Loading...
HomeMy WebLinkAboutMiscellaneous - 25 CAMDEN STREET 4/30/2018 (3)N O W w L D Q 3 S m N Z N O-1 o m o m a -I I ._ I Date..-! . .?. . 00 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 4n . 1r ................... has permission for gas installation ... ................... in the buildings of f -k ...................... at ............... I North Andover, Mass. Fee. Lic. No. j.) .. 2... .... GAS INSPECTOR Check# l o l C 6066 t4 Installing Company Name p�Ar �tµtDifJG.-�-t�Yt►�6� Check one: certlticate Address 1 O 6� 2g Corporation livor • - No fA� Partnership. Business Telephone g�8.4�0., t� 0 Firm/Co. — Name of Ucensod Plumber or. Cas FitterAg—A!-!' -INSURANCE COVERAGE: have a current .liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. t 1 Yes l No O If you have checked yes, please indicate the., type coverage .by checking the appropriate box.. A liability insurance policy. Other type of indemnity 0 Bond ❑ OWNER'$ INSURANCE WAIVER: i am aware that the licensee does not have the.insurance .coverage -coverage .by Chapter 142 of the Mass. General. Laws, and that .my signature; on. tars !permit application walves this requirement. Check one: Owner O Agent ❑ Signature of Owner or Owner's Agent hereby certify that all of the details and. information 1 have submitted (or entered) In above application'arearue and.accUrate to the best of. myknowledge and that all plumbing workandinstallation performed�urider the,permltissued tor this application will be in compliance with all pertinent. provisions of the Massachusetts State Gas :code and Chapter 142 of..the General Laws: Type of License: Plumber 11 Gasfitter �C Master ] Journeyman Signature of" Licensed Plumber or Gas fitter License Number i�7 - DateQ? TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies t h a t .ut-.'4..{.-r..B.��./- ....•••••••••••••••• has permission to perform .... %:.t.*�..!r ..................... . plumbing in the buildings of ............... at ..�. ?� dq�: e �....................... North Andover, Mass. Fee.�G .....Lic. Noj)-.5.?.. ........ �. 1.�-�a�.r�....... PLUMBING INSPECTOR Check # C 7450 Name of licensed Plumber 46&Vr 9LN__Y__AI6%E INSURANCE COVERAGE: have a current- liabilityinsurance policy or Its'substantial equivalent which meets the requirements of MGL Ch.. 142. Yes. � No 0 If you havechecked yes. please indicate the type coverage by checking tWappropriate box A liability insurance policy ' other type of indemnity .O t3ond 0` _ OWNER'S INSURANCE WAIVER-.1 am-aware that'the,licensee does notblu t ; the insurance coverage required by' Chapter 1.42; of the Mass. General . taws,.:AM that my signature on this permit application waives "this requirement. Check one: Owner C] Agent 0 Signature of Owner or,,Owner's Agent I.hereby certify that:all,of .the: details and.in(ortnation l have submitted (or entered) in above application are:true and aaxrrate to the best of my knowledge and .that all plumbing wdrk:and .installations�periomted under..tt a pertn�t'iss:red-for this application will be in compliarnce with. all j- pertinent provisions of the Massachusetts State Plumbing Code and}.C-haoter 142 of the General Laws• gnature of Licensed umber e Title Type of license: Master Journeyman O <CJ`. City/ own (0 IC S ONL' License Number_,_,__ OH7 -1— VVII.LIS&IIVIUIS Pleasant Nor North Andover, or MA 01845 Attom"s M Law Tel 978-685-3551 Fax 978-794-8363 November 22, 2004 North Andover Board of Appeals 27 Charles St. North Andover, MA 01845 Re: variance 25 Camden Street, petition 2004-020 Dear Gentlemen: I have recorded the Plan and decision from the Board of Appeals on November 2, 2004. The plan was recorded as document # 51031 and the decision as document # 51032 at 2:14 PM. Sincerely, John J lli r E C � � w E 0 NOV 2 4 2004 BOARD OF APPS Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Any appeal shall be filed Notice of Decision within (20) days after the Year 2004 date of filing of this notice Telephone (978) 688-9541 Fax (978) 688-9542 This is to certify that twenty (20) days have elapsed from date of decision, filed without filing of Gate %�O • ���00 Joyce A, Bradshaw Tom alta in the office of the Town Clerk, Property ah 25 Camden Street NAME: Rita E. Cunningham HEARING(*-. Aogaet 10 & September 21, 2004 ADDRESS: 25 Camden Street PETITION: 2004-020 North Andover, MA 01845 TYPING DATE: ember 24, 2004 The North Andover Board of Appeals held a public hearing at its regular meeting in the Senior Center,12OR Main Street, North Andover, MA on Tuesday, September 21, 2004 at 7:30 PM upon the application of Rita E. Cunningham, 25 Camden Street, North Andover, requesting a dimensional Variance from Section 7, Paragraphs 7.1, 72, 7.8 (2), and Table 2 for relief of lot area and street frontage in order to divide an existing conforming lot into two non -conforming lots per Variance petition 11-'77; and a Finding from Section 10, Paragraph 10.4 of the Zoning Bylaw that the Building Department denial is incorrect. The said premise affected is property with frontage on the North side of Camden Street within the R4 zoning district. The legal notice was published in the Eagle Tribune on July 26 &August 2, 2004; and read at the August 10, 2004 meeting. The following members were present: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard L Byers, and Albert P. Manzi, III. The following non-voting members were present: Thomas D. 1ppolito, Richard Ni Vaillancouft, and David R. Webster. Upon a motion by Joseph D. LaGrasse and 2°d by Richard L Byers the Board voted to GRANT dimensional Variances from Section 7, Paragraph 7.1 for relief of 500 sq. ft., 7.2 for relief of 25' street frontage, and Table 2 for parcels 23 dt 14 in order to re-establish petition 11-'77 per plan of Land location 25 Camden Street, North Andover, MA prepared for Robert B. 8t Rita E. Canningbam, Date: May 12, 2004 by Frank S. Giles, II P.L.S. #49793, Scott L. Giles Frank S. Giles Surveying, 50 Dearneadow Road, North Andover, MA with the following conditions: L There shall be a one family dwelling on map 85, parte 23 and a one family dwelling on Map 85, parcel 14, only. 2. The new dwelling on Map 85, parcel 14 shall be wed within the Residence -4 Zoning District setbacks. Voting in favor. John bE Panone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzri, M. Upon a motion by John M Pallone and 2i by Joseph D. LaGrasse, the Board voted to GRANT the applicant's request that the Finding be WITHDRAWN WITHOUT PREJUDICE. Voting in favor: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard L Byers, and Albert P. Manzi, III. The Board finds that the 1977 Zoning Board of Appeals had grounds to grant a variance, that the resulting lots will be more conforming than most abutting lots, and that the right side abutter's letter has satisfied the provisions of Section 10, paragraph 10.4 of the Zoning Bylaw in that the granting of this Variance will not adversely affect the neighborhood or derogate from the intent and pRrpose of the Zoning Bylaw. NOV 2 4 2004 Pagel of2 BOARD OF APPEALS ATTEST: <--` A True Copy �? Town Clerk r✓ Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Telephone (978) 688-9541 Fax(978)688-9542 Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the gent, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only atter notice, and a new hearing. Page 2 of 2 Town of North Andover Board of Appeals, Ellen P. McIntyre, Chair ' Decision 2004-020. M85P23 & 14. Mo"rry 6 O� tao ,�ti Zoning Bylaw Review Form Town Of North Andover Building Department liR" 27 Charles St. North Andover, MA. 01845 7.psc9�Iµt.�5 Phone 978-688-9545 Fax 978-688-9542 Street: [',a40 tiv S i map/Lot: I A / 4 Applicant: ;e, *a V- Pw b e y C u NNin, j, A iK Request: SU cli v «yonc Date: ' �l 41 ,o j,., fo 1o2 ovc4�7 4 o fg &I _ ; y _ o X Please be advised that after review of your Application and Plans that your Application is DENIED for the following Zoning Bylaw reasons: Zonina R-'-/ ,temedy for the above is checked below Item # Special Permits Planning Board Item Notes Setback Variance Item Notes A Lot Area Common Drivevvay Special Permit F Frontage Variance for Sign 1 Lot area Insufficient t✓S 1 Frontage Insufficient ye s 2 Lot Area Preexisting R-6 Density Special Permit 2 Frontage Complies Special permit for preexisting 3 Lot Area Complies 3 Preexisting frontage 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required e S 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient 2 Complies 3 Left Side Insufficient 3 Preexisting Height _--jp.5 4 Right Side Insufficient 4 Insufficient Information t(e 5 Rear Insufficient I Building Coverage 6 Preexisting setback(s) �e_ ' 1 Coverage exceeds maximum 7 Insufficient Information �-j S 2 Coverage Complies 5 D Watershed 3 Coverage Preexisting 1 Not in Watershed if S 4 Insufficient Information 2 In Watershed Sign 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 More Parking Required 2 Not in district 2 Parking Complies 3 Insufficient Information 1 3 Insufficient In `1 e 5 1 4 1 Pre-existinn Parklnn ,temedy for the above is checked below Item # Special Permits Planning Board Item # variance Site Plan Review Special Permit Setback Variance Access other than Frontage Special Permit Parkin Variance Frontage Exception Lot S ecial Permit A F1 F I Lot Area Variance Common Drivevvay Special Permit Hei ht Variance Con re ate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Independent Elderl Housin Special Permit Permits Zonin Board S ecial Permit Non -Conforming Lar a Estate Condo S ecial Permit Planned Develo ment District S it Permit Use ZBA Earth Removal Special Permit ZBA Planned Residential Special Permit Special Permit Use not Listed but Similar R-6 Density Special Permit Special Permit for Si n Special permit for preexisting Watershed S ecial Permit nonconformin The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file. You must file a new permit application form and begin the permitting process. -Building Department official SignatYTA Application Received Application benied Plan Review Narrative The following narrative is provided to further explain the reasons for DENIAL for the APPLICATION for the property indicated on the reverse side: Referred To: Fire Health Police Zoning Board Conservation Department of Public Works ArelA14CIF r6l .SvhdluIVe d JrCi Other C T AN C2 /fid PCV / 9 o� redv/ti �c�7�h (,(/� Iocr f "tl v s e c f7 ,A- 7-A l le oz �/4 Referred To: Fire Health Police Zoning Board Conservation Department of Public Works Planning Historical Commission Other Building Department TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION T�O, CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING `m; BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: gyXs�de4 /�2 cm - 7SZonin District d Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Requiredded Required Provided -30 Q 1,5-- ./V 130 1 170 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public X Private ❑ Zone Outside Flood Zone Municipal X On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Y2 s w 2.1 Owner of Record f2,1A r. C: s r191,?7de4 s Name (Print) Address for Service: r 979--61 . _ O -Sig�,tvr, Telephone , 5� 2.2 Owner of Record: Name Print AdcTress for Service: `l'7 J --G Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered. Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M X z O z M 90 0 on ic s r M r r z ^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildine hermit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: - FfiTIMATF.n Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbina Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number JEC llur4 7a UWlNEK AU lnUKILA'1'IUN TU BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT lap z / ` , as C/ wnQzjAuthorized Agent of subject property reby authorize �� K/ G �-- 7 / to act on a al tt rela ive tko this b t1 permit application./ , gna a K614er / (' t (-r ACA-) A-) Date Cs 7b 1, 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 Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIyMERS IST 2 ND SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE MAP 85, PARCEI ROBERT B. & RITA E. 25 CAMDEN S NORTH ANDOVEF AREA=O. Y' BK. 1200, PG. MAP 85, PARCEL 24 JAMES C. & CLAIRE F. BRADLEY BK. 7054, PG. 33 CAMDEN STREET , 1, -�l 9 63O N os Jam- �� MAP 85 PARCEL 23 12,000 S.F. S e MAP 85 PARCEL 14 12,000 S.F. 1/2" IRC \ ROD FN 00 Y� 1�� MAP 85, PARCEL 22 63O o ALBERT, JR&JOYCE C �> S WASHINGTON 15 CAMDEN STREET 1/2" IRON ROD FND. X65 NORTH ANDOVER, MA 01845 El)OVER ati AREA=0.18 PPEALS (HELD) BK. 1534, P.1.47 Is NoX15 1/2" IRON �a THE I ROD FND. I .. . PB\PLAN.DRG i' f MAP 85, PARCEL21 NARDONE, LAURA 11 CAMDEN STREET NORTH ANDOVER, MA 01845 AREA=0.18 BK. 5631, PG. 92 N o.: Date TOWN OF NORTH ANDOVER to BUILDING DEPARTMENT Building/Frame Permit Fee $ S, CHUS Foundation Permit Fee ZAD&Permit Fee $ Building Inspector 'X/24/% 13-40 oC W i W J_ I m U W W m 7 m 1 W W < a < J IN 3 LC W : I m R W a ■ Q 0 a. z r' W m m Z LL 0 uu o m W o Z Y N a W C 0 W z Z J 0 0 0 a g _ n v 0 W p p_ r W <' CL m p 0 - 0 0 .m 0 0 W r A 0 a ` -1 z _ ,,.- z W (r u w p W < m J o W J Z 0 o 10 J m d z U.ILW M J � W N K W 1 O 0 N Z N 2 m m p D 0 0 A z Z O J =! =! m O %A d r r < ID ID J < c o� m m m 3 m c N r I q oC W p W J_ I m 0 1— ■ 3 W m 7 m 1 W W < r• a J IN 3 LC W : I m a W a ■ Q 0 r L z r' W m m Z LL 0 uu o m W m Z J N a W C 0 W z Z J 0 S 0 a g _ 0kL v m W p p_ r W <' CL I0 p 0 - 0 0 .m 0 0 u r A 0 a ` -1 z _ ,,.- z W (r u w p W LL m J o W J 0 0 o 10 J m d z U.ILW J � m N K W 1 O 0 N Z n 2 m m p D 0 C13 z p W J_ I m 0 1— ■ 3 F. 0 m 7 m 1 W W < r• a J IN LC W : I m r m W a ■ 0 W CL ec r L C r' W c 0 Y W o 0 uu o m W i 0 Z Z W a W C I < W Z � W z Z N p F 0 W z N 0 Z m a¢ WW z 0 w z 0 m Z H a 'w ¢ r W D � 0 u Z m v Y ►- p O r W <' CL I0 p W >> Q 0 > 0 r C 0 a m z p W J_ I m v Z ■ 3 F. 0 m 7 m 1 W W < � 1 a J IN LC W : I m r m W a ■ 0 r L C r' W r 0 Y W o 0 uu o m W i 0 Sx Z W a W C I < W Z � W z Z N p F 0 d < W z N Z 0 Q u O Z m a¢ WW z 0 w z 0 m Z H a 'w ¢ r W D � 0 u Z m W Y W p O r W <' RS p W >> W 0 O 0 0 r C 0 a a m J J xu u i Z W ID O J o W J 0 Z<< < J m d Z d m W o I W J_ I m ■ 3 r_ A K m 1 W W < � 1 a o 2 LC W : I O 1 r m W a ■ 0 r L C LIL W r 0 Y W o 0 uu o s B u~ B i 0 Sx Z ►- ►- Z U z m = a 0 W o r LC < tj a tL O H S S W Ir u W r LL L6 W z z 0 u U z D m m z 0 H W o I W J_ I Z ■ 3 r_ A K m 1 W < � 1 a o L z LC W : I O 1 r m W a ■ 0 r L C LIL W r 0 Y W o 0 uu o s B u~ B i 0 r Z ►- ►- Z U 0 ¢ o J Y A u W Y W p O r W <' p W >> r 0 O 0 0 r C 0 a C m J J xu u i Z W ID O J o W 0 0 Z<< < J m d Z d U.ILW J � W O Z Z Z j ti u uIL o 0 0 0 z Z O J =! =! m O r r W ID ID ID J < c o� m m m 3 m z 0 H +JI o I W J_ I v ■ 3 r_ A K m 1 V � 1 o o L z W : O 1 r m W a ■ < LC v r L C LIL W ^ 0 Y 0 CL o 0 uu o s B u~ B C^ 0 ir L ►- ►- Z U o e o d< u O Z ��.. 3 o z �_ A u Y Y W p 'Q a •..i� 0 U u Z O W J C r +JI o I W J_ I v � I r_ A K m 1 V � 1 o o O _ W O 1 ' W a m < LC v r L W IL C d ^ 0 Y Z C^ 0 mm W Z z m c 0 0 r u u W W Z 0 p a r p W >> W 0 O 0 0 r , C m J J xu y I.- 0 a 3 ID r W V tl W W < < J m d d W < J � O W J C r +JI Z W < � v < r_ A K ,1 V 'vnJ V N o O W O _ r +JI < � ^� r ,hn A K ,1 V 'vnJ V O O W o f 0 ' W a < LC v aa p W IL C d P 7 0 a) NT>O A TIZD )-o W TA00 Z�_ N v5IC1 D O n _8O> D Nn O 00 0 p n S ; 0 m m m Z 0 0 0 x Op O m N Z D D Z Z Z N p Z N IIII m 0 N AD O((^�1 > Z Z� m o <K T ; H 0 0 z l > — m r -+ >01 — Ll -1 N N ' M Ln rm Z �mn nom=' >0 Z n C 11 o O D mM Illllllil_ IIII D� n I1llJI y >nx ,non>p =Z n Ip O�",ZZ =TT co x9, �jDD Z' co �r n =IipiT Mom Z e+ C T Cl! Ln z -0 m1 zF ll. T:; Z, .r Y � �y0 Z lK yftii� 0 �> T.. in mm �m 00. T I I a Q I I I I I" I Iu I I I I m r -+ >01 — Ll -1 N N ' M Ln rm Z �mn nom=' >0 L,zZ °3 � mM D� n 0�0 to . p3m mx -1 z > 2 !A n NO MZ° mN� Mom Z e+ C m0°0 Ln z r p r r°0 OZr Z � �y0 ��> ?�z m n 0 �> nz in mm �m 00. • �- 9 ON cD N 0 r� M cz W w Q O cc x w ; `U cn 0 w P-0� z z Q m"0 o w -a w , v G E U m F. 0 W z a c cG its w O H W u U 0-4 U a W -G 7 a � S v� id i% x O U a (¢j x p w' z G w z W w W w �- G W o z a U, v Q O cn o m c :cam --- : CM • c ` _o. _ o ac ca ca e� s o � N yam.. E Q m m D o CL o N E CCD 0 O ' O O m C O. SCL L N L O N N CD: m J N .a • `G C C m O W N W m L 'ave m c c NQ _ :mom CO P� N i9 L :• gOC•�Z O • � � O Q1 _ m p N � ay _ c Ll— �N m t0 LD �.. N nL•s Z O y-+ m cr. •E 0.0 0 N O Os G.) m v m w n CD -5 _ H'� O y=. m > ral G� O i � O o � Z � CL O CD I Com_ COD :2 CO La CL) •E MM W co O co .�.+ CL CL) OCJ O R O CL �Q H C C C O O CO.) J -a .Q O CR C Z CD -CL C Q. 0 C� .0 A a L--; IzV' O U C!) ral G� O i � O o � Z � CL O CD I Com_ COD :2 CO La CL) •E MM W co O co .�.+ CL CL) OCJ O R O CL �Q H C C C O O CO.) J -a .Q O CR C Z CD -CL C Q. 0 Insurance Adjustment Service, Inc. 172 Route 101 Unit 25 Bedford, NH 03110 (603) 606-7901 Fax (603) 606-7911 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139, SECTION 38 Date: 5-3-05 TO: Building InspectorA4@afa -E� RE: Insured: 7Robert & Rita Cunningham Property Address: ' 25 Camden Street North Andover, MA 01845-2803 Date of Loss: 11/1/2004 Policy Number: HO12059770 Type of Loss: water damage File or Claim Number: 22861 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct that information to my attention and include a reference to the captioned insured, location, date of loss and claim or file number. Thank you for your cooperation. Very truly yours, /Aaron etien Adjuster Ext. 110 RECEIVED MAY 9 2005 BUILDING DEPT. n Location 'No. X Date ZZ `_ -2-2 A NCRTN TOWN OF NORTH ANDOVER p Certificate of Occupancy $ • ; Building/Frame Permit Fee $ Foundation Permit Fee $ ---"� AC 14 Other Permit Feezj�Z,4 $ �� • `' �4",�7[jSeeWer Connection Fee $ NOS3 �Wai4�nnection Fee $ 'VAL $ /Vo° 14170foV'orCO/, � eCtC, Building Inspector Div. Public Works APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. p i LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE ZONE E �` i! SUB DIV. LOT NO. I 17,A60 ' LOCATIONC�ry� �,� • r� S PURPOSE OF BUILDING 5 6a P OWNER'S NAME 17hA ' �� rw�r�r NO. OF STORIES IZE X OWNER'S ADDRESST�r BASEMENT OR SLAB Nim VL.i ARCHITECT'S NAME �.q,/%l�ia� BUILDER'S NAME SIZE OF FLOOR TIMBERS 1ST ao 2ND _ L�1 3RD SPAN DISTANCE TO NEARES BUILDING DIMENSIONS OF SILLS y' DISTANCE FROM STREET POSTS /l//`y►� DISTANCE FROM LOT LINES - SIDES //'�7 REAR. 1 / " GIRDERS / AREA OF LOT/{l�� FRONTAGE f��C_/� ( ,L /� �/ HEIGHT OF FOUNDATION - _ THICKNESS IS BUILDING NEW f SIZE OF FOOTING X IS BUILDING ADDITION //[�2 MATERIAL OF CHIMNEY IS BUILDING ALTERATION/1 zi IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE � q�l, IS BUILDING CONNECTED TO TOWN WATER /V BOARD OF APPEALS ACTION, IF ANY V IS BUILDING CONNECTED TO TOWN SEWER (Ar) 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 J DATE FILED /L ` _ / (7d SIGNATURE OF OWNER OR AUTHO ^D AGENT F E E o OWNER TEL. # 419�a�a�� PERMIT GRANTED CONTR. TEL. 19 99�=— GONTR. LIC. # .4 &120/ 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EBT. BLDG. COST PER GO. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY SiOkIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA. APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. Nv-rnAl <T -.w' t ' OIL 1 T � ELECTRIC B'M'T 2nd _ _ CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE PINE 3 1 1 13 CONCRETE BL'K. BRICK OR STONE PIERS HARDW D— PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M AREA '/ 1/7 1/ FIN. ATTIC AREA _ NO BMT X FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 2 �_ 3 _ DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING ASBESTOS SIDING HARDW'D COMMON ASPH. TILE VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME- ATTIC STRS. & FLOOR (- CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I I POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBREL_ I HIP BATH (3 FIX.) MANSARD TOILET RM. (2 FIX.) _ FAT 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 WOOD JOIST 11 HEATING 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 i 11 Nv-rnAl <T -.w' t ' OIL 1 T � ELECTRIC B'M'T 2nd _ lit 13rd NO HEATING �,J MI W cd cl uj ri 1i5 1 G z c o m c o C y ' O C ' � O V V V�cc= me `*..a :tea CIO %�p o CD m C="c .. E m •m a E 3 • �_ c IN m Go_ c R y *j t C J y R o '00 r O m co m D 'D m y m cr- ci nct `m o m • C1 H z O c�o c � c = m mom30 N rp-. H Oma~ m Lu Vi C mo m y=... a is CL :s t ev c Z ac •E E o E •y O C3 ID 00 COD a ID. — O S E � o H s $ O.�m- O 0 6 O O 't 6 O O i O co 0 0 0 CO2 W i O O O V _cc CL COD O ca CO2 G O cc CLCO2 �D O i O O' cmQ c 0 CD O O J -a Z CD CL CA C ° a � O IE 0o w u o cn U q 1 o c o w o a rw u cd a x w as aw o w c w w w o w cn c w x O U o a: G u. z w a r. cry o z cn v Q o cn cl uj ri 1i5 1 G z c o m c o C y ' O C ' � O V V V�cc= me `*..a :tea CIO %�p o CD m C="c .. E m •m a E 3 • �_ c IN m Go_ c R y *j t C J y R o '00 r O m co m D 'D m y m cr- ci nct `m o m • C1 H z O c�o c � c = m mom30 N rp-. H Oma~ m Lu Vi C mo m y=... a is CL :s t ev c Z ac •E E o E •y O C3 ID 00 COD a ID. — O S E � o H s $ O.�m- O 0 6 O O 't 6 O O i O co 0 0 0 CO2 W i O O O V _cc CL COD O ca CO2 G O cc CLCO2 �D O i O O' cmQ c 0 CD O O J -a Z CD CL CA C 6t � Date. '� l `�! . f...... . „aaTH TOWN OF NORTH ANDOVER 0 «. o '6,6 tiOOL p PERMIT FOR GAS INSTALLATION This certifies that .. C'. `� �`:f. Zo has permission for gas installation X ` ............. . in the buildings of ..�.............�........ ?................ at ..... ^ :.... .` .:::................ . North Andover, Mass. Alj96 &ibo .............. Fee.. 40 15.00 ppin GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T/Date DO GASFITTIN G (Print or Type) C NORTH ANDOVER Mass. building Location ermit 6 Owners Name • New .7 Renovation Replacement El Plans Submitted T 1 P --Iz G (Print or Type) Check one: Certificate Installing Company Name Alee-or C� P- Address 7 % Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the .appropriate box: Liability insurance policy ©Other type of indemnity 0 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 coverages. Signature of owner/agent of property Owner F� Agent 0 I hcteby ccrtify 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 flat all plumbing work and installations perforated under' Permit isseed for this application will -be in compliance with all tinent provisions of the Massachusetts State Gas Cade and Chapter 142 of the Genual Laws. TYPE LICENSE: Plumber Gasfitter- Si nature of Licensed Master Plumber or Gasfitter Journeyman License. Number ENEEMEME OEM K ENEREEKEREERNME ONE OEM mommosommoommommoss on EM so (Print or Type) Check one: Certificate Installing Company Name Alee-or C� P- Address 7 % Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the .appropriate box: Liability insurance policy ©Other type of indemnity 0 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 coverages. Signature of owner/agent of property Owner F� Agent 0 I hcteby ccrtify 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 flat all plumbing work and installations perforated under' Permit isseed for this application will -be in compliance with all tinent provisions of the Massachusetts State Gas Cade and Chapter 142 of the Genual Laws. TYPE LICENSE: Plumber Gasfitter- Si nature of Licensed Master Plumber or Gasfitter Journeyman License. Number Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Any appeal shall be Sled within (20) days after the date of filing of this notice Notice of Decision Year 2004 Telephone (978) 688-9541 Fax(978)688-9542 in the office of the Town Clerk. Pro at: 25 Camden Street NAME: Rita E. Cunningham HEARING(S): August 10 & September 21, 2004 ADDRESS: 25 Camden Street PETITION: 2004-020 North Andover, MA 01845 TYPING DATE: September 24, 2004 The North Andover Board of Appeals held a public hearing at its regular meeting in the Senior Center,12OR Main Street, North Andover, MA on Tuesday, September 21, 2004 at 7:30 PM upon the application of Rita E. Cunningham, 25 Camden Street, North Andover, requesting a dimensional Variance from Section 7, Paragraphs 7.1, 7.2, 7.8 (2), and Table 2 for relief of lot area and street frontage in order to divide an existing conforming lot into two non -conforming lots per Variance petition 11277; and a Finding from Section 10, Paragraph 10.4 of the Zoning Bylaw that the Building Department denial is incorrect. The said premise affected is property with frontage on the North side of Camden Street within the R4 zoning district. The legal notice was published in the Eagle Tribune on July 26 &August 2, 2004; and read at the August 10, 2004 meeting. The following members were present: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. The following non-voting members were present: Thomas D. Ippolito, Richard M. Vaillancourt, and David R Webster. Upon a motion by Joseph D. LaGrasse and 2nd by Richard J. Byers the Board voted to GRANT dimensional Variances from Section 7, Paragraph 7.1 for relief of 500 sq. ft., 7.2 for relief of 25' street frontage, and Table 2 for parcels 23 & 14 in order to re-establish petition 11-'77 per Plan of Land location 25 Camden Street, North Andover, MA prepared for Robert B. & Rita E. Cunningham, Date: May 12, 2004 by Frank S. Giles, II P.L.S. #49793, Scott L. Giles Frank S. Giles Surveying, 50 Deermeadow Road, North Andover, MA with the following conditions: 1. There shall be a one family dwelling on map 85, parcel 23 and a one family dwelling on Map 85, parcel 14, only. 2. The new dwelling on Map 85, parcel 14 shall be constructed within the Residence -4 Zoning District setbacks. Voting in favor: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. Upon a motion by John M. Pallone and 2°d by Joseph D. LaGrasse, the Board voted to GRANT the applicant's request that the Finding be WITHDRAWN WITHOUT PREJUDICE. Voting in favor: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. The Board finds that the 1977 Zoning Board of Appeals had grounds to grant a Variance, that the resulting lots will be more conforming than most abutting lots, and that the right side abutter's letter has satisfied the provisions of Section 10, paragraph 10.4 of the Zoning Bylaw in that the granting of this Variance will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Pagel of 2 Board of Appeals 978.688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535 Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Telephone (978) 688-9541 Fax(978)688-9542 Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice, and a new hearing. Town of North Andover Board of Appeals, 1h/1 LJ Ellen P. McIntyre, Chair ' Decision 2004-020. M85P23 & 14. Page 2 of 2 A Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-088-9530 Health 978-688-9540 Planning 978-688-9535 r � w Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Any appeal shall be filed within (20) days after the date of filing of this notice Notice of Decision Year 2004 Telephone (978) 688-9541 Fax (978) 688-9542 in the office of the Town Clerk. Pro at: 25 Camden Street NAME: Rita E. Cunningham HEARING(S): August 10 & September 21, 2004 ADDRESS: 25 Camden Street PETITION: 2004-020 North Andover, MA 01845 TYPING DATE: September 24, 2004 The North Andover Board of Appeals held a public hearing at its regular meeting in the Senior Center, 120R Main Street, North Andover, MA on Tuesday, September 21, 2004 at 7:30 PM upon the application of Rita E. Cunningham, 25 Camden Street, North Andover, requesting a dimensional Variance from Section 7, Paragraphs 7.1, 7.2, 7.8 (2), and Table 2 for relief of lot area and street frontage in order to divide an existing conforming lot into two non -conforming lots per Variance petition 11-'77; and a Finding from Section 10, Paragraph 10.4 of the Zoning Bylaw that the Building Department denial is incorrect. The said premise affected is property with frontage on the North side of Camden Street within the R4 zoning district. The legal notice was published in the Eagle Tribune on July 26 &August 2, 2004; and read at the August 10, 2004 meeting. The following members were present: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. The following non-voting members were present: Thomas D. Ippolito, Richard M. Vaillancourt, and David R Webster. Upon a motion by Joseph D. LaGrasse and 2"d by Richard J. Byers the Board voted to GRANT dimensional Variances from Section 7, Paragraph 7.1 for relief of 500 sq. ft., 7.2 for relief of 25' street frontage, and Table 2 for parcels 23 & 14 in order to re-establish petition 11277 per Plan of Land location 25 Camden Street, North Andover, MA prepared for Robert B. & Rita E. Cunningham, Date: May 12, 2004 by Frank S. Giles, II P.L.S. #49793, Scott L. Giles Frank S. Giles Surveying, 50 Deermeadow Road, North Andover, MA with the following conditions: 1. There. shall be a one family dwelling on map 85, parcel 23 and a one family dwelling on Map 85, parcel 14, only. 2. The new dwelling on Map 85, parcel 14 shall be constructed within the Residence -4 Zoning District setbacks. Voting in favor: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. Upon a motion by John M. Pallone and 2's. by Joseph D. LaGrasse, the Board voted to GRANT the applicant's request that the Finding be WITHDRAWN WITHOUT PREJUDICE. Voting in favor: John M. Pallone, Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Albert P. Manzi, III. The Board finds that the 1977 Zoning Board of Appeals had grounds to grant a Variance, that the resulting lots will be more conforming than most abutting lots, and that the right side abutter's letter has satisfied the provisions of Section 10, paragraph 10.4 of the Zoning Bylaw in that the granting of this Variance will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Pagel of 2 .f Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535 .. Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Telephone (978) 688-9541 Fax(978)688-9542 Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice, and a new hearing. Town of North Andover Board of Appeals, Ellen P. McIntyre, Chair ' Decision 2004-020. M85P23 & 14. Page 2 of 2 a Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535 Date 14. ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING /� r� This certifies that ............. ............7....�..... �-��.-..........:......................................... has permission to perform .......�, ............ wiring in the building of .......................... !` '......................................................... at ..S...f....... '? f... .................................................. : North Andover, Mass. FeeW�..'d . ................. L>c. No.P .................................................................................... nr ELECTRICAL INSPECTOR Check 0 'own of North Andover >ayment Date Wednesday, February 17, 2016 )eposit Number 1602171 )perator Counter pc 1 ACR (MISC DEPT REVENUE) $60.00 4 .t' `_r— k'i; 'otal Paid $60.00 :ash $60.00 :hangs $0.00 teceipt Number gov00004543 !117/2016 9:37:27 AM Jame RYAN BARRY - PERMIT FOR WIRING :ashler Id. treascoll-17 Commonwealth of Massachusetts Official Use Only ' Department of Fire Services Permit No. Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank 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) K 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) 2_,5 Owner or Tenant Z -e,, , M Telephone No. Owner's Address Is this permit in conjunct' with a building permit? Yes Ea_No ❑ (Check Appropriate Box) Purpose of Building -,,64. l cs_ Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: w`� CONI& -Z— Completion ZCompletion ofthe followiae table may be waived by the Inspector of Wires. of Recessed Luminaires 7 - No. No. of Luminaire Outlets No. of Luminaires %p of Ceil: Susp. (Paddle) Fans of Hot Tubs Pool MUUV grnd. No. of Receptacle Outlets -30 No. of Oil Burners No. of Switches / No. of Gas Burners INo. of Ranges INo. of Air Cond. No. of Waste Disposers / "'"" Tntals INo. of Dishwashers I I Space/Area Heating KW I No. of Dryers Heating Appliances No. of Water KW No. of No! Heaters Siuns Ball JNo. Hydromassage Bathtubs INo. of Motors Tot, OTHER: 4ey '\ , n of •iv. ►•west_ KVA KVA _ Attach ad i es. Estimated Value of Electrical Work: C7bU---(Whenrequi) Work to Start: Z - /S —/lo Inspections to be requested in accon._..____-.. �. . �.u�, , ttuu upuu compienon. 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: 1NSURANCECI�k BOND ❑ OTHER ❑ (Specify:) X certify, antler the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: c LIC. NO.: Licensee: Signature LIC. NO.: iiOto/ 13 (If applicable, e r " e t" in the lice a number line.)� � AA Bus. Tel. No. - Address: �� �(wlX��tC�fC1, /Wt �l Alt. Tel. No.: i 5 -�yz7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety " icense: Lic. No. 1 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 PEPMIT 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 F 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. 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 Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 w Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass IN V Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass IN V Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com J' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN HK 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) 76 6", Owner or Tenant ��� ,�.1 Telephone No. Owner's Address Is this permit in conjunct' with a building permit? Yes R., No ❑ (Check Appropriate Box) Purpose of Building QS OLM 01, Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �� c�cw -z— Completion Completion ofthe following table may be waived by the Inspector of Wires. rlb. of Recessed Luminaires Z 5 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets se- a No. of Hot Tubs Generators KVA No. of Luminaires %p Swimming Pool Above ❑ In- . ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets -30 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches / No. of Gas Burners No. If Detection ting Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers / Heat Pump Totals: Number ' """"' """"'"' Tons """"""""" """" KW """'' No. of Self -Contained Detection/Alerting Devices S No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecN . o De 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 E uivalent OTHER: ex N n -(/, rw Attach additional detail if desired, or as required by the Inspector of'Wtres. Estimated Value of Electrical Work:� 0 -----(When required by municipal policy.) Work to Start: Z -15-1& 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 of perjury, that the information on this application is true and complete. FIRM NAME: c LIC. NO.:� Licensee: Signature LTC. NO.: 1e?fo/ L3 (If applicable, egr " xe t" in the licen a number line.) Bus. Tel. No.: Address: !"� � �oi%iQ-�i P41, (n) Alt. Tel. No.; I - 53 (-3�iZ-7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "P' -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 PEPMIT FEE. $ 0 -- 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. G1 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. 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 Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: 15_ G FINAL INSP TION: Pass M V Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massa chusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: 7 (Vi —SR ct —7L( Are you an employer? Check the appropriate box: Type of project ()required): 1. ❑Tama employer with employees (full and/or part-time).* 7. ❑ New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in $, delirlg any capacity. [No workers' comp. insurance required.] 9. ❑ Demolitl 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have :Ilemployees and have workers' comp. insurance.$ 14. Other 6. ❑ 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.] r *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not. those entities have employees. If the sub-cofi6c"tors have employees, they must provide their workers' comp. policy number. I am an employer that is pi'oviding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 04IM A (30 1 S C, 2 c Expiration Date: Job Site Address: Z� �avv, V1 City/State/Zip: 14 • „<<�Icx 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 herebyify under t ai sand pen Ves ofperjury that the information provided above is true and correct Phone #: Q—J -7 S 1 5659 - 7 q 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # z— r -7 -- 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 -contractors) 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 foi• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia i ",1 11 ~-------� Commonw' ealth of A4as ° Division of Registtati usetts Board ofElectn W R.YAN'S f2 £ 4 LISA L NORTH R� Master'Elec 'a 21833-A 07/31/2016 _Y `License No. Expiratioh Date. ' �}� 009325 -----_ Serial No " March 16, 2015 Inspector Of Buildings Town Of North Andover 1600 Osgood Street North Andover MA 1845 Claim Number: Policy Number: Company Name: Date of Loss: Insured: Property Location: To Whom It May Concern: 033547329 94256400003 Arbella Mutual Insurance Company 2/19/2015 Rita Cunningham 25 Camden St. North Andover, MA01845 Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Rob Cleberg Crawford & Company 204 Second Ave Waltham, MA 02451 CC: City/Town Fire Dept, City/Town Health Dept 1. I 11615 Date .... ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... VY .......................................... has permission to perform .....t.► ..e -Z-, i ...........!'Z—( .... (D .. t*V'��-.� ...... plumbing in the buildings of M A C5 0 0, L'r"�' C�-'e ...... . . . ............................................ .. at.2......................................... ... � . North Andover, Mass. .... ......................................... Fee.9.1.-M.. Lic. No. ��... ........................ ........................................................ `1- 2- PLUMBING INSPECTOR Check # W P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY vuzA- MA DATE ( ( ( PERMIT#- JOBSITEADDRESS JT Gs}7'. N , ( OWNER'SNAME ,Oje OWNER ADDRESS TEL sIFAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL NEW: FIR RENOVATION: © REPLACEMENT: FIXTURES Z FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK _ LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WAITER HEATER ALL TYPES WATER PIPING OTHER F(^- RESIDENTIAL N PLANS SUBMITTED: YES M NOM 10 1 11 1 12 1 13 1 14 J INSURANCE COVERAGE: hav current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY& OTHER TYPE OF INDEMNITY M BOND OWNER'S INSURANCE WAIVER: lam 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 M AGENT IMi 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 application will be in compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # SIGNATURE i MPW JP 01 CORPORATION �� #PARTNERSHIP 0#® LLC COMPANY NAME�,Q,rw — ADDRESS x CITY aVl % ^y e/ / _ _ _I STATE m- ZIP I e � Cf C(�� TEL FAX L_ CELL �� EMAIL Im N ❑ F- L IU M LL LL LL J ,b 1.J d^M 5J'V9 www mass.gov/dia Wormer§' Compensation Insurance Affidavit: Builders/Contxactors/Electricians/Plum ers. TO BE FILED WITH THE PERMITTING A7TISORI� i'. n, �o prim 1 Name (Business/Organization/lndividual): Address: City/State/Zip: of'L /hf,:zn/ /f'/_, Are you an employer? Check the appropriate box: Phone #: P/ 6 6 S7 S l.Q I am a employer with employees (full and/or part-time).* 2A I am a sole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself [No workers' comp. insurance requiredr t 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will __ _-__ ,_„ , , , P„�ar;ten insurance or are sole proprietors with no employees. 5.❑ T am a general contractor, and T have lured the comp. insurance. sub -contractors listed on the attached sheet. 'These sub -contractors have employees and have workers' 6. Q We are a corporaiioii and its. officers have exercised their right of exemption per MGL c. 1 4 d we have rio employees: [No workers' comp. insurance required.] Type of project (required): 7. [] Nd-W'd6nstriicii0n 8. [] Itemodeliiag 9, ❑ Demolition 10 ❑ Building addition nu Electrical repairs or additions 12. jM`pjunmDmg repairs or a L u -u 13•. [] Rb6f repairs 14.0 Other *Any applicant that checks box #1, must also fill out the section below showing their workers' compensation policy information. w affidavit i Homeowners who sA;miitlus affidavit indicating they are doing all work ane theme e of the sub -contractors hire outside and state wrs must heth t ar or not fhoseentitiess have such. TContraotors that checkthis box must attached an additional sheet showing , ..ee� rf+>,P c„h-contractors have employees, they must provide their workers' comp. policy num er. orkers' compensation insurancefor my employees. X am an employer that is providing3v information. Insurance Company Name: Policy # or Self -ins. Lic. Below is epolicy andyob sate ExpirationDate, City/State/Zip: Job Site Address: workers, compensation polzcy declaration page (showing the policy number and expiratio�nt date Attach a copy of the workers,. 0-00 Failure to secure coverage as required under til enalties?in. the form of aSTOPnal rWORK ORDER olation Iand a fine f up to $2050.00 a and/or one-year' imprisonment, as well as civil p ment may be forwarded to the Office of Investigations of the DTA for insurance day against the violator. A copy of this state coverage verification. X do Hereby certify,uaad the pa ns and penalties of perjury that tlae information provided above is true and correct. — ` Phone #: i �� Official use only. Do not write in this area, to be completed by city or town official. Permit/License # City or Town: Issuing Authority (circle one): i 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 1. Board of Health Z. Building Department 6. Other Contact Person: Phone #: The Commonwealth of Massachusetts w . ' for Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 d^M 5J'V9 www mass.gov/dia Wormer§' Compensation Insurance Affidavit: Builders/Contxactors/Electricians/Plum ers. TO BE FILED WITH THE PERMITTING A7TISORI� i'. n, �o prim 1 Name (Business/Organization/lndividual): Address: City/State/Zip: of'L /hf,:zn/ /f'/_, Are you an employer? Check the appropriate box: Phone #: P/ 6 6 S7 S l.Q I am a employer with employees (full and/or part-time).* 2A I am a sole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself [No workers' comp. insurance requiredr t 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will __ _-__ ,_„ , , , P„�ar;ten insurance or are sole proprietors with no employees. 5.❑ T am a general contractor, and T have lured the comp. insurance. sub -contractors listed on the attached sheet. 'These sub -contractors have employees and have workers' 6. Q We are a corporaiioii and its. officers have exercised their right of exemption per MGL c. 1 4 d we have rio employees: [No workers' comp. insurance required.] Type of project (required): 7. [] Nd-W'd6nstriicii0n 8. [] Itemodeliiag 9, ❑ Demolition 10 ❑ Building addition nu Electrical repairs or additions 12. jM`pjunmDmg repairs or a L u -u 13•. [] Rb6f repairs 14.0 Other *Any applicant that checks box #1, must also fill out the section below showing their workers' compensation policy information. w affidavit i Homeowners who sA;miitlus affidavit indicating they are doing all work ane theme e of the sub -contractors hire outside and state wrs must heth t ar or not fhoseentitiess have such. TContraotors that checkthis box must attached an additional sheet showing , ..ee� rf+>,P c„h-contractors have employees, they must provide their workers' comp. policy num er. orkers' compensation insurancefor my employees. X am an employer that is providing3v information. Insurance Company Name: Policy # or Self -ins. Lic. Below is epolicy andyob sate ExpirationDate, City/State/Zip: Job Site Address: workers, compensation polzcy declaration page (showing the policy number and expiratio�nt date Attach a copy of the workers,. 0-00 Failure to secure coverage as required under til enalties?in. the form of aSTOPnal rWORK ORDER olation Iand a fine f up to $2050.00 a and/or one-year' imprisonment, as well as civil p ment may be forwarded to the Office of Investigations of the DTA for insurance day against the violator. A copy of this state coverage verification. X do Hereby certify,uaad the pa ns and penalties of perjury that tlae information provided above is true and correct. — ` Phone #: i �� Official use only. Do not write in this area, to be completed by city or town official. Permit/License # City or Town: Issuing Authority (circle one): i 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 1. Board of Health Z. Building Department 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empl'o`yees. 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 defiii6d 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'dk 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 Iicensing 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 requked." Additionally, MGL chapter 152, §25C(1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the Workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if _necessary supply_sub=coniractor{s)-narne(s),-address(-es) andphone-number(s) ong-with-their-certifcate(s7�f - --- ----- 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 anLLC or LLP does have employees, a policy is required. i3e 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 IndustrialAccidents. 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 "fob Site Address" the applicant should write •"all locations4 (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax ## 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date......... 2 ....... �.............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S v This certifies that ............ 5.;:;.-.Q .......... kKke ...................................... has permission for gas installation )f in the buildings of.. . 0 As��th�� 'A' ....... ...... i ..... L ....................................................................... at .... . ...... ................. ....... . North And6ver, Mass. Fee)1...... Lic. No... -;(,0q .... ..................................................................... GASINSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE j PERMIT # _ JOBSITE ADDRESS C • 5' f OWNER'S NAME Gk OWNER ADDRESS , TEL�� FAX Tj'PE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL RN CLEARLY NEW: [J RENOVATION: REPLACEMENT: ON PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS- BSM 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 _ _ �I I IJf FRYOLATOR FURNACE GENERATOR �---- GRILLE ------- -- INFRARED INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _. _- --� OVEN POOL HEATERI= ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER _ KI UNVENTED ROOM HEATER WATER HEATER OTHER F[u , Now INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES N] NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY E] 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: OWNER0I AGENT E] SIGNATURE OF OWNER OR AGENT hereby certify that all of the detailSand 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. lu PLUMBER-GASFITTER NAME LICENSE # l 64 SIGNATURE MP A MGF EjI JP El JGF [] LPGI © CORPORATION [3# [=PARTNERSHIP ©#= LLC # COMPANY NAME: i_ -y - _ ADDRESS CITY '`%'zT/ STATE /ii6�}- ZIP �]TEL FAX CELL r—IEMAIL O z z 0 H U W � o z O �El W >- � W OO a Z U w �* a W o w w w w cn cW7 o a d J H a a co x w � a H Z O H a, C�7 %� The Commonwealth of Massa chusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 021142017 .. 1 0www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check tlie appropriate box: Phone #: 1. ❑Tama employer with : employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. FJ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.0 Roof repairs 14. ❑ Other *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 pi'ovidiiig workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: 7ob.Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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, 1 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 shalt 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 foi• 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' compensatiori'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that....... .... .. L .. ....... ... . has permission for gas ins alla ion .... ...... �n�.6A ................................. in the buildin gs of ........ MA -,..' z ....... .......... ............................................................. at .......... Z.. ... ...................... . North Andover, Mass. Fee?.O= ......... Lic. No. AZAI ....... ............ . GAS SINSPECTOR.- --.... -.....-..... ................................ G Check # 29-cl-n 0, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY'W �nO E 2 MA DATE PERMIT # V V JOBSITE ADDRESS A5_ &QwN 4e. rt S -t— OWNER'S NAME -JWP ADDRESS / ( ,6YeLS#0hP. C%,rc1t.,4,A r%J*UZr TEL 01-771462SS FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ❑ RENOVATION: ❑ REPLACEMENT: Di PLANS SUBMITTED: YES ❑ NO P— APPLIANCES Z FLOORS— BSM 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 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE 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 X❑ 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 a curate to the best of owledge and that all plumbing work and installations performed under the permit issued for this application will be in compli c ith all Pertine provi ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION © # 3631C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit # 3 CITY Methuen STATE MA ZIP 01844 TEL (978)689-0 24 A A FAX CELL EMAIL viens mvalle co .com Atz 0, I6te Uoti moii wealth of Massach usetts Office of Investigations 600 Washington Street Boston, MA 02111 vo az/ www.rnass.g'ov1dia Workers' Compensation Insuzr2nee Affidavit: BuilQders/CcrDfracEdrs/Electriciarts/Plumbelrs A RED diCg2Bt gni®ra�atio Please FrM>t f e�i�lo� Name Business/or anization/Individual : �Vl Address: o City/State/Zip:il' -v L ✓���� Phone #: Are you all employer? Check the appropriate box: 1.0 1 am a employer with 4. ❑ I am a general contractor and l employees (fill] and/or part-time)." have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ required.] 5- ❑ We are a corporation and its 3. ❑ l am a homeowner doing all work officers have exercised their myself. [No workers' comp. insurance required.] T 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 10.0 Electrical repairs or additions I l.❑ Plumbing repan-s or additions 12.❑ Roof reeplai-rs 13.❑ . ther<A4 006v-,p4pe,L 'Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatiGg 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 insurancefor my employees. Below is the policy and job site information. I---- Insurance Company Name: � 0 Policy # or Self -ins. Lic. #:� Expnation Date: 11%3�6 Job Site Address: OZS &AYV., K,r^ S'1— City/State/Zip: /V80% 4^4ug—r #1k, V4FVY— A ttach 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 lip to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine- of ineof tip to 5250.00 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. F do IlACebt' certify a�nrler the pains and penalties of perjury that the information provided above is trste and correct dstalki Q Phone 4: F icia! nese only. Do not write in this area, to be completer) by city or town officialy or Town: -- -- --Perm it/License#---.---------- .--- Issuing Authority (circle one): 1. Board of Health 2. Building Department . City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other— Contact Person:-— Phone #: a COMMONweALTM dF MAS AGkUSETTS,. Any o o -oa Moral BOARD. OF PLUMBERS AND OASF.ITTER.S ' ISSUES THE FOLLOWFUG'LICENSE LIG1ES:E6 AS A JOURNEYMAN PLUMBER PETER G VIEN$ 4z 9 BLUEB.I:RD� LAN.E / J AtXjNSON . *1 03811-23i9� 2.1635. 05/4,1//-6 2`1.3566 -- MEDICAL EOUIO_�MENT 4TRAINiNO AHD 999111 CERT/ F9C AT10 N, LLC Peter Viens Cert # 1023121001-12 10/2312015 Certification N. F. P.A. 99-2012 ed. ASSE 6010 Installer & ASME IX Brazer State of I#ie r- FianVshire GAS FITTERS Lf6thSE NAME: PETER VIEN1�-� ENDORSEMENTS STN, STIP DATE ISSUED: 10/1512013 DATE EXPIRES: 11/3012015 LICENSE #:GFE0700587 OSHA 600316337 0 U.S. Department of Labor occupational Safety and Health Administration Peter Vens has successfully completed a 30 -hour Occupational Safety and Health Training Course in Construction Safety & Health tT e ILL' 1 4'.romm0NWEALTW OF USE�� BOARD OF PLUMBERS AND WI: I'TTERS a . ISSUES THE FOLLOW NA LICENS L I lENSEb AS A MASTER PLWABER PETER G VI ENS .a 9 BLUEBIRD LANE ATKINEON •M 03811-2302 121 16 05/o a 16_.. 213585 Commonwealth of Massachusetts Department of Public Safety Hoisting Engineer License: HE -110323 J} 0 t PETER G MENS` 9 SI.UEBIRII I.1•a ATKINSON PFE1 038 • J� %��" Expiration: Commissioner 1111312015 state Of New Hanishire MECHANICAL IDENTIFICATION NAME: PETER VIENS LICENSEIREGISTRATION #: SERVICE GFE0700587 MASTER 3249 J�j XPi#2ATIC 45: GF: 11/3012015 PL. 11/30/2016 Commonwealth of Massachusetts Department of Public Safety License: PMU-001088: Pipefitte.r Unrestricted Master " `' t "3 til!► Peter G Viens 9 BLUEBIRD LANE :,V Atkinson NH 03611 , ' Expiration:1312D16 Commissioner state Of New Hanishire MECHANICAL IDENTIFICATION NAME: PETER VIENS LICENSEIREGISTRATION #: SERVICE GFE0700587 MASTER 3249 J�j XPi#2ATIC 45: GF: 11/3012015 PL. 11/30/2016 Commonwealth of Massachusetts Department of Public Safety License: PMU-001088: Pipefitte.r Unrestricted Master " `' t "3 til!► Peter G Viens 9 BLUEBIRD LANE :,V Atkinson NH 03611 , ' Expiration:1312D16 Commissioner