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Miscellaneous - 248 GREENE STREET 4/30/2018
IN NOD N 0 o m m M co m o oM 6--1 C) N O N � O co 0 Y N o L6 0 o N y 1L (0 L -2 W1 / � O ^U), W z `� O U q 7� ` N Z, Q E w � a) c .3 T y > � > pco a E p LL 0Z F— t0 O Q a > } cco L O W O-C LL (no U- U) E Z W Y LLJIL co 0 Y a� 0 0 0 F— c Q c`coo 'N 0 � Q W cu O Q z z W E O C O LLI E cu� + c m � Cn F- —_ z OLLJ co o - � � coa)c•�� 00 Z • v O_ z ^' T (A C •� Ncu 'fin � bq 1600 Osgood Street oqr�,e't`,y .. �SACHL45�� NoxtyAndover Tel: 97.8-688-9545 Fax: 979-688.9542 Sm B VSW�ESSAV FOR TO WN CLEW I�fIVl11C� Vt NMM: LW�C ` 5 : � rAa AAA � res: h-�o�K�� Co ensu l -h a ° t BUMDINGLAYODTPROVJDED: YES zoNmGBY.;mowu8ACTE: 0 o (N O ` C U L � D �� U U) N o LO w o N N W o U E Q Z 70Z 70I.L. N 7 o c > > p a E p LL 2) Z (o Q 0 0 M LL O W O o o U- Z LL W LLI co 2: 0. L 0 ( Y (1) i o L r O Q UJ 4-1 co co o cu U ~ Q Z O Z m �: E N �- O O w W N 70 U- :3 � C Cy ca Q - w "= Z W /Q Vi/ °- N raj a) O = LLJ d' co �I C �+ ;E E } L U C7 M L • a� Z /�� T • cn C L N U co 0 N ib Date..q g..k....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION t This certifies that.................... .............................................................................:. has permission for gas installation ... ...... VVj.A.�..A....P%.e in the buildings of ...2 �i Vvi� P?s.t� S �c;......................................................... .................... 48-�..:4................... North Andover, Mass. at ........................................... Fee .......'I'...-.... Lic. No.'�6 3 ......... �`z. ............................................................ ........ �-�,.� GAS INSPECTOR Check # � � �`l cJ�. t mv�f G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY E North Andover MA DATa = PERMIT # JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS I Same TEI IFAXI OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ APPLIANCES 1 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR f FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER A Reolace 1 Gas Meter III INSURANCE COVERAGE RESIDENTIAL❑ PLANS SUBMITTED: YES❑ NO❑ m0®iEc w I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicat4willbempliance with all Pe 'nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# I NATURE MP ❑ MGF ® JP ® JGF ❑ LPGI❑ CORPORATION Q# 3285CSHIP ❑# LLC # COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St WRAM CITY I Auburn STATE MA ZIP 01501 ]TEL FT8T832 3295 FAX 508-926-4347 CELL 508-832-4:6714:A EMAILJMarino@RHWhite.com w E• O z z 0 H U W Rv a d z w 0 a z z o N❑ d �- w � ~ w O a O Q W W a0 a C4 Q w w W N a U zz a a I-- cn U x J F a a Q v� S2 ui x w � w cn z 0 H U W A. cn z d x 0 x !, t •S' ..� :r.' .•i'21f1,7EtI¢IS''.I 7 ::;i + • '�:, �f. •: •.:i:;,• • i:: ^tar !:::k � '7�;:. IiI:. 1: If': t r{ ' Il..'r;'i• LL _ff•y'.7r: '%.I ' '%:i f�:y' i'�F'71 �:: • tl, r• J7r.; •(.�9p: rt •I .7 - t. '•';.. �:�r :p : .1 i.;S:(�, �•(({(} iF7.t t�F<' i.;; i�:iL''.�F : ' 7iF:f II'L{``:,ti '�;. t,: ',gip: � :;,:• ;y, ,;;, !•,:;. -,m:, ;�;; ; fVtT/�,) 1F ,�.r::; -,/f. 'r u', '::F �t::,�:r:•:: %ick': LLI LLW to tl1L�d Z• LN ,X . LR Win W • '•.0�� • "stn+:��-r- `-''.''; ?;i�'`.i:; � :a m`,. , "ic :`F� `���lt'�1 �' - �-�,�a•: . � I�_ f.��lti�- ��71 r .,®�,',i illtit:,�i(i,i';li•,',,4,�. .'1.L��•i 4��;j.,:.lt�;: `"'. ;ifi. •;b`y`i°:i(+ ;�+ :!r�'ii:7 I �t?!�i�ii! `: `,,.F, .i : :it .'Ft:::•rt: r;?.'^.•;r' ��i':�.1.. .'.rr.- :. e15� 1'.-f • xi, 'f i k '�:f::iii.',:5'?:F'•:.,.i��±.....:(.1:'i,,ii:':'t:;:r,.::1F��'J':f::':.-1•:l<':f's'. T \ 1 ACORID CERTIFICATE OF LIABILITY INSURANCE Page 1 oP z DATE 812912013 __E__ THIS CERTIFICATE IS ISSUED ASA 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 13ETWEEN 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 SUDROGATION 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 rig hts to the certificate holder in lieu of such endorsement(s). Willia Of Massachueetts, Inc. C/o 26 coAtvey Blvd, P. 0. Box 305191 NnAI1ville, TN 37230-5191 R. 13, White Construction Company, rno, 41 C—tral Street P. 0. Box 257 AuhUrl%, MA 01501 Ww}= vvyrr%M r NAIOtt INSURERA:The ChAxtOr Oak rico Snsurancg Company 25615-001 INSURER B:TraVOZgr2 Property Casualty Cezgpany of Am 25674-003 INSURER C:Nati=A:l Union Firs Insuranca Company o£ 19445-001 INSURERD; Travelers Ind&mnity Company 25650 -Dol INSURER F; V■L.R,1VG�1 t;L;K1IFICATI= NUMBER:20287680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I$SUGD TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. e - TYPEOPINSURANCE uU �Ur� POLICYNUMBER 70LICYEFF POLICY EXP A 9/l/2013 GENERALLIANLITY VTC2OCO 9771(9948-13 9/1/2014 LIMITS EACHOCCURRENCE E_ 2,000,Qp( X COMMFRCIALGENERAL LIABILITY ppqM TORENTEO PRE3(Eaoce�roncrl CLAIMS-MADET OCCUR .$ _ 3OA, QQ( MED EXP (Any one &teen R 1 p� 0 0 ( PERSONAL&ADV INJURY S GEN'LAGGREGATFLIMfTAPPLIESPER; GENERAL AGGREGATE 9 4�QQQ,00C PRODUCTS-COMP/OPAGG $ �QOO,OQO POLICY PRO LOC OMI3INEDSINGLELIMIT Z AUTOMOBILE LIABILITY VT.7C,ILE 977K955,A-13 9/1/2013 9/7./2014 X ANYAUTO accllaenc S 21000,000 BODILY INJURY(Perperson) S ALI.OWNED SCHEDULED ALITO8 AUTOS X HIREDAUT03 X NON -OWNED BODILY INJURY(Peraceldem) arsccldent A ^� AUTX Co Ded X C91l$ped S EACH OCCURRENCE � 000, 000 C UMBRELLA LIAR OCCUR BE8766140 9/1/2013 9/7./2014 l:XCEsa u a CLAIMS -MADE AOOREGATE $t 000, 000 DED x RETENTIONS jD,000 D WORKERAND AND EMPLDYER8' LIABfLITY YERS'LABILIT VTRit17B 8205A185-13 9/7./207,3 9/1/20j,4 � X U $ D y N ANY PROPRIETORIPARTNFR/FXECUTIVEr,; j OFFICERAIEMBFREXCLUDED? I� N(A VTC2RUB 9203.A71A-13 9/3,/2D13 9/1/2014 T.Of�Y W E.L.FACHACCIDENT F 1,000,000 NH)and UI((MendatsI ib Kellg I IUN Uh OPURATIONS Bola* E.L.DISEASE- EAEMPI:pYF.E S 1, 000, 000 .. El, DISEASE. POLICY LIMIT $ 1,000,000 xvidence of inmuzance Remark& 3chedula, If more epee& SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZI10 REPRESENTATIVE Coll, -4197604 Tp1:1694012 Cert:20287680 ©1988-2010ACORD CORPORATION. All rights reserved, CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD M Date.�00 . .......... �ao ,eaO TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ���?.�......�..+: !...'.`..................... has permission for gas installation ... �......................... . in the buildings of . 2 /.(, )? P- -. , ..... . ......... . at ..,�. �(, . � ." ... h ............ . . North Andover, Mass. Fee.. 6 . Lic. No..?� ::. ,G : , ....... . /GAS INSPECTOW Check # (( f \ 7141 MASSACHUSETTS UPQ F+iORM APPLICATON FOR PERMIT TO DO GAS FfM NG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations Permit # _ _aff '71 y Amount $ U Owner's Name z e F` 2�N 77, 7 New ❑ Renovation Replacement ® Plans Submitted ❑ or type) SS r ����� �`�, Check one: Certificate Installing Company Name- p (, � Corp. Address aOD Partner. usiness Telephone 7q 6 ,P !S l% )- ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 10 No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 10 Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 ...,...may 'l.y uiaL all „l tum ucuuib auu u„Uiinau(jn i nave suomineu dor entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 13( - Gas Fitter License Number — 0 Master MJoumeyman CIO rf) a o x w w a O v o H Gvl rL o ;Q U W x z QF" z z O F W F C7 F z [� d "" W fX w W W U x a ot � d � �° z o z o x � o x � .tea ° a° > SUB-BASEM ENT B A S E M ENT 1ST. F L 0 O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - 8.TH. FLOOR or type) SS r ����� �`�, Check one: Certificate Installing Company Name- p (, � Corp. Address aOD Partner. usiness Telephone 7q 6 ,P !S l% )- ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 10 No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 10 Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 ...,...may 'l.y uiaL all „l tum ucuuib auu u„Uiinau(jn i nave suomineu dor entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 13( - Gas Fitter License Number — 0 Master MJoumeyman The Commonwealth of Massachusetts Department of fszdustrial Accidents Office of Lnvestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DD1iCant Tnfnrmaf;nn Name (Business/Organization/Individual): Address: City/State/Zip: jn Ta , d MA n g� y Phone #: q n R Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. Nj I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t * " nt, 2+m1;r f tier L___ _ workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. © Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -- -- - .. zU. vut LUC SCcuon neioF: StlotJtng t.^eir wOr�:e:E ^ W,^e::Sa�ou pol2cy focWBu'Jn. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their worker;' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: �� ��-Pt's S City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unger the painnd penalties of perjury that the information provided above is true and correct 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 q - w 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 bee returned to the c. - y 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 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 of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 east 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.rnass..gov/dia A I I I 4 i 1 1 l p v M p 3 p ti fA -( __. 10 a w a o v�oo=-os AO w W 0 0 �' fD crt fD Q' 3 C N 3 t tCD ry B O O < m� f fro ,� rat N LO 3 co l f N aq v s lA'S = 4 .+ S a( mO + O n O .. D ' ro roc g < (/I N (D O Gt i f7 0 a N p 7 N 7 V i 7 4! K N < u t O CL t fT P r) ^ t rD i rr t f a z c/) c/) —n y Z.3 .�'w � O n _ o - CDo m: F�Q z D D O 0 z: 3 3 c rn Cn C/) �' Q A W N O C O m. D A K .0:p: cD m m :0 J ; : :O fk.P: < o 0 ` m CO) CD CD ® N �■ S l D n' N m: D ( :O O:O W U2 C C 'O O'O ) nP :A O: C/)' Z,w CD W " L m : M LTi o: a39 N: .o. CDO --ono ;o ; 3.° o .�'x 3:� �.^ Z.3 .�'w 's: o •a .Av'o'n: n _ m: F�Q ;3 m»:»:3,:3 a; 0 z: 3 3 c x' _:n ?: O O O O m t A W N O C O m. 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Ny �O� E ANN r) n• Date—s r -n . Ar. . . 4� .... 0 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING A This certifies that ..... 4--4gw .... 445.sa-6 ................................. has permission to perform ......... W/.,. I i wiring in the building of ... .-,T ..... Z aor".1. lglea &e-f4g ........................ at .... tF . ..........5.........7- .................... . North Andover, Mass. Fee.. Of ..... Lic. No 7 ................ . lw4- ELECTRICAL INSP$CMR Check# �qio(a7-- �"•�_ 7hECOADfO1bRE4LTHOF,,PL4 S crosE77S -- -- --- utfic� Use only Ir _ DER1RTY&NT0FPUBLICS4fTn Permit No. � BOARDOFFIREPREYMONMGI ZATIONS527C;tfR]2.'W Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORMELECRICAL WORK ALL WGRKTOBE PERFORMED IN ACCORDANCE WITH THE MASSAC LISSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ILLL L'VFORMATION) Date Town of North Andover To the Inspector of Wire! The undersigned applies for a permit to perform the electrical work described below. Location (Street &?Number) Owner or Tenant TAICC r AA AD.G -!f. , Owner's Address _ .Sit./`%. /SFS A -?, it, 0L Is this permit in conjunction with a building permit: Yeso No (Check Appropriate Box) Purpose of Building (J Utility Authorization No. _ Existing Service /0 b� Amp volts Overhead Q Underground a No. of Meters New Service Amps / Volts Overhead Underground Q No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. ofTransfonners No. of Lighting Fixtures Swimming Pool Above BelowGenerators and round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Ban No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS Tons No. of Disposals No. of Heat Total Total No, of Delection and No. of Dishwashers Pumps Space Area Heating Ton: KW Initiating Devices KW No. of Sounding Devices No. of Self Contacted No. of Dryers Heating Devices KW Detection/Sounding Devices Local Municipal No. of Water Hasten KW No. of No. of Connections Signs Bailasis No. Hydro Massage Tubs I No. of Motors Total HP OTHER Total KVA KVA Units No. of Zones , Q Other brnsarreCae� PI>tsiatidthetagliana�af114�t�C>etaaliaws [ha�eaaitaiLiabtldyharanePblrymdtdmgCrn�pleleCae'�eQisstfi�alitialtY}d�alat yFs aNp Ihavesubm9advdlidpratafsanvotheoffim YES NO ® If}wha%etfnclodYES,pleasenk*thetAxcfwmmybydedargile INSURANCE a BOND a alliER a ftmSpm&y) WcFkIDSM-JLL_ Inspmlion D* Rqueslad FIIOO NAME May I iot3tsee /n /?- Estnr ValwatEechicdl Wade S Rao Frml Lfo=NQ awK7/7t70"7-- Bt TdNa ?9 3%3 Mol !— AltTelNa`''i t O�ANER'S INSLRANCtIVAJIVER,IanawalethattheLicensedoesrahtati+eiheirz�aa>ceoae eorist It easreccebyM Casal Lam und9 tmysig traemftaspt�n>RRapp6mtionthistagtm� (Please the e OyLser gent Telephone No. &�,,PERMIT FEE o p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION J This certifies that c ....... has permission for gas installation .... in the buildings of .717. . ..... . ...... . at ..�.:'. !... �. !!'.: �..... f ......... North Andover, Mass. Fee. Lic. No. a .31 ..'... ..... U .. ........ . GAS INSPECTOR Check # ' 4122 MASSACHUSETTS UNHURM APPLICATON FOR PERMrr TO DO GAS FIrDNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date— Y. d Building Locations Y Y C12,e rn/ Permit # ! { L L Amount $ �( b Owner's Name J New ❑ Renovation ❑ Replacement [0 Plans Submitted ❑ (Print or type) jVM ri Al _� J Address fy r D 4-W i. -t Al 14 It � �O q Y Business Telephone 1 Name of Licensed Plumber or Gas Fitter S,4 f t/A4e e T 1 Qc& one: Cettificate Installing Company U Corp. ❑ Partner. NJ Firm/Co. . INSURANCE COVERAGE Check e• I have a current liability Insurance policy or it's substantial equivalent.Yes No If you have checlwd mss, please indicate the type coverage by checking the appropriate box. Liability insurance policy El Other type of indemnity ❑ Band 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 ofOwner or Owner's Check ori Owner I hereby certify that all ofthe details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions ofthe MassachusettshStatee,Gas Code and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber 6! ❑ Gas Fitter Icense um er Master ❑ Journeyman PER3CST NO.. aV 1 T APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. Z- LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK ;PAGE ZONE SUB DIV. LOT N46. — LOCATION IA?PURPOSE OF BUILDING OWNER'S NAME '-''�[r� 'i { � Pu (( kf NO. OF STORIES SIZE OWNER'S ADDRESS �L11..�rq $? ���L �[ BASEMENT OR SLAB ARCHITECT'S NAME _ SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME i 71i (W A fM y SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION V IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS i - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNA'FURE OF OWNER OR AUTHORIZED AGENT FEE PERMIT GRANTED 1-3 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. 'FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. # w CONTR. TEL. # CONTR. LIC. # H.I.C. # BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S OkIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE HARDW PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/2 % FIN. ATTIC AREA N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES B _ 1 22 f 3 I_ _ _ CONCRETE EARTH HARDIN'D COMMCN ASPH. TILE ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. 3 FLOOR CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD A TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. d COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ lit 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. ., 4v. a TOWN of NORTH ANDOVER AFFIDAVIT ••O- JVCDe3mt Cal=trr E o• r - • - • r.• � s• • •• - •ter./. •• a•ra� •• ar/ n••o•u rl • •• sw-/ • / r• Irt / .t • • ! ••° Or. • • - /r n •► • s• f• •t• - t r .� - .• .r3 1 •• ra •- .- s • t`u •- •• - • �r = =• u•nr_ ••w f Wra r_/ • •s•s • • f • •• a Type of Work: W (/-J D0 L3 R 6�0 L,4c e__M CN r Address of Work owner Name: Est. Cost Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Far of ce tree only Work excluded by law mat No. Job under $1,000 Date Building not owner -occupied° Gwner pulling owe permit Other.(specify ) Notice is hereby riven that: CWT ERS-Pi3ILI24G USER CWN PERMIT OR DEM-ING W= UNREGISMRID CNIRA=RS_ FUR APPLICABLE ELL1'1E IMPROVEMEZU WORK DO NOT HAVE A SS. TO ' HE ARBITRA- TION PROGRAM OR GUARAN1Y FUND DMER _ISL c. 142A. Sim u-6pa—.lties of perjury: I hereby apply.for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date s � r E o• r - • - • r.• � s• • •• - •ter./. •• a•ra� •• ar/ n••o•u rl • •• sw-/ • / r• Irt / .t • • ! ••° Or. • • - /r n •► • s• f• •t• - t r .� - .• .r3 1 •• ra •- .- s • t`u •- •• - • �r = =• u•nr_ ••w f Wra r_/ • •s•s • • f • •• a Type of Work: W (/-J D0 L3 R 6�0 L,4c e__M CN r Address of Work owner Name: Est. Cost Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Far of ce tree only Work excluded by law mat No. Job under $1,000 Date Building not owner -occupied° Gwner pulling owe permit Other.(specify ) Notice is hereby riven that: CWT ERS-Pi3ILI24G USER CWN PERMIT OR DEM-ING W= UNREGISMRID CNIRA=RS_ FUR APPLICABLE ELL1'1E IMPROVEMEZU WORK DO NOT HAVE A SS. TO ' HE ARBITRA- TION PROGRAM OR GUARAN1Y FUND DMER _ISL c. 142A. Sim u-6pa—.lties of perjury: I hereby apply.for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date P-4 CD O E O i � O v Z O. O CO) G C CD cn I O._ CO) o-0 ._ h OCD CD O a ~� CD O� �3 .0 O O O O O a �Q CO) c o Cc� 0 zCD V CLy � C c— '- c COD c o o C O N ' w C O H w 0 V 'nom -j w W ac x a m c c �q V 03r Q o� � � � •� v x � a°G w U a°' w c7 � pG w � co ° z v) f� .� OE cn P-4 CD O E O i � O v Z O. O CO) G C CD cn I O._ CO) o-0 ._ h OCD CD O a ~� CD O� �3 .0 O O O O O a �Q CO) c o Cc� 0 zCD V CLy � C c— '- c COD c o o C O N ' w C O 0 V 'nom ac m c c �q V 03r ► co E ¢ 3 �_ amo is 0 C N 43. E S 0 m c� 49 E y CM O r E.8 .gym a=te mom m cNz � O O L O Q C_ NC O C �C i o� N 0 :a 0 CD tU o CD r _ .� LL. y"' O 1=O N .E CL= r... m C •N Z O W ID C3U m"t _h O. O� O� CO2 CD =ZIN a.c� P-4 CD O E O i � O v Z O. O CO) G C CD cn I O._ CO) o-0 ._ h OCD CD O a ~� CD O� �3 .0 O O O O O a �Q CO) c o Cc� 0 zCD V CLy � C c— '- c COD NORTH FO 9 ,SSACHUS� Date. . 7...` -"- . `. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...57,%�.� has permission to perform .... J ................ plumbing in the buildings of ............. at ........'...... '.' ........ '.............. . North Andover, Mass. Fee. !.•.. '... Lic. No..? ....'... ......:...........arc° ....... . PLUMBING INSPECTOR Check # 5359 S-5 -)-S MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 2 N ti ,e R �S Date �l — °�— U .• Building Location k -e tp/ �' Owners Name ,J i�2�., Permit # Amount Type of Occupancy New Renovation Replacement © Plans Submitted Yes No ❑ FIXTURES (Print or type)/ Check one: Certificate Installing Company Name s j A I CL,- ie 4 U L (.1/!'I 61 A- 24 ❑ Corp. Address �`y Go Y r [)O 6 !h r.l gvef / � Partner. Business felephone 77,f R 31 Lij Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy © Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 0 Agent ri 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 Massachuse State P g Co�1e and Chapter 142 of the General Laws. By SignMre or Licensea rlumner Type of Plumbing License Title �'iG 3 � City/Town icense NumDer Master ❑ Journeyman 13 APPROVED (OFFICE USE ONLY Location . S7 No. Date TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permiee $ ACHU i Other Permit Fee $ 321,0 Sewer Connection Fee $ Water Connection Fee $fN TOTAL $ % Building Inspector P/22/�y3 32.50 PAID 35 33 Div. Public Works PERMIT NO. � APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP K40. I LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. FI I LOCATION ) PURPOSE OF BUILDING /1 /J OWNER'S NAME folp 14 orzeeallelifi& '_ NO. OF STORIES SIZE OWNER'S ADDRESS ARCHITECT'S NAME BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DIMENSIONS OF SILLS DISTANCE TO NEAREST BUILDIW DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED `� z 'J PERMIT GRANTED W 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST /] � V 0 V EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING OWNER TEL. # CONTR. TEL. # l J CONTR. LIC.# H.I.C. /J 3 35-(� BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY APARTMENTS _OFFICES _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH B 1 2 13 PINE CONCRETE CONCRETE BL K. BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL IN. B'M'TAREA _ '/ 1/1 1/ FIN. ATTIC AREA N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 �_ 3 _ DROP SIDING WOOD SHINGLES CONCRETE EARTH HARDIVD COMMCN ASPH. TILE ASPHALT SIDING ASBESTOS SIDING _ VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBRELMANSARD I I d I HIP BATH )3 FIX.) TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ter 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. .01 [j P" w w a z d O u o w° a cn Epi G z A Q o L w° °�° 004U m w p rCn 2 z co °a° co w O t a W c�° > cn m w a p U a�' ii z w a a iz z av, o cn • c� 0 m c gyp; c C-2 L N O C �. O V C.i C• C R R 00 C �a c 0 :.... «� a y Y O o m A t C. M.. L CO y a m y o m O N y CD mo c o CA O ' C2 cm c � m o � 4f CD r c o c a os 3 N O 4CD3ma O LU FE COD �� = oy0 � CD O C. -0- Ca w a, C/) W ►-a 0 I J Z LL Z O Q W U) z O U hi, F- m w J Q z cr- W Q LU W cn OFFICES OF:r Town of APPEALSi.. „ r NORTH ANDOVER BUILDING CONSERVATION oDIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR 12o Main Street North Andover. Massachusetts O ► 845 In accordance with the provisions of ;LICT.. c j0. S 5.4, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly solid waste disposal facility as defined by MGL. c 111, S 150A.. The debris will be disposed of in: (Location of Facility) Sienatu o Permit Ap cant Date :TOTE: Demolition permit from the Town of :forth Andover must be obtained for this project through the Office of the Building Inspector. J The Commonwealth of Massachusetts Department of Industirial Accidents iO ov811firafflaffm 600 Washington Street Boston, Mass 02111 Workers' Compensation Insurance Affidavit location: S, 5 P LEA SA 91 citV 0 \1/�NADVV�D , OA I i. \ 68P,4�� ❑ I am a h&neowner performing all work myself. ` F1 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. C] I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: comoanv name. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,$00.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. Ido hereby c under the pains and penalties of ury that the information provided above is true and correct _ ►3gnatur Date a0 Print name //'G�l� ��� / ��/tl �l7 "��/�, Phone # _ff! t —6173-7 official use only do not write in this area to be completed by city or town official city or t] check if immediate response is required contact person: permit/license # riBuilding Department pLicensing Board [Selectmen's Office 0Health Department phone #; rlOther (revised 3/95 PJA) .. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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. `i.'" "- v � s"3 . mW.,, t. '". t?i*" t �' ^/ Y � p+ ry � _ ,✓i �,Q r P � r,.' .,*�., e_,,, _ar, . i,.: ....'z? _ �/. a„l,<i, iF%,r. . 5.�3'_� cvs,�'�,_.x,. .µms ,_ x a n � /�'•✓ n f � Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 of investigations 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 7274900 est. 406, 409 or 375 Date...... ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ......f ...... .................. . has permission for gas installation in the buildings of �...:. :.....`................ at ....... ',........... %_:.I ......... ....., North Andover, Mass. Fee... ..... Lic. No— /. ....................... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: FII MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date 4uilding Location h Permit # .� Owners Name Z jV q mo) by py,� ,7/KL K • New Renovation Replacement Plans Submitted D FIXTURES (Print or Type) Check one: Certificate Installing Company Name Corp. Address in y Wl./g ny.� /p eb Partner. /jlidW e az M1'g Firm/Co. Business Telephone:_77�/-/% Name of Licensed Plumber or Gas Fitter r3),4 Ili 76 P,4 13 J ,VE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity F-1 Bond F1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent M I hereby certify that all of the details and information f have submitted (or entered) in above application are true and accurate to the best of my knowledge and that a!l plumbing work and Installations performed under Permit iueed for this application wilf_be in complianco with all pertinent provisions of tho Massachusetts State Cas Code and Qupter 142 of tho Genual laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber Gasfitter- Signature of Licensed Master Plumber or Gasfitter JourneymanlA'?0 License Number V • rrrrrrrrrrrrrrrrrrrrrrrrr■ rrrrrrrronrrrrrrrrrrrrrr■ .. _ arrrrrrrrrrrrrrrrrrrrrtrr■ . ... rrrrrrrrrrrrrrrnrrrrrrrrr .. ... nrnrrrrrrrrrrrrrrrnrrrr .. - ■rrrrrrrrrrrrrrrrrrrrrrrrr� ... ■rrrrrrrrrrrrrrrrnrrrrrr■ . ... rrrrrrrrrrrrrrrrrrrrrrrrrr .. - ■rrrrrrrrrrrrrrrrrrrrrrrrr : ... rrrrrrrrrrrrrrrrrrrrrrrrrr. (Print or Type) Check one: Certificate Installing Company Name Corp. Address in y Wl./g ny.� /p eb Partner. /jlidW e az M1'g Firm/Co. Business Telephone:_77�/-/% Name of Licensed Plumber or Gas Fitter r3),4 Ili 76 P,4 13 J ,VE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity F-1 Bond F1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent M I hereby certify that all of the details and information f have submitted (or entered) in above application are true and accurate to the best of my knowledge and that a!l plumbing work and Installations performed under Permit iueed for this application wilf_be in complianco with all pertinent provisions of tho Massachusetts State Cas Code and Qupter 142 of tho Genual laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber Gasfitter- Signature of Licensed Master Plumber or Gasfitter JourneymanlA'?0 License Number Location ca?Vg No. Date`�� Check # 0/ i 557 Building Inspector I NaRT„ TOWN OF NORTH ANDOVER 9 ► ; ; Certificate of Occupancy $ �+s3 CHUSE<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ `I n TOTAL $ Check # 0/ i 557 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING s Section for Official Use Onlyfk17"�'E, WELDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date 7- 1. 1 Property Address: 1.2 Assessors Map and Parcel Number: V9 Map Number Parcel Number 1 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sl) Frontage (ft) 1.6 WELDING SETBACKS (ft) Front Yard Side Yard Rear Yard Regutired Provide Required Provided Recluimd Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 zone — Outside Flood Zone 0 Municipal On Site Disposal System 0 2.1 Owner of Record 2nown ,-R,C)k&�; Name (Print) Address for Service: Signature Telephone 2.2 Au rued Agent / g<<<-7 I i Name P Address or Service: 97 . �L— "I - S3-7- ,96ature Telephone MEMO 11" 4 fa 10 1006- R 3.1 Licensed CoTtion Supervisor Not Applicable 0 AV, AA, C)5,), Z3 Address V License Number A — C? / 3-- �003 Licensed nstruc:on S �sor. Expiration Date 'fignaturc Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Ov, rl n wl (�,t V MW 14 y 7 (- -�' Company Name'. Registration Number 60-} W. &,Od/ /Ave* AL/4114 lq,&32- Address �1 — Expiration Date gnature Telephone 0 M X -4 X z 0 z M 90 0 ,n M G) SECTION a '4P4 C.0 ti' NSATi[�N 1 + Workers Compensation Insurance affidavit must be completed and submitted with this application. issuance of the building permit. Failure to provide this affidavit will result in the denial of the Signed affidavit Attached Yea ....... El No....... ❑ SECTibN 5-PROCES 1�tRBt Si CONSTRUCnPN C!i)�1TRtiL P ANTI` T C3 G CR 1I16 {C+dN Thi IYIQI E i ► 7Jr SsQ C F 3F Tl' ASl 1 S#'A1"i�) 5.1 Registered Architect: Name: Address Signature Telephone S:2 Regisie�ed:l'rnfe>ssie�8� �l�b Area of Responsibility Registration Number Expiration Date Name: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone i Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Company Name: Not Applicable 0 Responsible in Charge of Construction New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: .Q . A-2 A-5 ❑ A-3 ❑ ❑ Independent Structural En&eering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly 0 A-1 ❑ A-4 ❑ A-2 A-5 ❑ A-3 ❑ ❑ lA IB ❑ ❑ B Business ❑ 2A 2B 2C 0 0 0 C Educational ❑ F Factory ❑ F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional ❑ I-1 0 I-2 0 I-3 0 M Mercantile ❑ 4 0 R residential ❑ R-1 0 R-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ S-1 0 S-2 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION ]IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: --- Proposed Use Group: Proposed Hazard Index 780 CMR 34: Independent Structural En&eering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date I,(Idtq ,as Owne thoriz declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name � 4 ture of Owner/Agent Date Item Estimated Cost (Dollars) to be`t F Completed by applicant r permit �,r �a � 1. Building (a) Building Permit Fee 7S 0 V Multiplier 2 Electrical (b) Estimated Total Cost of Construction from (6) 3 Plumbing Building Permit fee (a) X (b)� �f / 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number �a t �Y � �i� . .✓ S k' / 3' :fi t r t (. 5: K � r x a :.tq �.� � a �r� a� .a trod `���'n§ �✓us � tx2� �t 9'�` �. nsk�; d.�,���'r:�',ki �r �k. �e�-! Hso� t � r��,�,'� ..f-ilri��'i Itil"' � � � `...,� � .: �.h.r�. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 Sr 2 ND 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ,.;. t. . oSlva."'k mom .1. `4 FORM U - LOT RELEASE FORM Y-13-0 "2- INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT i P LOCATION: Assessor's Map Number a SUBDIVISION STREET G `e Qc,% e_ PHONE PARCEL LOT (S) ST. NUMBER r_>2q Q *****************************************OFFICIAL USE ONLY*********************************** MMENDATIONS OF TOWN AGENTS: CONSERVATION TOR DATE APPROVED DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm DATE 3=cill 1 2v . R r 3=cill 1 2v D O b m z 0 W M i ON m m O CD 0 'S s Z O d O y � C CD o, CA ca CL) o� •g m m L- 1= t y..� ,CL CD O.a r_ Eft CD CD 0 � d �a c ev O C Z CD 0 CL C) vs c C — C C cc a y D LLI U) Ld U) Cc W W U) cza mcboo', a r ✓'; O� X cvv 'ate lotee.: = o x [� w A r +. a a Ea x G w o w E ir. W W o a: G w iY z o w G w W A cA b cn E cn z 0 W M i ON m m O CD 0 'S s Z O d O y � C CD o, CA ca CL) o� •g m m L- 1= t y..� ,CL CD O.a r_ Eft CD CD 0 � d �a c ev O C Z CD 0 CL C) vs c C — C C cc a y D LLI U) Ld U) Cc W W U) mcboo', cr r ✓'; O� X cvv 'ate lotee.: = o r +. O Ea o C y� Amo CL E� ./� o o O cm fizi r9!C 1 y H O �: 0 3 = C=M m Co = C C N �E m . mo a�L m �ymm CZ = o CM _ w � cco_ V ¢�_ O V N =CM J: l0 O C N •d= C F— um M Z E c .y o m 5 d 'O O CIO O 0-aIE.Con > z 0 W M i ON m m O CD 0 'S s Z O d O y � C CD o, CA ca CL) o� •g m m L- 1= t y..� ,CL CD O.a r_ Eft CD CD 0 � d �a c ev O C Z CD 0 CL C) vs c C — C C cc a y D LLI U) Ld U) Cc W W U) The Commonwealth of Massachusetts ('0. 4L" am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity =I am an employer providing workers' compensation for my employees working on this job. Cpmpan&� v name: h f\ Address sz+ Au�%, Commarty name: Address city:. Phone * Failure to Secure coverage as required under Sem 25A or MGL t52 can lead to the boosition d aiminai penalbes.d a fine up to $1; 500.00 and/or one years' Irnprisoment as wen as ciW penalties in the form of a STOP WOAK Obit and afire d (SIOD-OD) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification: UW the #)f&maffw p mkd above is bue anti carrect Official use only do not write in this area to be completed by city or town official' OCheak limmediate response is requied Building Dept Contact person._ RIM WORKMAN'S COMPENSATIOM !'Yate_ ,. 1 2- Phone # 1 J%.x.5"7 :0 Cl Building Dept p Licensing Board El Selectman's Office 0 Health Department D Offer North Andover Building Department Tel: 978-s$8_g..4 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shalt be disposed of in a properly licensed solid, waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: �xelx, (Location of Facility) Signature of Permit Appli�nt i Date NOTE: Demolition permit from tlae Town of North Andover must be obtained for this project through the Office of the Building Inspector a iiY 1. U4 ='y GREEN I CERTIFY THAT THIS PLAN WAS MADE FROM AN INSTRUMENT SURVEY ON THE GROUND AND THE STRUCTURES ARE LOCATED AS SHOWN HEREON. REFERENCES DEED BOOK 4173 PAGE 343 PLAN # 507 PLAN # 5211 ESSEX CO. LAYOUT OF GREEN STREET �oN OF M4814 oho GEORGE yGm C COLLINS No. 41784 l A��FFSStONP� 9�o suRVE�°�� 0=e - STREET CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MA. OWNER: JEFFREYAND MARIE ZNAA1113ROWSKI 248 GREEN STREET NORT M ANDOVER, MA. SCALE: 1 INCH =20 FEET DATE: MAY 8, 2002 JOB # 02-0456 BOSTON SURVEY, INC. UNIT C-4 SHIPWAYS PLACE CHARLESTOWN,MA 02129 (617)242.1313 NORTH O D Date. � .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING S/1CMU5 This certifies that /%...41.t�...`.�.... f has permission to perform ................i� . r...`..................................................... wiring in the building of ....2�!G l,1? irw �- ................... v .................................................. at .... ........ North Andover, CIO �!�.�� ... lel.- r ......... K. Fee .,,,t ...0 ........... Lic. No. f�/� LECTRICAL INSPECi'OR 4 Check # `� 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS . The Commonwealth of Massachusetts Dcportmcnt of Public Safcry$ 804RO OF FIRE PREVENTION REGULATIONS $27 CMR 12:90 3/90 $$,.ti ►�..s$ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All meek M be Krlwoned im accerdaace Milk $he Ma,aachusau Elrarkal Cade. Sty MR 12:00 (PLEASE PRINT IN X K OR TIP ALL INFORMATION) Date 2 4 3 0,:—' City or Town Of KokAA- Ar)t>o_ To the Inspector of Wires: The undersigned applies far a permit to perform the electrical work described below. location (Street i 0 -Mr or 0w►er's Addres Is this permit AS eonJunctton With a building psrmlc$ T481K No ❑ (Check Appropriate box) Purpose of building UtilLty Authorisation $0. EalaeLng Service Amps / Volta Overhead ❑ Undgrd ❑ N. ie Meter& New Service flops / Volts Overhead ❑ Undgrd [D No. o: Meters Nuober of Fssdera and Aopacity Location and Nature of Proposed Electrical Work SMA No. of Lighting Outlets No. of Not Tubs No. of Iransforsers IoW l KYA Ifo, of Lighting Fixtures Swimming Pool Above n• rnd. ❑ tend . ❑ Generators KVA No. of Receptacle Outlets Me. of Oil burners No• of tmergeney Lighting Untte No. of Switch Outlets No. of Cas burners .Battery FIRE AL.ARIIS No. of Zone& No. of Detection and lnitiscing Devices Ne. of Sounding Devices no. of Set(ctiSContain Devices _ Local ❑ Concti.a ❑Other Connectlnn No. of Ranges Ib. of Air Cond, Iota) tuna No. of Dlspoaala No. of Neat Total Iotal Pumps No. of Dishwashers Space/Arse Heating KW No. of DryersG Nesting Devices KW No. of Water Heaters KW no, at signpsallasu u w Voltage No. Hydro fLassage Tubs No. of hotors Total IIP V 11Y:,1j 1 INSURARCE COVERAGE$ Pursuant to the requirements of Massachusetts General Law& 1 have a current,Llablllt lnsufancs Policy including Completed Operations Coverage o Ltr substantlat equivalent. YESI(� HOU I have submitted valid proof of same to this office. YES NO (] if you have chec TEST pita&• indicate the type of coverage by chocking the approp$'iaie tax. INSURANCE BOND ❑ OWER ❑ (Plsaso Specify) Estimated Value of Electrical Work j'-'V('rt60' 60 xZ�r+tlnn ate Work to Start A s1A �> Inspection Date Requested$ Rough Final Slsned undo he penalties of perjury$ FIRM NAtE $ �• e 6t,�,a resp g LIC. N0. 11 K 3`Z) Q-1 License• �iM�i Slgnoturs LIC. NO. Address M 95 gess. Iet. Mo. -Alt OWNER'S INSURANCE WAIVER$ I as awn that the Licenses does not have the. Insurance coverage or is sub* stanList equivalent as required by flassachusects Central w , an that my Sit -Lure an this permit application wives this fequlfement. Owner Agent (Please check Dim) _/f Telephone No. PERMIT 1`11 f V Signature o Owner of Agent REGULATORY AUTHORITY 527 CMR 12.00: M.C.L. c. 22,s. 14; c. 149, s. 9L; c. 148, s. 10. 9/90/90 (Effective 7/15/90) 114.5 EMERGENCY Date ... :?-. d ! 1�, , . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...:'.....A...�.�..-c.�1?> ......... i...... . has permission for gas installation .-!� "a..'� .... .......... . in the buildin s of�..� .................................. at ..�... . ................ . North Andover, Mass, Fee:,:-."'. Lic. No........... .......................... GASINSPECTOR Check # 3 *, E.j1.3 MASSACHUSETTS UNIFORM ORM APPLICATON FOR PERMIT TO DO GAS FIT rING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date f7— 29- — pa Building Locations �i b %��r° r n/�` r� Permit #� Amount $ �— _Owner's Name J, iC �/U� ly► r Q o J._s/ New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Itone: Certificate Installing Company Corp. Address �cf7 ,C a(�O G I%%r�t`-�� -P� ❑ Partner. 13 Firm/Co. Name of Licensed Plumber or Gas Fitter 5A /v,17czW C 6L ,eR A 0 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ye—s please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [3Agent ❑ 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 ofthe Massachusetts,Stathe Gas Cede and Chapter 142 ofthe General Laws. (OFFICE USE ONLY) r Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �) 3 43 / ❑ Gas Fitter License Number ❑ Master ® Journeyman Date .% :. .?J"7 L TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ACMU 1 � This certifies that : `-:- ��r� ...� t-•` �?:�.. . has permission to perform . .................... plumbing in the buildings of ........... 'U-' at ...... ......... .... . , North Andover, Mass. Fee �lc: - ..... Lic. No.= �.�/..!`_ , . ,...� - // PLUM 1N��S INSPECTOR Check # 3 %�� /� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location ol L `2 C /1/e. ST Permit # 0-3.0 Y Owner A,18 rr 1 V-0 RQG/`SA ) Amount New ri Renovation 11 Replacement ❑ FIXTURES Plans Submitted Yes No (Print or type) Check one: Certificate Installing Company Name ��/� r�K2�l� Plvfi ,Fj,,,�� ❑ Corp. Address f !o 6 0 X a n 6 Partner. M 4 `f 3usmess Te ep one 9 f? k Z 5Z.Ci— I I I `l LAJ Firm/Co. Name of Licensed Plumber: '04 /t/ tq Iy fe-e Cmc., fe/o At 'insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 121 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 13 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus is ate P bing Code and Chapter 142 of the General Laws. By ig ~ re of LicenseuPlumDer T e of Plumbing License Title 363 City/Town icense lNumSer Master ❑ Journeyman APPROVED (OFFICE USE ONLY