HomeMy WebLinkAboutMiscellaneous - 281 BRENTWOOD CIRCLE 4/30/2018 (3),qq9
7692 Date..�:.
,,ORT#1
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
X
This certifies that . /5 lz:-� ....
has permission for gas installation
to 6,) e)
in the buildings of ....
at . 5P4�� ... e ................ . North AVnve .,as.
-� 0."'— Lic. No...3 OJA.
Fee.
GAS INSPECTOR
Check #
d
-C -N MASSA AS FITTING
uCity/Town: /V. "W",- MA. Date: Permit#
,p - -49�/L-
Building Location: a? ILI OwnersName:
GType of Occupancy: CommercialD EducationaIE] Industrial[] Institutional[] ResidentialPg-
New: L1 - Alteration: El Renovation: E] Replacement: Plans Submitted: Yes Ll No [q -
FIXTURES
M (A
W W
Lyg9lof License:
L\�Plumber
El Gas Fitter
P'liaster
Title
(d
Cityfrown
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03 X 0 Lu Lu L) U)
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0 LP Installer
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--U—SE—MENT
JST FLO—OR
-T"rF—LOOR
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FLO—OR
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iw—FL—OOR
71HF-- 6OR
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8 111 F -00—R
Installing Company Name:
Check One only Certificate #
Address: City/Town:-/J State:
Cq,."O-rporation
Business Tel: IKV�3ca�&a Fax:
El Partnership
Name of Licensed Plumber/Gas Fitter:
FirmlCompany
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL. Ch. 142 Yes 11 No El
If you have checked Yes, please i7ndizle- the type of coverage by checking the appropriate
box below.
A liability insurance policy FZ Other type of indemnity
Bond F1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this p—ermit applicWtion waives this requirement
Check One Only
Signature of Owner or Owner's 89ent Owner 0 Agent
By checking this box E]; 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
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Lyg9lof License:
L\�Plumber
El Gas Fitter
P'liaster
Title
Cityfrown
E]Journeyman
APPROVED (OFFICE USE ONLY)
0 LP Installer
Signature of Lic6nsVcf Plumber/Gas Fitter
License Number:
00-
8995
�+ 4" , . . ..' . -
0 4
10 VI
SA US
Date � - 0! 14.
TOWN OF NORTH ANDOVER
-PERMIT FOR PLUMBING
This certifies that
.......................
has permission to perform 64. __ .......................
plumbing in the buildings of . j0h.,�PAL. . . XOV,� .......
at. . 9P�/ o h ndover, Mass.
Fee. .. Lic. No...3(,)I.� .. .....
PIUMBING INSFECTOR
Check #
MAIIACHUS
MAISACHU11TTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
rClity/Town: 414 MA. Date:.. Permit#
Building Location:
I rc Owners Name: CN,,, L
Type of Occu pancy:
P CommercialD Educational[] Industrialo Institutiona[E] Residential Fq""'
I New: Lj Alteration: El Renovation: [j Replacement: [9"*�'Plans submitted: Yes [] No
IXTURES
DEDICATED
LU SYSTEMS
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BASEMENT
I ST FLOOR
2" FLOOR
3" FLOOR
4T' FLOOR
T
5T' FLOOR
67 FLOOR
7' FLOOR
FLOOR
Installing C . ompany Name: J�54A�,e NA i/nUnc, awj Check One Only Certificate #
V E316orporation
Address: CitylTon: Ab, State:
_q eA
Business Tel: L) Fax: El Partnership
El Firm/COmPany
Name of Licensed Plumber: Vmcej� ��o - 5 vkt
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 'No
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy D"�' '
Other type of indemnity E] Bond n
OWNER'S INSURANCE WAIVER: I am aware that the licenseegoes 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
er Agent
Type
By .Of License:
TUe 9 -Plumber Signature of lC nsed PIUMber
City/Town E�4aster Lice se
APPROV���� EjJourneyman License Numberr:
ONLY
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affida-vit: Builders/Contractors/Electricians]Plumbers
Applicant Information Please Print Le
NaMe (Business/Organizatioa/Individual): 1�iOY514�& 0,4.& . eA "—I,, L—L—
U
Address: V7 -2- 10-6/1 S�-
City/State/Zip: Af&i�b, MA- 6 -L -Kr Pholack -7
Are you an employer? Check the appropriate box:
I. R -fain a employer with 1
4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2 -El 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 capacit�.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.0 1 am a homeowner doing all work
right of exemption per MOL.
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. E] Now construction
7. [J Remodeling
S. F1 Demolition
9. E] Building addition
10TI Electrical repairs or additions
11. 0 Plumbing- repairs or additions
12.E] Roof repairs
13.B'Other 6;�e, tV64,
!Any applicant that checks box #1 must also fill out the sectfon below showing their woikers'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.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infonTiation.
I am an employ er th a t isp ro viding w o rkers I e om
pensation insurancefor my employees. Below is thepolley andjob site
Information.
Insurance CompanyName;
Policy # or Self -ins. Lic. #: C) C L– C 5,3 Expiration Date
JobSiteAddress: QZ1 ?:�V 01A� S rc City/State/Zip: /V 4VN46-� 0 1 g- q
Attach a copy of the workers' compensa tion 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
of up to $250.00 a day against the violator. Be * advised that a copy of this statement maybe forwarded to the Office, of
Investigations of the DIA for insurance coverage verification.
.1 do hereby certify under thepains andpenatiles of
pe,rjury that Me informationprovided above is true andcorrect.
S Ynattire: vl:,,
iL + Date: C—A
C.D
Official use only. Do not write in this area, to he completed by city or town official
City or Town: PermitfLicense #.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: Phone H:
6/08/2011 10:11 FAX 617 527 4078 Eastern Ins Newton
Q0001/0001
;ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE jMMIDDNYYY)
Tm 1 06/09/2011
CER S08.6S1.7700 FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, MA 01760
INSURERS AFFORDING COVERAGE NAIC #
INSURED FORSYTHE PLUMBING AND HEATING COMPANY LLC INSURERA: Selective Insurance Co of SC 19259
172 CHAPEL ST INSURERB: Hartford Fire Insurance Co. 19682
NEWTON, MA 02458-1308 INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU13JECT TO ALL THE TERMS, EXCLUSIONS AMD CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
WO
NO
TY PE OF INSURANCE
POLICY NUMBER
FULIGY EFFECT
DATE JMMIDDIYYYY)
ON
DATE (MMIDDMIM
LIMITS
GENERAL LIABILITY
—
A 9094226
06/08/2011
06/08/2012
EACH OCCURRENCE $ 1,000,000.
MERCIAL GENERAL LIABILITY
PREMISES (Ea occurrence) 6 300,000
HCOM
CLAIMS MADE M OCCUR
MED EXP (Any one person) 3 51000
A
PERSONAL& ADV INJURY S 1,000,000
GENERAL AGGREGATE $ 31000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 3,000,000
7 PRG -
POLICY M JECT El LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
$
SCHEDULEDAUTOS
(Per person)
HIREDAUTOS
BODILY INJURY
$
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: . AGG $
EXCESS I UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR D CLAIMS MADE
AGGREGATE $
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY
08WECLCS316
11/09/2010
11/09/2011
1 T`,`Ry-TLA,,TUS I ER
B
ANY P YIN
ROPRIFTOR/PARTNER/EXECUTIVED
OFFICERIMEMBER EXCLUDED?
E.L. EACH ACCIDENT 100,000
(Mandatory In NH)
ffrs describe under
E.L. DISEASE - EA EMPLOYEE 100,000
E.L. DISEASE - POLICY LIMIT S 5()0,000
3 tAL PROVISIONS below
E6
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSLEMENT I SPECIAL PREOLVISIONS
L;ANt;LLLA I IVN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRITTEN
NOIJ" THE CERTIFICATE HOLDER NAMED TO TME LEFT, BUT FAILURE TO DO 50 SMALL
IMf0SE 1108L
E ;[G�A�TION SIT. OF ANY KIND UPONTHE INSURER, ITS AOFNTS OR
Town of North Andover R111PRESE ATI
Building # 20 - Suite 2-36 A OR RE E
Norith Andover, MA 0184S I
ACORD25(2009101) FAX: 978.688.9S42 N4 %,it %I - 009 OIRD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of %ACORO
Date.
N2 44(016
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SS C14us
This certifies that . . r"'y /v:-* ( .... fix, // ..............
has permission to perform .... ..........................
plumbing in the buildings of A .....................
at. North Andover, Mass.
... ........
Fee. ...... Lic. No .......... ..........
i'PLUMBING INSPECTOR
V
Check # 1 &' J- / -
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSEM
-3rkpT
Building Loq�tion 2 y I u u�L
Owners Name
U
)- �-- oz,
Da�te
Pe I
t #
ount=
New Renovation Replacement Plans Submitted Yes No
Trint or type) Check one: Certificate
hastalling Company Name faq. . r, Corp.
Address' /0& f�,-1421/ owr,4 Partner.
k A-41- vl�A— Q 1 ----
Business Telephone e),o Firm/Co.
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checkifig the appropriate box:
Liability insurance policy [a Other type of indemnity 11 Bond
Insurance Waiver: L the undersi . gned, have been made aware that the licensee of this application does not have any one of the above
three insurance
ignature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Statep4ambing Co��Q)f the General Laws.
By: 757—p=a 01 LIcensea riumBer
Type of Plumbing License
Title 66 7 �- � I � —
City/Town Licease Numoer Master Journeyman
APPROVED (OFFTCE USE ONLY I
mom
0000000000MOWN
MONNOW
OWN0000
Trint or type) Check one: Certificate
hastalling Company Name faq. . r, Corp.
Address' /0& f�,-1421/ owr,4 Partner.
k A-41- vl�A— Q 1 ----
Business Telephone e),o Firm/Co.
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checkifig the appropriate box:
Liability insurance policy [a Other type of indemnity 11 Bond
Insurance Waiver: L the undersi . gned, have been made aware that the licensee of this application does not have any one of the above
three insurance
ignature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Statep4ambing Co��Q)f the General Laws.
By: 757—p=a 01 LIcensea riumBer
Type of Plumbing License
Title 66 7 �- � I � —
City/Town Licease Numoer Master Journeyman
APPROVED (OFFTCE USE ONLY I
Location
z . j
No
Date -,,/, Lei
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHUS
Foundation Permit Fee $
Other Permit Fee $ dw
TOTAL
Check #
15476 -Building Inspeccol/
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
E�TD�6 PERmrr NumBER: pop DATE ISSUED: Lin; q1-62,
A- A A
SIGNATURE: lfa4V I
Building CommissioneEjnEeEtor of Buildings Date V- AM,- 404. 1
SECTION I- SITE INFORMATION
1. 1 Property Addr
1.2 Asses. Map and Parcel Number:
Map Numbir Parcel Number
1.3 ZoningInformation:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Fr-tage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
Required
:F-
Provided
1.7 Water Supply M.G.L.C. 54) 1.5. Flood Zone Inforrugtion:
t
Public 11 Private '"Do z0fte Outside Flood Zone 11
1.8 Scwerage Disposal System:
mulucipat 0 OnSiteDisposat System D
SECTION 2 - PROPERTY . OWNERSEEIP/AUTHORIZED AGENT
2.1 Owner of Record
/3, ;<-
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES I
31 Licensed Construction Supervisor:
zt� k,-,V�o 4t57
Licensed Construction SupZi�visoi
e "'t
Address
Signatul`;Or -"'Telephone
Not Applicable D
License Number
fpiration Date
m �Contract
3.2 "cred Home 1�mrovc t C tractor
-Ce^--L
Not Applicable 0
/e, /
E01-pa'.Aame
:7T
Registration Number
6 ? -z—
Ad s
Epiration Dt.
Qua- e -Ae or 'Telephone
T
M
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0
W
or,
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90
M
0
mn
S
I SECTION 4 - WORKERS COMPENSATION MG.L. C 152 � 25c(6) -1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... El No... —11
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
xi t' B L1
Repair(s) [I
Alterations(Q
Addition 0
Accessory Bldg. 11
13molition 0
Other U,-Ip-ecify )z -
Brief Description of Pro3s d
&G W�T
c' -
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
bAy
L Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Buildinp Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total t1+2+3+4+5)
-CIA
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECT12MOWNERJAUTHORIZE"GENT DECLARATION
.,as Owner/A f subject
propert' ( '� <��D
y
Hereby decl th, statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
(9
Piiqame
2—
Si atur 'Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T11VIBERS I ST 2 No 3pu
SPAN
DMIENSIONS OF SILLS
DUvIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HFIGHT OF FOUNDATION THICKNESS
SIZE OF FOO'flNG x
MA FERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNEC'F]--,D TO NATURAL GAS LINE
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WARP bF.BUILDING REGULATIONS
Liclense: CPNSTRUCTIO'N SuPER-
VISOR
Numb6r- cs'',
046636
Birt, ate: K I I . 948
ires
603 Tr. no:
10578
To.
RAYMOND E DAM�H6
-(j§SE,JR
75 BUltERNUT LAI4�,,
MEtqtf�N, MA'G1844
inmtrai8,
NOME IMPROVEMENT COHIRACTOR
Registration: 101862
Expiration: 06/2912002
Type: Private Corporatio
RAYMOND 1. DAMPHOUSSE, JR.
Raylood Damphousse, Jr.
-7�' &-�vweutternut Lane
ADMINISTRATOR When hA 01844
North Andover Building Department
Tel: 978-6,98-954
DEBRIS DISPOSAL FORM
In accordan ' ce 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 irl a properly licensed solid. waste disposal facility as d
c11,S150A. efined by MGL
The debris will be disposed of in:
(Location of Facility)
_."�g�re of �ermttAppli?cant—
J Signature o
bate
NOTE: Demolitio * n permit from tl�e Town of North Andover must be . obtained for
this project through the Office of the Building Inspector
i "!
INSURER! THE TRAVELERS INDEMNITY COMPANY
1.
INSURED:
RAYMOND DAMPHOUSE & SONS
ROOFING CO INC
73 BUTTERNIUT LANE
METHUEN MA 01a44
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUM13ER: (.6KUB-GG3X466-A-Oi
RENEW AL OF (GKUB-663X466-A-00)
NCCI CO CODE. 11 .347
PRODUCER:
INTERNET INSURANCE AGCY
522 CHICKERING RD
NORTH ANDOVER MA 01845
Insured 15 A CORPORATION
Other work places and identfficallon numbers are shown In the schodule(s) attached.
2. The policy period Is from 08-22-01 to Oa -22-02 12:01 A.M. at the Insured's mallIng addressa.
3. A. WORKERS COMPENSATION INSURANCE* Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS UA131UTY INSURANCE: Pan Two of the policy applies to work.1n each state listed in
ftern 3A. The limb ol our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. 01HER STATES INSURANCE: Part Three of the policy OPPI195 to the states. If any, listed here:
SEE ENDORSEMENT WC 20 03 06
D. This policy Includes these endorsements and schedulw:
SEE LISTING OF -ENDORSEMENTS - EXTENSION OF INFO PAGE
be determined by our Manuals of Rules, Clasafficallons. Rates and Rating
4. The premium for this policy will W to verification gind change by audit to be made ANNUALLY -
Plans. All required information 13 sub)
DATE OF ISSUE: 08-2`1 -01 14L
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: INTERNET INSURANCE AGCY
6mal
753XF
ST ASSIGN: MA
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