lfi(.y�1 A 124r .No. Date 4w • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $-/', TOTAL r' 'P'�' $ Check# S Building In pect r Commonwealth of Massachusetts Sheet Metal Permit �j ("^ ((6 Permit# Date : lU` "2 �� L Estimated Job Cost: �IJC J Permit Fee: $ '07 Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 6 Applicant License# Business Information: Property Owner/Job Location Information: Name: Name: narct Street:5 ll m rn ,� ��' Street: —� t�' 'Ci I City/Town: City/Town: ��Yl Telephone: ` Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu.ft. V/ over 35,000 cu.ft. Sheet metal work to be completed: New Work: Renovation: HVAC V/ Metal Roofing Kitchen—Exhaust System Chimney/Vents Provide brief description of work to be done: ��1 ( e Fu rn au at I,-\)Cal� - INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[],1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By A Master ride ❑ Master-Restricted litylrown - ❑Journeyperson Signature of Licensee 3ermit# �w ❑ rn Joueyperson-Restricted License Number: -ee$ Check at www.mass.gov/dpl nspector Signature of Permit Approval CONTR0L# 6) 1 ! IMPORTANT 80+xz9 a 860ZISZ90 !}99 If your license is lost,damaged or destroyed; is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpi for ta: instructions to ensure the proper mailing of your Renewal Application and any other correspondence. I. a 4 3ah A�flBS�W�<£Zf This license is subject to Massachusetts General Laws and (� �} $�J�J�ZlB d 31NNOQ regulations.Your license.is a privilege,and cannot be lent or fP f assigned to any person or entity under penalty of law.Keep this r license on your person or posted as required by law and/or C� 11 !t �INttJdlAl regulations. tl S tit 36 1 11'10NIM0 7�©' .7F1 it Sdt1SS%' -. �� Si�fQM�►�.��i�,�,a�Ns SU3S;nH Hpj;� MNOW OO (4) I. CONTROL# 272, 8Fr MA IMPORTANT www.mass.gov/rmv 10A 0641-2014 06_10_1965 If your license is lost, damaged or destroyed;is inaccurate; or CLASS- 3 D: needs to be corrected,visit our web site a'.mass.gov/dpF for Ibi,pt..h..l b.. instructions to ensure the proper mailing of your Renewal Application and any other correspondence. EflDPR6rMrNr,- RESTRICTIONS- NONE NONE This license is subject to Massachusetts General Laws and regulations. Your license is a priviiege, and cannot be lent.or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law.and/or regulations. CHANGE OF ADDRESS.PRINT BELOW.PERMANENT 114Y a o ,0 ff 1_H V t. L o 01 3N11 A -jwv , _J0 S H .......... IS V WF. _LS 0 J13 M0110J 3HI :C'n .SISI9- n 3 1 D4.I PP 133PIS ievai.4 Project Name:Kaufman @i System:2 (001 (9v [3233 Main St,North Andover,MA 01845,USAnual J LAWRENCE MUNICIPAL AP,MASSACHUSETTS Summer Outdoor F: , Summer Indoor F. Design Grains: Daily Range: Winter Outdoor F: Winter Indoor F: Cooling RH: Elevation(Ft): 'y ' AED Excursion Cooling Loads 3� Duct Name Area Sensible Latent 5 Windows Windows&Glass Doors 220 7,229 0 Infiltration 25.2% Skylights 0 0 0 Doors 40 624 0 3.4% Above Grade Walls 1,940 12,338 0 Ceiling Floors 0 0 0 i16,8% Doors Ceiling 1,810 4,815 0 2,2% Ventilation 0 0 0 1 Infiltration 0 389 574 Internal 0 0 0 Above Grade Duct 0 1,448 21.3 Walls Blower Heat 0 0 0 43' AED Excursion 0 1,063 0 ITotal 4,010 27,906 787 Duct Heating Loads 7 Name Area Heat Loss Infiltration Windows&Glass Doors 220 17,043 6.2% Windows Skylights 0 0 i 28.8% Doors 40 1,464 Ceiling Above Grade Walls 1,940 28,402 l 1 Below Grade Walls 0 0 Ceiling 1,810 4,196 i Ventilation 0 0 Doors Infiltration 0 3,654 2.5''io f internal 0 0 Above Gradef Floors 0 0 Walls Duct 0 4,490 47.D% Humidification 0 0 z, � Hot Water Piping 0 0 Total 4,010 59,248 Warning:This application has glass areas that produced relatively large cooling loads for part of the day.Variable air volume devices may be required to overcomespike I s in j i solar load for one or more rooms.A zoned system may be required,.or some rooms may require zone control(provided by individual,motorized,thermostatically cle ontrod dampers) W i j AED Graph 12,000 Approved ACCA Mj8 —HTM Calculations Average 9,000 —Average -1.3 t 6,000 Q1 Calculations are based on the ACCA Manual J 8th Edition and are approved by RCCA.All computed calculations are 3,000 estimates on building use,weather data,and inputted values such a R-Values,window types,duct loss,etc.Equipment i selections should meet both the latent and sensible gain as 0 well as building heat loss.See Cool Calc Manual S Report for I' 8 9 10 11 12 13 14 15 16 17 18 19 equipment sizing verification. i Hours �_^_ Prepared by:Cool Calc Version 1.0_0 Beta_www.coolcaic.com Project Name:Kaufman (C*1 Ado�n�ISystem:1 ; i BETA C 13233 Main St,North Andover,MA 01845,USA �A Manual) i LAWRENCE MUNICIPAL AP,MASSACHUSETTS Summer Outdoor F: Summer Indoor F: ;, Design Grains: Daily Range: Winter Outdoor F: Winter Indoor F: rT _ Cooling RH: i_ Elevation(Ft): Cooling Loads Duct Name Area Sensible latent 5.91% Windows Windows&Glass Doors 224 7,943 0 Internal Skylights 0 0 0 16.4% 24°-0 Doors 40 624 0 Infiltration Above Grade Walls 1,976 12,567 0 1 3.1% Floors 1,930 3,188 0 Ceiling Flo _�� Doors Ceiling 130 346 0 I i% Ventilation 0 0 0 Floors Infiltration 0 415 611 9.6°! Internal 0 4,010 1,400 Above Grade Dud 0 1,716 225 Walls _..38% Blower Heat 0 0 0 AED Excursion 0 0 0 Tota) 4,300 30,810 2,236 Heating Loads i Duct � Name Area Heat loss f T3% Windows&Glass Doors 224 17,353 Windows Skylights 0 0 Floors 267% Doors 40 1,464 18.22% Above Grade Walls 1,976 28,929 Below Grade Walls 0 0 Doors Ceiling 130 301 Infiltration 2.1/ Ventilation 0 0 � Ceiling - Y Infiltration 0 3,891 0.495 'r Interna! 0 0 Above Grade Floors 1,930 12,810 Walls Dud 0 5,504 r 41,2% Humidification 0 0 f ; Hot Water Piping 0 0 Total 4,300 70,252 y --- ----- - --- { AED Graph 1z,000 Approved ACCA MJ8 —HTM Calculations Average 9,000 —Average *1.3 ! t 6,000 Co Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA.All computed calculations are 3,000 estimates on building use,weather data,and inputted values such a R-Values,window types,duct loss,etc.Equipment selections should meet both the latent and sensible gain as 0 well as building heat loss.See Cool Calc Manual S Report for 8 9 10 11 12 13 14 15 16 17 18 19 equipment sizing verification. Hours Prepared by:Cool Calc Version 1.0.0 Beta-www.coolcaic.com i l ® DATE(MMIDD/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE `� 7/23/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME, Emily Costello Costello Insurance Agency, Inc. aicoNno Ext: (978)374-6352 FAX (979)521-5127 AIC No 2 S. Kimball St. E-MAILss:ecostello@costello±nsurance.com PO BOX 5248 INSURERS AFFORDING COVERAGE NAIC# Bradford MA 01835 INSURER AArbella Mutual Insurance 17000 INSURED INSURER B Arbella Protection Ins Company 41360 Joseph A Dipietro Heating 6 Cooling, Inc. INSURER C: 5 South Summer Street INSURER D: INSURER E: Bradford MA 01835 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1572300124 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR IND WVD POLICYNUMBER MMIDDIYYYY MMIDDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO A CLAIMS-MADE ❑X OCCUR PREM SES a occTu ante $ 100,000 CPP 8500064551 7/25/2015 7/25/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 7 PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: AUTOMOBILE LIABILITY EO aBIcNdEDtSINGLE LIMIT $ 1,000,000 BX ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 1020042603 7/25/2015 7/25/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS X AUTOS Per accident PIP-Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 CPP 8500064551 7/25/2015 7/25/2016 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? A (Mandatory in NH) 0055120715 7/25/2015 7/25/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under IDESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) licensed electrician is Erik Piermattei CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Emily Costello/HOYECl ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nm4011 ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `6.�* 7/23/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Emily Costello Costello Insurance Agency, Inc. HCONN Ext: (978)374-6352 FAX No:(978)521-5127 2 S. Kimball St. E-MAIL ADDRESS:ecostello@costelloinsurance.com PO BOX 5248 INSURERS AFFORDING COVERAGE NAIC# Bradford MA 01835 INSURER AArbella Mutual Insurance 17000 INSURED INSURER B Arbella Protection Ins Company 41360 Joseph A Dipietro Heating S Cooling, Inc. INSURERC: 5 South Summer Street INSURER D: INSURER E: Bradford MA 01835 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1572300124 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL SUBR EFF EXP LTR TYPE OF INSURANCE POLICY NUMBER MM DIDYMM/DDYLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE Fz OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ CPP 8500064551 7/25/2015 7/25/2016 ME D EXP(Any one person) $ 5,000 PERSONALBADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO ❑ LOC JECT PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea acadentSINGLE LIMIT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 1020042603 7/25/2015 7/25/2016 BODILY INJURY Peraccident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ PIP-Basic $ X UMBRELLA LIAB R OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 CPP 8500064551 7/25/2015 7/25/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? F N/A A (Mandatory in NH) 0055120715 7/25/2015 7/25/2016 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) licensed electrician is Erik Piermattei CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Emily Costello/HOYECI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/gol4nn The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� ,, i Please Print Legibly Name (Business/Organization/Individual): t n 6,Y L i _(L' o'1 1 ny Address: EMI h &urnry-1rl City/State/Zi Phone #: Are you an employer?Check t e appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I ❑ employees (full and/or part-time).* have hired the sub-contractors 6 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' Y4. ❑ Building addition [No workers' comp. insurance comp. insurance.) required.] 5. ❑ We are a corporation and its 10.Wlectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] T c. 152,§1(4),and we have no employees. [No workers' 13T1 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: MOk loo � �lY[Jl _ Policy#or Self-ins. Lic. #: MSS I IDI I,S� Expiration Date: 6-k 2SS- 2o/(o Job Site Address: L ?3 H Q io City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. [do hereby certify and he pains nd enalties of per' that the information provided above is true and correct. --�" Si afore: - - Date: I ZO co Phone#: C-1 U ' t'2 -q111 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#: Date...', a.� ............... � OF r10RTly,� - o�a; TOWN OF NORTH ANDOVER PERMIT FOR WIRING �, - • '•; ; rte,.• +9 o t ,ss�►CMUS�t This certifies that ....... ? �-- ..................................................................................................... has permission to perform :% . wiring in the building of............... �'� ' t P� .......................................................................................... at ... •J�3..... -► ..�.... .....................North Andover,Mass. Fee ................Lic.No./ 3 ........... NN •' ELE TRICSPEC)TOR Check# v cz kA 1 t� Commonwealth of Massachusetts Official Use Only --4 E o Department of Fire Services Permit No. 13 3 Occupancy and Fee Checked ,M s BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 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) J-33 d- Owner or Tenant xq�e vN lCa u Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service aO Amps JJ4i /21&) 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: , G/' ( gy,,Lt,-d- s ds Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA f No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets W No.of Oil Burners FIRE ALARMS No. of Zones i 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 No.of Waste Disposers Heat PumpNumber 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. 1 Estimated Value of Electrical Work: .2TO 0 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . cdw n LIC.NO.: /03 f'G Licensee: �� ,. /�� o Signature LTC.NO.: IG,3,� P/,3 (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- q-7,1-st Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the ` notification of completion of the work as required in M.G.L.c.143,§3L. t Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench In_spection 1,1 S l c,- Pass iPass M T6L. ct, I 1,tk3s Failed Re-Inspection Required($.) ❑ Inspectors Comments: a � A-g 22 Inspectors Signature: v Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: t Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass 0 Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: y, per ? ^ Date: FINAL INSPE N: Pass Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: 74' DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i 1 The Commonwealth of Massachusetts £ Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 °t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �` 0> Please Print Lesibly Name(Business/Organization/Individual): C-4jair les/ /l Gin IrG Address: ` N. `/l/,'de �f r�,/i City/State/Zip: J e h-. 03 0-7 ej Phone#:__ Are you an employer?Check the appropriate box: Type of project(required): 1.E]I am.a.employer with employees(full and/or part-time).* 7. New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. F]Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10 0 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 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.t 6.p We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have na.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 thepolicy 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 ofperjury 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#: 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 bum 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 I :COMMONWOITH OF MASSACHI S&ir rte. BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A Eft JOURNEYMAN ELECT IR CIA is `�DWI�ftD A KANKA art 147 MILVILLE - ST ` LEM' NH 03079-2221 . ^ 10 X56 07/31/:16 61010 North Andover Board of Assessors Public Access Page 1 of 1 OORT" ■V orth Andover Board ofAssessors OF '6. u-< �< O re Ot t 9SSACHUS�� IQ� roperty Record Card Click Seal To Return Parcel ID :210/031.0-0003-0000.0 FY:2014 Community : North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales b Summary Residence Detached Structure Condo 233 L-B FAIN STREET Commercial Location: 233 MAIN STREET Owner Name: MARKEY FAMILY TRUST KARA A.KAUFMAN,TRUSTEE Owner Address: 233 MAIN STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 0.53 acres Use Code: 104-TWO-FAM-RES Total Finished Area: 3680 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 415,700 447,700 Building Value: 235,300 267,300 Land Value: 180,400 180,400 Market Land Value: 180,400 Chapter Land Value: LATEST SALE Sale Price: 1 Sale Date: 10/06/2010 Arms Length Sale Code: A-NO-FAMILY Grantor: MARKEY Cert Doc: Book: 12223 Page: 0237 http://csc-ma.us/PROPAPP/display.do?linkld=2433346&town=NandoverPubAcc 9/8/2014 NORTH F�IOg-t.ED ,,0,a�oA Town of North Andover + =o m: Machine Shop Village Neighborhood Conservation District Commission 1600 Osgood Strcet North Aiidover, MA 0184,5 SSACHUS� Application For Certificate to Alter Instructions: Fill out the form below and submit to the Machine Shop Village NCD Commission Chairperson(contact info below). The goal of this application is to provide a clear understanding of the proposed alterations,and how they vary from the existing conditions. Your application must include photos or plans of the existing conditions,and plans or drawings of the proposed changes. Include product&material descriptions for both existing and proposed conditions. Discussions with the Building Dept. or MSV NCD Commission are not a substitute for filing an application. Date: December 10, 2014 Contact Name&Address: Richard Kaufman (Phone 978-758-8599, Email rdkaufman0l @gmail.com) 233 Main Street b-u,\C erzv� L� North Andover, MA 01845 �� , Project Address: Same as above /7"CJIOI�l4 Project Description (attach additional pages,if needed) m Adding a 48x24 foot garage at end '~ Color of garage is gray and matche ( � Existing shed to be removed and rE Garage has human door and a win( 3 street. Garage has three white garage do( Information Provided: X Photo/Drawing of Existing Conditions X Photo/Drawing of Proposed Conditions see plot plan with proposed garage location. Description of Existing Materials X Description/Catalog Cuts of Proposed Materials to be used X Other Information(describe):Garage from Amish Backyard Structures See catalog page for materials. Driveway widened near garage for car access to two of three garage doors. Plot plan shows location of proposed garage. A certified signed copy is too large to scan and will be given to the Building Department. MSV NCDC Current Chair:Liz Fennessy,77 Elm Street,lizettafennessv@yahoo.com,978-688-2915 t a N/F FENTON 122.00' I � O c n m O EXISTNG 1n N SHED TO n 00 N/F PETRONE BE REIAOVED ST O SIZED L SDTOCA(ADE FEN. 1 40.90' 24.89' PROPOSED 1 STORY N 37 AS 27.07' to O rp w LOT #3 O CL AREA=22,678 S.F. rn =0.5206 AC. N/F FOURNIER N/F LU ~ LLI I DUSTING 2 1/2 STORY W.F.D. Q 0233 cr CD U7 98.28' MAIN STREET NOTES PLAN OF LAND o 1. SEE TOWN OF NORTH ANDOVER ASSESSORS MAP o #31 LOT #3 AND DEED BOOK #2388 PAGE #150 IN E.N.R.D. FOR SITE. NORTH ANDOVER, MASSACHUSETTS a- DRAWN FOR KARA A. KAUFMAN, TRUSTEE Lo OF THE MARKEY FAMILY TRUST OF a SEPTEMBER 21, 2010 j 233 MAIN ST. a m NORTH ANDOVER, MA 01845 Ln SCALE: 1"=30' DATE: DECEMBER 9, 2014 0 15 30 60 90 3 0 MERRIMACK ENGINEERING SERVICES 12/9/1 66 PARK STREET STEPHEN E. STAPINSKI, R.L.S. DATE ANDOVER, MASSACHUSETTS 01810 S P E C I F I C AT I O N S & COLOR OPTIONS 16'on center douol'e Ddpedge air pmeted roof Musses Rodshcetedlight ` with ex[eriaaprywoadl reall-keeand .. old Xuea; 'wily finish. Selkealing are made with maintenance-free vinyl siding or azcrT Dura-Temp T1-11 painted with your choice of Finished colors.Our doors and windows are all trimmed Soffit on all White with vinyl perma-trim or Miratec,which comes huilding5 ��_ aluminum with a 50-year warranty and will not rot, dows with�„� crack,peel,or warp.The trim is fastened with stainless Our buildings are delivered & Ynylor steel fasteners.Over the fully-assembled Dura-Temp 11 siding or hand-built onto your secured with years we have developed prepared site! galvanized a building that is practically nails maintenance-free in both Dura- - treavy-duty black .mss/e"extedorgrade cobnialT-hinges Temp and vinyl siding.We use a heavy- Treated Float ioists plywood floating rorthe doors 2 x 4-1&an center Pnasuretmalad'4x4 S`WideFlom duty black powder-coated colonial style hinge, tamdaffonheams Pressure Lj ----- - which gives the door a nice unique look,and Treated Skids ,a —6& —1 withstands the elements.Additionally,the keyed 16"WtdeFloers lock latch on the door gives you maintenance- I�} �+_34a T Tzr----1 e I free security for your yard and garden tools. 12"Wrde Floors 1,r Wide Floors SHINGLE COLORS Frame--4r 3V30 — "r Skids 4"x 4"pressure-treated lumber $ I$w Floor Joists 2"x 4"-16"on center pressure-treated Flooring s/"exterior grade plywood Black Brown Gray Forest Green Tan Weathered White Wall Studs 2"x 4"-16"on center Gray Exterior Siding • Wood Dura Temp with grooves every 4" WOOD SIDING COLORS • Vinyl D4Dutch alLap D4 • Vinyl Traditional D4 11f 00 Rafters 2"x 4"-16"on center Roof Sheathing W'4-ply plywood Roofing Lifetime warranty architectural shingles Doors Heavy-duty and double framed with 2"x 3"lumber Door Sills Aluminum sill protectors Black Blue Brown Buckskin Cedartone Clay Cream Sealer / f Skids 4 x 4"pressure-treated lumber f J Floor Joists 2'x 4"-16"on center 0 0t Flooring %"exterior grade plywood Wall Studs Framed 24"on center �_-' 0. Exterior Sidhig Dura Temp or vinyl on OSB Dark Gray Gray Green Pink Red Beige White Rafters 2"x 4"-24"on center 2"x 3"on 6'x 10'and smaller VINYL SIDING COLORS Roof Sheathing 1/2"OSB plywood Roofing 25-year 240 Ib.self-sealing asphalt shingles Doors Heavy-duty and double framed with 2"x 3" lumber We use Georgia Pacific Vinyl Siding or 07-77 Almond Clay Cream Gray Tan White Blue Dura-Temp T1-11 with Georgia-Pacific Haley Exterior Latex Paint VINYL TRIM COLORS Recommended Site Preparation: $ Osseo 3 to 4 inches of%"clean stone base. Use 4"x 4"treated timbers around perimetgr and make 12"wider and longer than shed. Black Blue Brown Clay Green Red Beige White Level stone evenly. Colors may vary. } e \ 7 l No M1 N � q *�41 b q 4 C p j �{ w " HI ll F° 9 'T ow. of Nam Andover NeWHodood Commagm 160003gpMSUret NorthAndo"roNIA01945 Certificate to mer Dmeme t lz-lcktLrd Lauf-met i 233 Main S+ mom-ft. A rld xce /N.4 Q t alis Pn*ctAd&-m= 5aAenC-- - (x=ch mUdand.p%ms,if ): iSriG �► � llft trdt'd {t ; � t LI i cmmmimim VC&M voted—T for 0 to wwal 'cue w Aker on G [s(ate s€ : si-117a �/t KO eS&W riffage mea Caa�csee��ti�ee gistciet Cts NCDC Page 1 Scanned by CamScanner i. I �IN N:I— ilwlwn � }�rwr.r.r. 1 911 LIFETIME ARCHITECTURAL �� _ ASPHALT SHINGLES 15132"TECHSHIELO RADIANT RIDGE VENT HEAT BARRIER ROOF SHEATHING ENGINEERED ROOF12 C- TRUSSES 024'O. TRUSS BRACING PER TRUSS V MANUFACTURERS REQUIREMENTS f Y ALUMINUM DRIP EDGE SIMPSON H2.5A HURRICANE TIES i i • , , WRAPPED ALUMINUM (2)20 TOP PLATE �II r � 'S FASCIA R SDFFTT III I 294 WALL STUDS @ 16.O.C. ............................ I ................._.............................; i...................._.... VINYL SIDING w1 x 1SWTECHSHIELDRADIANT b i I i i HEAT BARRIER SHEATHING i i 1 I t APPROVED ANCHOR BOLTS PER at.,, LOCAL CODE REQUIREMENTS °"'ode a W. • 2x1 PRESSURE TREATED .---—_e..tlPPBOX.f404g LpN,�. _ _—._„..._ �a i .. SOLE PLATE NOTE;CONCRETE FLOOtUFOUNDATk)N BY OTHERS, �. , ^' NOTE:MINIMUM 6'CLEARANCE KCTOW TOTOPOF I1 PLATE SE TION "A-A" SCALE:VY.1-0' Aw1 a+.w /1� wor wn aw.w.sa 4 r N/F FENTON 122.00' 1 O c n b DOSING SHED TO N Lo N/F PETRONE BE REMOVED ST O SHED L SWOOD OTOCKADE FEN D L- i 40.90' 48 24.89' PROPOSED 1 STORY N 37.43' 49 27.07' b LOT#k3 � O AREA=22,678 S.F. c =0.5206 AC. N/F FOURNIER N/F LU ~ W W EASING 2 1/2 STORY W.F.D. 1 Q #233 ct Lo MAIN STREET i i I NOTES FNORTH OF LAND c!) 1. SEE TOWN OF NORTH ANDOVER ASSESSORS MAP o #31 LOT #3 AND DEED BOOK #2388 PAGE #150 j E.N.R.D. FOR SITE. DOVER, MASSACHUSETTS U 00 KARA A. KAUFMAN, TRUSTEE Lo OF THE MARKEY FAMILY TRUST OF a SEPTEMBER 21, 2010 a j 233 MAIN ST. v NORTH ANDOVER, MA 01845 n O SCALE: 1"=30' DATE: DECEMBER 9, 2014 0 0 15 30 60 90 3 IIMERRIMACK ENGINEERING SERVICES 12 9 14 66 PARK STREET r STEPHEN E. STAPINSKI, R.L.S. DATE ANDOVER MASSACHUSETTS 01810 LEFT ELEVATION REAR ELEVATION ®®®® ®®®®®®®® ®®®® Lu ® U ®®®® ®®®®®®®® ®®®® C) FRONT ELEVATION RIGHT ELEVATION � od� Q m Y Fo^ U mod LIFETIME ARCHITECTURAL m ASPHALT SHINGLES 2 15/32"TECHSHIELD RADIANT RIDGE VENT U) HEAT BARRIER ROOF Q SHEATHING ENGINEERED ROOF 12 / \ TRUSSES @ 24"D.C.- 5� o TRUSS BRACING PER TRUSS MANUFACTURERS REQUIREMENTS ow a w N I J o SIMPSON H2 5A HURRICANE TIES o ALUMINUM DRIP EDGE z moo" WRAPPED ALUMINUM (2)2x4 TOP PLATE a y a I g Foo"o.,�oHo.oOOHE":-\ ° FASCIA&SOFFIT I 2x4 WALL STUDS @ 16"O.C. , "�o�oNs 0 .. .----------------------------------------------- ............-.....--.-.-- VINYL SIDING w/ 15/32"TECHSHIELD RADIANT `P HEAT BARRIER SHEATHING APPROVED ANCHOR BOLTS PER _ N LOCAL CODE REQUIREMENTS OEC.18.2014 oA— I 000" ,"., 0000" .r 0000" _______ APPROX.FLOOR LINE _ ELEVATIONS E"ice i� ERI„E�E g WE"INS I 2x4 PRESSURE TREATED PSN f SOLE PLATE NOTE:CONCRETE FLOOR/FOUNDATION BY OTHERS. SECTION FLOOR PLAN l 24'-0" :u�E.+a•+�' NOTE:MINIMUM 6"CLEARANCE FROM BOTTOM OF PLATE SECTION "A-A" TO TOP OF FINISHED GRADE SCALE:1/2"=1'-0" A-1 v�o,°.eTE o"mme",1e,mu N/F FENTON 122.00' LOT #3 0 AREA=22,678 S.F. EXISTING =0.5206 AC. Lo 0 SHED TO 1O N/F PETRONE BE REMOVED EXIST WOOD O SHED L L=Eo i 40.90' 24.89' PROPOSED i STORY OARAGE N 'a N 37.43' 27.07' N O t0 W O O CO O 0? N/F FOURNIER c� N/F LU LAJ m I o; ExlsnNc 2 1/2 STORY W.F.D. Q #233 i (.(J d' 98.28' _ MAIN STREET NOTES PLAN OF LAND c� 1 . SEE TOWN OF NORTH ANDOVER ASSESSORS MAP o #31 LOT #3 AND DEED BOOK #2388 PAGE #150 IN E.N.R.D. FOR SITE. NORTH ANDOVER, MASSACHUSETTS a- DRAWN FOR KARA A. KAUFMAN, TRUSTEE co 0 OF THE MARKEY FAMILY TRUST OF 0 SEPTEMBER 21, 2010 v OFAU�sf9 233 MAIN ST. 0 STEpHE ; NORTH ANDOVER, MA 01845 00 og stgtrt �� f N SCALE: 1"=30' DATE: DECEMBER 22, 2014 V) 0 15 30 60 90 12 22 14 MERRIMACK ENGINEERING SERVICES cy- q ' �� 66 PARK STREET STEPHEN E' SYMPI KI, R.L.S. DATE ANDOVER, MASSACHUSETTS 01810 Date../A)//z . .. .... .. HORT TOWN OF NORTH ANDOVER • PERMIT FOR 'GAS INSTALLATION �,SSACHUSEt� This certifies that . . . 1Iqf. ./ . . . , . . . . . d has permission for gas installation in the buildings of . . . /�(7,ke . . . . . . . . . . . . . . . . . . . . . . . . . . at . .Z. 3 /%M. .47 . . .. . . . . . . . ., North Andover"Mass. Fee. Lic. GAS INSPECTOR Check# ,/„30 7999 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK U1WCITY ®, )Qjo (,, . MA. DATE --57— ;4;�/,.2 PERMIT# JOBSITE ADDRESS d3 3 S,77 OWNER'S NAME GOWNER ADDRESS: ��-�-r��_ TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES 7 FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS t MAKEUP AIR UNIT OVEN POOLHEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY M 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 ❑ AGENT ❑ 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 the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this applicatio illb in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: I ROBERT M.DEMERS JR. LICENSE# 9737 ATURE COMPANY NAME: 12APOLLO PLUMBING&HEATING INC. ADDRESS: HATTUCK ST.PO BOX 466 CITY: I LAWRENCE STATE: MA ZIP: 01842-0966 . .. ...__ FAX: .978-683-5933_.— TEL: 978-688-1755 CELL:I EMAIL: apolloplumbing@comcast.net MASTER❑■ JOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑Q # 3046 PARTNERSHIP❑#=LLC❑# ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ M � FEE: s PERMIT#PLANREVIEW NOTES r COMMONWEALTH °:0 MASSACHUSETTS LICENSED AS A JOURNEYMAN PLUMB R ROBERT M DEMERS JR 30 ALBERT ST �, METHUEN MA 01844-231 18495 05/01/12 754.022 COMMONWEALTH OF MASSACHUSETTS RMMUMCKbAlmu AbrlllCK* EGISTERED AS A PLUMBING CORP ISSUES I rilS._ICENSE'fU ROBERT M DEMERS APOLLO PLUMBING & HEATING I , 30 ALBERT ST y METHUEN MA 01844-2316 3046 05/01/12 754021 . r COMMONWEALTH OF MASSACHUSETTS IN AS A MASTER PLUMBER ROBERT M DEMERS JR ji�-: 30 ALBERT ST METHUEN MA 01844-231 9737 05/01/12 75402 r a . • v� OP ID:TD ~C�R�� CERTIFICATE OF LIABILITY INSURANCE DATE �,i 12/21/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER 781-935-8480 NAMEACT DeSanctis Insurance Agcy,Inc. 781-933-5645 PHO Ext ac No: 100 Unicorn Park Drive E-MAIL ADDRESS: Woburn,MA 01801 PRODUCER APOLL-3 C ST ER IDO: INSURERS AFFORDING COVERAGE NAIC# INSURED Apollo Plumbing&Heating, Inc INSURER A:Selective Insurance Company PO BOX 466 INSURER B: Lawrence,MA 01842 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE D POLICY NUMBER MM/DDY� MMIDD//YYYY Y EXP LIMITS LT GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 01 A X COMMERCIAL GENERAL LIABILITY S1840821 01/01112 01/01/13 PREMISES Ea occurrence $ 100,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY JECI COMBINED SINGLE LIMIT $ 1,000,00 01/01/12 01/01/13 (Ea accident) A ANY AUTO A90912147 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS UAB HCLAIMS-MADE AGGREGATE $ 5,000,00 A S1840821 01/01/12 01/01113 $ DEDUCTIBLE X RETENTION $ $ WORKERS COMPENSATION WCTATU-SO R AND EMPLOYERS'LIABILITY 500,00 A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC7264182 01101112 01/01113 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) "ADDITIONAL INSUREDS LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN CONTRACT" Evidence of Coverage CERTIFICATE HOLDER CANCELLATION EVIDEN- SHOULD ANY OF THE ABOVE D S�IBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TH REF, NOTICE WILL BE DELIVERED IN EVIDENCE OF INSURANCE ACCORDANCE WITH THE POLI Y P OVISIONS. "IR REPRESENT TIVE 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD Date`.................................. l NORTh TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACNUS� This certifies that ...- -: ' ' ` .......................................................................... has permission to perform .......... wiring in the building of..................:..............�.v`�........................................... �' ..'."'�'^"' �' ..............North Andover,Mass. Fee: ............... Lic.NAZIlI -t 3' :.. e.�.u,........'� `..:..... : l:41..... ELECTRICAL INSPECTOR Check # X270 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Occupancy and Fee Checked i r BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank) 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: Z —a Q .,7 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) � 3 3 Owner or Tenant 400N /)I Ar-ACe Telephone No. Owner's Address a 3 3 /77 ,4,'4-/ Is this permit in conjunction >lwith a building permit? Yes ©' No ❑ (Check Appropriate Box) Purpose of Building ir7L�e n/ g e MC,le / Utility Authorization No. Existing Service,=?Ob Amps %a U/ -'VO Volts Overhead Ei�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: �r=��,(e..J tg e MG��C o'y Se�dy� F foo r Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- EJo.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 7 No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Total Tons g No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self- ontained Totals: .. .. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ NFUHI pal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: PC-no (When required by municipal policy.) Work to Start: 3 ',)F-O"] Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera .s in force,and has exhibited proof of same to the permit issuing office. NCE BO CHECK ONE: INSURAND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this a lication is true and complete. FIRM NAM E: L 4 ru.1 -lee- ;c— L r✓r— LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt"in the license number line.) Bus.Tel. No.:9��f'��a Address: , 'L , &e_5( Zif3 /1e-f/✓t-✓' In Q Alt.Tel. No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $i�— Signature Telephone No. 4 Date.....3`.5.....Z:..... .4 NORr"-1?°.t;�`` TOWN OF NORTH ANDOVER o PERMIT FOR WIRING �,SSACMU`�� This certifies that P.................................T/t..G —�ZG has permission to perform .......r .1 ` ................. ............. wiring in the building ofCISF . .................................... ............................................. at... ...........................Aorth Andover,Mass. dee. 5 ... Lic.No.&2'�.�3.................... ,1* ...... ELECTRICAL INSPECfAR Check # 10694 1� t� Commonwealth of Massachusetts y k Official Use Only a Department of Fire Services Pent No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PR WT RV I NK OR TYPE ALL INFORMATION) Date � -- S- 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersignedIves notice ofhis or her intention to perform the f electrical work described below. Location(Street&Number) 3 3 m,4,',y S-fes e.`-T- Owner or Tenant /Y)'r #- /K rs 0 o r i'V1 R C- Telephone No. Owner's Address _a S 3 m •"A/ S T e-e e- t— Is this permit in conjunction with a building permit? Yes ❑ No K (Check Appropriate Box) Purpose of Building /`f o u s 2 Utility Authorization No. Existing Serviced U 0 Amps /.1j/ .;t gC1Volts Overhead 13--ilndgrd❑ No.of Meters c�, ihTew Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters LNumber of Feeders and Ampacity � ocation and Nature of Proposed Electrical Work: _7—A15-F4r- Com letion ofthe ollowfn table maybe waived b the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above11In- ❑ TO.o mergency Lighting rnd. rnd. Battery 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 Initiatin Devices - No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons KW No.ofSelf-Contained Totals: Detection/Alerting Devices ;4o.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KVV Security Systems:*- NO.of WaterNo.of Devices orE uivalent Heaters �y No.of No.of Data Wiring: signs Ballasts No.ofDevices orE uivalent [OTEJUER: romassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent Attach additional detail ifdesired,oras required by the Inspector of Wires. Estimated Value of Electrical Work: S.;k O O (When required by municipal policy.) Work to Start: 3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofpedulry,that the information on this application is true and covplete. FIRM NAME: L A 14J r'1 e -4 C L LIC.NO.:14 I.a 40 � - Licensee: Signature LIC.NO.: (Ifapplicable, nter`exempt"in the license number line.) Address: t%o jo X 3 8 Bus.Tel.No.: j 7br• F.2 qA • /F s"7 Alt. *Per M.G.L c. 147,s.57-61,security work requires Department ofPublic Safety"S"License: Lie.No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ r , _ BLECMCAL P{'RMT No. l�Tt�'7��C�Q��ET�O?�►�`: .R."OUAY MON, '�ssetl [ - S+a3Ied�[ Re-inspection requiurecT($�0.00) [ ] ?�us,pectors'camrne�ats: (xnspectord,Signature-no�+nztfals) Pate 2..VJWAAL P C xOI�7; passeaL l:+UCCI--•( Re-inspection required($50.00)-[ � q'nspectors'comments.- Q:fispectorsRignature•-)ao Initials) date +GROU.LVD3N�'�Cq`xOZY: _ I'assecl--[ j p'ailecl_.[ � 7�2,e�inspectzonaet�ufrecT($50.U0)�[ J Inspectors'comments: (pnspectoxs'aignature-uolnitiaTs) Date 4,7NPECO�T—�E?c� CE: DATM CALLER-n.N a+ONAL C-9 : HAM:. Passed--[ ) +`afled--[ e-inspection xeq&ed($50.00)-[ ) kaspectbrs'commeAfs: I e (Zuspeetozs',�ign2ture rio jnitials) hate 'assed--[ � �+'axled•-[ �. 'ate�ns�ectionzegtured($50A0)�[ � asp actors,coVam.ents: - Qispectoxs"Signdu re-no Initials) Date D®OR TA.GN AM TO DE EEEED O17T.A"EEFT 09,91TE IF TJH.APXA TOM,INSPECTEDIS NOT ACCESSIBLE AND A n INSPECTION OY$50,00IN TO BE CHARGED. - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �.UV 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information )) Please Print Legibly Name(Business/OrganizatiorAndividual): L A 1-0 �[ G c__4 e,i C, 17 v L Address: / , D , 6 0 Y, 3 !R,3 City/State/Zip: /n e A c,,_ AVl A 01b-YY Phone#: A,r_e.,yoVn employer?Check the appropriate box: Type of project(required): 1.I�I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑B ilding addition [No workers'comp.insurance 5. El We are a corporation and its " required.] officers have exercised their 10.Utlectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. 7 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Q 1U Policy I e- Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certl under th a' p aloes of perjury that the information provided above is true and correct. Si atur • 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#: Information and InstructlonS • Y Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. E. 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 ofpublic 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 1 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth,of Massachusetts Department of Industrial Accidents Office ofInvestigatioits 600 Washington Street Boston,MA,02111 `fel,#617-727-4900 ewt 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727;7749 wvvwanass,govfdia • 9 8 U %,:j Date......8-3�...../. 4 NOR7M TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SS, US This certifies that �/`�Gt> �'7P ` G' .................. ....... ...... ................................................... has permission to perform ......... !.........�!...�:.......... wiring in the building of...........&M&J�-' .................................... M A 1 tv 5Z r; orth Andover,Mass. at ............... Fee... Lic.No.....z f S.................................................. r ELECMCAL INSPEMOR Check # 1 I Commonwealth of-Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION V-IREGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINTININKORTYPEALLINFO 4TION) Date: City or Town of: To the Inspec or of ices: By this application the undersigned gives not' e of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant (�L C lr M Q r Gj, Y Telephone No. Owner's Address 5ci rn Is this permit in conjunction with a building permit? Yes No ❑ BLDG PERMIT# Purpose of Building )-Ffm, f)G Uc m P_ Utility Authorization No. Existing Servicea� Amps / d�C, Volts Overhead Q Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity f Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of Total. Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o.o mergency ig ng rnd. rnd. ❑ BatteryUnits No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners JINO.of Detection and Initiatin Devices No. of Ranges No.of Air Cond. Tonsl No.of Alertinks No. of Waste Disposers Heat Pump 1`TuIn Tons_ KW No.of Self-Co Totals: ..."""."""""" Detection/Alerces No. of Dishwashers Space/Area Heating KW Local❑ Mun ❑ Other Conn No. of Dryers Heating Appliances KW Security Syste No. of Water No.of No.of Deviuivalent Heaters KW No.of Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: l`Q Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o Elec ical Work: 1 Q� (When required by municipal policy.) Work to Start: I 1 d Q Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND El OTHER ❑ (Specify:) I cert,render thepains and nalties of perjury,that the information on this application is true and complet _ FIRM NAME: 9 (rC4 r i c. /1 LIC.NO.:, a-f s 3 Licensee: Signature LIC.NO.: (If applicable, me "xempt"in the license number 'ne Address: z' Bus.Tel.No.. g "j r 5 �1/��C v Y•� A . Alt.Tel.No.:�• *Per M.G.L. c.147,s.57-61,security work requires Department of Public Safety"S"Licen LIC.NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. B signature elow,I hereby waive this requirement. I am the(check one)❑owner E]owner's agent. Owner/Agent Signature Telephone No. JPERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL I U INSPECTION: Pa ed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspect rs' comments: (Inspectors'Signature-no initials) Date �- 2.FINAL INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date [3.UNDER GROUND INSPECTION: assed—[ ] Failed—[ l Re-inspection required($50.00)-[ ] nspectors'comments: P (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date r 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial,Accidents Office of fInvestigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: ]3uilders/Contractors/JElectriciansfrIumbers Applicant Information Please Print Legibly Name(B.usiness/Organization/individual):_ /4-t'L', Ell,r U4l 1,(— 111 Address: //h C /'z r ��ivS e Gu City/State/Zip: /� `P A U C rl `'l�. 01, Y k( Phane#: Are you an employer?Check the appropriate box: Type of project(required): 1.PI am a employer with 4. El am a general contractor and I have hired the sub-contractors 6. F1 Now construction employees(full and/or part-time).* 2.❑ I am a sole proprietor or partner- listed on the attached sheet.r 7. ]c Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition ' working for me in any capacity. workers'comp.insurance. g, t]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑.I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.[]Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box##1 must also fli 1 out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or SeIf-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the.form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er•th pa d e alfies ofperjury that the information provided above is true and correct. Signature. Date. V, �O Phone#: "j(f d- �� 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.EIectricaI Inspector 5.PIumbing Inspector 6.Other ContacE Person: Phone#: • 1� `' MASSACHUSETTS UNIFORM APPLICAT[0WFOR PERMIT;TO:DOVL(J111�R�ry� ';'" ' (Type or Print) r� NORTH ANDOVER ,Mass. i;<: . `L• Date: /vdtl�y nj�� Building Location 2 _g, �'}�qs �� Permit # � Owners Name ZCAP�L-a-".. P-�6uf5->/'i�, V New Renovation Replacement Plans Sybmitted FIXT U E i,. = Y < 443to Ic Y' � o z h z cri a ac _ z o = z z o, > J ea W NX C3 tq X ~ a W of 2 om. d ti t O 40 z 0 7 a d Q W 09 O a J = t] 4 �` J W Z Q Y O 0. Q H Q ;i < W IL X W •i ~ V Y 1• O N N U) f- X O G e1 x z W ("' O V Z • • i < &_ < < Z _ < < O a J J < cc 6: W. < O < 1- 5p 3 �c ..t m to Cl a � � = l- h u. o o to < � W tv 4 SUB-913SMT. • •. BASEMENT 1ST FLOOR 2NO FLOOR 3RD FLOOR Yq pfi 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR L±:L H± t (Print or Type) nn Check one: Certificate Installing Company Name (-1 P Corp. Address Partner. Firm/Co.�� Business Telephone 2 2- Name Name of Licensed Plumber: 6?':�:' �_Kf:p) Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity E] Bond ❑ Insurance Waiver: I, the undersigned, have been made aware- that the licensee of i this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent% ❑ , ) Il Aercbr eettify dial all of Ute details and in(otnution t have subiniticd(at entacd)in shone application ite lase aw`4plsle to Use best W say —•- kAowkdge and that all plumbing work and installations l.ctfntnicd undci rctonit blued(at this application win be tawysuawpe wkh A pathwo"pwj# time"of*A Massadtusalts Statc Plumbing Codc and Chsptct 142 of the(:cnogal Laws- 1i Y Title Signature of 'Licensed Plumber City/Town: Tv of Plumbing License �f- Q � zooP 1vrn 7AFFICF USE ONLY1 License Number 13 Master ❑ Journeymaa Date . 35 .5 <" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS US G') This certifies thah.-Ax . . . . . . . . . . . . . . . . . . . .ICT. . . . . . . . . . . . . . . . . has permission to perform � e plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR 11/cn!97 10:33 3,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer NORTH ANDOVER, Mass. Dais qt—V 2,5..l 0_2,7. if eundtno ,��, Location I o) /o� S—t PetmR Owner's Name a>O,\) mpn-l( x New O Renovation O Replacement Plans Submitted: Yes p . No dr FIXTUAE8 « s W a « ,«, « o s ►- w a J « � a 44 M t X a s is « r= •« H V s ~ ► i s 0 00 no 0 s N Y a .. ` S M t > 1W oe Y a epi = o g « s a W W .. O °s A � i i a i i � • .w o $us-!lMT. @Assuan 1!T FLOOR IND FL00R INDFLOOR 4TH FLOOR .. FTM FLOOR AL •TM FLOOR FTN FLOOR - eTM FLOOR Mock one: Cadvicale Installing Company Name - J l�• — P - .:_ . _- Q Coto. Address 0 Partnership 0Flrm/Co. Business Telephone Name of Licensed Plumber ��-� ��Y— - -• INSURANCE COVERAGE: „, _. _._._..._...._ . I have a current Ilablity Insurance polcy or Its substantial equivalent. Yesci2F� No ❑ If you have checked y . please lndlcate the . type coverage by checking the appropriate box A liability insurance pdicy Other _ r �. type of Indemnity ❑ 13orW 13 OWNER'S INSURANCE WAVER: ( em aware that the Hceniee does not have the Insurance coverage required by Chapter 142 d the Masa. General Laws, and that my signature on thle permit appitcaUone w4bss-Ih1 _ Checie one: .. . - Signature al OwnK at G*not's.AGent -. . . . Owner Q ._ 1 h.r•by Mft that al of the detals and blormallon(haw txrbrnftt•d for•nler•dl ti above 1tww1•dq•and that al phnnbrnq work and In,taxatlona ��►�e tcu�audaacrrata b Ips.�ot.pgy_ 1 1!r P*dormsd under the p•rrM issued br we tbn will be.In p+Alnen proNslons of a Massachusetts Slate Plumbing Code end Chapter 112 of at oornplanq with ill HY . i This na urs Cltyflawn Uo•nse Number r M'PrIMED(OFFICE USE ONLY) Typ•d Plumbing License: Jou�ne Yms% 13 5 i / Date. . „aRTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION o � f P •r ,SS'q uSES This certifies that `. •": . ."• • • • • • • • has permission for gas installation . . <% ':. . .*.�. . . . . :- in the buildings of . .... . ..~". , ... ..�. . . • • • • • • • • • •�• at o . . . . . 7 . . . ., 14rth Andover, Masa. cri Fee s .`.. Lic. No.. .c�.°�``. . GAS INSPECTOR 0 WHITE:Applicant CANARY:Building Dept. PINK:Treasurer > Date. �. . . ��• rr 70. �u 5 TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING ,SSACNUSE� This certifies that '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . has permission to perform y. . . . .'. . . . . . . . . . . ...f.. . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . !'?-! .... . . ... . . . . . . . . . . . . . . .r~ North Andover, Mass. Fee. . . . . . . . .L . No.. . : . !�`l. �.-.,. 'G'��,rt, . . . . . . . . . Lu. PLUMBING PECTOR Check # f �� (• WHITE: Applicant CANARY: Building Dept. PINK:Treasurer i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTHANDOVER,MASSACHUSETTS Date Building Location _ / 0J(a/ wners Name 0) 4/ 6 Permit Amount T e of Occupancy New ❑ Renovation Replacement Plans Submitted Yes No FIXTURES r d � Ey A (�Y) RASUVIM SLSI�VIC m iffam ZD Rfm Sly ROM 4M R= 5M ROM 6IH ROCR 7IH FIOCIt 8IH FI�OQ2 (Print or type) Check ;installing Company Name a ElCo Certificate `p' Address L E] Partner. ol Business Telephone — ta F�/Firm/Co. ja Name of.Licensed Plumber. � Insurance Coverage: Indicate the �eoiins urance coverage by checking the appropriate box: r Liability insurance policy Other type of indemnity Q Bond ❑ Insurance Waiver. I,the undersigned,have been made aware thatthe licensee of this application does not have any one ofthe above v three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massausetts State Plu g C Chapter 142 of the neral Laws. By: igna o icens umber Title Type of Plumbing License City/Townase um er Master /� Journeyman APPROVED(OFFICE USE ONLY /�' Date. . o'.".��':'4 TOWN OF NORTH ANDOVER . o PERMIT FOR PLUMBING ,SSACMUS� This certifies that . ., /. . �. �.l l. . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . .r. t. 1-+.:f s.`: . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. Lie. No.. C. SS. . . . . III PLUMBING INSPECTOR Check # 126 22 . 7320 Go, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �\ (Print or Type) l :� n?da V�` Mass. Date 3—/� 2.00] Permit —7-LL— Building "7T Building Locationa3 3 1A, S�; _ Owner's Name CSL Type of Occupancy -- .New ❑- Renovation ❑ Replacement 1p Plans Submitted: Yes ❑ No ❑ FIXTURES B..P. # SEWER #' SEPTIC # . 3ca,�o 1x.0a yS 00 � Qz � u� N J } U a Z W O Z a ¢ �a x ~ Z o 0 0 ¢ x W rn u~i x ¢ ~ ¢ W rn Y a Z z Z 3 Q n (n O D J 3 Y g m ° N ' = Q 0 Q J CO ¢ Q Q 0 Q F 61 Wx rn o o 3 x rn c� = o ¢ 3 x m 0 SUB-BSMT. BASEMENT 1ST FLOOR ) 2ND FLOOR 3RD FLOOR e 4TH FLOOR .5TH FLOOR rr 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name APOLLO PLG & HTG INC Check one: Certificate # Address 1SHATTUCK ST PO BOX 466 M Corporation 1097C _LAWRENCE, MA 01842-0966 ❑ Partnership Business Telephone 978-688-1755 ❑ Firm/Co. Name of Licensed Plumber DONALD DESRUISSEAUX INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes N No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy. KI Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. t, Check.' ne: t +' Signature of Owner or Owners Agent n Owner Agent. O I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installation performed under the permit issued for this application will be in compliance with all pertinent provisions o1 the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Title Signature of Licensed Plumber Type of License: Master X1 Journeyman F.) Cityrrown License Number 8699 APPROVED(OFFICE USE ONLY) BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHE$ PROGRESS INSPECTIONS FEE N0: APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING it PLUMBER PERMIT GRANTED DATE 1g PLUMBING INSPECTOR f!• Date. .j .1.` . . . ...... .. TIy OF NOR 'I,Y or �` TOWN OF NORTH ANDOVER ti D 41 PERMIT FOR GAS INSTALLATION . 9 ` SACMUSE�� This certifies that . . . . .. . . . .f. . . . .'�. . . . . . . . . . . . . . . . . . . has permission for gas installation . . . .0. ..`..i . . . . . . . . . . . . . . . . in the buildings of . .. f!C? h f.,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . 3 . . .1. �. ? <. . . . .'. . . . . . , North Andover, Mass. Fee.-2. . . . . . . . Lic. No.. . 1 dAS INSPECTOR Check# D 6 7 5932 MASSACHUSETTS UNIFORM( APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) , / QrQ ad , Mass. Date 3_1 Permit# 3 t Building Location 233 Nn-on S9' Owner's Name cafWL— J'`'�AfLIC�y Type of Occupancy Now ❑ Renovation n Replacement IQ Plans Submitted Yes ❑ No ❑ O�spO . 07 Y w W rn U Z tr Uj to X cn [C O � (n _ � W W W FO U Co � Z rn z o W ~ ¢ } z z 0 1- W 00 w t— w w O o w W ¢ o W W CO(n J Z Q = Or U � W O W H _ fr Z Q W -J Q W F- t- >_ rn O Z O Z W 0 t- W Q W > tr W ::) Z Q X Q m O O W W O W F- fr 2 0101 2 1 u. D 3 0 0 U cc > a a 1— O SUB-BSMT. BASEMENT A 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company. Name APOLLO PLG & HTG INC Check one: Certificate Address. 1SHATTUCK ST PO BOX 466 Corporation 1097 C LAWRENCE, MA 01842-0966 0 Partnership Business Telephone 978-688-1755 '0 Firm/Co. Name of Licensed Plumber or Gas Fitter_17a A&Q be-SkV/SSs�4U k INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes Qd No ❑ I If you have checked yes, please indicate the type of coverage by checking the appropriate box. f A liability insurance policy IXI Other type of indemnity O Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sA ent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best-of my knowledge and that.all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142.of the General Laws. _ _.._... General t BY Type of License I U Plumber Title ❑ Gasfittergriature of Licensed Plumber or Gas er i City/Town ❑ Master ! APPROVED OFFICE USE ONLY) ❑ Journeyman License Number 8699 O BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES NO. PROGRESS INSPECTIONS MERCURY TEST FEE FINAL INSPECTION APPLICATION FOR PERMIT TO DO GASFITTING NAME TYPE OF BUILDING LOCATION OF BUILDING PLUM-2ER OR GASFITTER LIC. N0. } PERMIT GRANTED DATE 19 i GAS INSPECTOR 87 6 S Date +0 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� This certifies that . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .,2 3 3 ./&#/<,. . . . . . . . . . . . 4. . . .. North Andover, Mass. U Fee.L/. c� .Lir. No.q.. .7. ?. . . . . . . : . . . PLUMBING INS CTOR Check # _ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING b City/Town: N. 0 tJ D U V f-2 MA. Date: 11-16-10 Permit# Building Location:a 3 I"�'1 ig Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:® Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES cast'co5?- DEDICATED 33 poo 6O z SYSTEMS ,//o of l�% Z '^ u O 0 me z 2.11 01 z cc Y 9 sa Z d Z Z i A z Z a W g d � o 12 c a z e o o W z Z u d , = 3 3 tJ g 0 3 z a 0 3 0.L6 0 "' O*11 o W Y a o o > > o = o a a a i3 a m o o x S 3 oc �n �n H 3 3 3 o a 3 ° SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR S FLOOR I FLOOR —in'—FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: APOL10 PING & ITPG INC PO BI?X 466 ®Corporation 30 'V6 L Address: 1 SEIl TTUC C ST aty/Town: LAWRIIJCE State: MA ❑Partnership Business Te978-688-1755 Fax: 978-683-5933 ❑Firm/Company Name of Licensed Plumber: Robert M. Demers Jr. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑Plumber Si at re of Licensed Plumber City/Town 0 Master `� APPROVED OFFICE USE ONLY) ❑Journeyman License Number: FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) v FEE: S PERMIT# APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER LICENSE NUMBER: PERMIT GRANTED❑ DATE: PLUMBING INSPECTIOR Location "> •3� �� IAJ S+ No. Date 'c,7-3 01 NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ � o►b�Vii.�`,• a AcMustBuilding/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ��9 Check # r r� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING o MMMM ,3 . M. BUII.DING PERMIT NUMBER: DATE ISSUED: 0 D / 00r yCT SIGNATURE: • Building Commissioner/I or of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: NumbdfParcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re 'red Provide Required Provided Re red Provided C 1.7 Water SupplyM.GL.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT n 2.1 Owner of Record Name(Print) Addres�ervice: Signature Telephone 9 G 2.2 Owner of Record: Name Print Address for Service: C 2 n Signature Tele one SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: �(y OL r (-,—A—, ,-� License Number Ad cess e-27 Z ! j'lam( 6 ig T. G� _ / _J Expiration Date am nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Regi tratio Number. Address 1 d Expation Da Si nature Tele hone SECTION 4-WORKERS COMPENSATION(NLG.L. C 152 § 25c(6) se b 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.......0 No.......0 SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: `� /� . /IV T/` &6 cJVO c56%co G �I� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction zio O d r p 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNE AGENT OR CONTRACTQR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize_ to act on My behalf,in all matters relative to work author6ed by thi uilding permit application: Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Printf 5 ature of Owner/A ent D I=11 11 IN NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVIBERS 1 ST 2ND 3RD SPAN DIlvMNSIONS OF SILLS DIMENSIONS OF POSTS DEV ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL.OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Z a The Commonwealth of Massachusetts Department of Industrial Accidents ' d Office of Investigations F Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: oQ Z r'e- Location cl-e l r a 0 L IT c/ c7 Clty Phone # 97 0 — 79 7 —)95 I am a homeowner performing all work myself. i Q I am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Y { Com an name: Address Phone#: + Ci : Insurance Co Policv# Com an .name: Address City Phone# Insurance Co Poliev# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties ora fine up to$1,500.00 and/or one years'imprisonmentaswell as.civil.penalties3nlheform-ofa_STOP_W_ORK_ORDER and.-afiine of J.$100.00)asiay.againstme. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. Ido hereby certify and r e pains and pen ies of , rjury that the information provided above is true and correct. DateIt I Signature Print name ✓ C� 7 Phone# 9 7 ! =�---- �i Official use only do not write in this area to be completed by city or town official' i+ City or Town Permit/Licensin Building Dept j ❑Check if immediate response is required E3 Licensing Board p Selectman's Office Contact person: Phone#: Health Department Other ,I Town of North Andover t%ORTH 4 �tteo 16 16 Building Department �°- L : 27 Charles Street _ North Andover Massachusetts 01845 ^^ (978)688-9545 Fax(978) 688-9542 � �oCI 01.Kk ��SSgcHus��y DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a. The debris will be disposed of in/at: Facility location gnatur o'f Appli- nt Da NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NORTfy own . of over No. -� " �` 414�oc„�� dover, Mass., 7,9 0 ATED P90\ C S H E BOARD OF HEALTH PERMIT T Food/Kitchen Septic System POA0,41 d 4' �� #0 / ��r /It BUILDING INSPECTOR THISCERTIFIES THAT..................................................... ............................... ........................... Foundation ..... ....................................... S� has permission to erect..V IN.41................. buildings on ...a3.3.... N............................................. Rough to be occupied as 1~ N .04 PIF 0 Chimney p ...S�.......... ..�...s ......P............................. ...... h..... .................................................. 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. M 31 P .3 Yg. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ................. ... ........... ... ...... Service 41000BUILDING INSPECTOR 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 Wali To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. B SEE REVERSE SIDE Smoke Det.