HomeMy WebLinkAboutMiscellaneous - 28 SAMUEL WAY 4/30/2018r- /, I,.; tz 400,
Date
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that. .... ... ....
... ei.N 9_4 ....................
has'permission to perform . . . �f.c-j
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
wiring in the building of E_ ........................ 4,
at ...........
.............. No Andover, Mass
Fee4.�� ..Lic.No.2.323q
ELECT ICAL INSPECTOR
Check.#
?278
2012 Massachusetts Elechical Code Amendments 527 CMR12-00 § RtIle 8: inaccordance-withthe7provis-Iom
electrical permit shall he issued to the person, firm or . ep . of MG.L. c. 143, 3L, the
permit application form to provide notice of installation of wiring shall be unfforin throughout the Commonweal ,
on the prescribed form. After a pe th and applications shall be fided
rmit application has been acc ted by an inspector of wires apbointed pursuant to M. GI c. 166, § 32, an
orporation stated On the Permit application. Such entity shall be responsible for the
notification of completion of the work as required in UCTI. c. 143, § 3L,
Pennits shalLbe Emited as to the time of -ongoing construction.activity, and maybedeemed-by-the -Inspector-of-W.ireseabandoned-and-iny.aHd-ifhe—
or she has determined tliat the authorized -work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be pennitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the pta,�Iit appDroation.
n The Permit Extension Act was created by Section 173 of QLiapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote7jo&growth and long-term economic recovery and the Permit EAension Act furthers this
plupose by establishing an automatic four-year extension to ceitain7permits -and licenses conceming the:usc or development of real property. With
limited -exceptions, the Act automatically e&ends, for four years beyond its otherwis e applicable expiration date, any permit or approval that was
"in effect or existence' during the qualifying period beginning on August 15,2608 -and, extendingthrough August 15, 2012.
8 — PermittDate Closed:
El Permit Extension Act — Permwhate Closed:
Note:)Reapply for new permitIR-_
7;- -,,,
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. f 11-2 5
occupancy and Fee Checked
[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusefts Electrical o C), 527 C 2.00
(PLEA SE PRTNT INM OR TYPEA LL NFORMA TIOA9 Da Im
UZL-5,
City or Town oh NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gips no4ce of his or hel ini��ntion to perform the electrical work described below.
Location (Street &
Owner or Tenant
Owner's Address
Is this 'permit in conjunction w%h a, ljuildiV ermi yes
Purpose of Building (\-( a ML4
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
No V (Check Appropriate Box)
Utility Authorization No.
OverheadEl UndgrdF]
Overhead [_] Undgrd [_1
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above n In-
Swimming pool grnd. grnd. El
No-.-OTEmergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I.Nymt?.�K]J�A§
K.W ...........
0 el -Contained
Det'ection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [I Municippi El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Rguivalent
OTHER:
Atiach additional detail ifdesired, or as required by the Inspector of 07res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in dccordance with I�EC 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 operatioif 'coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURKINCE [I BONDE] OTHER 0 (Specify:)
I certify, under th ins an enalties qfPerJu t fi plete.
y,tha te information on this application is true and com
LIC. Ni
FIRMNAME:
IV) i r
Licensee:A,—) 8 Y) n YT -0)-4 Signature HJW_7vizl�- _LIC. NO.: - E A 61
11 -
(Ifapplicable, qtr exfmpt in the I' ns number lined _rA
Bus. Tel. No.:
ne
Address: L -i ri Yr-- Ub_n tVk). 6:3251_ Alt. Te. -I. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Departm&nt of Public Safety "S" License: U
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 $
Signature Telephone No. FEE:
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 shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PAP -TIAL ROUGH INSPECTION:
Pass R?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
RO GHY16PECTION:
PasK
Failed
Re- Inspection Required 0
-
Inspectors C
,Wments: /1)
k
(f, A VAA
1 -2 -
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass F?1
Failed IN
Re- Inspection Required El:
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organizati6n/Individual):_U,8V)D Vlnf,�t
Address:- 9 �-t�iu � orl�E - . . � *
City/State/Zip: 05 �And
_kjt�hVlr� Phone 4:
Are you an employer? Check the appropriate box:
LEI I am a employer with
4. El I am a general contractor and 1
(employees (full and/or part-time).*
have hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
. Al
require J
officers have exercised their
E] I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. M New construction
7. E] Remodeling
8. E] Demolition
9. E] Bu9ding addition
10. Viectrical repairs or additions
11.E1 Plumbing repairs or additions
12.E] Roof repairs
131� Other
Nny applicant that checks box# 1 must also Eli 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.
�ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that isproviding workers'compensation insitrancefor my employees. Below is thepolicy andjob site
ffiormation.
isurance, Company Name:
olicy # or Self -ins. Lic. #:
Expiration Date:
)b Site Address: City/State/Zip:
Vach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
3 ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
- up to $250!00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Lvestigations of the DIA for insurance coverage verification.
do hereb� ti under thepains andpenalties ofperjury that the information provided above is trite and correct.
Date.. N-1
.anatare:
Official itse 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 detmed 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 of 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 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
6QQ Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
evised 5-26-05
jA0Fip1
Date . it 70 . .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . ................................
has pennission for gas installation. . .........
in the buildings of ....
at ... LA.A.' ..... North Andover, Mass.
Fee. Lic. No. ... .....
.... ..... ... .. .. ...
GASINSPECTOR
Cheek#
xx V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM'GAS FITTING WORK
CITY MA DATE JIPERMIT#.
ADDRESS
JOBSITE OWNER'S NAMEJ
G
OWNER ADDRESS L-�F_7 TE
.,,� 4 �t2B'AZ!�_ __PaFAX
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAX
CLEARLY
I NEW: D RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES F-11 NOY
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER . . . . . . 'Jj
FIREPLACE
FRYOLATOR
FURNACE —j
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS I_ I
MAKEUP AIR UNIT
OVEN I—A
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT L -J.
TEST
UNIT HEATER
ILINVENTED ROOM HEATER J=
WATER HEATER
THE
j 1 11-- J I I J I L�J L �--
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES'XNO F31
I 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 2ensee 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 -01 AGENT E-11
SIGNATURE OF OWNER OR AGENT 4.
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 c^pliance with all Pertinent provision ofthe
Massachusetts state Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME -V LICENSE # SIGNATURE
IVIPO�d MGF 0-1 JP 0-j JGFF-11 LPG] CORPORATION # PARTNERSHIP 0#[ LLC #
COMPANY NAM ADDRESS
CITY STATE ZIP
FAXI-E4 CELL EMAILI
�b ga —C"
xx V
COD
0
co
co a -
w
Cl)
z PA
0
<
C40D
1�
L\_ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): tPI—VA49 A)Q, d"-ZJAJ6 Q�dp
Address: PU
City/State/Zip: Mo. AAk0UkA_11__ MA...0159 e #: of M - LO 17 9 Z-6,
0, U a
Are n employer? Check the appropriate box:
I
I am a employer with
4. El I am a general contractor and I
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.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
required.]
officers have exercised their
3. 0 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.] I
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F1 New construction
7. F1 Remodeling
8. E] Demolition
9. n Building addition
10. El Electrical repairs or additions
I I-VIPlumbing repairs or additions
12U. Roof repairs
13T] 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.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andJo'b site
information.
Insurance Company Name: GUMA, I NQ tM.1009:gr - G r?=4:1
Policy# or Self -ins. Lic. #:
UX
Expiration Date:
Job Site Address517 S- o,44V_pc�
57-4�28 s4mu
City/State/Zip: tL-AAamL,
Attach a copy of the workers' compensation -policy declaration page (6owing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
firie up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby c�rtjf
y under the pains andpenalties offierjury that the information provided above is true and correct.
Phone #: 9 28 - Li ?b - 1 )9,02�,
Official use only. Do not write in this area, to he completed by city or town official,
City or Town:
PermitALicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing e m.ployees. However the
owner of a dwelling house having not more than three apartments and who 'resides therein, or ilie'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'thht "'every state or'lo'cal licensing agency shall withhold the issnance I 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 (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
,Tembers 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 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-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www,mass,gpv/dia
Date.. ��.2- ?—
................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4-.
This certifies that ....... .. 74
has permission to perform .......... ..................
wiring in the building of ........ ..........................................
at?.5�4'07'1 V eL .....
.......................... .. North Andover, Mass.
Fee. 9K��.... Lic. No. ��?D ... / /,14 �.. �4j; ...... A4
ELE&RICAL NSPECTOIr
Check o
87i 1
Ap
JQ6-\ Commonwealth of Massachusetts Official Use Only
Q a Department of Fire Services Permit NO.
Occupancy and Fee Clecked
u,p BOARD OF FIRE PREVENTION REGULATIONS rRev. I/o7] (leaveblank)
r
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (M[EC), 527 CMR 12.00
(PLEASE PRBV7 flV D�W OR YTPE ALL BVFORAL4 Y JOA9 Date: Ll- -Z/- C)
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By thds apphcation the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ��, ,/
Owner or Tenant 'aj, Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building _,� / Ublity Authorization No.
Existing Service Amps volts Overhead Undgrd No. of Meters
New Service Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: /A,, "AY -C
1.1qn" A. f�17^ ...
Attack additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: il Id -V 4-0, (When required 'by municipal policy-)
Work to Start Inspections to be r—
equested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such co e is m force, and has exhibited proof of same to the permit issuing of6ce.
CHECK ONE: INSURANCE BOND [] OTHER [] (Specify:)
I certify, under die pains and penalfies ofperjury, that the informadon on dt& application is true and completee
F71RM NAME: YU qj VC4 LIC. NO.:_8'f-5_C
Licensee: D, Sollivan Sigimture LIC. NO.: -2 2 Y 7_/>
(7f applicable, enter "em -mo, " in the license number Line.)
Address: �2 -7 /11 /,0 Bus. TeL No.: - ZY
AIL Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Departrnent 0 public Safety "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 hemby waive this requirement. I an the (check one) E] owner El owner's agent
Owner/A-gent
Sign2tare Telephone No.
j, _ _-g
- � by 1hcJ!,L o r A, ires.
No. of Recessed Luminaires
No. of CeL-Susp. (Paddle) Fans
gor
No�
. OF jp
0
Trandormers KVA
No. of Ltiminalire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminni es
Swimming Pool Above o In-
No. of Lnwrgency 1411ting
grad. grnd. P,Battery
Units
INo. of Receptacle Outlets
i
No. of Oil Burners
FME ALARMS
FN,. of Zones
No. of Switches
No. of Gas Burners
No. -of Detection and
hutiatint Devices
No. of Ranges
otal
No. of Air ConcL Tons
-
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number I Tolls
JKW
N-0. of Neff-contained—
Deteetim�/� Devices
No. of Dishwashers
Space/Are& Heating KW
Local [] Municipal
Connection Other'
No. of Dryers
Heatiag Appliances KW
Security Systems: *
No. Devices
No. of Water
Heaters KW
No. of No. of -.-
of or Equivalent
Data Whing:
signs Ballasts
No. of Devices or Univalent
No. Hydronisk sage Bathtubs No. of Motors Total B1P___ Tei—lecommunications wirin,-
ices or Eanivalent
Attack additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: il Id -V 4-0, (When required 'by municipal policy-)
Work to Start Inspections to be r—
equested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such co e is m force, and has exhibited proof of same to the permit issuing of6ce.
CHECK ONE: INSURANCE BOND [] OTHER [] (Specify:)
I certify, under die pains and penalfies ofperjury, that the informadon on dt& application is true and completee
F71RM NAME: YU qj VC4 LIC. NO.:_8'f-5_C
Licensee: D, Sollivan Sigimture LIC. NO.: -2 2 Y 7_/>
(7f applicable, enter "em -mo, " in the license number Line.)
Address: �2 -7 /11 /,0 Bus. TeL No.: - ZY
AIL Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Departrnent 0 public Safety "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 hemby waive this requirement. I an the (check one) E] owner El owner's agent
Owner/A-gent
Sign2tare Telephone No.
r
f
40
Policy # or self -ins. Lie. #: W(,
- ------------ Expirafim.Date..
Job Site Address: '? F &,,,�
A,Iacl a cD" of the wo city'statezip. --- 0
Failure to secure c . Overa rkM' cOMPCIQ�tiA3�D Policy declaration page ohowwg the Policy number and expiration d2te�
, ge as required under
fine up to S 1,500.00 and/or one_Year Mpriso Section 25A of MGL C. 152 can lead to the imposition of criminal p
Mnent, as well as civil pe;Wfies in the fmw Of a STOp WC)p enalties of a
'K ORDER and a fine
Of UP to $250.00 a #aY against the violator. Be advised that a copy of this statement may be forwarded to the 0Iffice of
Investigations of the DIA for insurinice coverage velification.
I 1W here -by Cerd-fy unde;- j*,paim ad PTIFfties ofp--J*7 tha� the infenwaoff P'"'ded abOve is bw and coI
3iL,TMtz"-L Z, /_.e ;K) /"- .0 0'
Junc: ff: , II of 4,1 11 111 1111
Ust AI Do "at wrde in rh& areg, tv be conVZejte_.d 0 City OT town offidd
City or Town:
I— : PermWLicense #
U Ug AuxucritY (circle one):
I. Board of Healh
6. Other 2- Ba"Ing DePartmient 3. CitY/TOwn Clerk 4. Elechical Inspector S. Plumbing Inspector
Contact Person:
Phone *
Tke Conunanweakk Of Massachuseft
4- t
Department of lndu�tridAcciden&
Or-
Offwe of Invesdgatiolu
600 Wasismgton S&-ftt
Boston, MA #2111
www-inassgovIdia
Workers' Compensation Iftshrance Affidavit: B'LiWer&/ConbactorsMiectrici&RL/pimmbers
A.pWjca
t Information
Name (BUSnIiiizafionAndividuW):
_5_J///1W__
Address .2-
City/State/Zip
Phone#.. tloe�,? _(f Y7X
on an employer? Cheekthe appropriate box:
FAm
am R employer with
Type of Project (requi -red):'
4. 1 am a general contractor and I
�10
employees (fun andVo5W__time).*
2. ED I am asole prupriew or
have hired the sub-contractDrs 6. E?$Jew construLtiori
.
pailner-
ship and have no employees
listed on the attached sheet 1 7. E3 Remodel ing
These
working for me mi any capacity.
sub-cont3actots have
work=' insurance. 8. 0 Demolition
[No I workers, oomp. insurance
comp.
5. El We are a corpomtion mid its 9. E3 Building addition
3.[3req I
f am 2 homeowner doing
officeri; have exercised th 10. El Electrical repairs or additions
all work
mYself ENO -work=` comp.
right of exemption per MOL I 1 -0 Plumbing repairs or additions
c. 132, § 1(4), and we have no
insurance requirr4] t
12.F1 Roof -
-employees, (No workeI repairs
GOMI insurance required.] 13.[].Offier ----------
*Alwy "Umm tha dmcks bo)e#t `M 11so 19f
M the notion Wow showTng
14o—_vnm Who utbrntt this affwsv,t hWimning they "leir worked'6ompmation
kmiftoors liw dieck this bo;c am doing a work and them hke otaside conmictom 'olicrj'
— &u0bW an adilitiona) Www mug submit A n0w &fFxiw#
indmn* u&dL
showing. tha,mn, oftil, w&cm*whU
am an employer Zia ispr0*fiNZ:woFkM, ad th* wonII camp. poji,), fir&QgM.
inforrnatio&
GOAVinsad0ft iftsurancefor mr. wrp*g= Below is the PVA7 and* site
Insurance Company Name: <5� Ka n �' /V
Policy # or self -ins. Lie. #: W(,
- ------------ Expirafim.Date..
Job Site Address: '? F &,,,�
A,Iacl a cD" of the wo city'statezip. --- 0
Failure to secure c . Overa rkM' cOMPCIQ�tiA3�D Policy declaration page ohowwg the Policy number and expiration d2te�
, ge as required under
fine up to S 1,500.00 and/or one_Year Mpriso Section 25A of MGL C. 152 can lead to the imposition of criminal p
Mnent, as well as civil pe;Wfies in the fmw Of a STOp WC)p enalties of a
'K ORDER and a fine
Of UP to $250.00 a #aY against the violator. Be advised that a copy of this statement may be forwarded to the 0Iffice of
Investigations of the DIA for insurinice coverage velification.
I 1W here -by Cerd-fy unde;- j*,paim ad PTIFfties ofp--J*7 tha� the infenwaoff P'"'ded abOve is bw and coI
3iL,TMtz"-L Z, /_.e ;K) /"- .0 0'
Junc: ff: , II of 4,1 11 111 1111
Ust AI Do "at wrde in rh& areg, tv be conVZejte_.d 0 City OT town offidd
City or Town:
I— : PermWLicense #
U Ug AuxucritY (circle one):
I. Board of Healh
6. Other 2- Ba"Ing DePartmient 3. CitY/TOwn Clerk 4. Elechical Inspector S. Plumbing Inspector
Contact Person:
Phone *
Date ..... /z -
TOWN OFNORTH ANDOVER
PERMIT FOR WIRING
This certifies that tj
..........................................................................................
has permission to perfor7n ....... "X X .............................................
. ...........
wiring in the building of ........
........ North Andoyer, Mass.
L Rj�;�.i�
Fee'V�� .......... Lic. No��. ........... P . ..... .. ..... . . ..........
EL I A N-
V
Check # /,) �� f I
8698
/ �fl
�C\ Commonwealth of Massachusetts
f Fire Services
Department o
BOARD OF FIRE PREVENTION REGULATIONS
;OIffif, c :ia I :U s jeO n :iyW7
�4
Permit No.
occupancy and Fee Checked
[Rev. 9/051 (1,,v, blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 27 CMR 12.00
(PLEASE PPJNT.BV LVK OR TYPE ALL 1NFORAL4 TION) Date: Lf / 9JO 01
City or Town of: A), AA)C)0Vtb2 To the InspecItorlof Ares:
By this appiication the undersi-fied gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) vc, I
Owner or:Fene t ZhrrW,5aD Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes
No [] (Check Appropriate Box)
PurDose of Building "S�Ijh) Z,11,10 G- Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd
�jew Service ALmps j?_Q Q&O Volts Overhead Undgrd
Number of Feeders and Ampacity 1- 2-0o AMP
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters A_
Cnmnlptinn nf thp folinwing table n7av be waived bv the Inspector ol Wires.
Attach ailaitionai detaii y aesirea, or as requirLu Dy Ine 111,)P"LU1 UJ
Estimated Value of4ectrical Work: (When required by municipal policy.)
Work to Start: qlooj Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C6rERAGE* Unless waived by the owner, no permit for the performance ofeiectrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such covyage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [Z BOND [I OTHER 7 (Specify:)
I certify, under the pains andpenalties ofperjun,, that the information on this application is true and complete.
FIRM NAME: Interstate Electrical Servic rpor.at', LIC.N .:A-5217
14 s 'Po
Licensee: Pasquale A. Alibrandi Signature Z-1 I
�L I� 00
(Ifapplicabl� 67ter t" in il7e license nurnber line.) Bus. Tel. No.:97 8-667— 5 2
"'gi e Alt. Tel. No.:
Address: Tre Cove Rd., N. Billerica, MA 01862
*Security System Contractor License required for this work; if applicable, enter the license number here:
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) D owner E] owner's agent.
Owner/Acrent I PERMTT FEE: S t-7 1
Signature` Telephone No. f
No. of i otal
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans J
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimmina Pool Above Ei In- El
el grnd. grnd.
N a. of E—mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JNo. 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
neat rump
J.KW ...........
...........
No. of Self -Contained
No. of Waste Disposers
Totals:
Deitecti( n/Alerting D ices
No. of Dishwashers
Space/Area Heating KW
a1sE Municipal 1-1 Other
Loc Connection
Heating Appliances KW
Security Systems:*
No. of Dryers
No. of Devices or Equivalent
o. of Water KW
No. of No. of
Data Wiring:
Heaters t
Signs Ballasts
No. of Devices or Equivalent
____TNo.
Telecommunications Wiring:
No. Hydromassage Bathtubs
of Motors Total HP
No. of Devices or Equivalent
OTHER:
Attach ailaitionai detaii y aesirea, or as requirLu Dy Ine 111,)P"LU1 UJ
Estimated Value of4ectrical Work: (When required by municipal policy.)
Work to Start: qlooj Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C6rERAGE* Unless waived by the owner, no permit for the performance ofeiectrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such covyage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [Z BOND [I OTHER 7 (Specify:)
I certify, under the pains andpenalties ofperjun,, that the information on this application is true and complete.
FIRM NAME: Interstate Electrical Servic rpor.at', LIC.N .:A-5217
14 s 'Po
Licensee: Pasquale A. Alibrandi Signature Z-1 I
�L I� 00
(Ifapplicabl� 67ter t" in il7e license nurnber line.) Bus. Tel. No.:97 8-667— 5 2
"'gi e Alt. Tel. No.:
Address: Tre Cove Rd., N. Billerica, MA 01862
*Security System Contractor License required for this work; if applicable, enter the license number here:
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) D owner E] owner's agent.
Owner/Acrent I PERMTT FEE: S t-7 1
Signature` Telephone No. f
9
Lkc
il
le�
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 488 Date: August 3. 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 28 Samuel Way
MAY BE OCCUPIED AS Sinifle Family Dwelling
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE
BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Edgewood Retirement Community
16 Samuel Way
North Andover MA 01845
BuAding Inspector
Of
APPLICATION FOR CERTIFICATE OF OCCUPANCYfiNSPECTION
Buildina Permit#
-11*11
ADDRESS/LOCATION OF PROPERTY
kLtA-y�
.Map. Parcel Lot Number
SUBDI'VISION
DATE REQUESTED FILED/READY FOR INSPECTION -2
CLOSING DATE ON PROPERTY:
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE. COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGFD IF THPATRI If"n Or -
DOES NOT MEET ALL APPLICABLE CODES.
Pelwift Issued to:
Address
SIGNED
R
erUlnlN
CONSERVATION
PLANNING
DPW - WATER METER
F 77 -1
SEWERIWATER CONNECTION '711 WO I
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCYfiNSPECTION REQUEST
C6DPW
Signature
File: Application for OC form revised Jan 2007
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Project Number:
Project Title:
Project Location:
Scope of Project:
Re��istered Architectural and Engineering Services
Construction Control Affidavit
DSA Project #0706.00
Edgewood Retirement Community Cottages
#28 Samuel Way, North Andover, MA 0 1845
22 Individual Cottages
In accordance with Section 116.0 of the Massachusetts State Building Code 1, Allen DewingJr., MA
Registration #4301 being a registered professional engineer/architect, hereby certify that I have prepared or
directly supervised the preparation of all design plans, computations and specifications concerning:
Entire Project xx Architectural Structural
Mechanical Fire Protection Electrical
Other (Specify)
For the above named project and that, to the best of my knowledge, such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code. All acceptable
engineering practices and all applicable laws for the proposed project.
I further certify that I shall perform the necessary professional services and be present on the construction site
on a regular basis to determine that the work is proceeding in accordance with the documents approved for the
building perrnit and shall be responsible for the following as specified in Section 116.2.
1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are
submitted by the contractor in accordance with requirements of the construction documents.
2. Review and approval of the quality control procedures for all code -required materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine, in general, if the work is being performed in a
manner consistent with the construction documents.
Upon completion of the Work, I shall submit a
the project for occupancy.
No. 4301
CONCORD,
MA
s to the satisfactory completion and readiness of
F:\DSA Project Files\Edgewood 0706\05. Project Word Docurnents\a. Correspondence and Transmitfals\vi. Misc
Registered Engineering Services
StructuralConstruction Control Affidavit at Comoletion of Structural Work
Dat
'kORT
0 0
TOWN OF -NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
S CHU
This certifies that ............ ..............
has, permission for gas installation V. kl%,.
in f
the buildings o�
.........................
at North Andover, Mass.
ci
Fee. A Lic.
CTO
GAS INS
Check #
6819
4C\
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO GAS FITTING
-V
Cityfrown:/ Or�h-14Md&Vef--MA. Date: &IIS= 6!2 Perm1w...--
Building t=atiorc a Nan
K LS 0 Q1 bf f I WLt V Owners Fke Woo J Ret, re
Type of Omupancy: COmffwcW [3 Educational [I Industrial [I InsWAonal [I Residential
Now: gaz" Alteration: Renovation: 0 Replacement: 0 Plans Submitted: Yes[] No 0
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Ched* One Only -PeirtifiPate
Installing.Company
... . . .. . -256.1 7tC
WM
Partnersh
L L
Ip
Businew T
FinnIC6rnpany
Name Of I-Icensed Plu
mberfGft F.- Id
Man
INSURANCE COVERAGE.
I have a current Ila F 1111811111111M Policy or Its substantial eqtdvalemvddch ineets the requirements of MGL Ch. 142 Yes I@ No 0
If you have checked Yes. please Indicate the 4W of covenW by checking the appropriate box below.
A liability insurance policy 0
Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I ain aware Oat the lkmsw dam not have the Insurance coverage required by Chapter 142 of -the
Massachusetts General Laws, and VM my SkInaturs on this pennit aliplicadon waives this requiremerit.
Check One Only
Skinature of Owner or Owner's, Agent Owner 0 Agent
By Checking lide box U; I WNft cWft diat all of the details and hd6nnation I have submted for entefeM regwdhv aft application we am and
accumte to to best of my Knowledge and #wt all PknWng work and installations perfamed under the pem* Issued for this application will be in
compliance with all Pertinent provialon of the Masseclumeft State Pkunblng Cqd* and Cliapter 142 of the Genwal Laws.
ft I 0 -Plumber 1 110-// -�;�
=Q;4 W, 4
Date.
Y�j TOWN OF NORTH ZDOVER
PLUMB
PERMIT FO PLUM13ING
&This certifies that ... ............. ........... d .......
has permission to perform ...... ....... ....... ........
plumbing in the buildings of ....... ...........................
at ........ ..................... North Andover, Mass.
............... .......
Fee. Lic. No. 1.3 ��) . .
PLUMBING INSPECTOR
Check
FIXTURES
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
Cityrrown: juori'-i AyJ6,j(N— mA. Date: q Permit#
Building Location: 26 5-00202,1 Owners Name: Ca 40 -U ->06c) Roo-l"ie-MEA a
Type of Occupancy: Commercial E] Educational Industrial [] Institutional [] ResidentiWR
Now: 0 Alteration: E] Renovation: Replacement: Plans Submitted: Yes D No 0
FIXTURES
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BASEMENT
-T'FLOOR
imy-F-LOOR
Yw FLOOR
4' FLOOR
5nrFLOOR
-WR F—LOOR
7TH FLOOR
8'- FLOOR
Check One Only Certificate #
Installing, Company Name. MOn8tiold-PlUmbift -n
W&K mil nc-
2561 —C
Corporation
Address: 36 Jackmairt;sL...-L CitylTown:Ge rgetown Siatii—MA
[I Partnership
Business Tel: !W3,62 493� Fax.- (978)352-5410-
FirmlCompany
,Name of Licensed PlumberTirnothy J. Ma�nsfifdd
INSURANCE COVERAGE:
I have a current liability neurance policy or its substantial equivalent which meets the requirements of MGI- Ch. 142 Yes No [I
If you have checked Yes. please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy E] Other type of indemnity E] Bond El
OVWNER'S INSURANCE WAP/ER: 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 Oft requirem nt.
Check One Only
Owner El Agent E]
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information t have submitted (or entered) regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all
Pertinent provision of the Massachusetts state, Plumbing Code and Chapter 142 of the General Laws.
By Type of Licenw.
Title Plumber Sigfiature of Li�!�
21JAaster OQ
Cityl-rown O.Iourneyman License Number 13437 /C;�
APPROVED (OFFICE USE ONLY) I I
Registered Engineering Services
Structural Construction Control Affidavit at Completion of Structural Work
Project Number: DSA Project #0706.00
Project Tide: Edgewood Retirement Comi-nunity Cottages
Project Location: #28 Samuel Way, North Andover, MA 01845
Scope of Project: Wood Framed Cottage with Concrete Basement and Foundations
In accordance with Section 116.0 of the Massachusetts State Building Code, 1, Geoffrey S. Conway,
MA #32753 being a registered professional engineer (structural), hereby certi�, that I have prepared.
or directly super%,ised the preparation of all design plans, computations and specifications
concerning:
Entire Project _Architectural XX Structural
Mechanl*call Fire Protection Electrical
.Other (Specify)
For the above named project and that, to the best of my knowledge, such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, all
acceptable engineering practices and all applicable laws for the proposed project.
I further certi�, that I have performed the necessary professional services and have been present on
the construction site on a regular basis to determine that the work is proceeding in accordance Nvith
the documents approved for the building permit and have beenresponsible for the following as
specified in Section 116.2.
1 . Review for conformance to the design concept, shop drawings, samples, and other
subinittals, which are submitted by the contractor in accordance with requirements of the
construction documents.
2. Review and approval of the quality control procedures for all code -required materials.
3. Been present at intervals appropriate to the stage of construction to become generally
familiar with the progress and quality of the work and to determine, in general, that the work
has been performed in a manner consistent with the construction documents.
0 , F
GEOFFREY
Geoffrey S. Conway, P.E. Date S. CONWAY
M STRUCTURAL
Nlo.3275
.6
I S T