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Home My WebLink AboutMiscellaneous - 281 BLUE RIDGE ROAD 4/30/20180 M Iialytical, LLC .3 (A Wi HOW Road, Ayer 01 MA 432 C , lient: Charles M. Rollins Co, Inc, 126 Depot Road Bakford, MA 01921 i FAX NO. :9784863319 Oct. 25 2010 01:18PM P1 Tol: 978-391-442� Pax, 978-1914643 LabNumber: 117512 Wclv�ilc: IIIIP://www.N;iulioliiAiial -=L 7-- ylical-coln I Ne thin number with,,111 corj,eSpcqj(l0jjC.Q -Certificate of Analysis 6281 13:1ue:Rldge RjDad, North Andover MA t MCI, MRL - Wellhead SQn7P1e(f,' 1011912010 6:00:00 AM by Client E.coli, 11 OOML NA-,MUG-SM9222(n Total Coliform Bacteria, /I OOML MF-SMa22?.B Calcium, MG/L EPA 200.7 Copper. MG/j, EPA �00.7 Iron, MGiL EPA 200.7 Magnesium, MG/L EPA 200.7 Manganese, MG/L EPA 200,7 Sodium MGiL EPA 200,7 Alkalinity, MG/L SM 23208 Ammonia, MG/L SM 4500-NH3-D Chloride, MG/L EPA 300.0 Chlorine, Free Residual, MG/L SM 4500,CL-G Color Apparent, CU SM 2120B Conductivity, UMH08/CM SM 25108 Hardness, Total, MG/L SM 2340B Nitrate as N, MG/L EPA 300.0 Nitrite as N, MG/L EPA 300.0 Odor, TON SM 21 SOB pH, PH AT 250 SM 4600-H-8 Sediment, po : s/naq I— -- - ---- Sulfate, MG/L EPA 300.0 Turbidity, NTU EPA 180 ReportDate, 10/25/2010 Date (if Analysji Allaily4A Absent O/Absent Absent 10/20/201011:30:ODAM M-MA1118 # >200 O/ftsent 0 10/20/2010 11:10: 00 AM M-MA1 118 51,9 Not Spec 1 10/22/2010 M-MA1118 ND 1.3 0101 10/22(2010 M-MAII 118 # 0.32 0.3 0.01 10/2212010 M-MA1118 13.6 Not Spec 1 10/22/2010 M -MA I i i a # 0.085 0.0$ 0.005 10/2212010 M -MAI I 16 4.3 See Note 1 10/22/2010 M-MA1 118 162 Not Spec 1 10/20/2010 M -MAI 118 ND Not Spec 0.1 10/2012010 M -MA 1118 26 250 1 10120/2010 M -MAI 118 ND NotSpec; O.0z 10/20/2010 M -MAI 118 15 15 1 10j2MO1O M-MA1118 605 Not Spec 1 110120/2010 M-MA1118 186 Not Spec 2 10/22/2010 M-MA1 118 0.11 10 0.05 10/20/2010 M -MAI 118 ND 1 0.01 10/20/2010 M-MA1118 0 a 0 10/20/2010 M -MAI 118 7.5 6.5-8,5 NA 10/20/2010 M -MAI 118 NEG NEG 1 OM/201 0 M -MA 1116 20.8 250 1 10120/2010 M -MAI 118 4.2 Not Spec 011 10/2012010 M -MAI 118 MCL,7Ma)dtYwrn:0ontaminan1 Lavol (EPA Limit), MRL = Minimum Reportlng Level Sodium Guirlelines- Mass 20, EPA 250, # = Ressult Exceeds Limit or Guideline NO z NoneDetected (<MRL), * = Background Bacteria Noted Massachusetts Certified Laboratory #MA 1116 David L. Knowlton Laboratory Director Page I of 1 FROM FAX NO. :9784863319 Oct. 29 2010 04:15PM PI --rl it RMEEUED I N ea,loba- Alialytical, LLC 3 1 A Willow Rolid, Aver MA01432 Client: Charles M. Rollins Go., Inc. 126 Depot Road Boxford, MA 01921 '1 .1: 97x-�393-4428 [lax: 978-391-464.1 Welisito: littp:HwA,w.NaBlioKi,,knILtytical.cotii Certificate of Analysis 281 Blue Ridge Rcoa:d, Norlh A�ndover �M�A M'th' Patradic cr Mcthod - Wellhead Sampled: IW712010 1.00:00 PM by Client Total Colifofrh Bacteria, 11 ODIVIL IVIP-,9W2225 C. 'C'"T L, 9 2010 )WN OF NC LabNu HEA' TH n .-ARTME U -w this aurril:xr with all corrusporicidn—ce ReportDate� 100/2010 Reiult MCL MR[, Date of.Anallysils Anallyst 0 OlAbsent 10/28/20109:30:DOAM M-MAli'18 M�L-lvluximum CQntaminant Level (FFIA Limit), MR1., - Minimum Reporting Level Sodium Guidelipgg- Mass 20, EPA 250, # = Result Exceeds Limit or Guideline NO = Norie tMtLfi&ed.(<lVlRL), SackpUnd Sacteria Noted MassachUNUS COMM Laboratory WAI 118 David L. Knowlton Laboratory Director Page 1 of 1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ZIA.U.0-1 .... ......... . ........................ has permission to perform ..................... I.. .. 00-1 ........... plumbingin the buil ings of ............................................................................................. 71 . . ........... ............ r\ ......... .... ), North Andover, Mass. V Fee ... Lic. No. T PL,UM***Al*N**G*'*'IN**'S'*P'* Check# 11"All DEDICATED GREASE SYSTEM___ I__ DEDICATED GRAY WATER sYs-TEm OWN- FI-MIOWN F- -0- FW— FW—W F - W-- FN—W F1 W I ON 0— FM—W P ft DEDICATED WATER RECYME-s-YsTu F-.-F-Fm- WFN I W-0 I F1 171 011 1 -0 N 0- K FW—W r W-- FO -0 F1 —W FW—K FM— W FW— FW—K FM— I'M 9 '"s W W F rl 11 M. ME F�- F�- F �-- F�- F�- F�- F�- F�- FEW I F �-- F�- r�- I I I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES O'NO M-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY Pi 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 permit application waives this requirement. CHECK ONE ONLY: OWNER 01 AGENT IR -J SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this appKation are tru� and accu te to the best of my kno d b and that all plumbing work and installations performed under the permit issued for this application !I] be in comp ance Vi I ertinent r v1slo f e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# -(/SIGNATfJRE MID P-3-0"-Jp 01 CORPORATION RI # PARTNERSHIPD# LLC E� COMPANY NAME i �j I ADDRESS i CITY OW �g STATEF-A-.1 zip I d & 2.-5,6 TEL FAX CELL 17 -11 EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 4 MA DATE ::IIPERMIT#. JOBSITE ADDRESS e- J OWNER'S NAME POWNER ADDRESS TELE FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL Q PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO F -I FIXTURES"I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM JL IL J DEDICATED GREASE SYSTEM___ I__ DEDICATED GRAY WATER sYs-TEm OWN- FI-MIOWN F- -0- FW— FW—W F - W-- FN—W F1 W I ON 0— FM—W P ft DEDICATED WATER RECYME-s-YsTu F-.-F-Fm- WFN I W-0 I F1 171 011 1 -0 N 0- K FW—W r W-- FO -0 F1 —W FW—K FM— W FW— FW—K FM— I'M 9 '"s W W F rl 11 M. ME F�- F�- F �-- F�- F�- F�- F�- F�- FEW I F �-- F�- r�- I I I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES O'NO M-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY Pi 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 permit application waives this requirement. CHECK ONE ONLY: OWNER 01 AGENT IR -J SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this appKation are tru� and accu te to the best of my kno d b and that all plumbing work and installations performed under the permit issued for this application !I] be in comp ance Vi I ertinent r v1slo f e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# -(/SIGNATfJRE MID P-3-0"-Jp 01 CORPORATION RI # PARTNERSHIPD# LLC E� COMPANY NAME i �j I ADDRESS i CITY OW �g STATEF-A-.1 zip I d & 2.-5,6 TEL FAX CELL 17 -11 EMAIL Ira 0 zo ui CL *k LU U) < LLJ U) > LU co z 0 M CL (L < U) LU LL The Commonwealth ofMassachuseUs DepurtmentoflndusiyiqlAccidii�ts Office ofinvesfigations 600 Washington Street Boston., HA 02111 vmmass.govIdia Workeirs' Compensation Insurance Affidavit: BuilderslContractordElectri , clans[Phimbers AppReant Wormation Please Pr Ledbily Name Cpusinosdargadzationmidyidual) - ----- Address: City/State/Zp; Phone iV: Are you an employer? Check the appropriate box: Type of project (required): 1. F1 I am a employer with 4. El I am a general contractor a -ad 1 6. F1 New cOnstraction employees (fall and/or part-time).* have hired the sub -contractors 7. [] Remodeling 2,111 am a solD proprietor or partner- listed on the attached sheet. I ship and1aveno-employees. These sub -contractors have 8. El Demolition working for me, in any capacity. workers' comp. insurance. 9. El Building addition [No workors' comp. insurance 5. El We are a corporation and its 1011 Electrical rep*s or additions required.] officers have exercised.their 3. El I am a homeowner doing all work right of exemption p or MGL 11. E] Plumbing repairs or additions MYS elf [NO workay . 91 6omp. c. 152, §1(4), and we have no 12.Q Roofrepairs insurancereqafred.] t employe6s. [No workers, 13.0 Other comp. insurancoreqaired.] "Any applicaut that checks boxfil must abO fit out thosectiolibef6wshowingtheir Workers' compensationpolicyinformation. T Homeowners who sibmit this affidavit indicating they ti� d9ing aU work and then hire outside contractors must submit a now affidavit bidicatiftg such. Untractors tbat chdkthis box must attached m Md1tiond sheet showing the name ofthe sub -contractors and their workers' comp. policy information. famanem r m mpf e s. et w 1 th p lie an I b sit pfoyer that isproviding workers'colnpensation ifisuraneefo ye oy e B o s e o Y do e infbimation. Insurance Company Policy # or Self- iU. UG. 9-: ExpirationDato: lob Site Address: Pfty/State/Zip: Attach a copy of the workers' comlpen�atlon-policy declaration page (showing the policy number and expiration date). Failure to secure Goverage.as reqyuleduader Section 2,5A ofMGL o. 152 can lead to the imposition of crimiiial. penalties of a fine up to $ 1,50 0.0 0 and/or 66 -year imprisoment, as well as civil p enalties in the form of a STOP. WORK ORDER and a fine ofupto$250.00 a day against the violator. Be advised that a co-py of this statementmay be forwarded to the Office of Investigations of the DIA for insurance, coverage verification. I I do 11'ereby cergJy under Aepains andpenaftles ofperjury that the information provided above is true and correct. Date. khone 4: .. official use only. vo, not write in this area, to be com pleted by city or town official City or Town: Permit/License Issuing Authority (circle 6ne): 1. Board of Health 2. Building Department 3. C41T-own Clerk 4. Electrical Inspector 5. Plumbing Ynspector 6. Other CoatactPerson: Phone Information and Instructi ons Massachusetts General Laws chapter 152 requires all employers to provide workers, comp satio f th k ploye S. Pursuant to this statute, an em eal n or 0 em 0 ,ployee is dofmail as "...every person hi the service of another under any contract ofhiro,. eWess: or implied, oral or written." An employeils doEmed as "an individual, partnership., association, corporation or other legal entity, or any two o 0 r M re of the for�joiqj engage d In a j oint enterpris q, and including the, legal repros entatives of a- do c o as o d employ rodelv&r or. trusteed an individual, partnership, askelation or other legal enflty� employing employe s. . pr, or the 0 ltweverth:e, owner of a dwal1ing house, having notmore than three apartments and who Xesides therein, or the occupant of the dwolling: house of another who employs persons to do maintenance, construction or repair workou such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to b a an omployor.,, MOL 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, MOL chapter 15�, §25C(7) states "Neither the commonwealth nor any of its political subivisions shall enter into any contract for the performance ofp-ablic work until acceptablo evidence of compl4uco with the insurance requirements of this chapter have beenprosented to the cQatracting authority." Applicants Pleaso.fill out tho workers, cOm -118aiiOn affidavit Completely, by ch gtho boxes that applytoyo sita on nd Pe ockin ur at! a 'if li6c0gsa*� SUPAY sub-contractor(s) name(q), addross(es) and phone nmbor(s) along with their coMr ,ate(s) of iu=ance- Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLTC or LLP does have 0mP1OYoes,apoHqyisreqWred. Be advised that thii affidavit maybe submitted to the, Department of Indusbial Accidents for con&mationofinsuranco coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that th6 application for the permit or license is being requoded, not the Dep,artment of Industrial Accidents. Shouldyou. have any questions regarding the law orif you are requiredto ob'tala a*orkersl componsationpolicy, please call the Department at the, number listed below. Self-insured companies should enter their self-insurance license number on the �pprqpriato Eno. City or Town Officials Please be sure thattho affidavit is complete andprinted-logibly. The Department has provided a space attho bottom of the affidavit for you to fill out in the event tho Office of Investigations has to contact you regarding the applicant. Pleas ' a be -sure, to fdl in the permit/11conso number which will be used as a reference number, In addition, an applicant that must submit multiple pormit/licenso applicationsin any given year, need only submit onG affidavit indicathig curr6nt PORGY information (ifnecessary) and under "Job Site Addross4 the applicant should -write "all locations in - (Citv or tow1r)." A 6opy of the affidavit that has becin officially stanap od or marked by the city or town may be provided to -the- applicant as pro of that a valid affidavit. ii on f -do �or fature Piormits Or licenses. . A new affidavit must b a Mqd out each year. Vhoro ahomo owner or citizen is obtaining a license oipormitnot related to any business or commercial venture (i.e. a dog license orp'ermit to burn leaves etG.) said -person is NOTrequired to complete this affidavit. The, Office of lnvestigation� would like to thank you in advance for your cooperation and shouldyqu have my questioT, please do not hositife to give us a call. The Departmenes address, telephone and fax number: Tho C=Monw, Galth of Mo Depadmout of Jndu*ial Accident Off toe of JAwstipaon's 6bG Washkgoa 8b:eet BostonXA02111 T01 # 617-7-27-4900 W 406 or- 1 -877 -MAS . �9, MF3 Revised 5-26-05 Fax# 617-727-7749 _WWW-Mus,govIcha A '2 . I Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ......... . ... . ..... I V .. �.A.e . ........................................................... has permission to perform ...... do-)e� (�eevv-,Je� ........................................................... wiring in the building of ......... vl:P 0,,,e ....................................................................................... "at ....... . ...... . e-, NAh Andover, Mass. ... ........ ,Fee ... . ......... Lic. No.R.��.q.� ....... . P'Q ........... . ......... -.71 .................. % Check 4t LECTRI CZ W&S �P�EC'T�O�R rn (flmmonwaa& ol VaijacLetb Apad.d olJim S .. ic. BOARD OF FIRE PREVENTION REGULATIONS 2`6110, rm, Official Use Only Permit No. k �__) I _!�> I 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL JWFORMA TION) Date: 3 / 4 / 2015 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 281 BLUE RIDGE ROAD Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building SINGLE FAMILY DWELLING Telephone No. No 1:1 (Check Appropriate Box) Utility Authorization No. Existing Service Amps Volts Overhead Undgrd New Service Amps Volts Overhead Undgrd Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: BATHROOM REMODEL No. of Meters No. of Meters ComDletion of the followin L7 table mav be waived bv the InSDector of Wires - No. of Recessed Luminaires 11 0 No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KV A No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 7 Swimming Pool Above Ei In- grnd. grnd. 0 f Emergency Lighting Battery Units No. of Receptacle Outlets 5 No. of Oil Burners FIRE ALARMS INo. of Zones No. of Switches 8 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 Number I Tons I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [] Municipal Connection 0 Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Dhtu Wiring: I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 coverage is in force, and has xhibit d f of same to the t issuing office. CHECK ONE: INSURANCE H BOND El OTHER n �� lic I c eiWft, u n der th e p a in s an d pen a Ides ofp erju ty, th a t th e info r4o n th is a on is true and complete. '41 FIRM NAME: BRIAN LAVOIE LIC. NO.: 28664E Licensee: BRIAN LAVOIE Signatu iz LIC. NO.: 11648 A (If applicable, enter "exempt" in the license number line.) Bus. Tel. No. - 9788157263 Address: - P.O. BOX 2240 METHUEN MA 01844 Alt Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of 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 hereby waive this requirement. I am the (check one) El owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ In 4r, 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): IBRIAN LAVOIE ELECTRICAL LLC P.O.BOX 2240 Address: City/State/Zip: IMETHUENMA01844 1 1978 815 7263 — Phone#: Are you an employer? Check the appropriate box: I - IT I am a employer with 3 4. 0 1 am a general contractor and I employees (full and/or part-time).* 2. 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. E3We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. E3Building addition 10. 13 Electrical repairs or additions I I.E3PIumbing repairs or additions 12. [0 Roof repairs 13. El Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 andjob site information. 1ATLANTIC CHARTER INS Insurance Company Name: VVCY1 OQ59102 Expi Policy # or Self -ins. Lic. #: ration Datel 31/_�-)_ IM R�VEIRIDGE ROAD Job Site Address: City/State/Zip: IN. ANDOVER MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine oflup, to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under 01eipains and� �nes pe_ �perjury that the information provided above is true and correct. 13 / 4/ /2101 Phone M IM 815 JT263 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact e son: Phone #: a AOL p_g"a—, W Safety Insurance 0 Fonn of Notice of Casuafty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 0 1845 NORTH ANDOVER, MA 0 1845 RE: Insured: CHRISTOPHER SKOWRONEK Property Address: 281 BLUE RIDGE ROAD, NORTH ANDOVER, MA Policy Number: HMA 0265033 Claim Number: BOS00030396 Date of Loss: 6/12/2012 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $ 1,000.00 or cause Mass. Gen. Laws, Chgpter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chqpter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com 6/18/2012 Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ........................... . . ..... ...... ...................... has permission to perform .... 7.. ...................................................... /& I LZ wiring in the building of ....... 4— In..t.el ..... ............................. . ........ . North Andover, Mass. .... . ............ . . t ........ Lic. No . ............. ...... . ... ..... ........................ Fee'5e:� iL�icml IAN troR JO* Check # / 6-5 ":� �0 9 1 Al Official Use Only Commonwealth of Massachusetts P -�t No. ern CIO Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Al I work to be performed in accordance with the Massachusetts Electrical Code (MEC), 511 C1,,1R 1111 k4 �2A 0 (PLEASE PRJNT IN INK OR TYPEALL INFORMA'770M 9 City or Town of: N- A-A)DIOU&R. To the By this application the undersigned gives notice of his or her intend on to erform the el Location (Street& Number) �)X/ AL -015— 01)(5C lk 1) OwnerorTenant OPRts f TpAlunliq Owner's Address Is this permit in conjunction with a building permit? Purpose of BuildiRg Existing Service Amps I Volts New Servic -Amps I —Volts Number of Feeders and Arnpacity hone No. '5� 1 2-1 (4 1 ? 71 Yes [I No El (Check Appropriate Box) UtWt� Authorization No. Overhead Undgrd F1 No. of Meters Overhead Undgrc[E] No. of Meters Location and Nature of Proposed Electri'cal Work: IN6R6UMD Tock- . Completion of thq following table mav be waived by the Inspector of Wirev. I No, of Recessed Fixtures No,. of Ceil.-Susp. (MaYd1e) Fans I No, of � Total Transformers KVA No. of Lighting Outlets N6. of Hot Tubs Generators KVA No, of Lighting Fixtures Swimming Pool Above n- grn d. Rrnd. ergenCy Ughnng Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALA11M.S I No.of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of AIr Cond, Total Tons No. of Alerting Devices No. of Wasfe Disposers Heat ump Tntals: �' umber Tons I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [3 Municipal r_1 Other �onnection L -J No. of Dryers — Ifeating Appliances . XW security Systems: No. of Devices or Equivalent No: of Water - Heaters Kw I No. of ..No. of Signs Ballasts Data Wiri'ng: No. of Devices or Equi lent va No, Hydrom assage Bathtubs No. of Motors Total HP Te—lecommunications W . Ir No, of Devices or Equ!iya Ee OTHER: Allach additional detail ifdesirei, o,- ?., rvq_*,--,-d 11-,--,,1-e biq)�Ltw �!'Wire.f. INSURANCE COV_EP_AGr,: Unless waived by the owner, no permit for the -performance of electrical work may issue =less the licensee provides proof of liability. insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c . . fi e, and has exhibited proof of same to the permit issuing office. 'Vrage is in orc -n "V CH�CK ONE: INSURANCE Jfl BOND Ej OTHER 0 (Specif)�) 7 ,y/U WLI (Expiration Date) Estirnated Value of Electrical C (When required by municipal policy..) Work to Start: Inspections to be requested in. accordance with MEC Rule 10, and upon completion. I ce'rfify, under thepaids andpenalties ofpeijuty, that the, information on this qpplication is true and complete. FIRM NAME: E) -o i - 1 i LIC. NO,:_ql,� Ignatu Licensee:A p - 7- H 0 /1 LIC. NO., (�f appl' bl�_Anle�- "ex. t 1h 'ca e /ice'Ve number lin.L) Q �f �A/lp C Bus. Tel; No.: 9 '2 1 Address: f7,0 - 44 6 1_1 L1 D1 OWNER'S INSURANCE WAIVER: I am aw4,ie that the Li-censee does not have the liability i J urance coveragq normally required by law, By my signature b�-,Iow- I:her'by-,wai.ve this -r *�men t; I am the (check one)'[] owner [I owner's a , gent. q. Owner/Agent .4-j. Signature �g Telephone':No, [7P7ERMITFEE,$ k�, 0 /Z-- -7 - I C-�- o P, /-i,— "*"' Aj�ej�;/L, k -"k 9 Date ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION N This certifies that.. /'� ........... has permission for gas installation f T in the buildings of . S'�, 1� ......................... at .5 ........... North Andover, Mass. Fee. Lic. No../ ),I AS INSPECTOR Check# ))�5 -k 6592 MASSACHUSETTS UNIFORM APPLICATION F9R P ,ERMIT TO DO GASFITTING Mass. Date /�/2.�/O`' 200K Permit# Buil din, Location Owner's Name Sk 0 UIPQP,6�-& d.?l 114,C11106E AD Type of Occupancy A&-9/0 New n Renovation Replacement g!' Plans Submitted: Yes [3 No 0 Instaffing Company N� C41-LfyAA-.4,1)(-c-t &LY.2 Address -C?/ LIF-Lhaq- ST A �j DAI jej)- hA 0 1 eLt C - Telephone q1W &81991)-1 Name of Licensed Plumber or Gasfitter Q-EFE Check one: Er'Corporation o Partnership 0 Firm/Co. Certificate " Lff) INSURANCE COVERAGE: I have a current liability 0surance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes 20' No 0 If you have checked 3ms, please mid4'pate the type of coverage by checking the appropriate box. A liability, insurance policy Other type of indeninity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner 0 Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of sachusetts State Gas Code and Chapter 142 of the General Laws. By Type of Licme: Title 17111.br B-'k.ta SioahWof Licensed Plumber/Gasfitter City/Town 0 GafitW 0 Joumeyman License Number APPROVED (OFFICE USE ONLY) 1, 10 R -All .11 RMSERV115�11� MEN MEN ME ME M NOME 0 =�WMMMMMMMMMMNEMMMMM EMMMMEMMMMMMMMMMMMMMM Instaffing Company N� C41-LfyAA-.4,1)(-c-t &LY.2 Address -C?/ LIF-Lhaq- ST A �j DAI jej)- hA 0 1 eLt C - Telephone q1W &81991)-1 Name of Licensed Plumber or Gasfitter Q-EFE Check one: Er'Corporation o Partnership 0 Firm/Co. Certificate " Lff) INSURANCE COVERAGE: I have a current liability 0surance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes 20' No 0 If you have checked 3ms, please mid4'pate the type of coverage by checking the appropriate box. A liability, insurance policy Other type of indeninity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner 0 Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of sachusetts State Gas Code and Chapter 142 of the General Laws. By Type of Licme: Title 17111.br B-'k.ta SioahWof Licensed Plumber/Gasfitter City/Town 0 GafitW 0 Joumeyman License Number APPROVED (OFFICE USE ONLY) Aft DateAl- has permission to perform ..... ty. - ��- - � — - - ........ 5 /((, L4 ox -t -e / plumbing in the buildings of ............... ........ f ............. at. '�. P. R.I. ........ North Andover, Mass. Fee -201-11 I . ....... Lic. No.I.J. �J. 1 .. ......... PLUMBING INSPE&OR Check# '� � <;Cy 7899 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,qc This certifies that J ......... has permission to perform ..... ty. - ��- - � — - - ........ 5 /((, L4 ox -t -e / plumbing in the buildings of ............... ........ f ............. at. '�. P. R.I. ........ North Andover, Mass. Fee -201-11 I . ....... Lic. No.I.J. �J. 1 .. ......... PLUMBING INSPE&OR Check# '� � <;Cy 7899 N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date�.6 20 09-' Permit# Building Location L UE-Ri D6E Ph Owner'sName S�,QIUR61VEIT- Owner Tel# TypeofOccapancy New 11 Renovation 11 Replacement Er-- PlanSubmitted: Yes 11 No 13 FIXTURES Installing Company Name C Check one: Certificate Address C1 I [� U-Qklop-7— ,�7— O-Co-rporation jY- &?muck hIA- ot �qr 0 Partnership Business Telephone # q *� r 6 9-1?0M11 � 11 Finn/Co. Name of Licensed Plumber fq7� -d-, INSURANCE COVERAGR I have a earren lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 If you have checked yes, please indicate the type coverage by checkin the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 OWNEWS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General IAws, and that my signature on this permit application waives this requirement. Check one: Owner 11 Agent 0 Signature of Owner or Owner's Agent I herebv certifv that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledg e and that -all plumbing work and installations performed under th t issued for this application will be in compliance with all pertinent provisions of City/Town APPROVED (OFFICE USE ONLY) Chapter 142 of the ws. TIT , it Signaturt-7ifs& Plumber Type of Ucense: Master Journeyman 0 License Number Date ...... // — 1-3-e 7 . ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING /�67- ................................... This certifies that ................................................ S"alee-c' 5Z C6,112 , ��7W SYSA--,--7 has permission to perform ............................. ��V. .......................... wiring in the buildingof .............. ........................... ... ... ... ... . .... .. ....... Rof4 . ................... . North Andover, Mass. at ...... 110. .................................. /5� FeeLic. No . ............. ................... A ......... 1,6 Off ELEcrRICAL INSPECTO Check # -3 5 S 06 77911 Official Use Only RMTEMPM Permit No. -779,P Occupancy and Fee Checked BOARQ,OF FIRE PREVENTION REGULATIONS (Rey.]/07] (leaveblank) APPLICATI,PN FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (M EQ, 527 CM R 12.00 (PLEASE PPLVT LVWK OR TYPE ALL LVFORMA TION) Date: // - f - e,�7 City or TAn of: AJ p,,j4)oJg_J\_ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforrin the electrical work described below. - Location (Street& Number) 10-kC NUE A Owner or Tenant _f,\'XktS <,)a A 0 N t, Telephone No - Owner's Address Is this permit in conjunction with a building'permit? Yes El No. N (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead Undard 0 11 New Service Amps Volts Overhead Undard Number of Feeders and Ampacity Location and Nature ofPr;oposed Electrical Work: No. of Meters No. -of Meters e_C'UrV�q oi- t-tm 14Larm, ComDletion of the following table may be waived by the Inspector of Wires. No. of Recessed�`Luminaires No. of Ceil..-Susp. (Paddle) Fans No. of , Total Transformers KVA No. of Lumi . naire Outlets No. of Hot Tubs Generators KVA No. of Lumin2ires �_Above [i In- Swimmin- Pool t, grnd. ernd. NT of Lmergency Lighting Battery Units No. of Receptacle Outlets No. orOil Burners . FIRE ALARMS JNo. 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 Alertina Devices el No. of Waste Disposers eat P R�R_Moutamls: LLME!oe.E.. �,L_EqL�i __2as JKW No. of Self -Contained Detection/Alerting Devices No. of Dishw:ishers Space/Are2 Heating KW LOC21 CD Municip�al El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. oT Devices or E6ivalent No. of W_�ter Hearers No. of No. of Signs Ballast:; Data Wiring: No. of Devices or E uiyalent No. Hyd ornassage Bathtubs ital HP I elecommunic; No. of Devi( OTHER: -2 A ttach addidonat ian q desired. or as required by the inspecdur uj rr it Zi. Estimated Value of Electrical Work: (When required by municipal policy.) . Work to Start' IA Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE cbVERJVGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance inclu(?ing "completed operation- 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: INSURANCE 3 BOND OTHER [I (Specify:) I certi fy, under the pains andperraldes ofperjury, that the information on this application is true and complete FIRM NAME: Nb -T' 'SeCurt:f� 2 c- r V Cc h0s LIC. No.: Licensee: 7-4 Yl ol& - Signature NO.: - fJ ffopplicable, enter -e-Temor, in the lieense numker line.) Bus. Tel. No.: to L',J Address: 19 0_L1AJ7_n 'be- , Uq eoo,4? Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety -S" License: Lic.No. M37 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) El owner 11 owner's a ' cent. Owner/Agent Signature Telephone No. [PERMIT FEE. S o ZOK 2P .=z 3 CD CD fn r < co .. f. z �T xm Cn M rn cn c, Ij M. Ul 0, M-0 co r— m x > m m > C-) 0 (D > � --o . 1-1� Z. -r) CD '7 r"I cc, M IQ 0 > CD LA4 Z CD -U m > CD co 0 C) cz C) CD l< C�ll > N) -U z C7 0 C, 0 Uico 7- 3: 0* z m M rn 7- > C3 0 C M U (n Cfn) 0 w m z m ;q . 0 m W ) U) z In m r) U) C, -4 = 0 Z > Lil 0 rn ILI U) nature. Location m Nue IM�c Rd - No. 310-3 Date 'P', TOWN OF NORTH ANDOVER Certificate of Occupancy $ '7 Building/Frame Permit Fee $ CHUS Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL s �3, ,�ItL 'v,6— Building Inspector 0 j 08/23/9A 13:34 78. 00 PAID Div. Public Works r- F F C C 71 cn �o rl cn IIS� cn > �_: CA -1 CA ICII z rill ,14 C4 cn 0 CA cn CA CA 'A 14 -M -i i -4 CA C cn C F -4 -4 cn cn —In Zi CA CIL F ORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT_1��/"'�--J�41') PHONE LOCATION: Assessor's Map Number PARCEL/8 SUBDIVISION STREET >( C'9' ST. NUMBER W ""'OFFICIAL USE "?/0/4Ct RECO MENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED COMMENTS KID. V -c TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH R-HEALT DATE REJECTED_ ('\ N./ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS. - 4'r— -5: e -A-., -r- — PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm DATE 0 Ice e -le - 0 7r, �c r.. s ;e /:lZ.4,V x- -4' .1--er ,,e,torZ AIV 'r..* j'A"r 1 0.- ir 0 f4-eLAI 't U) m m :1) m m m Cf) m Cf) 0 m CA co az CO 0 CL r— CD CL cr cc 0 9-w-wNw 1 16: a: 1= CD CA 10 CD a) a) Cl) CO) 10. C) c 0 c CA cm Cl) CD CD CD CD CA z CD CD 0 cr CO) lob COD CD Ac0 I nm CO) " !� 6*0 z CCD c-, a, == a, ':- 0 = M lr�n LO. -n =r CL �* 0 Fn - CD a =r W C.* C. CD CO) .0 Irl C2 CD CA 0 S CC2 cm cc2D 7R C, a � ca. 0 co C =r jg% CD 4 m co Go 0 cr CD ac CO) L co CD =r CD CD w CA to C'l Q 0 =r CD CO) qu -CoD ci =r *ob CD C/) CD C/) 0 =r: CD 0) CL ca C2 c cm CD.: lltjb� C) (A 0 (n 2 - z o m :3 rD :5 �o 0 C: - cn C) �a 0 r: m — n 0 C/) 0 Ia. > co� 0 C) z cf) 0 rA N 7-% )"Ni 0 Co. a—.. cc 0.. Q� N C� 't -,, OF TO N C� 't -,, OF � "d '' 171,101 310 , I m < co Til or � "d '' 171,101 310 , I m < co of% The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavft IName Please Print Locati Citv Phone I am a homeowner performing all work myse!f. I am a sole proprietor and have no one working in any c3npac�ty I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address Citv: Phone Insurance Co. Policv Comoanv name: Address Citv: Phone#: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MC -L 152 can lead to the impcsi=tnai penalties of a fine up to $1,5CO.00 and/or one years' in ' onscnment as well as civil penalties 'in the form of a STOP WORK ORDER and a 51ne of (S100.00) a day against me. I understand that a copy of this statement may be f0rN2rded to the Office of Investigations of the CIA for coverage verification. I do hereby certdy under the pains and penaities of pejurl that the infcrmation provided above is true and ccrrect Signature. Print name Official use only do not write in this area to be ccmpletea by city cr town cfficial' City or Town Permit/Licensinc hone #r F—iChe�-,k if immediate response is required Contac,lperscn: Building Dept E] Licensing Ecard F -I Selectman's Office E] Health Department 7 Other North Andover Building Department 1, Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by IVIGL c 11, S 150 A. The debris will b7 disposed of in: �10e--J 7Z::�,� S,�- (Location of F�� ignature rmit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Date -0. No 44,- "" 3 7 ,40RT" I 0" 0 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING T�ls certifies that ............................................ �a%-slpermisslon to perform plumbing in the buildings of .................... at ...... , North Andover, Mass. Fee':�� Lic. No .......... ...... r ............. PLUMBI G INSPECTOR Check # "J 5S, WHITE: Applicant CANARY. Building Dept. PINK: Treasurer MASSACHUSETTS 'UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING M—\ ftnt or Type) I& 411' /04V/1� - Mass. Date— 4�, Permit Building Location Owner's Name 06�W AlIKII Type of Occupanc New C3 Renovation El Replacement Plans Submitted: xiszc No 11 B. P. 7- r' SUB—BSMT. BASEMENT IST FLOOR 2ND- FLOOR ZRD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing. Company Name Adover - PI bq. & Htq-. Co. , I nc. eck one: Certificate 74r Address --20 Aaean Dr.. Unit -10 �r Z Is Corporation 2122 Ile-thuen. Ma. 01844 [1 Partnership Business Telephone (9-78) 685-8383 13 hrm/Co. Name of Licensed Plumber George LaRose INSURARCE COVERAGE: I have a currePtiability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. . Y,3 12 No C1 If you -have checked yes, pl icate the type coverage by checking the appropriate box A liability Insurance policy :7 Other type of Indemnity 11 Bond F7 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the In . surance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Acent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed nder the permit issued for this application will be in compliance with all o " pertinent provisions of the Massachusetts State Plumbing4�Md Chapt r 142A eneral Laws. '3u"' ':t' p r ture of s r Title Signa n ed Plumber Chy/Town Type of License: Master Journeyman CD 4W,0VM—F0E—F7ji!�E USE —ONLY) Ucense Number ( )QR3 SEWtR# FIX7URES SEPTIC# U3 0 0 z T Qj W 0 W CL Lj = JJ .j in P- 0 W = W a) X 0 < LU M 0 LL Cj �j > 93 cn < 01 -C 0 _j 0 < LU X— M 1— 4 0 0 0 Z i 3: 03 U. 01 0 Installing. Company Name Adover - PI bq. & Htq-. Co. , I nc. eck one: Certificate 74r Address --20 Aaean Dr.. Unit -10 �r Z Is Corporation 2122 Ile-thuen. Ma. 01844 [1 Partnership Business Telephone (9-78) 685-8383 13 hrm/Co. Name of Licensed Plumber George LaRose INSURARCE COVERAGE: I have a currePtiability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. . Y,3 12 No C1 If you -have checked yes, pl icate the type coverage by checking the appropriate box A liability Insurance policy :7 Other type of Indemnity 11 Bond F7 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the In . surance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Acent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed nder the permit issued for this application will be in compliance with all o " pertinent provisions of the Massachusetts State Plumbing4�Md Chapt r 142A eneral Laws. '3u"' ':t' p r ture of s r Title Signa n ed Plumber Chy/Town Type of License: Master Journeyman CD 4W,0VM—F0E—F7ji!�E USE —ONLY) Ucense Number ( )QR3 Date .... ............... 7 7 ORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION /7� This certifies that .................. .............. has permission for gas installation-:��--� ....................... in the bujlding� of ... ; ........ ........................... ..r. _V, at .).(t .... ...... a North Andover, Mass. Fee-.-,-. . . . . . . Lic. No. GAS IN 9TOR� ...... WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4ASSAa1USETTS UWORM APPLICATON FOR PERMIT TO '6� FfrMG Date or print) 771__., i-4uKirl AL'4UVVtll,, IVIASSACHUbt"b Building Locations 2:L_4/ (�36— - Permit Amount S i. P -i n i or type) Check one: Cenificate Installing Company ',Jame Andover PIN. & Htq. Co., Inc. 171 Corp. 2199 20 Agean Dr. 9' Uni t-1 0 Partner. Business Telephone -Name oC Licensed Plumber or Gas Fitter Geor(je LaRosa F�,Finn/Co. IN'SUR-ANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M* NoM If you have checked ves, please indicate the type coverage by checking the appropriate box. Liabillry insurance policy Other type of indemnity Bond 1 Owner�s Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the I Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: S i gnarure of bwner or Owner's Agent Owner EJ Agent 1:1 - : hereby certift�,.hw all of the details and information I have submitted (or entered) in above application are true.and accurate to the bcsi ot'mv kn,-wledge and that all plumbing work and installations perfed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State 96 , ode and q"r 142 of the General Laws. By: Title CirviTown --�PP ROVED ioFi.-icF. USE ONI.Y) Signature oT Licensed Plumber Or Gas Finer Ell"Oplumber 9983 F-1 Gas Fitter License Number Masfer Joumeynnan Owner's Name 4ffL New 7 Renovation 7 Replacement ID/ - Plans Submind i. P -i n i or type) Check one: Cenificate Installing Company ',Jame Andover PIN. & Htq. Co., Inc. 171 Corp. 2199 20 Agean Dr. 9' Uni t-1 0 Partner. Business Telephone -Name oC Licensed Plumber or Gas Fitter Geor(je LaRosa F�,Finn/Co. IN'SUR-ANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M* NoM If you have checked ves, please indicate the type coverage by checking the appropriate box. Liabillry insurance policy Other type of indemnity Bond 1 Owner�s Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the I Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: S i gnarure of bwner or Owner's Agent Owner EJ Agent 1:1 - : hereby certift�,.hw all of the details and information I have submitted (or entered) in above application are true.and accurate to the bcsi ot'mv kn,-wledge and that all plumbing work and installations perfed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State 96 , ode and q"r 142 of the General Laws. By: Title CirviTown --�PP ROVED ioFi.-icF. USE ONI.Y) Signature oT Licensed Plumber Or Gas Finer Ell"Oplumber 9983 F-1 Gas Fitter License Number Masfer Joumeynnan C Z z X --t Z- C G W z ;.; — — Z z W z W z C -- z C z --t C ?3 SU B-B:t SEM ENT B A S E M EN T i sT F L 0 0 R �.N D. F L 0 0 R 3 R D F L 0 0 R 4T 11 F L 0 0 R 5T 5 F 1. 0 0 R 6T 11 F L 0 0 R 7T 11 F L 0 0 R 8T If F L 0 0 R 77H i. P -i n i or type) Check one: Cenificate Installing Company ',Jame Andover PIN. & Htq. Co., Inc. 171 Corp. 2199 20 Agean Dr. 9' Uni t-1 0 Partner. Business Telephone -Name oC Licensed Plumber or Gas Fitter Geor(je LaRosa F�,Finn/Co. IN'SUR-ANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M* NoM If you have checked ves, please indicate the type coverage by checking the appropriate box. Liabillry insurance policy Other type of indemnity Bond 1 Owner�s Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the I Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: S i gnarure of bwner or Owner's Agent Owner EJ Agent 1:1 - : hereby certift�,.hw all of the details and information I have submitted (or entered) in above application are true.and accurate to the bcsi ot'mv kn,-wledge and that all plumbing work and installations perfed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State 96 , ode and q"r 142 of the General Laws. By: Title CirviTown --�PP ROVED ioFi.-icF. USE ONI.Y) Signature oT Licensed Plumber Or Gas Finer Ell"Oplumber 9983 F-1 Gas Fitter License Number Masfer Joumeynnan