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HomeMy WebLinkAboutMiscellaneous - 26 RUSSELL STREET 4/30/2018�' _N O O 0 N OO O O Date .. z� `2/*`-./ ........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION e-UyP �un�ry a Thiscertifies that..............................................................................................................I.... has permission for gas installation .... { .1 �� C -- C-\ --,V, 1 in the buildings of ........ Qvf Sa at ... ..-,,,P....... "<.t�... !�gt.......... . North Andover, Mass. Fee.�?.U., Lic. No.. .1. 7 '... ........................... ...... .............................. GAS INSPECTOR Check # 92%; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 5/6/2014 PERMIT # 1111 G-- JOBSITEADDRESSI 26 Russell St OWNER'S NAME I_reS N e—. GOWNER ADDRESS I Same TELF ]FAXI TYPE OR OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALO PRINT CLEARLY NEW:❑ RENOVATION: Q REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOQ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 1 9 10 1 11 12 13 14 BOILER BOOSTER ®® CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER F771 FIREPLACE FRYOLATOR �® FURNACE GENERATOR GRILLE 0 INFRARED HEATER LABORATORY COCKS 0 MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Re lace 1 Gas Meter _ x 0 a d Piping as Needed INSURANCE COVERAGE Dave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO ❑ 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAME I Joseph Marino LICENSE # 8736 SIGNATURE MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION Q# 3285C PARTNERSHIP❑# LLC ❑#� COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 TEL (508 832-3295 FAX 508-926-4347 CELL 508 832 4614 EMAIL JMarino@RHWhite.com "J w F O z z 0 F U W a z a d w a z°El z C) U❑ w � CA � ~ w o w o F 0- z w rn tq w > Na a w ° W Q w Na d o o, a a U J F a CL tH Q CO) Cd = w 1- LL. F °z N z 0 F U v W a rA 4 Q O -Yl DATE (MMIMOON YYI CERTIFICATE OF LIABILITY INSURANCE Page 1 of 08/29/2013 PHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIF48ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BKOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poliey(ies)must be endorsed. if SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does notconferrights to the certificate holder in lieu of such endorsernent(IS). willi4 0£ Masaftchueetta, Inc. c/o 26 Century Blvd. P. 0. Box 305191 Nalghville, TN 37230-5191 R. H. White Conatractiou Company, Inc. 41 Ca4ntrAl Street P. 0. Box 257 Auburn, MA 01501 xrt. 877-945 737 8 l ialr,�NO)! aeo-sv_r cextificates_C�willis . cos INSURERS AFFORDING COVERAGE NAICit A!The chart" Oak rite Tnsuranc-4 COMpaay 25615-001 g;Travalors Property Casualty Company o4 Am 25674-003 C -National Union Piro xasuranea Company of 19445-001 D -Travelers Ind&=i.ty Company 25658-001 nu,n,A�l Ikl""OCD. COVERAGES CERTIFICATE NUMBER.- 20287680 BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES REQUIREMENT. OF INSURANCE LISTED BELOW HAVE TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE TERMS, INDICATED. NOTWITHSTANDING ANY OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL CERTIFICATE EXCLUSIONS MAY BE ISSUED AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN CFD BY PAID CLAIMS NSR DO' SUB POLICYNUMBF PRRED1U LIMITS Typ60FIN3URANCE VTC2000 977RD940-13 9/1/2013 9/1/2014 EAcIIOCGURRENCE F 2,000,Q00 j,. GENERAL LIABILITY pAM TORENTF,D PRE $ (Ea oceu�ncr) $ 30Q-,09.0 X COMMERCIAL GENERAL LIASII.IT( MED EXP (Any one person),$ 10� 000 CLAIMS^MADE OCCUR PERSONAL&ADV INJURY S. 2 ODO, 000 GENERALAGGREGATE 3 4, O Q 0 0 0 O PRODUCTS-COMPIOPAGG j_-4 000 000 GEN'LAGGREGATE LIMITAPPLIES PER: 11 $ POLICY PR a LOC VTJCAP 977K955A-13 9/1/2013 9/1/2014 OMBiNEDSINGLF,I.IMIT accident 2,000,000 BODILY INJURY(Perpereon) $ a AUTOMOBILE LIABILITY • ANY AUTO ALI,pWNED SCHEDULED BODILY IN IURY(Peraccidont) eraccldent $ AUTOS AUTOS 3C NON OWNED S X HIRED AUTOS AUTOS X Co Dad. � 0911 Ued B88766140 /1/2013 9/1/2014 EACHOccuRRENCS $ 9, 000, 000 C UMBRELLALIAB 31 OCCUR AGGREGATE 1—P,000,00 S X Excess LIA5 cLAIM8-MADE DED $ RETENTION$ 10,000 WORIfER9COMPENSATION V�ItAVB B205i�185-13 9/1/2013 9/1/2014 U X TAr{Y_LI D AND EMPLOYHR&'LIABILITY y(((N___ VTC2XUB 9203.A71A-13 9/1/2013 9/1/2014 E.L.EACHACCIDENT � 1,000,000 E.L. DISEASE -EAEMPI,OYF.E S 1,000,000 D ANY PROPRIETORIPARTNERIEXECUTIVE� NIA OFF(CER/MEM9EREX0LUDED7 ((MandittogryInNM) F -L, DISEASE•POLIC`/LIMIT S 11000,000 ire ;deadtibe andor IS U�tst,KIV I ION UI• UPFRAMN3 haIOW __ _-,--.._. ��,�r,nuetinrenoustVEHICLES (AttachAcord 101,AdditonsiRemarSchhodvla,Irmoreepaee(srequlred) Evidence of insurance ACORD 25 (2010105) SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCEI.I_ED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ;4197604 Tp1:1694012 Cert:202876$0©19Sa-2010ACORD CORPORATION. All rights reserv( The ACORD name and logo are registered marks of ACORD Location No. ©a7 Date TOWN OF NORTH ANDOVER F 9 Certificate Occupancy $ of ►.�s'••°'E<�' �4CHUs Building/Frame Permit Fee $ a� O Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C L LIJ Check # 4 17454 ✓� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING nk Sit dm X W +(> iieC01* BUILDING PERMIT NUMBER: a DATE ISSUED: SIGNATURE: (L Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION LI Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lat Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ private ❑ Zone Outside Flood Zane ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record /.&/)/ ��— O.&�/ /J Name (Print) Address for Service: Signature Telephone 2:8 Owner of Record: 1 ame Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: �/�� !o/ /-rt- f d/ 6 ey Address yy Signature Telephone Not Applicable ❑ / _ License Number /0/0 d � Expiration ate 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1,7 Company Name Registration Number Expiration Pfie Address✓ STgnature V Telephone SECTION 4 - WORKERS COMPENSATION (11 Workers Compensation Insurance affidavit must be comb in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work chec New Construction ❑ Existing Building 0 Accessory Bldg. ❑ Demolition ❑ Brief Description of Proposed Work: P . ti . C 152 § 25c(6) and submitted with this application. Failure to provide this affidavit will result Repair(s) ❑ Alterations(s) 0 Addition 0 Other ❑ Specify �I,{J ,l .{.✓� I SECTION 6 - RSTIMATFD cnNSTRITCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building F (a) Building Permit Fee Multiplier 2 Electrical G (b) Estimated Total Cost of Construction 3 Plumbing ;t' QC7 Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection jfl ab 6 Total1+2+3+4+5 ,5'7c V Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ��/a�'✓J �%�� as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorize y this building permit application. Signature of Owner Date SECTION 7b/ OWNER/AUTHORIZED AGENT DECLARATION I,/ir���✓���%/ 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 Nam Si tune of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHDv NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL. GAS LINE YNANA l�' 7 TWOMEY & LEGARE CONTRACTING Professional Building / Remodeling P.O. Box 366 Shaun Twomey No. Andover, MA 01845 Doug Legare 978-685-7447 978-556-1547 NAME OF OWNER AIX Mel-_5Je-4r ADDRESS OF JOB�`�� S Ste. %✓ ✓ `' q'1�G� C� fyl/� TEL. DATE: We hereby submit estimates for: �=�C 7 �r �� coy c-- , �j �✓� iy � /�- o ow. Sl�c- /,�' L—ac t�7t��r� t��— S°'/�- � �f "/� c�'z.� r Xnlcz -i��r/} F •— S c. iL11-1&X - 'T/ t C t� S , •��/ Sl/�-L2� Cw �: / �`�i� i .�s�"`T� .S� / /mow /-4(-- CA?31.y-PSS .7e�gS. CC'7" 7) n We Propose hereby to furnish material and labor -complete in accordance with above specifications, for the sum of: dollars ($ '2 C g 1 0 F — ), Payment to be made as follows: l�. 00 0, ' &ID&S,nnj 5%L,tom! w6- /0 ooz,) L'40C/Y` Authorized Signature NOTE:This proposal may be withdrawn by us if not accepted within days. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined above. Signature /} Date of Acceptance: (/ Signature m m m m YI m mm C2 CO) d COD Cl) C � � d 'O O c') Z y 06 o �, ? O � O d 0 CD CDCL O ..�%. Q CD CD 0 CD mm 3 C CD H. C C= y CD i v CA o CD 71 CD 0 CD - pt cn d O cn V 0 cn C CZ�p m -� aogg S y =Bmf m c-3 40 Z CL m y m .� C EF'S =ra..a o Er ,a m o y �0 0 �m m S > >mCo. m �. 0. Z19.cm, I. CD p :yo CL .-. -. m o or CD m co CD DC, O N ` N d d Q c - 5. C m ti m N y Q ' 7 O 01 N o� �CD. CD � Am XF yCD h �Ico ='O* C -J C -J: CA H 0 9 0 c O w �e g (IQrw 'b z w C) R iy � TJ p) n'CD cn 77 a H 0 9 0 c r� Location t No. Date TOWN OF NORTH ANDOVER o # y Certificate of Occupancy $ Building/Frame Permit Fee $ sACMUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� c� Check # 7 J 2V,3 /` Building Inspector L,r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 13 —0e 6e SIGNATURE: Building Commissioner/InspeCtor of Buildings Date &—,/ SECTION I- SITE INFORMATION " I 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 60_& — n Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Frontage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard R"red Provide Rred Provided Required Provided 4-- 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 zone Outside Flood Zone 0 Municipal n On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Name (Frint) Address for Se Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 M nAt."N Licensed Cons ctio—n gulpervi r, I License Number e, 'S Addrels' NJN_�_ 1�b97.-)? 3�f f os Expiration Date Sigdatu& Telephone 3.2 Registered Home Improvement Contractors ontra Not Applicable 0 e ave sS Dov' Company Name C. Registration Number Addre%sN 7-:0 3 �_ r7 Expiration Date Sign'atLi'� -Telephone "a M z 0 6 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building emit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 571 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONRTRTTCTTON COCTC I Item Estimated Cost (Dollar) to be Completed by permit applicant FFC3TEQPT3Y m f 1. Building V C-1 (a) Building Permit Fee Multiplier 2 Electrical v� U (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on M lf, in all matte re t' o work au razed by this uilding permit application. t( 11 Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT `DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief— L Print N tl t 3 b Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB S1ZE OF FLOOR TIMBERS I 2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 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,S150A. The debris will be disposed of in: NV (Location of Facility) t Signature of Permit Applicant It Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 11/13/2003 PRODUCER NORTH ANDOVER INSURANCE AGENCY, INC 9 'TAVERLY ROAD NORTH ANDOVER NA 01845-2415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED Michael Rodden 47 Prescott Street North Andover NA 01845— INSURER A: NATIONAL GRANGE MUTUAL INSURER B: TRAVELERS PROPERTY & CASUALTY INSURER C: INSURER D: INSURER E: 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS A GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire $ 500,000 x COMMERCIAL GENERAL LIABILITY MED EXP (Any oneperson) $ 10,000 CLAIMS MADE FX I OCCUR NPP37395 02/01/2003 02/01/2004 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY JEC LOC / AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS / / / / SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS / / / / NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO / / / / AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE $ DEDUCTIBLE / / / / $ RETENTION $ WORKERS COMPENSATION ANDWG EMPLOYERS' LIABILITY / / / / STATU- OTH- X TORY LIMITS I ER E.L. EACH ACCIDENT $ 100,000 LE.L. DISEASE - EA EMPLOYEE$ 100,000 g 849K419 01/01/2003 01/01/2004 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHK:LESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HnLnFR I I anni 0NAl OISIrRPO' INSURER LETTER' CANCELLATION ACORD 25-S (7/97) © ACORD CORPORATION 1888 *,ni INS026S pgio).od ELECTRONIC LASER FORMS, INC. - (800)327-0545 Page I of 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AU ORI PR North Andover MA 01845- ACORD 25-S (7/97) © ACORD CORPORATION 1888 *,ni INS026S pgio).od ELECTRONIC LASER FORMS, INC. - (800)327-0545 Page I of 2 i x w O w cn v cn a� 0 z a o r p w — O cG ^C U - G w a 0 C/) z p r� G w a o w � w p n' a v� G w U a u: w � a a a a c� cn v O cn � c c �a� c o c i O ` O O Cc V rC c R A m c >� :N= O3 Q gym.. G ".� O Ju W yr m � Z Q a d v N . ° o EE ; oQ. V w ,* m C RECon L • o 3CO CD :10 �p Om m J c c � m = c� N • � N m m o :ave y m m E N_ Z rr N O N c O A cm S O cm c .E N m Z 0 Z O O zip f W.V. ►-V 14 O Z O O I H h .E L CLC O v CO) 0 CO2 C O O C cc CLCO2 L Q v O CL H C QM C O .0 m m V/ cr W w IrLU t t C y Q O cc a. C3CD m N c CD W c yr 0++� C LL LU(a R .m CL c u N cacm m 6 O V d O O� C* m* .0C2 z _ F— m E N_ Z rr N O N c O A cm S O cm c .E N m Z 0 Z O O zip f W.V. ►-V 14 O Z O O I H h .E L CLC O v CO) 0 CO2 C O O C cc CLCO2 L Q v O CL H C QM C O .0 m m V/ cr W w IrLU Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .. . .............. ...................................... has permission to perform ........ /2 if ......... .................................................. wiri�g in the building of ........ ?.I .............................................................. ,e at...................d1..............a.............5....................... No -Ah Andover, cir Z-2 Fee... ;-5.V ........ Lic. NOI&ICI ................. LECCAJ,,I' Check # 5353 THECOjWOATHEALTHOFMASSACHUSETTS Office Usol!n 3, DEPARTAIEWOMMICS4MY Permit No. 4.1� BOARD OFFIREPREVE MONREGULWONS527 CMR ]2.'00 Occupancy &Fees Checked 1� APPUCATTONFOR PERMUTO PERFO ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS CTE CODE, 527 CMR 12:00 --� / (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dates / 2 � � O 7 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perf, the electrical work de cribed Blow. Location (Street & Number) Z Owner or Tenant A ts / Owner's Address Is this permit in conjunction with a building permit: Yes- No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground r --J No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 7-6-01M 6 UT No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures A) Swimming Pool Above Below ri F1 Generators .KVA CJ round eround , No. of Recenocle Outlets No. of Oil Burners No_ of Emergency Lighting Battery Units No. o-'Scc,itch dutlets p (� No. of Gas Burners No: of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals / No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW NQ, of Sounding Devices / Nd. of'Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connections No. of Water Heaters KW No. of No. of A Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP THER- uuiceCovwge. Pt mmnttotirregmmntsofMa%achuscmGerietalLaws aveaamwllab>btykaw&mfthcymkxhngC,ompIftOpwawmCDverageoritsatsmntWopmiert YES NO aveabmittedvalidproofofsametothe0ffim YES r -7p 1fyvuha%&dlec-1odYES,pleaseindicaletherypeofoovaageby �gthe �°�box� SURANCEE L BOND r7 MHM F1 (Please -specify) •I • rn I n:•1 • �. r • :• :,r.• ExlmahonDa� Eslirnated Vahleof)lecttical Wodc $ Rough FRA LieNo. % 5('F6 3,4 e Signatate �— Lic=NO Busn m Tel No. P/ -7r 69'2 6 Z 6 2 hese � /[� �1 i�"� AIL TeLNo. 77e 3 7 s7 $"'7 3 Wg2'SINSURANCEWAIVER; lam aware that theli=wdoes nothavethe insurat)cr-coveiageoritssubstanlialapx,, lentasreglmedbyMa%achusenGena Laws that my signature on tins permit apphcation waives this mqumyo t :ase check one) Owner® Agent Telephone No. PEI?jMIT FEE $ t�y rgna ure ot Owner or 77gent Name Name: Location: The Commonwealth of /Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass, 02111 Workers' Compensation insurance Affidavit Please Print City Phone # 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 my employees working on this job. Company name: Address City: Phone #: •'� Insurance. Co. Poticv # Company name: , Address City: Phone #: Insurance Co. Policv # 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..penaltiesin.lhe.form-af a -STOP WORKORDFR.,and_a fine_cf.($1Ao.OD)_aiiayagainst..me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Official use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Licensing Board Selectman's Office Contact persona Phone #. Health Department Other Date ..... TOWN OF NORTH ANDOVER 40 PERMIT FOR GAS INSTALLATION �9SSACMUSEt This certifies that .......... .. has permission for gas installation . ............ ............. in the buildings of .. .......................... at �G - & North Andover, Mass. Fee x,:.Z?7�. . Lic. NoAlfJ'. . e ........ C R Check # 4794 MASSACHUSETTS (Type or print) NORTH ANDOVER, Building Locations --:� 6 TON FOR PERNff TO DO GAS RITNG Date 3�L�a,4oaL,t Permit # Amount $'" W Owner's Name�� eT� � �A$&; 7b New ❑ Renovation Er Replacement ❑ Plans Submitted ❑ (Print or ty e) Q f Che e: Certificate Installing Company Name �iP.4n!/iL(� / �rrt Bt�� �ht�s4�C/LA�T%i.[71-torp. Address �T ❑ Partner. Alp gT If? usmess Telephone__ —❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �9AA S 04 /j&=z277' INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please i icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ 1 Bond ❑. Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusettjtate Gas Code and Chapter 1,42 of the General Laws. by: Title City/Town 1APPROVBD (OFFICE USE ONLY) Signature of Licensed Plumber Or Lias Fitter ❑ Plumber A)j iRq ❑ Gas Fitter LicenseNumber ❑ Master ❑ Journeyman w a o a w a O Cn .. x H F p zO E~ W z CA H O O O z E• WC7G �1 E" z v� WE -4 PL4 0 W 0 v� a' WWz d O O OZ W D SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 1 2ND. FLOOR 3 RD. F L O O R 4TH. FLOOR Mf 5 T H. F L O O R 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or ty e) Q f Che e: Certificate Installing Company Name �iP.4n!/iL(� / �rrt Bt�� �ht�s4�C/LA�T%i.[71-torp. Address �T ❑ Partner. Alp gT If? usmess Telephone__ —❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �9AA S 04 /j&=z277' INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please i icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ 1 Bond ❑. Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusettjtate Gas Code and Chapter 1,42 of the General Laws. by: Title City/Town 1APPROVBD (OFFICE USE ONLY) Signature of Licensed Plumber Or Lias Fitter ❑ Plumber A)j iRq ❑ Gas Fitter LicenseNumber ❑ Master ❑ Journeyman C s, Date. ..d/ NaRTM TOWN OF NORTH ANDOVER '• O PERMIT FOR PLUMBING ArSit C HU This certifies that_... ''"'.:: �!r` "3'7`• •••••••.•. has permission to perform .. t-� ter.- ... .,............... plumbi.ngJin the buildings of s� �'. /��<.� �r�rC�.. .. .......... . at ... f. .....................:......... . North Andover, Mass. Fee / ..... Lac. No. Check # .� ............ PIUNVIBI� INSPECTOR (. u ��� M 0 MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building New Renovation APPLICATION FOR PERMIT TO DO PLUMBIN of Occupancy Slit FIXTURES Plans Submitted Yes Date Qu- I Zv Permit � Amount (Print or type) Check one: Certificate Installing Company Name GrRAnv:LLP. )0Za tA,1Agj pLAeA?7na 47-b- ro Corp. Address Partner. Csv o' t Business Te ep one ?7R—CR9-7,6 74' Firm/co. of Licensed Plumber: /g—'00 as %Y%• Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity D Bond 0 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State Plumbing Code nd Chapter 142 of the General Laws. By: SignaLure oi.Licenseu rJUMDel Type of Plumbing License Title C�)/S 9 City/Town Eicunse TIMM Master Journeyman ❑ APPROVED (OFFICE USE ONLY •.• o AfJ�'� Date. ?. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... e./.l�. �. ..... ��� . f?� ................. has permission to perform ... Or ................ plumbing in the buildings of .... R.`?.S. ST. r L at ...P.k�-.J. f-. (. (................. . North Andover, Mass. Fee.. % .... Lic. No. .,l.O. ......... PLUMBING INSPECTOR Check # ) % 5798 L MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) I NORTH ANDOVER, MASSACHUSETTS Date 11 -1 -3 -Ll -2 Building Location �l )Sc Owners Name [� �9t Permit # J-7 erji- Amount 7 JV -0 Type of Occupancy New 0 Renovation Replacement 1:1 Plans Submitted Yes No FIXTURES (Print or type) Check one: Certificate Installing Company Name tit .,( Corp. Address 3�1-- <<' .3 Partner. r !� Business Telephone C� 1 - ���(� Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance I hereby certify that all of the details and best of my knowledge and that all plumbi g compliance with all pertinent provisions o C By: Title City/Town APPROVED (OFFICE USE ONLY Agent ❑ f=installations or ent red) in above a on are true and accurate to the rme under P t d or this application will be in e r 42 of the General Laws. Type of Plumbing AJourneyman ❑