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HomeMy WebLinkAboutMiscellaneous - 25 IRONWOOD ROAD 4/30/2018r WASHING MACHINE CONNECTION Fp— -F- - -F-F-WFM-FM- _ M7F_ F MWF FOMFOMMMME WATER HEATER ALL TYPES WATER NFING J I JIL-AL-I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES M'NO M-11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [E( OTHER TYPE OF INDEMNITY BOND P1 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 [I AGENT IDI 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 co4lance with all Pertinent ovis n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6hc"J( PLUMBER'S NAME # SIGNATURE mpff ip D CORPORATION 01 #�PARTNERSHIP [31 #= LLC COMPANY NAME A— ADDRESS CITY '1STATE Fk—,-WjZIP I TEL FAX CEQ3. EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY CITYL MA DATE PERMIT # 7z67-7 -1 q JOBSITE ADDRESS'S NAME OWNER OWNERADDRESS' i TEL _JIFAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL ET' NEW: 01 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO© FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 I'l 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I - I __jj -j __j -1 DEDICATED GREASE SYSTEM -71 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN �j J FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY -J ROOF DRAIN f SHOWER STALL SERVICE/ MOP SINK L TOILET ---J URINAL WASHING MACHINE CONNECTION Fp— -F- - -F-F-WFM-FM- _ M7F_ F MWF FOMFOMMMME WATER HEATER ALL TYPES WATER NFING J I JIL-AL-I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES M'NO M-11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [E( OTHER TYPE OF INDEMNITY BOND P1 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 [I AGENT IDI 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 co4lance with all Pertinent ovis n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6hc"J( PLUMBER'S NAME # SIGNATURE mpff ip D CORPORATION 01 #�PARTNERSHIP [31 #= LLC COMPANY NAME A— ADDRESS CITY '1STATE Fk—,-WjZIP I TEL FAX CEQ3. EMAIL RK N ❑ w a The Commonwealth of Massachusetts f Department oflndustrialAccidents d 1 Congress Street, Suite 100 = ` Boston, MA 02114-2017 "t www mass.goh/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/liidividual): Address: y City/State/Zip: Es '-MPS7o+�) #•t� 6�Mhone T* -7 X)t. Are you an employer? Checktlie app`ropriafe box: Type Of project (required): 1. ❑ I am.a. employer with employees (full and/or part-time).* 7, Q New construction 2.t?rl am a sole proprietor or partnership and have no employees working for me in 8. Fj Remodeling any capacity. [No workers' comp. insurance required.] 0. ❑ Demolition 3.. ❑ I am a homeowner doing all work myself, [No workers' compAnsurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition ensure that all contractors either have workers' compensation insurance or are sole 11,. ❑ Electrical repairs or additions proprietors with no employees. 12. Eiflumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � 13.0 Roof repairs These sub -contractors have employees and have workers' comp. insurance.: 6. F1 we are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), andwe have no. employees, [No workers' comp. insurance required.] *Any applicant that checks box #1 must alsd'fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must"attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, %ey must provide their workers' comp. policy number. I aM an employer that is providing workers' compensation insurance for my employees.' Below is"the policy and job site information. Insurance Company Name: Policy # or Self -ins. 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 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 cert4 under the pains anojpen ylties of peijury that the information provided above is true and correct GL/ Phone #• 603 3 d<- /117 a– rr 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. EIectrical 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 o 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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you .are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE F, ` 617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ! r' CITY -� MA DATE /� PERMIT #� JOBSITEADDRESS5g$'LiedlUdt)i OWNER'S NAME 5461, GOWNER I r ADDRESS TELFA TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL_j EDUCATIONAL RESIDENTIAL it CLEARLY NEW: [Q RENOVATION: REPLACEMENT: 03 PLANS SUBMITTED: YES E] NOE] APPLIANCES 7 FLOORS--D 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 - - - - -i ( z POOL HEATER ROOM / SPACE HEATER! ROOF TOP UNIT TEST- UNIT HEATER ! UNVENTED ROOM HEATER WATER HEATER OTHER................................ L_ _.. - ..... . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ITNO I 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: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes of my nowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli a with Pertinent visi e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,q!C- Waf- _ - -- LICENSE # ( SIGNATURE _ _ MP YGFE] JP ® JGF D LPGI © CORPORATION ©# PARTNERSHIP [D#= LLC E]#= COMPANY NAME:(,(llts �L6. s kf TG ADDRESS CITY STATE ZIP ]TEL FAX � CE 3 1" EMAIL 1909al _ Ca. .>F4) tr - - — - W�W E1 O z 0 H U W z O �rl W } W F- w aCO O w w w CO) a o a a a ice. U ami _I a a � w x w H LL H z 0 H U a c c�7 . a The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 t Boston, MM 02114-2017 ,y. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Ind,-vidual): Mu& 6U[b,-7C-,- /' (� 4t 41% , Address:_ _ _ _ City/State/Zip: I ✓52e✓l-6 a%c', O phone #: 603 Are you an employer? Check the appropriaie box: Type of project (required): 1. ❑ I am.a employer with employees (full and/or part-time).* 7. ❑ New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. El Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp -insurance required.] t ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ❑4. ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. Mumbing repairs or additions 5. ❑ I,am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13Roof repairs p These sub -contractors have employees and have workers' comp.. insurance.$ 6. ❑ we are a corporation and its office1 1.rs have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who subniif 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-coritractors Irave employees,' they must provide their workers' comp. policy number. I am an employer drat is pioviding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIP, for insurance coverage verification. Ido hereby cer - under the pain ndpenalties ofperjury that the information provided above is true and correct. Signature: Mz Date: Phone #: (fid • 3 �'1�(i l %�— 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, expres's 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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 Wednesday, May 18, 2016 03:03 PM W *Plumbing Permit *2-11- Y X E C I % https://northandoverma.viewpointcloud.com/#jrecords/20374 .: Apps viewpoint II>a IMaura I Town of North Andover, MA Home 20374 +Add to a project Profile *Plumbing Permit - Replacement of Fixture/Appliance (Commercial or Residential) Records Approvals TIMELINE Submission receivedPayments f May 18, 2016 at 2:59p n inspectiom Plumbing Permit ReviewDOCUrnents fir• In Progress Applicant ` Lo. Permit Fee Paul White ! 2`_ Analytics Payment L 603-329-6172 At map @ pewtmp@gmail.com Permit Issuance i 511 Document Help Attachments —OT09N01001F_Wed_May_18-2016_19:01 �J .. (Uploaded May 18, 2016 b, i+Acura Deems Primary Contractor Search for your contractor using the search bar belt required. - _ Firm's (Businessl Name PIS Pa License # Uc 11718 M. Wednesday, May 18, 2016 03:03 PM 0 fD "Gas Permit #20377 . ViewP: x - E- C I [; htlps:/%northartdoverma.viewpointcloud.com/#/`records/20377 APPS tD Viewpoint Town of North Andover, MA . 20377 +Add to a Project *Gas Permit - Replacement of Existing Fixtures/Appliances (Commercial of Residential) TIMELINE nda ave N �. Submission received May 18, 2016 at 3:04pm r e5 \ Gr O`er Applicant i Lo, Paul White 2`_ 603-329-6172 At @ pewtmp@gmail.com Um SII Attachments LJ—OTSMVOIOOIF_Wed_May_18_2016_19:Oi Uploaded May 18, 2016 by Maura Deems Primary Contractor i Search for your contractor using the search bar beat required. Firm's (Business) Name PIS Pa - _ License # TYI 11718 Wednesday, May 18, 2016 03:06 PM Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: John & Barbara Simons 25 Ironwood Road HP1008148 3/1/2015, Water/Ice Dams 31745-M Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mike Peterson On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: John & Barbara Simons 25 Ironwood Road HP1008148 4/28/2014, Water/Mold Damage 29593-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the persgns named above at the addresses indicated above by First Class Mail. 7 D , ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 �I� HoRTN pf ,aAtip O P • i - i ;,SSACH SEt Date..... �s....`...-1........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING J` This certifies that .......!.�... ......I .....t.�../�'.......................................... has permission to perform ...... 4 a .. t.�. ........................................... wiring in the building of .... S. /. . Z:...'......................................................... at .... 2-.?............................. ....... . North Andover, Mass. Fee ....�..)............. Lic. No. ................ _ .:...... N............. JELECTRICALINSPECTOR Check # 3 1 4636 TIMCOMMONWEUTHOFMA.S94CHUSE7TS Office Use only DEPARTARMOFPUBIICSAMY Permit No. BOARD OF FIREPREVEMONREGULAHONS5VCW 12-W Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORMELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:0 , (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) ate /I A Town of North Andover To the In ector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street � Owner or Tenant Owner's Address Sr,- Ykp Is this permit in conjunction with a building permit: • Yes ® No (Check Appropriate Box) Purpose of Building ,n Utility Authorization No. Existing Service ,. Amps / Volts J Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Elect_461 Work nt )cz i. -{- �, v� S� FCc�nn l �/ fZ'X) Y►'1 G r )t'i v No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round 0 ground No: of Receptacle Outlets 1 t No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections a No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• Insula =Cowerag- Rmanttotheragtm soDk%mdugcMGetteralLaws IhawaauiurtLiabl�tyhl5tatauoePblicyinchxlungComple>e Co oritsstiA&id alegt ivalem YES ElNO Ibavl mbniioBdvalidproofofsametotheOffim YES NyoubavedrdadYESpkasefidcatedieNmofoDNwigeby ct�cldrtgtt� atebox INSURANCE BOND 011118 WotktoSatt 1rWedimDaleReguestetl Signed underTr puialhes of petjtuy. FtRMNAME (Spm) Est mated VakrofE1ical Wdk $ r� =�oG Oro - Rao._ Lice>SeNV. Sigrratm IicemNo X562 BusirmTeLNo. t /-S'j A_ �y�►g- QISc � V�►�} GI�� AhTUNo. OWNER'SINSURANCEWANER;Iamawatetha drLcensudoesnothavetheitmuanoecoveWoritssubsUbalegLuvalffltaswquaedbyNh% d asdtsadi C -c a Laws and dAmysignAiectitrispemvtapplicationWaiNvsttrislegtritwxxi (Please check one) Owner Agent . Signature ot Uwn—er-3r-Tg=n Telephone No. PERMIT FEE Q NORTH, o� • �+ 0-1 k � r ;,SSACNUS� This certifies that Date /a.7.,.?c!'. - ? / TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 9.t.... 9.1gkI. G Ur?,. '....... has permission to perform .... P.F-.%?......................... plumbing in the buildings of ... !. . . . ............ . at ...257-113 0k !� P.U. A ...1) 11, ... , North Andover, Mass. Fee. s v - .. Lic. PLUMBING SPECTOR Check # 5003 i1 C) — MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING fPrint or Type) Mass. DateA - Permit # S ® 0 3 Building Location_ N%��(%� C&K. Owner's Name `' f i /,/D ��idLt fel �J , � �� ✓ Typeo�"� f Occupancy r New 0- Renovation ❑ Replacement ❑ Pians Submitted: Yes ❑ No ❑ B . P . # SEWER# FIXTURES SEPTIC# Business Ta!ephan. e. Name of Licensed Plumber Check one: ❑ Corporation ❑ Partnership � n'iiir v0. Certificate # INSURANCE COVERAGE: I have ae!lt 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 coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Acent I hereby certify that all of the details and information I have knowledge and that all plumbing work and installations per pertinent provisions of the Massachusetts State PlumOfiV Me Stgnat (or entered) in above application are true and accurate to the best of my PPa� the permit issued for this application will be in compliance with all iapRer 142 of the Genera! laws. Type of License: Master Journeyman ❑ APPROVED 0 FI S ONLY) License Number &% F- V1 J N 2 O Y Z > f-+ W Y_ J N } V < N Q W ¢ QJ O W �<• W N H U ¢ H Uf U. 2 _ :. n' Qi X r 9 N E' y = rC W < W 3 UJ ¢ Y Ci W < S F- 1= >F O N O N Z = N +y H Y Z d O C F� N < = Z W W f- O Y Q 'b x O < J J < ¢ ¢ M < 3¢ p < m CY Z o O SUB-BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Business Ta!ephan. e. Name of Licensed Plumber Check one: ❑ Corporation ❑ Partnership � n'iiir v0. Certificate # INSURANCE COVERAGE: I have ae!lt 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 coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Acent I hereby certify that all of the details and information I have knowledge and that all plumbing work and installations per pertinent provisions of the Massachusetts State PlumOfiV Me Stgnat (or entered) in above application are true and accurate to the best of my PPa� the permit issued for this application will be in compliance with all iapRer 142 of the Genera! laws. Type of License: Master Journeyman ❑ APPROVED 0 FI S ONLY) License Number &% PER)fIT NO. 064" APPLICATION FOR FIRMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP K40.00 LOT NO: Dano6 I 2 RECORD OF OWNERSHIP (DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. -I LOCATION yJp; PURPOSE OF BUILDING�(j OWNER'S NAME R \ _ Flat r} �% I /�J< / l /� 1 �7 \ ✓/MVV./ /' NO. OF STORIES 5 ZE K 1 � s- g%R� \"� OWNER'S ADDRESS C'��11� BASEMENT OR SLAB ARCHITECT'S NAME �� JV/ti. "} 1G •'�> SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME/Irr-y 9 %/ SPAN DIMENSIONS OF SILLS DISTANCE TO NEAREST BUILDING _L __� DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND ,}_) D WILL BUILDING CONFORM TO REQUIREMENTS OF CODE �-� .57 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER Y IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR/AUTHORIZED AGENT FEE &/ PERMIT GRANTED Fon, x-19— 3 PROPERTY INFORMATION LAND COST EST. BLDG. COSTal G? (� EST. BLDG. COST PER SQ. FT. / EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. N 6 3 ` 7 CONTR. TEL. # CONTR. LIC. AF 11 H.I.C. # I I 1 OCCUPANCY SINGLE FAMILY _ STORIES I_ MODERN KITCHEN MULTI. FAMILY TOILET RM. (2 FIX.) OFFICES FLAT SHED APARTMENTS CLAPBOARDS DROP SIDING WOOD SHINGLES ASPHALT SHINGLES _ CONSTRUCTION 2 FOUNDATION _ 8 INTERIOR FINISH _ B 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE WOOD RAFTERS HARDW'D AIR CONDITIONING ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING PIERS PLASTER UNIT HEATERS 7 NO. OF ROOMS GAS DRY WALL B'M'T 7 2nd _ 1st 13rd I ELECTRIC NO HEATING _ UNFIN. 3 BASEMENT AREA FULL 1/1 1/1 �/. FIN. BM'T' AREA FIN. ATTIC AREA ✓ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN GAMBRELMANSARD I TOILET RM. (2 FIX.) FLAT SHED 4 WALLS Aj I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES ASPHALT SHINGLES B CONCRETE EARTH HARDW'D COMMON ASPH. 1 2 3 �_ _ _ ASPHALT SIDING ASBESTOS SIDING _ VERT. SIDING STUCCO ON MASONRY _ STUCCO ON FRAME WOOD RAFTERS BRI ON MASONRY BRICK ON FRAME AIR CONDITIONING ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY rj ROOF ACl I 10 PLUMBING GABLE HIP BATH (3 FIX.) WOOD JOIST GAMBRELMANSARD I TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING L- y t � BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. 8 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 7 2nd _ 1st 13rd I ELECTRIC NO HEATING P, DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nulber, Expires: Birthdate' CS 002685 02/24/1998 02/24/1941. Restricted to: 00 ROBERT N LANGEVIN jG 795 DALE STREET ` NO ANDOVE, u 01845 HOME IMPROVEMENT CONTRACTOR Registration 111990 I Type - DBA — Expiration 02/11/99 i ROBERT LANGEVIN BLDG REMOLD k4 RT M. LANGEVIN ADMINISTRATOR DALE ST N ANDOVER MA 01845 G � ` a' \ Lu LLLZ ' 3 Q 0 0 to 0 z i ccc 0 F- a 0 Z O 0 Z 8 0 Q 0,0- 0 °0 7 W 0Q Z z I i N F WI44 v 7u a 4 /1 V � 1� Z a `V N W C W < wW C Z < Z C 0 Z 0 < N NW C U C F W Z W = C < ZJ F U N O < m 0 i c Q U F C 0 U L — Z_ J L 0 �� a L FjI < z @ �'^ ! l rL 0 w o 0 � ` 1> rt E U 0 v C C ��`•. 0 L �l mf6 t W F 4 Z Q F Q F N L 0 < 0 O 1 �I, j Z L W N F N 7 W Yf F L6 C z Q a p 0 N 0 O V U ` O = L 0 ^ mw W 0 o o o F � w L u u u f. ¢. Q C w 4< c. p D Q V i c Q U F C 0 U L — Z_ J L 0 �� a L FjI < z @ �'^ ! l Lx� 0 w o 0 � ` 1> rt F Q C L 0 v C C ��`•. 0 L mf6 W F 4 Z Q F Q F N , F Oi 0 < 0 O 1 �I, j Z n D ]� W N F N 7 W Yf F W C z Q z a p 0 N 0 O V U = U F C 0 U L — Z_ J L 0 �� a L FjI < z @ �'^ ! l 0 w o 0 � ` rt F Q C L 0 v C C ��`•. 0 L mf6 W F 4 Z Q F Q F N , F Oi 0 < 0 O 1 �I, j Z n D ]� W N F N 7 W Yf F f N C W U < C 4 0 w N W V' W = p 0 N U W < U C O F w ¢ < l9 = L 0 ^ mw W 0 W N W 0 V U W W U < F ? 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'fl C Z ts 0 CL ai L.7 N2 c C C c CLy D -\ The Commonwealth of Massachusetts :._ Department of Industrial Accidents — � Oif� sllo�g�IQs' 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit icnr-%nrP rn_ - noficv 9 Failure to secure coverage as required under Section 25.E of N(GL 15'_ can lead to the imposition of criminal penalties of a fine up to S1 500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Invesdgadoas of the DLA for coverage verification. I do hereby ce r unci th Onsan penalties of perjury that the infonrtasion provided above is true and correct Signature Dateir� OF Print name \\ ' � Vt LJ Phone 9 official use onlv do not write in this area to be completed by city or tows official city or town: permit(licease l f ,Building Department C]Licensing Board C] check if immediate response is required ❑Selectmen's Office C]Health Department contact person: phone 0; rjOther (�imd IM PIA) p -.S�-Y, Date ........1.. o- 17.-...7. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform .::.................................... wiring in the building f*4' .... . �Gc at .....�� ... ,.�•••...., '/al.:......... ,North Andover, Mass. Fee ....75..... Lic. Notrltco 6 .................. CTRICALINSPE OR Clc y�O30 ,AI10/91 10.44 WHITE: APPIAnt CANARY: Buildinzwt. PAIDPINK: Treasurer office Use Only u �ommIIn>u�ttl of �c agoar4usdt Permit No. �� lepartmrnt Of �Vuh11L _afrtq Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 390 (leave blank)�� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date `{- !�! - `? - (XK or Town of NORTH ANnOV .R To the Inspector of Wires: The udersioned aoolies for a permit to perform the electrical work described below. Location (Street 8 Owner or Tenant Owner's Address is this permit in conjunction with a building permit ltkYes (t-4� No ❑ (Check Appropriate Box) Purpose of Building P ����� Utility Authorization No. Existing Service - Dc7 Amps Zavi volts Overhead ❑ Undgrnd No. of Meters New Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES NO = I have submitted valid proof of same to the Office. YES = NO Z If you have checked YES, please indicate the type of coverage by checking the appy nate box. ( - 9� INSURANCE�.y BOND OTHERSpecify) �t (Expiration Date) Estimated Value of Electrical Work S �� Work to Start Inspection Oate Requested: Rough Final Signed under the Penalties of perjury: / E - FIRM NAME LIC. NO. Licensee Signature LIC: NO. Bus. Tel. No. �9 LS2_J__ Address ^r Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE S X-6565 Total No. of Lighting Outlets / a y No. of Hot Tubs © No. of Transformers KVA No. of Lighting Fixtures I Above Swimming Pool grad ❑ In - grnd. ❑ Generators KVA I No. of Emergency Lighting No. of Receptacle Outlets / I No. of Oil Burners Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Cond. tons Initiating Devices No. of Sounding Devices No. of Self Contained No. of Disposals E7) No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Municipal C Other Local ❑ Connection t No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES NO = I have submitted valid proof of same to the Office. YES = NO Z If you have checked YES, please indicate the type of coverage by checking the appy nate box. ( - 9� INSURANCE�.y BOND OTHERSpecify) �t (Expiration Date) Estimated Value of Electrical Work S �� Work to Start Inspection Oate Requested: Rough Final Signed under the Penalties of perjury: / E - FIRM NAME LIC. NO. Licensee Signature LIC: NO. Bus. Tel. No. �9 LS2_J__ Address ^r Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE S X-6565 Location a S P0'0 o n No. 912 Date �OR�h TOWN OF NORTH ANDOVER � 9 e ; ; Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # g YC) 6438 AlrCa"- X Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEMyO�yLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: q d AX SIGNATURE: Building Commissioner/lfisf=tor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: J �'�C7 tJv.14o D fe D dz ivy c o; 0 ` Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 1%J6141j' 4 ,11%-5-6141j' Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Congtruction Supervisor: License Number 5 ,T 1 -OA,-,E Add res �y l C' y Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ /l / 9 9 C) Company Name Registration Number Address Expiration Date Signature Telephone Ma M X ic Z O SECTION 4 - WORKERS COMPENSATION (AG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. —Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all a Gcable New Construction ❑ Existing Building ❑ - Repair(s) ❑ Alterations(s) ❑ 4 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: L/ 0 I X l9f'6vym 420177et) Z) /V X30 D,4ce SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFiCIAuJSE'QILYr„, 1. Building '­ (a) Building Permit Fee Multiplier 2 Electrical r/ (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X tbl© , 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 g a(j Check Number cnZ SECTION 7a OWNER AUTHOR ZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. —Signature of Owner ate SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name t. Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS 1 ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U LOT RELEASE FORM 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. **************** ***********APP (CANT FILLS OUT THIS SECTION******�**************** c' APPLICANT PHONE 0"!r -3 `5'0 LOCATION: Assessor's Map Number A PARCEL��O SUBDIVISION LOT (S) 1,�CSTREET /eF�� WDDC ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** RECONJAUIENDATIONS OF_>TOWN AGENTS: /CONSERVATION ADMINIS ATOR DATE APPROVED �% DATE REJECTED COMMENTS u c4S /O07 -6vn Ln &,a of :1'30 ­� hfi TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTEO DRIVEWAY PERMIT ffOrTo FIRE DEPARTMENT- J RECEIVED BY BUILDING INSPECTOR Revised 9\97 im ,TE 0� O AllL1� N a �y W W R (� •►00°»» n .q� S7+q r7 In f )p it Ili 1081;17c D :. ,am 7r 7eg7 0 3 i 'oo O=r -02H O ;sem ��'� IOn1' tetsd+O e7 m t Z "70 V/ . 0 do co ,'a e r Re, Ory+ al M �7 w n V b 7 bK D Y N H D o�..� o ° morn spyp 'aa"� ;o ;o MO 7'i e�+R p �7 A Ax ;ma5io p w � r* = Puoze Z d D 07 7r ', e0`r0 O Ne7R• a Ci O .R+Re ; Z e e r i? • 7 CL 1 7 � F p w r v y rov�m o `0p bml a' b Z Q1 � Sll_3S�t\ a� o 0 N I eC° gulf, 2 o' ow- m O 7� �-}y ✓ • d O r O r r -V s Me xD e. o z .•.+•- e Z Z o C a �� ^ ds e '�' � ed7 Z N ' T �C ns d-rs n.+>• D�� r- O D • d^ dV Z C -iow rnJ �� m p 7 m g p•� 1 s� N o s�.s '.. C Cl) _rn m Z to �0 �o WCD ;z YMZ e w NV� d dA " p 1 (7 � c o d J 1 ns Do Sd bN O' y 4 -Zi g o H o Z �• m C'7 a t► � W W R (� •►00°»» n .q� S7+q r7 In f )p it Ili 1081;17c D :. ,am 7r 7eg7 0 3 i 'oo O=r -02H O ;sem ��'� IOn1' tetsd+O e7 m t Z "70 V/ . 0 do co ,'a e r Re, Ory+ al M �7 w n V b 7 bK D Y N H D o�..� o ° morn spyp 'aa"� ;o ;o MO 7'i e�+R p �7 A Ax ;ma5io p w � r* = Puoze Z d D 07 7r ', e0`r0 O Ne7R• a Ci O .R+Re ; Z e e r i? • 7 CL 1 7 � F p w r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Perrnit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid -waste disposal facility as defined by MGL c11,S.150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant :31� 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 111990 Expiration: 2/11/2005 Type: DBA ROBERT LANGEVIN BLDG & REMOLDING ROBERT LANGEVIN 795 DALE ST N ANDOVER, MA 01845 Administrator z` BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 002685 Birthdate: 02/24/1947 4 Expires:'02/24/2004 Tr. no: 17862 Re` stricted: 00 ROBERT M LANGEVIN 795 DALE ST N ANDOVER, MA 01845 Administrator qQe 696-34;,�Q The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Afdavit Name r OYFt;T ' 4fi-N(!i�-a N 1✓ Name: �R o &—cR 7— - -p4tN� V 1 dU Please Print Location. 2L— �O P c cs©G D ED Po, Ati Ddv Ef M A City /R1® A -N i7 DYER Phone # ? 6"?r 6- 3 z; o -7 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. Company name: Address City: Phone # Insurance. Co. Policy # Company name: , Address 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 welLas_chM penaltiesln2leimn-fa-STOPMRKDPMER-wd_a fire.-fl$1DA-OD)-aAayagainsi-ore. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification do hereby certdy under &&Pam and penalties ofperjury that the frrfomrahon provided above is true and correct. Signature Ze(lzf4- ,:),3 t b3 Printname �T LA-Nr,E VI IJ P1mne.# �f i� T��6'3� d -7 Official use only do not write in this area to be completed by city or town driciar City or Town Permii/Licensi � El Check if immediate response is required Building Dept .p Licensing Board El Selectman's Office Contact person: Phone # Health Department Other Cf) M M Cf) 0 m 10 az CD O ar O d CL n� .p o o p d� Q CD o CA 10 CD .Ot 0 cop) 10CA) Cl) CA 'O O CA C) CD O �F CD CD a y CD CO2 1 0 O CD O CD C Ka —0 o� y ME O -• h _a0�o y § O m n m m CD HC2c0 3 m z =r-CCMLFn H '_•1 =r O =r go' CO) O O m y p N0 il ? m eo = > > m y m O n0•► O O W 0 y CC2 e7 �:� o VJ 0 CD m m y o n•fl b c a �CD i y O. d '.44 Q � H C.<IE CD � 9 •••F y CA ^ �+ V�J Cp m ♦ : Y iW m Of y m �z o� -- • A• OOC3 z CDCDo Cj CD O C �Z Q 0 n CM3C b :7U: o n G � w 0 4 / -X ti w (n PJ 0 tri ',.r1 0 °'. 'z 0 oGa 7MM' Z x w n a" 7d G oa a, G p � t•� (n b n -Op 00 QCL n xcn W luv z 0 H 0 0 c