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C ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..F ...... .... has permission for gas installation 6w ... ak. ....PJ.. in the buildings of ............... ...... - ...... at.4.!� ... .. .................................. No An ver, Mass. GI k ................. ... . rt Fee 6D.-.49.... Lic. No. . ...... . .. . . ......................... G 9SPECTOR Check # 3; 'I U'.j'I 7 OTHER i tn4s rnC,1Sr_ 0"46 rq,UKAWGt GUvtKRt9t have a current liability insurance policy or ifs substantial equivalent which meets the requirements of MGL Ch. 142 YES ® NO Q I IF YOU CHECM YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHEMNG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Q OWNER'S INSURANCE WAVER: I am aware that the licensee does not have the insurance coverage requhW- by Chapter 142 of the i Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER AGFNT Q SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding the application are true and accurate to the best of my kro edge and that all plumbing work and installations performed under the permit issued for this application well be in c0mpl' with I Pr provision of the Massachusetts State Plumbing Code and Chapter 942 of the General Laws. PLUMBER-GASFITTER NAMES'cafi PrEr'FC� LICENSE # / � Z Si Np RE MP MGF Q JP © JGF Q LPGI ® CORPORATION ®# ,3�p PARTNERSHIP LLC Q#1 COMPANYNAMEFp�Ee-z; -J ADDRESS xo3 c_i-A-(-Ta,4 %-c CITY STATE�ZIP o2a-zz_ TEL EMAIL__-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �j. DRYER FIREPLACE FRYOLATOR CITY Nca`:+� s►..ad�tc - -- MA DATE _ t� 1� PERMIT# 16Ad{�C INFRARED HEATER JOBSITEADDRESS 2� CO— (_-ILArt NAME vA &iu1aI_r G _OWNER'S OWNER ADDRESS Mk^r L-_t�9 M_ TE FAX ZPRPE RIlVT a OCCUPANCYTYPE COMMERCIALQ. EDUCATIONAL.® RESIDENTIAL„ . CLEARLY NEW:E] RENOVATION: Q REPLACEMENT: (� PLANS SUBMITTED: YES i NOQ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 1 8 1 9 10 11 1211 13 14 BOILER BOOSTER CONVERSION BURNER _ OTHER i tn4s rnC,1Sr_ 0"46 rq,UKAWGt GUvtKRt9t have a current liability insurance policy or ifs substantial equivalent which meets the requirements of MGL Ch. 142 YES ® NO Q I IF YOU CHECM YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHEMNG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Q OWNER'S INSURANCE WAVER: I am aware that the licensee does not have the insurance coverage requhW- by Chapter 142 of the i Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER AGFNT Q SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding the application are true and accurate to the best of my kro edge and that all plumbing work and installations performed under the permit issued for this application well be in c0mpl' with I Pr provision of the Massachusetts State Plumbing Code and Chapter 942 of the General Laws. PLUMBER-GASFITTER NAMES'cafi PrEr'FC� LICENSE # / � Z Si Np RE MP MGF Q JP © JGF Q LPGI ® CORPORATION ®# ,3�p PARTNERSHIP LLC Q#1 COMPANYNAMEFp�Ee-z; -J ADDRESS xo3 c_i-A-(-Ta,4 %-c CITY STATE�ZIP o2a-zz_ TEL EMAIL__-- 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 i tn4s rnC,1Sr_ 0"46 rq,UKAWGt GUvtKRt9t have a current liability insurance policy or ifs substantial equivalent which meets the requirements of MGL Ch. 142 YES ® NO Q I IF YOU CHECM YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHEMNG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Q OWNER'S INSURANCE WAVER: I am aware that the licensee does not have the insurance coverage requhW- by Chapter 142 of the i Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER AGFNT Q SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding the application are true and accurate to the best of my kro edge and that all plumbing work and installations performed under the permit issued for this application well be in c0mpl' with I Pr provision of the Massachusetts State Plumbing Code and Chapter 942 of the General Laws. PLUMBER-GASFITTER NAMES'cafi PrEr'FC� LICENSE # / � Z Si Np RE MP MGF Q JP © JGF Q LPGI ® CORPORATION ®# ,3�p PARTNERSHIP LLC Q#1 COMPANYNAMEFp�Ee-z; -J ADDRESS xo3 c_i-A-(-Ta,4 %-c CITY STATE�ZIP o2a-zz_ TEL EMAIL__-- Date .'�Z//�Z.�.... . ~o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... av 24"-� 41 5 {{!...... has permission for gas installation :. �'�..... / in the buildings ofJ. �r�h? �............................ at ... . GA/ !... ............ , North A oyXT ,G. Lic. N-4Fee.�,, GASINSPECTOR Check # ,-?O'Ili 8152 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 0622 A"VM- , Mass. Dat2012- Permit # Building Locatlon25 M &M- DR, Owner's Name SIPMV LAMB i - MOKIR Al�fflbli �. HA Type of Occupancy. S/AJ�+� ��iMJ� New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ G Installing Company Name_COLUMBIA (Sb,S GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET XO Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone q 7 8' 691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9, No ❑ If you have checked rtes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X( 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: SignatuFWof Owner or Owner's Agent . Owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abovepplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ By T e of License: Plumber Signature of Licensed Plumber or Gas /jA Title Gasfitter Master License Number City/Town Journeyman APPROVED (OFFICE USE ONLY ✓I" r UNSEEN •• ■��■ MEN Installing Company Name_COLUMBIA (Sb,S GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET XO Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone q 7 8' 691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9, No ❑ If you have checked rtes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X( 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: SignatuFWof Owner or Owner's Agent . Owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abovepplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ By T e of License: Plumber Signature of Licensed Plumber or Gas /jA Title Gasfitter Master License Number City/Town Journeyman APPROVED (OFFICE USE ONLY ✓I" Date ...... -21 ' ' 0 '!0,I '! 0, ' " "IN TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that=�! .5,cLT ................ has permission to perform .......... ........................................... ... .............. ..... wiring in the building of......... ............................................. at ............ I ................. North Andover, Mass. Fee ..3 � ........... Lic. No.../., h .............f' 1;Z ICAL E� Check # 10 13Y 7 7269 A J Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 4 Occupancy and Fee Checked [Rev. 1/07] (leave hlankl I APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfonned in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3 —2- (/ 7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. l Location (Street &Number)Z g Ca l e /< /1,� Owner or Tenant c /� v Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building A `,, i Utility Authorization No. Existing Service 2 c U mps /za / 2 y Volts Overhead [9� 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: Completion of the ollowin table ma be waived by the Inspector of WirE No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets 2-� No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑o. rnd. grnd. orEmergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal F1Other Connection No. of .Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wire Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ? - 2t'—e/ 7 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 coverapAs 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: , .r H LIC. NO.: f f' 3-? Licensee: .&,,,, % Signature LIC. NO.:4L7 f 3 �y (If applicab e, en .r "erem t" in the license number line.) Bus. Tel. No.• r% - 2� Address: Z.� . Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departm t of Public afety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By try signature below, I hereby waive this requirement, I Gin the (Cheek one) ❑ ownet ❑ Owfier's agent, Owner/Agent rPERMIT FEE: $ Signature Telephone No. ()-I � qqq 2Z51 29r -0n 5, 3" 7r X-8" X-19" 10, 8„ 3-0" x 5'-0" 3-0" x 5-0" 3-0" x 5-0" 2-0" x 2-2'-0" x 2-0" i (fl N th k 9-0" I O �i w O C* N � � N I s master bedroom tp coo ch O n o - bathroom k " , m, , ", 0-0" n 2 -0 x 2 -0. x 2 -0. x 2 -0 t� N 362- 5- 4"2 -3" 2-2" 16'-7" 29'-0„ � I I i i i i i i I I 0 E4. E� m awoo NOQird -- — 'rid OMIRLYSIHS �v %$ yfir=J•Q r71/✓A. 'I Y . • ��Q�� f � Y Y� AW3A *1 +'�► S c333o10 HZIs 004 ,Ag -Ms *479 b'f xv:J cloom v � { I u �• Ylogy-i"" ns 7c •"mow � .6� _ •• a /7f) �G1d2r�a '1X1 " F / Z\7 .00) COC. G�1 TC 0411-C. PL O T PIAN IN DRAWN FOR I HEREBY CERTIFY TO THE TITLE INSUROR AND TO THE BANK THAT THE DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE -MWIV OF N0. ,4"c0✓GY2 ZONING REGULATIONS REGARDING SETBACKS FROM STREETS k LOT LINES.' 1 FURTHER CERTIFY THAT THIS DWELLING IS NOT LOCATED IN E FE ERAL LOOD HAZARD AREA AS SHOWN ON F CO PANEL f z5oa c' 8 0003C.�a OR72 bA rE THIS `PLAN- FOR MORTGAGE PURPOSES - NOT FOR BOUNDARY DfTERf,PidTION BOUNDARY INFORMATION TAKEN FROM EXISTING RECORDS. M •/y�90 -510111? Y /"IC3 d - /1/103r/ e. Y /2 cic.41- Y i MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 018101 i Location��^� No. J Llif Date ~ TOWN OF NORTH ANDOVER Certificate of Occupancy $ �' b •'c�' Building/Frame Permit Fee $ �ssncNust Foundation Permit Fee $ Other Permit Fee TOTAL Check #-3 18753 `Building Inspector U f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATf2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMB DATE ISSUED: SIGNATURE: l Building Commissioner/I r of Buildin2 Date .,,ua.a.vi. a-uaais u�rvMaAllV1� 1.1 Property Address: 1.2 Assessors Map and Parcel Number: .2s Co13 I I 'All A -.,do yc:> e-- Map Numfier Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: t-11 210 � .-Zoning District Proposed Use I Lot Area Frontage�t% 1.6 BUR DING SETBACKS ft Front Yard Side Yard ,;2 % Rear Yard` R redProvide R 'red Provided R uired Provided 1.7 Water Supply U(ift.40 1 1.5. Flood Zone Infomution: 1.8 Sewerage Disposal System: Public Private Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes _ No ' 2.1 Owner of Record Name (Prin Address for Service: Signature Telephone i I 2.2 Owner of Record: 411 /Q 61, i Name Print Address for Service: Signature Telephone ' SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ ,eo /�� 1 ✓_ Li used Construction Supervisor: S 0 o 23 , 11�21License Number Addre3WA,�-3b o /0,6 / i Signature Telephone Expiration Date r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address --- — Expiration Date Signature Tel hone rVKm U - LV 1 KGLGA�C rvRm /Q�Z3/—aQ� 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��L - LOCATION: Assessor's Map Number SUBDIVISION p STREET v2 S 4 I/ � G y -e Ak TOWN OFFICIAL USE ONLY PHONE F`3 PARCEL I LOT (S) ST. NUMBER DATE APPROVED G,I\Y 1112�9� DATE REJECTED �— I TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS I i FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED i . SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED i PUBLIC WORKS - SEWERIWATER CONNECTIONS ! i DRIVEWAY PERMIT FIRE DEPARTMENT I .7ECEIVED BY BUILDING INSPECTOR DATE R*VINW 9%97Im The Commonwealth of Massachusetts Department of Industrial Accidents ~° I„ Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Le Name (Business/Organization/Individual): Address: R ie 5s City/State/Zip: !V�d Phone #: 1�<O'/ 4110 3 Are you an employer? Check the appropriate box: . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.)2 1 am a sole proprietor or partner- ship and have no employees 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 have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. ❑ 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 (requr 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions i 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.F Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I I do hereby certify under the pains and penalties of perjury that the information provided above is true and 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 #: NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined 6y MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: f C® -v r-4 ,�„ "� 10" (Location of Facility) Fire Department Sign off: Dumpster Permit Signature of Permit Applicant Date 'tEXT. " PLYGREpOAp�D WMATWNG 2x4 MW IsLpK UV SCREEN 'lI4THOU.r CL08E0 SOFFIT llf�:2YA SUB -FASCIA IMETAL raUTTER CONT. VENT " Ad,a t. 4-4 -e-- 2xis Gtr8 ej•`whew �s 71K` 0.8.8. BOARD SMATNK40 cn 29'-0" /r-----5-3" 3-8" 7r 3-9" 10'-8" 2=9" 2=11 "-� 3-0" x 5=O" X-0" x 5-0" 3-0" x 5-0" 2-0" x 2-2-0" x Z-0" � M r cp N X i 4 00 N � C31 ; k A W 4 '- O W (V O X master Fbathroom bedroomZk��Cn k r " r r"r r rn 2 -0 x 2 -0. x 2 -0 x 2'-0" F, N 3'-0" x 5=4"--+-2-3"4-2-2" � v" 29'-0" i �k� ocO _ GgTE 04 /t_G'. " I HEREBY CERTIFY TO THE TITLE INSUROR AND TO THE BANK THAT THS DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE -Mw.., OF Na.,oni0✓6',? ZONING REGULATIONS REa4RDING SETBACKS FROM STREETS k LOT LIKES." " I FURTHER CERTIFY THAT THIS DWELLING IS NOT LOCAVED IN E FE ERAL LOOD HAZARD AREA AS SHOWN ON F CO( PANEL f -2-50098 0003 C ._ 4 OR72 r, -z-9-3) $T1'H$ .1S' �G.bATRI THIS `PLAN FOR MORTGAGE PURPOSES - NOT FOR BOUNDARY DRfER figiTION.. BOUNDARY INFORMATION TAKEN FROM EXIS1`ING RECORDS. M .�yi90 X PLOT PLAN IN N012T7-1 /�iyoovc I , HRS57. DRAWN FOR I S/t�NG Y r✓�r� c y rz 1- 4. Y ZO MERRIIlACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 I �-dl ChIp" 41 I V • z tR x z � z v O � � w � O w a r'1 Wl � w a �II w Cqcn .[ w° cn w° c°4 v U w O pG cd C w" V O c�: G w O w ca' °co cn G cn c c m c o LZ c ` h • � C 3 O V CL C R R L O O � EQ :.R o o a E� .00 a C2 c_ ts CD C c h :mm o �3co cm m� C c � N1 co E� COL COS • C �Q H Qct co aZ CL m N C S m CL 4- 0 Ly 0C +�+ .y dt C a �- .0 QE ca CD ��CD f/� a O ' C -0 S w a F- z $ CL 4- E it Go SCA W cm O cc co S m 0 cm c M N m t O Z O 0 G C C.— CO) p 'C W i � y O O '� m m CL �' ♦_-. t C c 3' � O �CD CD 4 CLL cc cc Ol a cMa eCv V 'fl C 'ICD CD C. l y cc E W Q U) W 19 W OWC W U) z � � z v O � o w � O N ..., r'1 Wl G C C.— CO) p 'C W i � y O O '� m m CL �' ♦_-. t C c 3' � O �CD CD 4 CLL cc cc Ol a cMa eCv V 'fl C 'ICD CD C. l y cc E W Q U) W 19 W OWC W U) V z 1 ui _ H °C y Z 40 r c� o ` w � c 0 .a •, � ~ rZ i �� U) 1� l ° ♦�' IV- U � ° M o CD c w° :z o C8V) C/) ui _ H °C y Z 40 r c� o ` c h o c 0 .a c ao o CD c :z o o Cc CO Ea 2 c m�o o a E c :0m c� V w 's cm O c_ E y :mm L. CC CO Q1 m y =m •;.0 C Ca y C M � y O o o aC � m ' r.+ •p c ' c0a acs m cf S m H C.3 Z O CZ o ` co c S •c m y O c m im�3 N $ y oL. o� m Z •y CA c •- C •E = •C v vi = o CMO a O� �10 y C Cyp =�amm� 6 cop) Q H O .CO2 � m c0 CD 0 03 CL CD O O O Cc O a a_CMa CO2 O O d O CD CO2 Zt CL L) CO) � C! ca C C � =I d ! YI N W W ce W co ,_ v Date. /.-ll,,,q(v,... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................. has permission for gas installation . ..--�- ........... . in the buildings of ...! .... U........... ............. . at Fee - Lic. No..W,., . Check # C;;= 3 5432 North Andover, Mass. �f GAS INSZ( MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN'G r_ (Print (x Type) i .-Mass. Date –� C� Permit j 8ugding Location !�� Owner's Nameir New ❑ RenovationNh Replacement C] Type of Occupancy Plans Submitted: Yes❑ No ❑ Installing Company Name 'Fss 1 [7 (SIC - Address -lea L—A 1!;�C Check one ❑ Corporation ❑ . Partnership Certificate i Bus!ess Telephone !jig Q67 !k4Z [DFirm/Co. Na of Licensed Piumber or Gas Fitters INSURANCE COVERAGE: I I have a cu eat liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑ fi you have checked Vis, please Indicate the type coverage by checking the appropriate box. A liability insurance policy's Other type of indemnity ❑ Bond ❑ I 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 wa-�es this requirement. Check one Owner❑ Acer; ❑ Signature of Owner or Owner's Agent -- I hereby certify that all of the details and information 1 have submitted (or entered) in above a.pplicati true_ and ato the best of my knowledge and that all plumbing work and installations performed under the rmit issued for this . pli n xu a th m lianoe v all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of e Gen r flaws. II B>' T of License: � d ' I i umber gnature of Lice sed Plumber cr Gas ter + True Gasfitter qvzster License Number FA I2C0_7S_ City/Town JoumeyTnan I t NL • i • ar ®N OEM MENNEEMEtEEMENEREN Eft ... ■t��t��t�tt/��//��■ .. - ■��t��t��tt�t111■■fit■ Installing Company Name 'Fss 1 [7 (SIC - Address -lea L—A 1!;�C Check one ❑ Corporation ❑ . Partnership Certificate i Bus!ess Telephone !jig Q67 !k4Z [DFirm/Co. Na of Licensed Piumber or Gas Fitters INSURANCE COVERAGE: I I have a cu eat liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑ fi you have checked Vis, please Indicate the type coverage by checking the appropriate box. A liability insurance policy's Other type of indemnity ❑ Bond ❑ I 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 wa-�es this requirement. Check one Owner❑ Acer; ❑ Signature of Owner or Owner's Agent -- I hereby certify that all of the details and information 1 have submitted (or entered) in above a.pplicati true_ and ato the best of my knowledge and that all plumbing work and installations performed under the rmit issued for this . pli n xu a th m lianoe v all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of e Gen r flaws. II B>' T of License: � d ' I i umber gnature of Lice sed Plumber cr Gas ter + True Gasfitter qvzster License Number FA I2C0_7S_ City/Town JoumeyTnan I t NL 2 1--04 Date.............. 149.................... '0"T TOWN OF NORTH ANDOVER -It PERMIT FOR WIRING This certifies that ......... ......... 402� ..................................... ..................... ( ....................................... has permission to perform---.7-:-,/� — 6 ' 111; �11 wiring in the building of.;4j,*-/ .............................. at A' ..... X,4. ............. North Andover, Mass. Fee�............... Lic. N—A ... /.y. ... &.e.Y. �.2 ............... �1 ........................... ELECTRICAL IN ' Check # c 6Jr 3 R Commonwealth of Massachusetts Oficial use only Permit No. Department of Fire Services o� Occupancy and Fee Checked � r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank i APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 1 All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 ' (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /a,/oV,, City or Town of: Ane-loUPe_ To the Inspector of Wires: t By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) o25- CDI(?r,Qke. De"k Ve, Owner or Tenant Owner's Address 1`y Telephone No. q7, -O)', X83-6Str,8 Is this permit in conjunction with a building permit? Yes E9" No ❑ (Check Appropriate Box) 1 Purpose of Building t D i rp g � c�a � Q -�. M �1.� � p iM �. Utility Authorization No. S 5 � � (y' Existing Service i tDO Amps 1d0 /) 4 0 Volts Overhead Undgrd ❑ No. of Meters New Service 900 Amps 17.() /,9-40 Volts Overhead ['� Undgrd ❑ No. of Meters 1 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �n4 100 Ar,%A S2 cui aUC) A,rnQ sery% QQ. v Completion of the following table may be waived by the Inspector of'Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total i Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool rod. bode ❑ n -rod. ❑ o. o cy ig tog , Batte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. o election and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of elf -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other 1 Connection , No. of Dryers Heating Appliances Kms, SecuritySystems: No. of Devices or Equivalent No. of WaterKW o. of No. of Data Wiring: 1 Heaters Signs Ballasts No. of Devices er Equivalent ! No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent �. OTHER: Attach additional detail ifdesired, or as required by the &rTector of Wires. ' INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless uii, iia,iis."-n'.i r^v'viuiil proof Wi iuviiii insurance including 66Completed operation" coverage or its substantial equivalent. The undersigned ert'i^fes that �5�3ch cover gte'if to force, and Inas exhibited proof of same to the permit issuing office. t_,RECK07NE: INSURANCE 71JViil} ❑ iJ1. 1L1 ❑ (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /,z d ; Inspections to be requested in accordance with MEC Rule 10, and upon completion. I I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: An c� c e _u) t�h'� }�2y Signature LIC. NO.: A 19 30 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: t003 So, Ir 4 I S I Address: IO S -r ScL�erh Q �1 03Cr?�( Alt. Tel. No.: tw3 '10 1 — lq!o(o OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 557, 0O Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only \ Permit No. ( 319— Occupancy and Fee Checked [kev. 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /,Z%24, /%� `a City or Town of:i�>..'� 1 j j J, ��/,; ,t r� 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 S ('cAecka -kc'_. ;1 t Owner or Tenant A, Telephone No. c -� Owner's Address Is this permit in conjunction with a building permit? Yes I Purpose of Building No ❑ (Check Appropriate Box) Utility Authorization No. 7 U � U V (a Existing Service i (Y3 Amps iA L),40 Volts Overhead Q New Service -)(20 Amps 11.0 /X40 Volts Overhead Number of Feeders and Ampacity Undgrd ❑ No. of Meters I Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: CC) A,., u -40C) fe)- 0 Completion of the following table may be waived by the Inspector of Wires. No. of Recessed FixturesNo. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ n- ❑ rnd. grnd. o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners of Detection aad No. Initiating Devices No. of Ranges No, of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munic'pal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. orDevices or Equivalent No. o. o Water Kms, o. o o. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: .attach udditionut detail ij'desired, or as required bV the InsIvetor oj-{fires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless `:i4. +,....,i_.:.:. •S4�villa..t �+Sti�Sl �+aide+aetY ti7�lli:lt3tie "completed operation' coverage or its substantial equivalent. The u,:6_: ,s,;i_6+LL! iIi, s.iE>st �uci'� uvea- �e is it(fvitir. ditd itas exiiibArd proof of same to the pernllt issuing office. I iii lC QNt: 1.14iU (C spiralion t�attl Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /.z. / 6) ; Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, tinder the pains and penalties of periuty, that the information on this application is true and twinplete. FIRM NAME: LIC. NO.: Licensee: /a;�,� l y«�\ty Signature�tr:��^\i�.l\,r '��;�V LIC. NO.: + (If applicable, enter "exempt" in the license number line.)Bus. Tel. No.: tras;l `%`:`s `l t' Address: IQ Ix .\,\.i:ryls }z 5,,,Ae yN Q --A 01�1(:' Cf Alt. Tel. No.: L.c'3 90t -it OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normall,r required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a Owner/Agent Signature Telephone No. PERMIT FEE: $ l /P qji Date......... .. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ` 4 � J This certifies that ........G?'� ;--'.......... . has permission to perform .. �`-- .................. . 'F plumbing in the buildings of .��-�-��-j� ..................... . ai ' ................... U ... , North Andover, Mass. Fee .�4 .' .. Lic. No %%� +� . --� AV ........... UMBQq', NSPECTOR / 1 Check # 67Z5 a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING o, (Print or Tvne) o P�?IF-, , Mass. Building Location 2s, &D- /E, Date _t—_L-1E2'"5 ~ Permit# cl- yi?_- Owner's Name 44-^C (C Type of Occupancy New ❑ Renovation R_ Replacement `, FEATURES Plans Submitted Yes ❑ No ❑ I Installing Company NameLL��f1T5rC� �Oz Check one: Certificate Address /5, bCraa -jr - ❑ Corporation /Zar.144 Off ❑ Partnership usiness Telephone 9;0 as-- 9041 ❑ Firm/Co. Name of Licensed Plumber INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy V. Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations.perf rmed under the permit issued for this application will be in compliance with all pertinent provi ribns o t(/he ett S ate' P mbing Code and Chapter 142 of the General Laws. By Signature o icense Plumber I I Title Type of License: Master Journeyman ❑ ; City/Town License Number I APPROVED OFFICE USE ONLY) zz Z Y Q I F- cn -jV. O q Z W W W Y Q� Q= F- Z O 0 OJ �I I1J W u)= W Q Cc W () Cl) Y i d Q(L Q� X v z D¢ Q w M 2 a W Z o Q (n z oC rr OLLJ• u_ W 2 Q 2 0 2 Ja. F- Q `e �Oir J Q> F- Q O CQ WQ D Z O O (� Z Z W O U 2 S Y Q J CZ l W: Q Q J O 2 Q F- J (n J u- Q in X 5 o Q3: Q O a: Q m F- O SUB-BSMT. BASEMENT 1ST FLOOR j 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company NameLL��f1T5rC� �Oz Check one: Certificate Address /5, bCraa -jr - ❑ Corporation /Zar.144 Off ❑ Partnership usiness Telephone 9;0 as-- 9041 ❑ Firm/Co. Name of Licensed Plumber INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy V. Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations.perf rmed under the permit issued for this application will be in compliance with all pertinent provi ribns o t(/he ett S ate' P mbing Code and Chapter 142 of the General Laws. By Signature o icense Plumber I I Title Type of License: Master Journeyman ❑ ; City/Town License Number I APPROVED OFFICE USE ONLY) 6276 Date .... 1. ?7. — / S-- 0 5— ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �—%-e This certifies that ....... ..... .................... has permission to perform ... eX-i� ... ..................... wiring in the building of ......1.y . .... /;!�� ........................... i / ........................ at ......... D North Andover, Mass. Fee,Zs.... Lic. No/ V!Iq ........................ fj.4?... ELECTRICAL INSPECTOR— Check # —9-649—/— Commonwealth of Massachusetts Official Use Only - _ Department of Fire Services Permit No. `mak Occupancy and Fee Checkedl BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 i (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /Z lmlao , City or Town of:�,k,/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) Owner or Tenant 6i3 4(y�n� `;`; li/ [�,, ` h Telephone No. Owner's Address Z--- o nl o n n -4P Is this permit in conjunction with building permit? Yes [� No Purpose of Building Utility Existing Service Ion Amps /-2.0 1,2- V 0Volts Overhead EK New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity ❑ (Check Appropriate B6x) Authorization No. Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: i ,,> � rk'r,, 4 A Lo %4k coc rvt ar ✓1 r4 a sic r — Comnletion of the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA. No. of Lighting Fixtures Swimming Pool Above ❑ In- d1:1 rnd. rn. o. o Emergency ig mg Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and j Initiating Devices 1 of Ranges No, of Air Cond. Total Tons No. of Alerting Devices INo. No. of Waste Disposers p Heat Pump Totals: - Number Tons KW No. of Self -Contained I Detection/Alerting Devices I No. of Dishwashers Space/Area Heating KW Local ❑ M n icipa n El Other' No. of Dryers i'3' Heating Appliances KW Security Systems: No. of Devices or Equivalent' No. of Water Heaters KW o. o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent i No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent i OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covers a is in force, and has exhibited proof of same to the permit issuing office. I CHECK ONE: INSURANCE ;OND ❑ OTHER ❑ (Specify.) (Expiration Date) Estimated Value of Electrical Work: _ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: A adw-w 0110jey Signature LIC. NO.: 4 ,036 1 (If applicable, enter "exempt" in the licede number line.) Bus. Tel. No.: 663 94S 04 Address: /l� A);)I»9m6 5f �A /rm /UN 433 y Alt. Tel. No.:/o43 �i0/ —) �/o& OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally j required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ $S I Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only',, Permit No. Z, 7 Occupancy and Fee Checked tev. 11/99] (leave hlank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /Z /&)/Q; City or Town of: -qn, >l,,yP 2 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) _ Cn I p c, 4 P 1D S" 1) g 9 I Owner or Tenant 5i d 4 1 I r / L1, ,-,,, a, Telephone No. �c- 76 Owner's Address C 0l e n a i2_ Is this permit in conjunction with a building permit? Purpose of Building Existing Service /0() Amps /z0 / z yy Volts New Service Amps / Volts Number of Feeders and Ampacity Yes EZ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead Lam" Undgrd ❑ No. of Meters_ Overhead ❑ Undgrd ❑ No. of Meters i Location and Nature of Proposed Electrical Work:r 1,kC nu r4 lle,.L iYl l�ncc()M c7 vi� a� e�— Completion of the follow4nQ1table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA 1 No. of Lighting Outlets No. of Hot Tubs. Generators KVA No. of Lighting Fixtures Swimming Pool rnd. Above 11n- rnd. ❑ o. omergencyiging Battery Units ' No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Tons I KW I No. of Self -Contained 1 Totals: Detection/Alerting Devices 1 No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection � No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW 0.0o. Of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: E01 Attach additional detail if desired. or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that suchCovera a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE he ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) 1 Work to Start: 12 /vs Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: A i��ePGc� 15) Max Signature LIC. NO.: 41 e3ci/ (If applicable, enter "exempt" in the licen a number line.) Bus. Tel. No.; &�3 .F3,'• 4/S Address: /J SA lr"m /U/� 45571 Alt. Tel. No.•1%'a3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ � � t Signature Telephone No. S Location C—;) ` ! No. / J Date TOWN OF NORTH ANDOVER /• A At Certificate of Occupancy $ �CHUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # / V "*I Z. -- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: r ^- ✓"l CC S SIGNATURE: Building Commissioner/I for of uildin Date SECTION 1- SITE INFORMATION 1.1 Address: 1.2 Assessors Map and Parcel Number: �Pro—peity Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (so Frontage ft 1.6 BUILDING SETBACKS 11 Front Yard Side Yard Rear Yard Required Provide Required Provided Re 'red Provided 1.7 Water Supply MGL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: 09i Signa r Telephone , 2.2 Owner of Record: i Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Li c Construction Supervisor: Not Applicable ❑ . t7� r ✓i �/7 1-4 G JI I � �� Licensed Constriction Supervisor: l J '�l� C� License Number ` � S� i3r✓�'i�iLFf., j' L rr '�'l �KV��K � - - - — - - Address � F 7 ExpiratYon Date Signature . Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ PAo N n 41'i s Z -- Company Name Registration Number (�/ % i3 t • rA 1-1 ✓-r yyl .tel o Ad ss 7 Expiration Date { nature Telephone 1 o A ® a ® 0 E-, c a z w a O y L2 cn w° a U w w -� a CLC cc A m C .. Q f I o � 1 CD Z C. O CA cm I C C Q ■� CA Q CLQ CA 'E m m CD � O O O L CSC O � ca. cca = a =Z = c Cc CL o 0D co C CD CL C.3 CA O C CO _. y R. 0 CD U) ccW W ccW V/ c 0 o I O y C •C� CLC cc A m C 40j; p �a �.C ® con S d� o o c E O y t 3 I� : y C •- O m C y y � C 0 �_ m o C • 0 PC h O m =OOmUlC w C a fA d=am t O m v •� .0p c ` ocm CD 0 CIL0 CD W Cc =CD o .y O H W E C =_.+ v .y Z O LO CL Ca OmE= g m40 a o h O f I o � 1 CD Z C. O CA cm I C C Q ■� CA Q CLQ CA 'E m m CD � O O O L CSC O � ca. cca = a =Z = c Cc CL o 0D co C CD CL C.3 CA O C CO _. y R. 0 CD U) ccW W ccW V/ Town of North Andover V%ORT#f Building Department 27 Charles Street North Andover, Massachusetts 01845 x (978) 688-9545 Fax (978) 688-9542 °�s °O°p, I.K•,,'� caaus�� ti 1 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Sign)�Se of Ap meant Date NOTE: A demolition permit from the Town of North Andover mu st be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: i City Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity E/24m-_a employe roviding, workers' compensation for my employees working on this job. companyname:�/ 1-e ti t s c, N S 2 c�c, �_'t Ni G C V S rt C 'I Address 5 i , ✓L r(� fv 1 City: Ant- ;'POEN A Phone # T , L" s C11F Company name: Address v13 - G -M --Go City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) 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. I do herby certify the pains and penalties of perjury that the information provided above is true and correct. (./. 1,7 Print name r+-1 Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: Phone FORM WORKMAN'S COMPENSATION /.Z --7o a ( ❑ Building Dept 1. ❑ Licensing Board ❑ Selectman's Office _ ❑ Health Department ❑ Other I 1 RAYMOND E. DAMPROUSSE, JR. AND SONS ; ROOFING CO., INC. 1 BOX 431 LAWRENCE P.O. �y MA. CONSTRUCTION LAWRENCE, MA 01842 , L SUPERVISOR LIC. #046636 TEL: 683.4588 HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSULATION Date From:' .) , (N eme) (Add,...) To: RATNOND E. DANPNOOSSE, JR, AND SONS ROOFING CO., INC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 I (we) hereby authorize the Contractor to furnish all materials and labor necessary to install, construct and place the Improvements described below in -on building located at No. r "Street, City 'A/ , ;..� A,,; �.' ' State ?i. 1 in accordance with the following specifications: f t 1,1 1 1 1� .I 1 1 1 1 1 1 10 C, BUILDING PERMIT 01Xt%OR 9�.Q '[ TH TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION q -« Permit No#: ` Date Received.f 4" gSSACHUs�� Date Issued: ibi I ORITANT: Applicant must complete all items on this page LOCATION" PROPERTY OWNER MAP PARCEL: F Print 100 Year Structure NING DISTRICT: Historic District Machine Shop Village yes (DI yesyes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building T One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition❑ Other �T ❑Septic ❑ U1lel1 ? a 0• Floodplain 11 Wetlands ❑ U1/atersheds Distract; CRIPTION QF WORK TQ BE PERFORMED: Identification - Please OWNER: Name: Aritimcc- Contractor N me: Email: neo, Address: 4 In or Print Clearly Phone: Supervisor's Construction License: Exp. Date: Home Improvement License: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.• $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ "?-�- `) 1. �� An FEE: $ 4(.P — Check No.: �� Receipt No.: �'l� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinnning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature, Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes j Planning Board Decision: Comments ,i 3 Conservation Decision: Comments Water & Sewer Connection/signature Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,,FIRE B�EI'SAR!TMENT�Tem D�umpser ontsite>yes-�:`°:r�� t cated at 124 ain Stee'`re Department �i .•,�,,.,� r= ...=r..i , �� = i�c" ..�`�3f'�A �� '►��. '�„�� '` z , 4�. a .�' 'l�r�' r` ca �a - � e�- i �-""'�r—•� �:..� � �_..,�..,., ��'�"ri�t 4, t X!i �.. ,�.'�I r�•`�f r��X �l .,�s,_. �� '*�.'t��:r� a `� } an�..@.rx.a,a.�4-'4t4�fi+•G"s ;ysjyi^t t• „., a } ��t'§ t a '`1.,, '7. rtt+�'q* Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: lies MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Nu I Ls and UA I A — wor aepart ment use L3 Notified for pickup Call Email m Date Time Contact Name 3 Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract � Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products . TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) • Building Permit Application • Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 4 2012 IECC Energy code 4� Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location 2 v� C` '�(Z- v C No. It�2 cl 7_U � 0 Check # t a D 3 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ f -- Foundation Permit Fee $ Other Permit Fee $ .,4 TOTAL $ Building Inspector L-' Ems* n y w LL D 0 m O L 1_+ \ O LL E +�+ U Q. V1 p a Z Z m C O f4 "O 7 LCL L = LL' C U LL p u v, Z Z CC J �• L 7 d' LL O a (n Z U J W L 7 d' U •> In @ LL oc O v a Z L 7 N LL F - Z LLIa Q Lu a uj LL N i m O Z ++ 41 N 4i Q Y O N O cc v o 'C. L CL tL =j o' JW N V Q ✓ L N _ W 0 � • �+ C) _ Qh _, y L. N d M �J t/1 L �m cm 0,0 - "a ._ o as o z CL — H C o ac .N 3 ami c ° � Q. o. d ami 0� c .y ++ _ co v Ow O = _ CL uj •� °� m = 'o. o Ln - =-W-W W E U0.-= V Q. o -a 0 +r CLy°'>y= c N -= O tz- .S C.ov AJ E I- 4) d CL �a U) _ In L- 0 O _ .O N d s 0 z O 2 Z O G to Z W w 0- x W CL cn J. m rm-7 .a d 00 I- CL CL �a CU ca J 'O O Cl) Z CL ^N Federal 10 # 05.0405628 RUSE Engineering RI Contractor Registration No Milli MA Contractor Registration No 120979 RISE A division ofThiclsch Engineering ENGINEERING" 60 Shawmat Unit #2, Canton, MA 02021 CONTRACT 339-502-6335 FAX 339-502-6335 Page 1 PROGRAM 7X6 CONTRACT m ErrTEREO WO aE IME£N IUSE CMA -HES ENCINU 4MOnMCWTOMERFORWORKAS WSCRIM OSELOW ......_.........................._..__..�...._._..____.._...._ ...___...._,..,.,.T._ .,_......... ......,.._.. ...... _._ ._._,...._... ........... _.._....... .- w...____._....—.._....w....•......._.._._........_.........._—._.._..1.._...__..._......_._._. CUSTOMER PHONE DATE CLIETrr A Timothy Mcguire (978)314-3987 02/05/2016 419480 ;WORK ORDER 100003 ....... ..w _.....::._..... _,... _::._,,....... _.w_.. ___.....� _...,.__ ...., _.._ SERVICE 8TREET eltitR6 ST(R;ET 25 Colgate Drive 25 Colgate Drive BItJJH6 CITU, STATE,7JP.__....._.._. ......_..... .,,. > _ . _ _:.. , • . Nardi Andover, MA 01845 North Andover, MA 01845 _..... __ __...... _._....__.___ ; ,3 8 -20Z t+� � € - JOB JOB DESCR[PTlON '= y HAZARD HARRIER: We have identified that then, are recessed lights present in your home, unless the recessed lights are ocrtifted i as IC -rated (insulation Contact Rated) we mill create a 3" clearance space around the fixture by using fib«gtass blanket insu"1 Pion damming material, no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. ! I ` 50.00 AIR SEALING: Provide labor and materials to seat areas afyatr home against trnstefill, excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seat your home can include caulks, foams and other products. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (windows ure not generally addressed.) This will require (8) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cfm is not guaranteed. Il At the,compiction of the weathcrirAlion work, and at no additional cost to the henreoWnct, a final blower door and/or combustion Why analysis will be conducted by the sub -contractor to ensure the safety of arc indoor air quality. I I !$680.00 AIR SEALING: Provide tabor and materials to seal areas of your home against wastcfui, excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests 10 assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary areas for scaling include air leakage to attics, basements, attached garages and other unheated arms (windows art: not generally ! addressed.) This will require (2) working hours. A reduction in cubic feet per minute (cfm) ofair infiltration will occur, but the actual number of cfm is not guaranteed. ! At the completion of the weathediAtion work, and at no additional cost to the homeowner, a final blower door and/or combustion i ! safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. $170.00 AIR SEALING ADDER: (4) working hours. I $340.00 DAMMING: Provide labor and materials to install al r layer of R-38 unlaced fiberglass baits to (I00).square feet for damning Purposes. I 5201.00 ATTIC FIAT: Provide labor and materials to install a 4" layer of R -I4 Class I Cellulose added to (192) square feet of open attic t space. I $21,6.96 ATTIC FLAT: Provide labor and materials to install an 8" layer of R-28 Class I Cellulose added to (12 10) square feet ofopen attic space, I 51,617.70 Fix exisTiNG iNSIILATioN: Sheth the vapor barrier, flip, or rc:-position (192) square feet of insulation in the attic area. I $48.00 MIC IC ACCESS: Provide labor and materials to insulate the back of (t) attic hatch with 2" rigid T herrnax board. Weatherstrip the j perimeter. I $6040 I Federal 1O 0 064 RISE Engineering RI Contractor Re RISEAContaactorR division ofThlclsch Engineering ENGINEERING 61)ShawatultUnitffi2,C2nton,MA02021 CCiNTR 339-502-633.5 FAX 339-502-6341 Page 2 PROGRAM THIS CONTRACT RS 0 CMA-HES ENGINEERING AND Ti DESCRISED MMM CUSTOMER ........ ........... __._.._._. _._... PHONE DATE Timothy Mcguire (978)314-3487 02/05/2016 419480 90003 SERaVICE STREET - -__ ___.. _.._...._....... ..._._............ SLUNG STREET... , .. .._. . _._....... �a »• Wim ....... 25 Colgate Drive 25 Colgate Drive,;" , __ ,__ ......_. ..,.._.......... �,..._.._............... _.. _ ._..... , �_ � .._... _.., i........,- aERva6E pTY,!TATE LP SLUNG CITY. STATE, YIP North Andover, MA 01845 W North Andover, MA 01845°] I ' .. JOB DESCRIPTION I VFN*nl.ATION: Provide labor and materials to install ventilation chutes in (46) rafter bays to maintain air flow; $92.00 RASEMEN7 CEILING: Provide labor and materials to install (146) linear feet of R-19 unlaced fiberglass insulation to the perimeter i of the basement ceiling at the house sill. I I I $255.50 RISE Engineering will apply all applicable, eligible incentives to this contractYou will only be billed the Net amounL Currently; I for eligible measures, Columbia Gas offers 73% incentive, not to exceed S2,OW per calendar year, and an incentive of 100% for the I Air Sealing measures up to the first $690 and an additional S340 if savings arc justified by the auditor. i I For the safety and health ofyour home's indoor air quality, we will be conducting a blower door diagnostic or the available air flow in your home both before the wort: is begun, and after the wentherization work is complete. We will also conduct a full assessment of the combustion safety of your heating system and water hcater. 'chis has a value of $90 and is at no cost to you. Total allowable I wcatherization incentive is $3,110. i Sh0.00 i i i1 i I I I Total: $3,815.16 Qu a� ,� Program Incentive: $3,110.01 r ( Customer Total: ST05.1 WE AGREE HEREBY TO FURNISH SERVICES -COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATION& FOR THE SUM OF I ***Seven Hundred Five 815/100 Dollars $705.151 I UPeD ru" INSPECTION ANO APPROVAf. SY "I, ENGWEEpUe2:. CUSTOMER AOREES TO REMY AMOUNT our IN FULL WTWKST OF 1%W" SE CHARGED MONri0.Y ON ANY I - WaSAEI BALANCE Af'rER 36DAYS. SEE REYERII£:FOR IMPORTANT NNFORMATROH ON DUARAtNTEES. -M-NTa 9!!! p *R. SCNEDUedNO, ANO CONTRJ{GTOR REOINTAATIDN. DO NOT SIGN THIS CONTRACT IF THERE ARE! A5�11( SPACES aIRNA - Atlk�nI/bS9 CUSTOMER ACCEPTANCE I NOTE: TSD CONTRACT MAY BE WITHDRAWN By US IF NOT EXECUTED WITHIN GATE OF ACCEPTANCE ..„... . ",S ACCEPTANCE OF CONTRACT : THE ADM PRICES. SPECIFICATIONS AND CONDITIONS ARE 30 D* AS SPECIFIED. PAYMENT WILL BE MADE AS OVTU�NED ARM AU7HORIIEp TO 00 TNEWt1RK The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 I i www.mass.gov/dia i Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nlicant Information Please Prinit Le2ibll Name (Business/Organization/Individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd Citv/State/Zip: Nashua NH 03063 Phone #: 603-324-1974 Are you an employer? Check the appropriate box: . ❑✓ I am a employer with 100 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance req u red.] 3. ❑ I am a homeowner doing al I work myself. [No workers' comp. insurance required.] T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have 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): I 6. ❑ New constructi6n 7. ❑ Remodeling 8. ❑ Demolition I 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repair or additions 12.❑ Roof repairs P/1 Other Other Weatherization *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy inforniation. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees. they must provide their workers' comp. policy number. I am an emplgver that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE American Insurance Company Policy # or Self -ins. Lic. #: WLRC 48151553 Expiration Date: 6/30/2016 Job Site Address: City/State/Zip: NAIUPC ©�� J I Attach a copy of the workers' con4ensation 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 penllties 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 herebv certifv under the pains and penalties of perjury that the information provided above is tare and comet. vVJ--%LT- 1.1/' Official use only. Do not write in this area, to be completed by city or town of City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 6. Other Contact Person: Phone #: 5. Plumbing Inspe�tor I I `- CERTIFICATE OF LIABILITY INSURANCE MED EXP (Any one person) DATE(MM/DD/YYYY) 06/2412015 PERSONAL S ADV INJURY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 0 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 BEMIEEN THE ISSUING INSURER(S), AUTHORIZED S4, OOD, OOO REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER I X POLICY ❑ PRO-❑ LOC IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, Isubject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT $4,000, 000 AOn RiskSerV1Ce5 Central, Inc. NAh7E: OTHER: Southfield MI office ACNE Ext: (866) 283-772? FAX (S00) 363-0705 ( ) (ac. No.). m 3000 Town Center E-MAIL v Suite 3000 ADDRESS: I 0 = Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE NAIL: INSURER A' Old Republic Insurance Company 214147 ("ca acudem Corn. INSURER B: ACE American Insurance Company 27667 20BINSURED 6Jimmy mmy Ann Drive 6 Daytona Beach FL 32114 USA - INSURER C: ACE Fire Underwriters Insurance Co. 20702 INSURER D: r INSURER E: ALL O'WNED SCHEDULED INSURER F: COVERAGES CERTIFICATE NUMBER: 570058348882 REVISION NUMBER: Z THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE EEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH'ICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE: TERMS, X HIRED AUT OS X NON -OWNED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PROPERTY DAMAGE Limits shown are aslrequested S 'TYPE m � OF INSURANCE S LICY EXP LTR iNSD VWD POLICY NUMBER h1OL`C YVYY I fMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LLABILITY MWZY30a 83a Ub 1� b/� LUl EACH OCCURRENCE $2�, 000, 000 CLAIMS-MAGEX❑OCCUR. DAMAG O N ED $2�000,000 PREh11SES E2 occurrence) ESCRIPTION OF OPERATIONS 1 LOCATIONS / VEMCLES (ACORD 101. Additional Remarks Schedule. may be attached if more space rs requi' vidence of Coverage RTIFICATE HOLDER Builder Services Group, Inc. A TopBuild Company 260 Jimmy Ann Drive Daytona Beach FL 32114 USA CANCELLATION�C SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE I EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VAT THE POLICY PROVISIONS. a�..e AUTHORIZED REPRESENTATIVE I �iSI 1 ©1988-2014 ACORD CORPORATION. All rights reserv6d. %CORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I MED EXP (Any one person) 325 , ODO PERSONAL S ADV INJURY 12,1000, 000 0 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S4, OOD, OOO v X POLICY ❑ PRO-❑ LOC JECT PRODUCTS - COMPIOP AGG $4,000, 000 m OTHER: o 0 A� AUTOMOBILE LIABWTY Mhri-B 304835 06/30/20IS106/30/20161 COMBINED SINGLE LIMIT � ("ca acudem S5, 900"Doo • ANY AUTO BODILY INJURY ( Per person) r O ALL O'WNED SCHEDULED Z AUTOS AUTOS. BODILY INJURY (Per awdentj d X HIRED AUT OS X NON -OWNED PROPERTY DAMAGE m � AUTOS Per a—d-1 UMBRELLA LIABI OCCUR, EACH OCCURRENCE � CJ EXCESS LIAR CLAIMS -MADE AGGREGATE DED P.ETENTION B WORKERS COMPENSATION AND WLRC48251553 06/30/2015 06/30/2016 PER EMPLOYERS' LIABILITY YIN All Other States OTO - y` STATUi E ER ANY PP,OPRIETOR/PAF.TNEP./EXECUTIVc C OFF ICER'mrEMBEREXCLUDED% N/A SCFC4815190 06/30/2015 06/30/2016 EL EACH ACCIDENT $1,000,000 (Mandatory b Iun If yes, tlescnbe ander Wi onl y E L. DISEASE -EA EMPLOYEE $1 , D00, OOD DESCRIPTION OF OPEERA71ONS below I E L DISEASE -POLICY LIMIT S1,000,000 — ESCRIPTION OF OPERATIONS 1 LOCATIONS / VEMCLES (ACORD 101. Additional Remarks Schedule. may be attached if more space rs requi' vidence of Coverage RTIFICATE HOLDER Builder Services Group, Inc. A TopBuild Company 260 Jimmy Ann Drive Daytona Beach FL 32114 USA CANCELLATION�C SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE I EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VAT THE POLICY PROVISIONS. a�..e AUTHORIZED REPRESENTATIVE I �iSI 1 ©1988-2014 ACORD CORPORATION. All rights reserv6d. %CORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I . �� .�; l��. �\�{`� _ \J � �§ \ ?®\\ �� . :_ &\ 12, /�3 .\\ .\° \\� z \ \ E2\ § \ / / t \\� \\\ _ � ��\ \ \ f / w \ \ � I §_ƒ I §\ \ � } / � �\\ � : � i }$ � �} \ I )\ / I §3 I ) r �§ \ �� I / 12, O I- Q = LL O m Y \ O LL N a N u fl_ N 0z W IL Z z m C O N v 7 LL C 3 OC N C U _ LL LU N Z Z J C t : d' _ LL U CLH N ? U W J W s 7 W N u j� N _ N LL OC O a N U) t O' w _ M LL i i i I Wu �I Q{ W LUm C LL I I L v m O z a+ N (% Y O N O O R C . •CL L CL ai C• O O U. w o =a O 0 L �J L in > C CD L O C d C N — � CF)0 N .Q Em- O a) z C.M— . N O O �i C Q�d � � c cc r •U) rt+ C tm v dMW O O C Q L L c 1- p y m v m WC 'a+_+ O O LL '2 • N N C gym � .2 Lu .E v m c L V Q O N O w M O �_- t . CLoV O LU Z (z o C'� m 0 or: z V LLI cn CL OL z W cn �w CL z N I N N W O E CD �O z !� �N DWl O .- 0 I� �Emm a 0 s AWO �+ d im O _Vm o �a cn ro V J Im •0-O U) z l� O ' 0 an ccr •� C Q •U Federal 10 0 05-0405029 A � . > , RISE Engineering RI Contractor Registration No 8180 MA Contractor Registration No 120979 RISEw A division of Thicisch Engineering ENGINEERING" 60 Shawmat Unit N2, Canton, MA 02021 CONTRACT �� 339-502-6335 rAX 339-502-6345 Page 1 PROGRAM TM CONTRACT 0 EtrrEmEo O7T0 eEzwEETr RISE CMA -HIS Aa ANO Tt{ts txrsTOMER FOR tYoror Aa DESCRfBEpeELOW _�_._...._.,_............ _.... ....... ....._._._...._.__..,,,.,_. ..�...__._.. _._._._ ,,..,._.. ...._.... ....... ------ ..... CUSTOMER PHONE ._.OATE CUEMS CUSTOMER WORftORM Timothy Mcguire (978)314-3987 02/0512016 419480 00003 SERVICE STUFFY on"NO STREET 25 Colgate Drive 25 Colgate Drive �. , _.._.. _ ...__._.. _ _. ___.... . .. .............. _._ _ ... _.. _ ._.... ....__.. __ _ w.. SERVIeE CRY. r3TATE, ZV IRLUNG CM.BTA-MW ' _ i...... W.,:,.: . North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION HAZARD BARRIER: We have identified that there arc recessed lights present in your home. unless the recessed lights the certified as IC -rated (insulation Contact Rated) we will create a 3" clearance space: around the fixture by using fiberglass blanket ir'isulatmn damming material, no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. $0.00 AIR SEALING: Provide labor and materials to seal areas ofyour home against wasteful, excess air kakatu. "Ittis work w8i be performed in concert with the use of special toots and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. primary I areas for sealing include air leakage to attics, basements, attached garages and other unheated arras (windows etre not gencrully i addressed.) This will require (8) working hours. A reduction in cubic feel per minute (cfm) of air infiltration will occur, but the actual number of cfm is not guaranteed. i At thc,completion of the weatheriration work, and at no additional cost Io the homeowTucr, a final blower door andlor combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. 5680.00 AiR SCALING: provide labor and materials to seal areas of your home against wasteful, excess air Icakage. This work will he performed in concert with the use of special tools and diagnostic tests to assure that your horne will be left with a healMl level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary I areas for scaling include air leakage to attics, basements, attached garages and other unheated arms (windows are not generally i addressed.) This will require (2) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cfm is not guaranteed. At the completion of the womtherirxutinn work, and at no additional cast in the homeowner, a final bknvee door andlex combustion safety analysis will be conducted by the sub -contractor to (,more the safety of the indoor air quality. $179.00 AIR SEALING ADDER: (4) working hours. $340.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unlaced fiberglass balls to (100) square feet for damning j purposes. I $20x5'.00 ATTIC FLAT: Provide labor and materials to install a 4" layer of R -t4 Class 1 Cellulose added to (192) square feet of open attic I space. $21696 ATTIC FLAT: provide labor and materials to install an 8" layer of R-28 Class I Cellulose added to (12 10) square feet of open attic space, I $1,657.70 FIX.EXISTING 1NSUL+1TION: Slash the vapor barrier, Flip, or re -position (192) square feet of insulation in the attic area. I $48.00 ATTIC ACCESS: Provide labor and materials to insulate the back of (t) attic hatch with 2" rigid'ilcermax (ward. Weatherstrip (lie -- perimeter. $60.6 i Federal 10 0 05-0405629 RISE Engineering *alion No 8186 MA Co traaContiacctor or �iMmilon Ne 120979 RISE A division of Thiclseh Engineering EiUGINEERING", � 60 Showmnt unit #_, Canton, MA 02021 CONTRACT 339-502-6335 FAX 339-502.6345 Page 2 PROGRAM TICS CONTRACT tS ENTERED WTO BETWM ME, CMA-HES ENGINEERING A "MCUSTOMEReoawat AS mcniBERaEt m _.. _........ _._...___.__ _ _. _ __ ._ _._. ,_... ............ m._ ._ _. ......____. ..._ .., __............ .............. .......___ CUSTOMER PHONE DATE CLIENTS WOMORDER Timothy Mcguire (978)314-3987 02/05/2016 419480 0603 SERYtCE STREET eI4AM0 STREET 25 Colgate Drive M�_.,..... _ .,... _...._. 25 Colgate Drive........ _._..... t1�= .. BERa+pE CnY, STATE, ». enLUND CRY. SYATE.2JP m-* .: ..,. �• ..,�..._. .. �_.. ';. North Andover, MA 01845 North Andover, MA 01845 I J.).. F 201 ... JOB DESCRIPTION'` I VENTILATION: Provide labor and materials to install ventilation chutes in (46) rafter bayx to mninlain nir Iluw. $92.00 BASEMENT CEILING: Provide labor and materials to install (146) linear feet of R-19unfaccd Qberglass insulation to the perimeter of the basement ceiling at the house sill. 5255.50 RISE Engineering will apply all applicable, eligible imxativcs to this contract, You will only be billed (k Net amounL Currently, I far eligible measures, Columbia Gas offers 73% incentive, not to exceed $2,000 per calendar year, and an incentive of 100'% for the Air Sealing measures up to the first $680 and an addilional 5340 if savings are justified by the auditor. For the snfcty and health of your home's indoor air quality, we will be conducting a blower door diagnostic of the available air flow in your home both beron the %York- is begun, and after the we nthcrization wart: is complete. We will also conduct a full assessment of the combustion safety of your healing system and water heater. This has a value of $90 and is at no cast to you. Total allowable wcatherirattion incentive is $3,110. $00.00 I I I I �I 1 t/,' 1 tJlh'L r 4 % Total: $3,89516 Q a ow 0-H. Program Incentive: $3jillM i1 Customer Total: $705.15 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE $PECtnCA nON& FOR THE Sum OF I ***Seven Hundred Five & 151900 Dollars $705.15 UPOHFWALUISPECTION ANO APPROVAL BY RSE EM44NEERIFIO. CUSTOMER AGREES TO NMI AMOUNT DUE W FUU- WTERESTOF 1% W U BE "ARM NOUT&Y ON ANY I UNPA�DALANCE ATTER:16eLlY,.SEE-REVERSE FQR IMPORTANT WFOR►AATION ON TWARANTFasS. RIGWTB OF REpBtON, SCHEDtAaJG AND CONTRACTOR REGISTRAT70N. 00 NOT SIGN THIS CONTRACT IF THERE AREEANZAIL"K SPACES .Y .............. . _ _ .__ ........... _..� AO�hA9 CUSTOMER ACCEPTANCE I NOTE: En cum CONTRACT MAY BE wMoRAWN BY us R' Nor mmin DATE OF ACCEPTAN/pCE .. ..� :,„_„.,,.„„ ACCEPTANCE OF CONTRACT TWE ABOVE PRICES. SPEWICATW4 AHD CONDIMUS ARE. ll 30 DATE, SATISFACTORY TO US ANDARE HEREBY ACCEPTEO. YOU AREAUTIOUEEOTO DOTTMWORK i AS SPECIFIED. PAYMENT Wal. BE MADE AS OUTLINED ABOVE The Commonwealth of Massachusetts Print Form Citv/State/Zip: Nashua NH 03063 Phone #: 603-324-1974 1 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 100 4. ❑ I am a general contractor and I employees (full 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 ,. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] �� c. 152, § ](4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): i 6. ❑ New construction 7. ❑ Remodeling i 8. ❑ Demolition 9. ❑ Building addition', 10.❑ Electrical repairs 6r additions 1 l.❑ Plumbing repairs 6r additions I. 12.❑ Roof repairs 13. ✓0 Other Weatherization *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy inlbnnation. j T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name ol'the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees. they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for n v emplovees. Below is the policy and job site information. ACE American Insurance Company Insurance Company Name: P y + - Policy # or Self -ins. Lic. #: WLRC 48151553 Expiration Date: 6/30/2016 Cit /State/Zi Job Site Address: Cv Y P� � Attach a copy of the workers' co ensation 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 ORDER1and 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 herebv certifv under the pains and that the in formation provided above is true and .... _ n�*o•. � ri�� n Oficial use only. Do not write in this area, to be completed by city or town of City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other ' Contact Person: I 4. Electrical Inspector 5. Plumbing Inspector I Phone #: i CERTIFICATE OF LIABILITY INSURANCE DATE( iII 0IYYYY, 06/24/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTIlORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER- IMPORTANT: OLDERIMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, sbbject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT I AOn Risk Services Central, Inc. NAME. Southfield MI Office (AIC.PHONFA t866) 163 71?? (800) 363-0105 m 3000 Town Center lA c. No.): o Suite 3000 ADDRESS: o Southfield MI 48075 USa I INSURER(S) AFFORDING COVERAGE fNA1C: x INSURED limm INSURER BINSURER A' Old Republic Insurance Company 24147 1260 0BCorp. : ACE. American Insurance Company 2267 Jimmy Ann Drive I Daytona Beach FL 32114 USA INSURER C: ACE Fire underwriters Insurance Co. 2071)2 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570058348882 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAI IM SD CIA S. Limits shown are as requested S101 fENERT OF INSURANCE OL CY O C Y. LTRRANCE p j INBD V✓vD OUCY NUMBER hi MJDDIYYI'Y (MRIIDDR'Y1'YI LIMITS A X _MGENERAL LIABILITY P-0k2Y304834 b J 15 b/d !01 7 EACH OCCURRENCE 1 � , OHO, 000 ADE X❑ OCCUR. DAMAG O N 0 S2,00 0, 000 PREMISES Eioccun-ence) MED EXP (Any one person) $ 25 , ODO PERSONAL S ADV INJURY $2,00b,000 GEN'L AGGLIMIT APPLIES PER GENERALAGGREGATE 14,006,0001 m X POLICRO- ❑ECT LOC PRODUCTS-COMPIOPAGG $4,OOd,000 OTHEAAUTOMOBITY MI B 304835 06/30/2015 06/30/2016 COMBINED SINGLE LIMIT 1(Eaaca [$5,DODx700 X ANYABODILY INJURY(Per person)Z ALLO'SCHEDULcD BODILY INJURYPer acudem)AUTOSAU705mX HIRED X NON -OWNED PP.OPEP.TY DAMAGE I cc AUTOS Per acodenl — i T= UNERELLA LIARN OCCUR, EACH OCCURRENCE I U EXCESS LIA13 CLAIMS -MADE AGGREGATE DED P.ETENTION ! B I WORKERS COMPENSATION AND #SCFC4815190 C48151553 06/30'2015 66/50/2016 PER OTI�- EMPLOYERS'LIABILI7Y YIN Other Stales X ST ATUiE ER C ANY PP.OPRIE TOR i PART NEP, I EXEC UTIvc NE L EACH ACCID[NT S1,000,000 OFFIC EFUMEMBER EXCLUDE D% ❑ N 06/30/2015 06/30/2016(Mandatory b NF1) Only E L. DISEASE -EA EN,PLOYEE $1,000,000 If yes, descnbe under DESCRIPTION OF OPERATIONS below E L. DISEASE -POLICY LIMIT 1,000,000 - I E SCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached i1 more space is required) vidence of Coverage IR _J ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE ~ POLICY PROVISIONS. Builder Services Group, Inc. AUTHORIZED REPRESENTATIVE A TopBuild Company 260 -Jimmy .Ann Drive Daytona Beach FL 32114 USA 1_ ©1988-2014 ACORD CORPORATION. All rights reserved. ! CORD 25 (2014101) The ACORD name and logo are registered marks of ACORD I ( ! I ' I• ! ' I axm� 7/' T- 0 ' on' s u nri e r A_" Fajrs and B u s I n s s Renu at- 11 10 Park Plan Sulie 5170 Boston-.Mass-achusetts 0211 v Honie finprovement Contraic-tor Registration BUILDER SERVICES GROUP, INC. L RICHARD SCHWART7 110 PERIMETER RD NASHUA, NH 03063 Officr ofCc. Insumer Affairs c1 Busintss JZt,_,uiziA)n Horor- IA PPOVEMENTCONTRACTOR Kegist+ ra wn: 179141 Type Expiration, 6125512016 Supplement :-'2rd UILDER SEPVICE-c GRCUP. INC. ICHARED S-r'H*',j'lf-.RTZ 50 JOAMY DRWE AYTONIA BEACti. FL `x2114 i Registration: 179141 Type. Supplement Card Expiration: 612512016 1:j)(inle -)Lddress and return card. Marl, reas. 6 1 n for chan,,,t. Address RcneN+aj Faiploynien, l Lost I and License or rt< istra,,ion valid for individul use only before the expiratiop irate. If found return to: Ofifice of Consurner.Aflfairs ind Business Revulation 10; Park MaZL - suitc "1170 Bostor, MA 02 116 Not vnfid,lwithout sionziure L_ N u+ C r l: .w C t•.i I i ro J