HomeMy WebLinkAboutMiscellaneous - 28 EMPIRE DRIVE 4/30/2018 (2)A RBE LLA:
INSURANCE GROUP
Elaine Dupuis -Lane, Claim Manager
10/03/2016
NORTH ANDOVER BUILDING COMMISSIONER
1600 OSGOOD STREET, BUILDING 20, SUITE 2035
NORTH ANDOVER, MA 01845
Claim Number:
033730289
Policy Number:
92031400004
Company Name:
Atbella Mutual Insurance Company
Date of Loss:
06/24/2016
Insured:
CHRISTOPHER FRAZIER
Property Location:
28 EMPIRE DRIVE, NORTH ANDOVER, MA
To Whom It May Concern:
Claim has been made involving loss, damage, or destruction of the above captioned property,
which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,
to be applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer. Kindly include a reference to the captioned insured,
location, date of loss and claim number.
Very truly yours,
Cynthia Holden -Amor
Claim Service Specialist
Property Claim Office
800-272-3552 ext.7549
Fax 617-773-4760
CC: NORTH ANDOVER HEALTH DEPARTMENT
1600 OSGOOD STREET, BLDG 20, SUITE 2035
NORTH ANDOVER, MA 01845
CC: NORTH ANDOVER FIRE DEPARTMENT
124 MAIN STREET
iioo Crown Colony Drive I P.C.Box6qqi95 I Quincy, MAo2.269-9195 I telepbone(800)ARBELLA I www.arbella.com
L,) , (�,"Y-Y,,,A
-p- f,7z"AA
Date ..... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
0
This certifies that /7--
............ . P ....... ....................................................................
. ..........................
has permission to perform .............
................................................
wiring in the building of ....... / R 47 C�
.......................................................................................................
>2 0, el-),
....................
at .................................................................. . I North AAndov"er,,Mv1a
Fee.. -.6 ...... Lic. No.
I CAL INSPECrO
Check..
Commonwealth of Massachusetts
Department of Fire Services
B OARD OF FIRE PREVENTION REGULATIONS
Official Use Only
PermitNo.
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLE,4SETRBVTINIYKORTYPE,4LLJNFORMATION) Date: S�- ?0 - le4
City or Town of- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her mitention to perform the electrical work described below.
Location (Street& Number)_ FIR�- eyqVii-e- At—
Owner or Tenant Telephone No.
Owner's Address
Is this permit in'conj unction with a building permit? Yes F1 No El (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead [] Undgrd 0 No. of Meters
New Service Amps Volts OverheadEl Undgrd R No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion ofthe following table mav be wal-ved bv the Inspector of Wires.
.-L
No. of Recessed Luminaires
No. of Ceil.-Susp. (1?addle) Fans
No. of Total
Transformers KVA
No. of Luminalre Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In-
swimming Pool grnd. grnd. F1
No of'Emergency Lighting
Baitery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE AL
of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
I.Ny.!Rb. er.
.
I Tons
* ** *]*
I KW
No. of Self -Contained
Totals:
I
I—
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El municipal E] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydrornassage Bathtubs
No. of Motors Total IV
Telecommunications Wiring:
No. of Devices or Equivalent
[OTHER:
Attach additional detail ifdesired, or as required by the Inspector of Wres.
Estimated Value of Electrical Work: XCCX�> -- (When required by municipal policy.)
Work to Start: T� — -Z t - Itf Inspe 6tions to be requested in accordance with NMC 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 operatiore' coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
cBEcK ONE: iNsuRA-NcEE1 BOND [I OTHEREI (Specify:)
I certify, under thepains andpena ies ofpejjury, �iat the information on this application is true and com
plete.
FIRM NAME: LIC. NO.:
gv *,- A-, e I :
Licensee: Signature LIC. NO.
(1fapplicable, enter "A in the licensqlnu be
In ra
Bus. Tel. No., F-2'rr '251 j
Address: Alt Tel. No.:
*PerM.G.'Lc.147,s.57-6l,secud work req -hires Department of 156blic Safe "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 my signature below, I hereby waive this requirement. I am the (check one) 0 owner El owner's agent.
Owner/Agent 65761
Signature Telephone No._ PPIMIT FEE: $
111
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the Provisions of M.G.L. c. 143, § 3L, the
Permit application form to provide notice of installation of wiring shall be Uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification Of completion of the work as required in M.G.L. c. 143, § 3L.
Permits sball be limited as to the time of ongoing construction activity� and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not prog'ressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act fiirthers this
purpose by establishing an automatic four-year extension to certain Permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
[0
. :Rule 8 — Permit/Date Closed:
P
***Note: Reapply for new permit 0
0 Perm t
Permit ]Extension Act — Permit/Date Closed:
Pass M Failed Re- Inspection Required ($.) Ei
ispectors Comments:
Inspectors Signature: Date:
3ERVICE INSPECTION:
Pass M Failed EN Re- inspection R quired ($.) 0
Inspectors Comments: .
_Lnspectors Signature:
_
Date:
PARTIAL ROUGH INSPECTION:
Pass [N Failed
Inspectors Comments:
Re- inspection Rec,uired ($.) 0
Inspectors Signature:
Date:
IZOTJGH INSPECTION:
Pass n? Failed
Inspectors Comments:
Re- Inspection Required El
Inspectors Signature:
--------------------
Date:
'INAL INSPECTION:
Pass Failed
��Fa�tled
nspectors; Corn�mee ts:
Re- Insperti— 'D)-- ired 0
I Inspectors Signature:
�: WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
Date:
If
The Commonwealth ofMassachusetts
Department ofindustriqlAccWks
Office ofInvesfigations
600 Washington Street
Roston, MA 02111
k VtJ www.mass-govIdla
Workers' Compensation Insurance Affidavit: Buffders/ContractorsfFIectriciansfpliimbers
Appli Information Please Print Legibly
:cant -
Name (Businessiorganization&dividual):
Ar1r1ri-q.q- )w k>,,Md1-
Phone#:
a you an employer? Check the appropriate box.
) yc
Type of project (required):
lama employerwith_
4. El I am a general contractor and I
6. E] Now Onstraction
-1.1
employees (fall and/or part-flme).*
3
/2—
have hired the sub -contractors
listed on the attached sheet. �
7. �EMemodaling
Ell am a s olD proprietor or partner-
ship and1avono-employeas.
These sub -contractors have
8. El Demolition
-1
worldug forma i -many capacity.
workers' comp. insurance.
9. El Building addition
[No workars' comp. insurance
5.0 We are a corp oralion and its
logUlectrical repairs or additions
required.]
3111 am a hoiaeowner d0ng all work
officers have exercised.their
right of exemption per MGL
11.[] Plumbingrepairs or additions
myself EEO workers' comp.
c. 152, §1(4), andwahaveno
12,Q Roofrepairs
inSUMUGO required.] T
employe6s. [No workers'
13.0 Other
comp. insurance required.]
'Any applicantthat checks boxfif mustalso fill outthe sec.tion belm showhigtheir workers' compensation policy information.
t-Horneownerswho submitihis affidavit indicatingthek Diu d9ing all worK and then him outside contractors must submit a now affidavit indicatiftg such.
tContractors that checkthis box must attached an *a'dditional sheet showing the name of the sub-rontractors and their workers' comp.policyinformation.
f am an employer that isprovidifig workers'comquensation insuranceformy employees. Below is thepolicy andjoh site
information.
lusurance CompmyNamo:. H4 - , 9
filloc - �Voo 2?�Z
Policy # or Self -Ins. Lic. 9: Expiration Data:
Job Site Address:
Attach a copy of tl�e workers' compensatioup olley declaration page (showing the policy number and expiration date).
Failure to secure coverage.as re * dunder Section 25A ofMGL o. 152 can lead to the, imposition of criminal penalties of a
Rwe
fine up to $1,500.00 and/or bncuyear Mprisopment, a� well as civil penalties iii tho 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
Jnvestigations ofthoD1A#w4hmrance, coverage verification.
-1 do Iierehy "it erlary that the infarmation provided above is true and correct.
Official use onfy. Do not write in this area, to be completed by cl(v or town offircial
City or Tow -u: PermitgAcense 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town, Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Pers
Phone 9:
Information and Instructi
ons
Massachusetts General Laws chapter 152req*es all employers to provide, workers' compensation for their employees.
Pursuaiit to fMs statute, an er1zP70Ye,- is (101mcd as "....overYpersonktho service of another under any contract of hire, -
wress or Implied, oral or written.,,
An emPloyeils defitied as "an individual, p artnership, ass 0 clat.1011, corp oration or other legal entity, or any two oxmora
of the t6r6�6iuj engaged in ajoint enterprise, and including the legal representatives of a:deceased employpi, or the
redelv&r orftstceof an individualpartnership, as�oclatio_u or Other legal ontity� employing employees. lEwevorth:a
owner of a dwelling house, having notmore than three apartments and who resides thereln, or the occupant of the
dwelling house of another'who employs persons to do maintenance, construction or repair work . on sii6h dwonkg 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 loleal licensing agency shall withhold the issuance or
renewal of a license or p ermit to op erate a business or to const"ruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance With the insurance coverage required."
Additionally, mGL chapter 15 -2, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpablic work until acceptable evidence of compliance with the hasuxanco
requirements of this chapter have boonprosented to the contracting aathority.11
Applicants
Pleaso,fill out the Workers, coinponsailon affidavit completely, by cheeldng the boxes that apply to your situation and, if
ji&egsary� supply Sub-contractor(s) name(s), address(es) and phone number(s) along with their ceracate(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 workers2 componsationiasuranco. If an LTLC or LLP does have
employees, a policy is required. Do advisedthatthl'
s affidavit may be submitted to the Department of industial
Accidents for conffimationofinsuranco coverage. Also be sure to sign and date the affidavit. iheafffdavitshoujd
be, retuniod to the city or town that thO* application for the, permit or license is being requested, not the Dep'attmont of
Industrial Accidents. Shouldyou have ally questions regarding the law or if you are requiredto ob'tabi a *orkers,
compensation policy., please call the Department at the, number listed below. Self -Insured companies should enter their
self-insurance license number on the appropriate ao.
City or Town Officials
Please. be sure that the affidavit is complete andprintedlogibly. The, Department has provided a space at the bottom
of the affidavit for you to fill out in tbe event the. Office of Investigations has to contact you regarding the applicant.
Please be -sure to JM intbo P61111it/licOnso number Whichwill be used as a reference number. fn addition, an applicant
ffiatj�mst submitmultiple pormit/licenso applications in
any given year, need only submit one, affidavit indicating curr&nt
policy information (if necessary) and under "J'ob Site Address; the applicant shouldwrito "afflocations in . (CitV or
towV)." A: copy of the affidavit that has b con officially stamp ed or marked by the city or town may b o provided io—iho,
applicant as pro of that a valid affidavit. ii on file �cr fatum P arnilts or licenses. . A new aff id avit mu, st b o fillqd 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 jormit to butu leaves etc.) said person is NOT required to complete, this affidavit.
The, Office ofinvestigations'wouldliko to thankyou in advance foryour cooperation and should y9u, have any.questions,
please, do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho Ommon
wealth Of Afi
Dapartment QffadijMal Accidonts
Off ke offuVestfgWoug
600 Waftgtw Stma
B o5ton, MA 02111
Tel, 0 617-7.2-.7,4900 QA 406 ox 1 -87 -7 -MAS
9AFF,
Revised 5-26-05 Fax 0 617-727-7749
_www-magov/dia
r�
f
t
Date ....... Y ...... /'-/
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
..........
This certifies that ........ ................ ..
.....................................................
k/I
has permission to perform ............................... 2 . . ...... .. . .........
wiring in the building of .......... If 'x ......... /Ire ..............
at .... North Andover, Mass.
FeZef�.:F"Lic. No'lom�?' .........
'i]L� A*L INSPECTO
Check #,I -Z7 -,K -l- V
10755
Commonwealth of 14assachusett,,
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Permit No.
Occupancy and Fee Cliecked
tev. 1/07] (T..1,1
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CNR 12.00
ry
P Z Wo
MMT
(PLW.EPRWVVflVX0JZ Sa I t�
City or Town oh NORT11 ANDOVFR OA9 Date: J
13Y this application the und='V;:-a Pves 'uO= Oi Ins or her mj6Tt—o To the er, r of Wires:
Location (Street & Number) 74-- 4- n to perform t!,- electrical work descxibed below.
,&— 2 X-- .-.;- -
Owner or Tenant
Owner's Address
Is this Permit In conjunction with a building
Purpose of Buildiar . L
Exisdng Service
NMg—ervice
2 -el 0 Amps Z2���o Volts
Number of Feederij IndAmpacity
LOcAtiou and Nature of Proposed ElectriW Wrk.
Of Recessed Luminaires
Of Luw1usire o1,ti,-1:g
of Receptacle outlets
of Switches
-------------
of Ranges
of Waste Disposers
of Dishwashers
of Dryers
Heaters lKW
Hydromassage Bathtubs
OTHER.
No- -------
4,qu L -J (Check Appropliate Box)
Utility Authorization NO. �O
Overhead n
. of Ce'L-SUSP- (Pskddle) Fans
imining Pool , bove
d. n
of Oil Burnerl,
of Gas Burnen
of Air Coud. _�o
Area Heating KW
g Appliances '
KW
Ao. Of -
Ballasts
Of Motors TOWHP
Unegra L.J No. of Meters
Undgrd OfMeters
Fal
ALARMS ING.- Of Zones '
of Alerting Devices -
0 8=22t 0 O&W
Estimated Value Of Electrical WOTL. Attach additional detail 0�dMftd- or ay r0quired by the Inspector o
Work to Staft V (When required by municipal policy.) wires.
�-tions �tobe =equested in accordance with �,MC Rule
, 10, and upon completion.
INSURANCE COVERAGE: 'Unless waived by the Owner, no Permit for the Performance of electrical work may issue unless
the ficensecprovides proof of liability insurmce including "'Completed operation7' coverage or its Substantial equivalent. The
undersigned certifies that such coverage is * e. and has exhibited proof of same to
CHECK ONE: INSURANCE 0 OTHM M �Specify* the Permit issuing office.
I ce7Wfy, under thepains andpenaldes of perjury, &at the W
0"Na&non
s 4P
FnM NAMM: &W and complev-
Licensee: I I C. N 0..,,0
d 41 1
(If applicabl Signature.
Address: r e number lhw.) LIC. NO.0! �—r
Bu& Tel. No..
*PerM.G. c. 147, 9. 57-61, security work requires artment Public S "S"License: AIL TeJL No.-'
OWNER'S INSURANCE WAIVER:- I am aware that Lie. No. *,
required by law- By my signaWre below, I hereby wai 'he Licensee does not have the liability ' -------
Owner/Agent ve this requirement I am the (check insurance coverage nozmajly
Signature TelePhone No. zmmt��
ELECTRICAL PEP -NUT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
1. ROUGH IKSPECTION:
Passed— Failed — Re -inspection required (Mn -nn) - r 1
2. MAL INSPECTION:
Passed Failed –
Inspectors' comments:
3. UNDER GROUND INSPECTION:
Passed – [ I Falled – f
Inspectors' comments:
4. INSPECTION – SERVICE: —
DATE CALLED NATIONAL jjR—ID.
PRSSLX!-- 1�_ Failed –
Inspectors' ��o �Mcnis�-�
5. INSPECTION - OTHER:
Passed – [ I Fail;T
Inspectors, comments: -
- no initial
no
-DO
- no
- no
NAME:
,-inspection required (S50.001
Date
=12 _Cj_
Date
Date
Date
Date
DOOR TAGS ARE TO BE FELLED OUT AND LErr ON SUE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIOBLE AND A RE -INSPECTION OF $50,00 IS To Mr -w"
Date 2Z. 2612 -
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
J
This certifies that ..... f ............ ......
has permission to perform ... 5 /.-" ............
wiring in the building of
.1 .........................
at ...... 2. N h Andover, Mips.
Fee Lic. No!�W5� . . .
E TR
LE / ICAL INSPE OR
Check#
11041
Commonwealth of Massachusetts Official Use Only
Permit No. (C -q
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 1/071 (leaveblank) ,
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLEA SE PRflVT IN INK OR YYPEA LL JXFORAIM TION) Date: (A/ Z--7—/ 2-0 \ -z-
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or liq intention to perform the electrical work described below.
Location (Street & Number) �Z(;� t-- P --t 9 -% e—
Owner or Tenant C Fe ON -z-x t-,� TelephoneNo. -,S709 99-e) ZI(Ac�
Owner's Address '2 -Fs F-r�,4tkq-e-
Is this permit in conjunction with a building permit? Yes No D---- (Check Appropriate Box)
Purpose of Building Jz 'e. V�. UtilityAuthorization No.
- Existing Service — Amps Volts
New Service — Amps Volts
Number of Feeders and Ampacity
Overhead [:] Undgrd [J
OverheadF] Undgrd El
Location and Nature of Proposed Electrical Work: JgU/z,!�JC,,z-
No. of Meters
No. of Meters
f�^ iot;�" nrAo fnrl�wina tnh7p mny hp. wnhood hv the InsDector of Wires.
00 Attach additional detail zJ destrea, or as requirea Dy rne inspecror uj rrims.
Estimated Value of Electrical Work: (When required by municipal policy.)
WorktoStart: %'/!�/12— Inspections to be requested in accordance with I�IEC 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 operatioe' coverage or its substantial equivalent. The
undersigned certifies that such cove�W is in force, and has exhibited proof of same. to the permit issuing office.
CHECK ONE: INSUIRANCE Ej� BONDE] OTHEREI (Specify:)
I certify, tinder the,pains andp�nalties ofperjury, that the information on this application is true and complete.
FIRMNAME: I V�ue'J`l ,�, C, C- -J A- r--� LJLU. IN".:
700t -1C
Licensee: e'19 apo W\, , k Signature LIC. NO.: Z 4 it 3-,D
(1fapplicable, enter "exempt" in the license number line. Bus, Tel. No.- -9,2 r &r -i qvej
Address: F() 0Y 4 7 z- U4)A L -re 1113 AAA 6-A Alt.Tel.No.:
*Per M.G.L c. 147, s. 57-61, security work requiret Department of Public Safety "S" License: Lic. No. 6._S 0 3 L
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)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. PERWT FEE.- $
-
No. of --- fo t —al
No. of Recessed Luminaires
No. of Ceil.-.Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above o In- E]
Swimming Pool grnd. grnd.
No. of Emergency UgEting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE
0. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
No. of Self -Contained
No. of Waste Disposers
Totals:
..........
J.KW ...........
............
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Mun'c'PP' El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
iNo. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
00 Attach additional detail zJ destrea, or as requirea Dy rne inspecror uj rrims.
Estimated Value of Electrical Work: (When required by municipal policy.)
WorktoStart: %'/!�/12— Inspections to be requested in accordance with I�IEC 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 operatioe' coverage or its substantial equivalent. The
undersigned certifies that such cove�W is in force, and has exhibited proof of same. to the permit issuing office.
CHECK ONE: INSUIRANCE Ej� BONDE] OTHEREI (Specify:)
I certify, tinder the,pains andp�nalties ofperjury, that the information on this application is true and complete.
FIRMNAME: I V�ue'J`l ,�, C, C- -J A- r--� LJLU. IN".:
700t -1C
Licensee: e'19 apo W\, , k Signature LIC. NO.: Z 4 it 3-,D
(1fapplicable, enter "exempt" in the license number line. Bus, Tel. No.- -9,2 r &r -i qvej
Address: F() 0Y 4 7 z- U4)A L -re 1113 AAA 6-A Alt.Tel.No.:
*Per M.G.L c. 147, s. 57-61, security work requiret Department of Public Safety "S" License: Lic. No. 6._S 0 3 L
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)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. PERWT FEE.- $
MMER GRODND )NSRXCTION.
agsad—r I
CAISAM.4 OUR--' 13.
, 'se
-11—F I
gedbys, commeits.
Data
rVWe CIY,-n-r-,f '1-� rTO-CV A WW A trf"A IWO IVOOV,
M
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_
Address: ?b ot, 0 r � ?
City/State/Zip:,
U,ty) %__.4-1 "
V% U -e C, & C,
% �- rl Phone 4: q 2 r 6 (0 t q0 --7 �
y an employer? Check the appropriate box:
IA�re
tam a employer with L4
4. 11 1 am a general contractor and I
1, employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet. t
ship and haveno employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp.
c. 15�, § 1 (4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n New construction
7. F1 Remodeling
8. E] Demolition
9. F1 Building addition
1 OJE3161ectrical repairs or additions
11. [:] Plumbing repairs or additions
12.El Roof repairs
13.n Other
'Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
.ram an employer that isproviding workers' compensation insurancefor my employees. Below isthepolicy andJob site
nforipation.
nsurance Company Name:
'OlicylY or Self -ins. Lic. M Expiration Date:
ob Site Address: ?- E- IF,,,) I 1z C 12 t c,, f-- City/State/Zip: Noz- fi mA c) i s u r
I
Utach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
-'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
rivestigations of the DIA for insurance coverage verification.
do hereby certi& tinder thepains qy4.Lenalfles o
fper/ury that the information provided above is trite and correct.
hone #: _-` q 7 8� & (aj Cr o rl /
Official itse only. Do not write in this area, to be completed by city or town official,
City or Town:
Permit[License #
2--112
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NUSSAFE
�-evised 5-26-05 Fax # 617-727-7749
www.mass,gov/dia
10
9
4SS41b -U,
4,6 OF
MMONWEALTH
Rill: ZIM-Wom
=-�gt L
r
TEM C-O'NTRAtTOR_-�
TERED SYS
SUESX
4rx76azliiPENSE T1
S,
S-f-AL,EtITR ONIC SY`
BRI
U -�WH Ilt
0� 4' E
�-t- H ING T� N
0
'88-
N M A 0
'7' AV�- INGTkO
0
4. 0
0�0
4 C
db_MAM_0ffWEALTH OF MASSA-'CHUSE
L C t- 1 r% 1 1 M N Z)
-7--!,�--.-A.AREIGISTERED -SYSTEM YtitHNICI
ISSUESTHE'XBOVELICENSE Tow�':':�' . . . . . . .
t�l R A'lj La'gy W141TE
A S'H I.N G Tb N AVE,NlUlt.�%
" -13
N TIOW "'MA 0 18 8 7,;;-2
Z-26�45 D -077'31/13 -848'00,1 -7.]-
K_
LICENSE NO. EXPIRATION DATE SERIAL NO,
_w
92.
DEPARTMENT OF PUBLIC SAFETY
S - License
Number: SS CO 001034
Ex0ires: 05/29/2013 Tr. no: 350.0
S -License: BEST ELECTRONIC SYSTEMS
J
BRADLEY J WHITE
25 WASHINGTON AVE
f WILMINGTON, MA 01887
Commissioner
9354
C us
us
This certifies that
Date. $104//Z-.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
............... ...............
has permission to perform ... / . &,,Me / ...........
plumbing in the buildings of ... .................
at ... 0 n�il�r4:7 61, 4
... ............. No h Andjovet, Mass.
F e e i c. N o. ,4r-Zavr� ......
PLUMBING INSPECTOR
Check #
S:-,\
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
POWNER
TYPE OR
PRINT
CLEARLY
CITY V-tolkr-IA 'N�-tow-r- MA. DATE S VL PERMIT #
JOBSITE ADDRESS —is 1&mp'a- OWNER'S NAME O�U%*&P QILL,%Acs5 U -c -
ADDRESS TEL FAX
OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL D RESIDENTIAL
NEW,9 RENOVATION: REPLACEMENT: Ej PLANS SUBMITTED: YES Ej NO F
FIXTURES I FLOOR- 13SMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED S ECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS
DEDICATI) GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/ MOP SINK
T011 F -1
URINAL
WASHING MA HINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabilitv_insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes [ON. El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX 13ELOW
LIABILITY INSURANCE POLICY J?r' OTHER TYPE OF INDEMNITY [I BOND El
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 p'ermit application waives this requirement.
Signature of Owner or Owner's Agent - CHECK ONE BOX ONLY: OWNER [] AGENT Ej
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 penmit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME STE1`1+1510 C- GALIOSKY SIGNATURE
LIC#-1031tS MP Rr JP El CORPORATIDN E?�# PARTNERSHIP LLC [I
COMPANY NAME 6AL40SKY ADDRESS: P-0- GQx r7ol
CITY— HAVCRKIL�L STATE rA-'4- zip 01131 . EMAIL—vvvvw. mrplumbeqW I. co^1
TEL 4"71;-37q-1?q3 CELL -501B-50CI-5q0,4 FAX Q76- 5AI - 44131
Fl
I
"I
Uo
Ic
ri)
E CD
4 �
0
C
cn
UD
>
Ln coo
0
Da —q
CD
El
52
cn
3
m
Permit NO: ewV1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
ANT:
* 2&, =A -1)v
Date Received
must complete all ftexn�.an this page
'6 -\/ ae— (/V�- *-,/
Z—L(1
Print
70N -TL Historic District yes
MAPNO:/Z) PARCEL: INC, DISTRICT.
Machine Shop Village yes no
no
100 year-old structure yes ab
TYPE OF IMPROVEMEWT—
PROPOSED USE
Resifttial
Non- Residential
"ew Building
klbne family
13 Addition
0 Two or more family
0 Industrial
11 Alteration
No. of units:
0 Commercial
11 Repair, replacem;-n—t
0 Assessory Bldg
0 Others:
11 Demolition
0 Other
--Erm NINUM"M
o -g—'go-
NO tim-a-i ME
--
th U
'Mo
AJ
- �SIA U -
OWNER:
RON OF WORK TO BE PERFORMED:
11to LLIAir- —2, Rev r6nm 2-
L'-1
or Print Clearly)
Address:t�77 WA 1 6 0 -i-:� LA x) a M fi
CONTRACTOR
Address: c -A-7-7 W A SP'idu
— R�L-3 / q41
—?q1-306
WANK
Supervisor's Construction License: Z�00 Exp. Date: 'V
-A� & 90
Home Improvement License: - -- ?2- z Exp. Date:
qARCH ITECUENG I NEER Lp tr V Phone:q
Address:/'?& -,QA&) V- 9t MA017-33 Reg. No.
FEEsCHEDul THE T M E 1 5. R A
-E., BULDING PERMIT. $1Z00 PER $1000.00 OF TO AL ESTI ATED COSTBAS D ON $ 2 00 PE S
Total Project Cost: $ FEE:
CheckNo.: �������.ReceiptNo.:
NOTE: Persons contract unregistered contractors do not have access to the guarantyfillid
"K.
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
• Building Permit Application
• Workers Comp Affidavit
Lt Photo Copy of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
ci Floor Plan Or Proposed Interior Work
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or DeGks
• Building Permit Application
• Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
ij Copy Of Contract
• Floor/Crossection/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
NOTE: 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
• Mass check Energy Compliance Report
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
��n all cases if a variance or special permit was required the Town Clerks office must stamp the decision front the Board of Appeals
ihat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
inust be submitted with the building application
Doe: Doe.Building Permit Revised 2008mi
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: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
El Notified for pickup - Date
Doc:.Building Pennit Revised 2011 Junefti
it
Plans Submitted o�/ Plans Waived 11 Certified Plot Plan M/Stamped Plans �rl
TYPE OF SEWERAGE DISPOSAL
Public Sewer M",
Taiming/Massage/Body Art
Swimming Pools
Well El
Tobacco Sales El
Food Packaging/Sales
Private (septic tank, ctc. El
Permanent Dnmpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT n
COMMENTS
CONSERVATION Reviewed o
DATEAPPROVED
X
ENTS
Comm U VJ4.1, AC11-7 fy
HEALTH Reviewed on Sicinature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: —Zoning Decision/receipt submitted yes
Planning Board Decision: Comments__.
Conservation Decision: Comme
Water & Sewer Connection/Signature & Date DrivewayPermit
DPW Town Engineer: Signature: Located 384 Osgood Street
FM DEPARTMENT - Ternp Dumpster oil site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Location
Date
Check #;k
25022
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
A-/
/,tuil6ing inspector
<LIN s
The Commonwealth ofHassachusett
De
partment oflndustrialAcdde�ts
Office of -Investigation g
600 Washington Street
Boston, MA 02111
UF Www-massgovldia
Workers' Compensation Insurn-nep. Aff;,].�,;i_ inv_* v -, - __ - r� .
#:
're YOU an employer? Check the appropriate box:
LEJ I am a employer with . 4. El I am a general contractor and I
Type of project (required):
2. Kiemployees (full and/o�_p �_time).*
am a sole proprietor or
have hired the sub -contractors
listed
6. Now construction
partner-
ship and have no employees
on the attached sliget. 1
These sub-cOntractors have
7. Remo deling
working for me in any capacity.
Workers' comp. insurance.
8. El l5emblition
[No workers' comp. insurance
5. El We ate a corporation and its
9. 0 Building addition
required.]
3. 1 am a homeowner doing
of
ficers have exercised their
I O -E] Electrical repairs or additions
all work
myself [No workers' comp.
right Of OxemPtion, per MGL
c- 152, § 1 (4), and we have no
1 LEJ Plumbing repairs or additions
insurance required.] f
employees. ONO
[W90 workers
12.0 Roofrepairs
Colan inslim-nn. . 13.
13.n 0 er
*Anyv appli I VLJLLUv I
P li ant that checks box #1 must also fIll out the section below showing their workers' compensation policy inform
T Homeowners 4ion.
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 ofthe sub-rontractors and their Workers' comp. Policy information.
1am an employer illat isproviding workersl compensation
in
fo.-maflan. '"Slira"cefo"WeInPloyees. Below isthepollcy andjob site
Insurance Company
Policy # Or Self -ins. Lie. #':
Expiration Date:
Job Site Address:
Attach a copy of the workers, c City/State/Zlp.-
OmPensation Volley declaratioa page (showing the Policy number and expiration date).
Failure to secure coverage as required uhder Section 25A ofMGL c. 152 can lead
fine up to $1,500.00 and/or one-year imprisonment, as well as civil to the imposition Of criminal Penalties of a
Of up to $250.00 a day against the viodator. Beadvise' d that a copy Penalties in the form of a STOP WORK ORDER and a fine
Investigations of the 139 for insurance coverage verification. of this statement may be forwarded to the Office ok
Official use on&.
City or Tow.n:
Do not Write in this area, to be completej by
c!1Y Or town official
Permffiy.
Issuing Authority (circle one): -------- cease ff
I. Board Of Health 2.13ullding Department 3. CitY1ToWn Clerk' 4. Electricalfaspec
6. Other tor 5.Plwmbing Inspector
0- / //,?,-
ContactPerson:
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 i;defmod as "...every perso
'I or writtea.11
express or implied, ora U in the service of another under any contract of hire,
Ad' em
,ployer is defined as "an individual, Partnership, association., corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint orit ; 0, and including the legal re
erpris presentatives of a deceased employer, or the
-receiver or trustee of an individual, partnership, association Or other legal entity� empl `
owner of a dwelling house having not more than three apa OYmg employees. However the
I rtfuents and who resides therein, or the occupant of the
dwelling house of another whoomploys persons to do mainten *
ance, construction or repair work on such dwelling house
or on the grounds or building appwonant 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 shallwithhold the issuanceor
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 insuranc6 coverage required."
Additionally, MGL chapter 152, §25C(7) st�tes "Neither the commonwealth nor any of its Political subdivisions shall
enter into any contract f6r the Performance ofpUblic work until acceptable evidence of com�liance
requirements of this chapter have been presented to the contracting authority.,, with the insurance
Applicants
Please fill out the Workers' compensation affidavit completely,
necessary, by checking the boxes that apply to your situation and, if
sUPP1Y sub-contractor(s) name(s), address(es) and phone, riumber(s)
insurance. Limited Liability Companies along with their certificate(s) of
(LLQ or Limited Liability Partnerships (LLp) with 310
members or partners, are not required to carry workers, compousa 0 employees other than the
ti .11 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 In'dustrial
Accidents for confirmation of insurance . coverage. Also besure to sign and date the fflda t a d t
be returned to the city or town that the application for the permit or license is being req a V! - The ffi avi should
in , law or ifyou are required to obtain a workers'
Industrial Accidents. Should you have any qyestions rega�d g the uested, not the Department of
compensation policy;please call the Depahment at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Eno.
City or Town Officials
Please be sure that the affidavit is complete, and printed gibly. 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 ponnit/license number which will be usedas a referenc6 number. In addition, an lie
that must submit multiple permitIlicense app ant
applications in any given year, need only submit one, affidavit indicqing current
Policy information (if necessary) and under 4'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 pr* oof that a valid affidavit is on file for future perrhits or licenses. A new affidavit must be filled out each
yoar. Where a home owner or citizen is obtaining a license or permit not related ta any business or commorcial venture
(Le. a dog license or permit to bum leaves etc.) said person is NoTrequired to complete this affiddvit.
The Office of Investigations would Eke to thank y0iiin. advance for your cooperation and should you have any questions,
—please donot hesitate to give us a call.
Thif Department's address, telephone and fax number:
Ukl- 00-1,11,113-lowNea-ILth, of
jv1j
.,js�ad',RL
.
Department of Tadustrial Accidents
Offike Of InVOSUgations
600 Washington street
BostQn;M& 02111
TQd- # 617-727-4900 ext 406 or 1-877,MASSAFE
Revised 5 -26 -*05 Fax # 617-727-7-749
Www-massjz-ovjdia
IV)
Ok
M
W
Cd
C/)
0
Cf)
CO
Cf)
Cf)
UU
0
S
4-j
t3
6
u
E
cc
Z
CD
CO2
cm
ca
CD
.ca
E cc cc
CD
CD
C3
CM
Ca CD
E: CMCC
ca
CD cc
= Cc
C.3
,FL CD
co ts
ca
cc
cc
'a
CO2
It
w
w
CO)
19
LLI
uj
1%
LLI
UA
CA
I
0
C/)
u
cz
-TJ
::l
-a
::,
pq
-
:i�
u
Cd
lz
x
to
z
0 -
x
co
r.
9
cz
.5
C/)
V
0
E
C/)
C/)
0
Cf)
CO
Cf)
Cf)
UU
0
S
4-j
t3
6
u
E
cc
Z
CD
CO2
cm
ca
CD
.ca
E cc cc
CD
CD
C3
CM
Ca CD
E: CMCC
ca
CD cc
= Cc
C.3
,FL CD
co ts
ca
cc
cc
'a
CO2
It
w
w
CO)
19
LLI
uj
1%
LLI
UA
CA
I
ca C..)
cc cc
CC3
=CD
E
CF
ts
co
CL
.2
z;
c-,
CD
mi
ca
C>D
Cc
CIO
cm
:3
cm
4=3
C)
cm
cp
C=O2
-CC*,
C3
Cl
C L
cm
cc,:,,
c
0
CD
Cc
Lu
w
-0
cl; W
ca — Q
4=
uj
C3
16.
W
E
C43
CL
CA
Cl
CD
Z
CL A
C/)
0
Cf)
CO
Cf)
Cf)
UU
0
S
4-j
t3
6
u
E
cc
Z
CD
CO2
cm
ca
CD
.ca
E cc cc
CD
CD
C3
CM
Ca CD
E: CMCC
ca
CD cc
= Cc
C.3
,FL CD
co ts
ca
cc
cc
'a
CO2
It
w
w
CO)
19
LLI
uj
1%
LLI
UA
CA
I
01.
w;
rA
Cf)
0
C/)
cn
0
C/)
Z.
0
C/)
C/)
fi-
R
0
103
4-j
co
0
E
CD
co
CL
co
cm
C
CO2 'o
CD
LA
E cc cc
CD 0 CD
L- 1�— =
CL — 4-0
CD
a)
CD
C3 CL.
CD CL.
cc
CJ
"EL CD w
CO2 ts
CD
CL
C.3 CO2
cc
cc
CL
CO2
5
LLI
0
Cd
w
LLI
19
ui
ui
U)
�2
-0
0
�24
U>)-
u
C/)
or.
cts
r
::j
u
co
r
co
r.
:3
—co
r.
;T4
E
0
'o
t
C/)
o
E
cf)
Cf)
0
C/)
cn
0
C/)
Z.
0
C/)
C/)
fi-
R
0
103
4-j
co
0
E
CD
co
CL
co
cm
C
CO2 'o
CD
LA
E cc cc
CD 0 CD
L- 1�— =
CL — 4-0
CD
a)
CD
C3 CL.
CD CL.
cc
CJ
"EL CD w
CO2 ts
CD
CL
C.3 CO2
cc
cc
CL
CO2
5
LLI
0
Cd
w
LLI
19
ui
ui
U)
C2,
o
C.3
CL
C3
CA
E<
CD
11
ca
C) co
cm
oc
2ga.
ca
coo
CD
CD C2
CLC -3
in
La 0 MD
cm
32
.5
ca
CD L*
C.3 a
Om
Cl
CL, -
C2
co
CD
COD
LU
Mm
C42
CD
—
P
Ma
C=Ljj
183 'CAM
e
ui
L3
93
0
C*
CL
CA
CD.5 .0
.0 'A —
E:a,s
CD
O's CL4.. Cc
:20
Cf)
0
C/)
cn
0
C/)
Z.
0
C/)
C/)
fi-
R
0
103
4-j
co
0
E
CD
co
CL
co
cm
C
CO2 'o
CD
LA
E cc cc
CD 0 CD
L- 1�— =
CL — 4-0
CD
a)
CD
C3 CL.
CD CL.
cc
CJ
"EL CD w
CO2 ts
CD
CL
C.3 CO2
cc
cc
CL
CO2
5
LLI
0
Cd
w
LLI
19
ui
ui
U)