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Home My WebLink AboutMiscellaneous - 284 BRENTWOOD CIRCLE 4/30/2018 (2)N N O g A IO Z bo o � b � m Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: Robert H. Pangione Property address: 245 Brentwood Cir North Andover, MA 01845 Policy #: 0154896 Loss of: 2016/05/15 File or Claim No. AD 1994 Claim has been made involving loss, damage or destruction of,t1he above captioned property, which may either exceed $1,000.00 or cause Mass. — Gen.–Laws,_Chapter-143,–Section-6 to be applicable. If any notice under Mass Gen Laws, Ch. 139 Sec. 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, locaticn, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. Sig`n�-ture and da-�e PO Box 55098 I Boston, MA 02205-5G98 617-951-0600 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: LAUREN-CONNOLLY Property Address: 284 BRENTWOOD CIR., NORTH ANDOVER, MA Policy Number: HMA 0414382 Claim Number: BOS00062794 Date of Loss: 2/8/2015 Company: Safety Indemnity 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, Chyter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, ChUter 139, Section 3B 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. Eric Yablonski Claim Examiner 7/10/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3550 Fax: (617) 531-6650 Email: EricYablonski@Safetylnsurance.com 61 u3 Date ...... TOWN OF NORTH ANDOVER 6'0 PERMIT FOR WIRING S.— ' -T SACHUS This certifies that ....... ......... ................... has permission to perform ....... .......... wiring in the building of ................. ��A4.4-Y-L- ................................... # at .............. 4..;9Y ... .. i�� ......... . North Andover, Mass. Fee.. R .... Lic. No).�4.Q-? 7AP ......... dic�r.;icA-L M;EnOe Check # DEffiMNW0FPEKX&*jffY Perridt No. BOAMOFFP,EPREVMMRBGULAMVSM7aMD.W Occupancy & F;..0 ChWkW APPUCATIONFORPERAIZTTOPERFORMELE w0nme ALL woRK To RE PERFORMED IN ACCORDANa wrrm THs mAssAcHussTs ELEcmxAL CODE 7 Cmit 12:00 (PLEASE PRINT IN INK OR TYPE ALL INMRMATION) Da Town of North Andover To the Inspector of WIM3: 11c undersigned applies for a permit to perform the electrical work described below. 7. Location (Street & Number) Owner or Tenant owner's Address is tws permit in conjunction ith a budding permit Yes[13--No 1:3 Purpose of Building t t> W"T-) &a,(— Existing Service c;LaO Amps New Service Amps� �/Volts Number of Feeders and Ampacity Overhead overhad e- L (Check Appropride Box) Utility Authorization No. Vn—&qround EEr' No. of Meters Underground M No. of Meters Location anti Nam of Proposed Electrical Work �=-W - X M2227> Na of UrAft Untift No. of Hot WX M. Of TOW Nm of Ughtin Figures Z Swbwdm Pool, Above " Below KVA C; (Q rl No. of Emerjeucy Ugh Battery Unite KVA No, of Receptech Oudeft o(Ou flumere No. of Switcb Outlets No. of Go Bomwo FUtE ALUM lqm of Zones No. of Rartgn No. of Air Cond. ToW Tom No. orveiecti" W No. of Disposals No. of Hest Total PtIMIN Tom jaidaing DrV*ft No. of Sounclhq DA= No. of Dishwashers Spece Arm Heging KW No. of Self CouNbW Detwdav&an&X Dnk= L -d 0 municod Connection No. of Dryere Heating Devices KW No. of Weter Hemere KW No. of No6 of Siva BdbAb No. Hydro Mauqp Tube NO. of moun Total HP kR==QA0* Qradlm — — I Itxke&ftn1kdVddp103fGf=Z1Dd1!0ft YM NO 13 dnb ft b(IL ff" 13 Wi!&Wd1etjFcfcomWby ML3aWi BCM 1:3 am ED nw** -- BoNdOoDge VAzdEbc"Wak$ RZ* 1 --ICL F*W 4--j tt 44tL HRMNANS Lic=Nu 190S--7,4 Lim= -7( . E—r Adtoo Uq /4 GWI*,WSMJRANZWAMRI=mntwdieLimwdmmthmbia==CDWWajs 4' 7W N1 Mam check one) Owner ri Agent Telephone No, 3agnarare or uwncr of Am — mm.,PERW FEE 0 DEFAMAWMEMW&VEry Pam* No. BQ4M0FFMPRMNMNRBaUMA?S527GM,UM -0 1 OCCUP09 F= Checked APPUCA71ONFORPERAETTOPERFORMELEcn;UCAL WO AU WORK To BE FMMRM2D IN ACCORDANCE WTfH THE MASSACHU33T3 MICTRICAL CODII, 527 CMR 12:00 CPLEASE PRINr IN INK OR TYPE ALL INFORMATION) D Town of North Andover To the Inspector of Wires: ne undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) owner or Tenad C:qkj LA -1 14AO Owner's Address CY Is this pernfit in conjunction,71th a budding pertnit: YeSED 'go [3 (Check Approprism Box) Purpose of Building r= L Utility Authorization No. EXi3tinX SCMCC C;LaO Amps 1 ��VJLIVolts Overhead No. of Meters Undewound C3 No. of Meters New S Amps...L.Volts overbod Number of Feeder, and AMPAL*Y Location and Nam of Proposed Electrical Work --'I FZ=M-7) 1.5- E, -K75 7-7 No, of UOft Oatku W of Hot Tube NO. Of ThOSAMMM Totd KVA No, of Ughft RIMM 3whunins ?" Above zmww 1:3 guom"d G=M,= KVA No. of Receptub Oudeft at on B MIL of E—sevey tjordil Babery Uniii; Nck of Switeb Otudels No. of Ou Swum FME ALARMS No. (if Zones No. of Ronpit No. of Air Cond. Totd TOM Ho. of Dracdon ujd No. of Dispo"k No. of Had Totd Totd Pumps TM xw Wdsting Davica No. of SamdInj Davion No. of Dishwuham Spece Am HeMing Kw NO. of SW Contidmd DOMWONA08oft Devices Loed mwdcipd Othw No. of Drym Huft Devices Kw 0 connectiew No. of Wa9w Hostem Kw No, or No. of sive BRIbAl No. Hydro Mausp Tabs Ha of blaim Totd HP hu=QMW FMIMID&OPME111 =*Mod�GazdL. -- — lhmaamnljd*jun=,FbL-Ikk*gcmlor—*:rcomwcribstabdwegivAbt YES 1hvwahrAWvMpVdC(ssM1Dft0MM YM Bft baL 13 r)0uhM MLWX3ZT3a—Bcm 13 am 13 Do EftmWVAzdBamWwak Wo[kiDSM D*Rqz*d Fz* i -11-t 414-q- FoW 9gmd=J fEMNANSPI: --7,4 U=Nd 9"M A Td NW? 7 0 ALUNd 7)h GVV�WSMMMaWAM1=&=1MftLizw4-=w1 dz' (Plesse check one) Ags. ailgriarm or UW or Atear 0 T�lephone No. WT FEE I .: �� _� �/� �� tee, d� Location No. Date 19 ena--- Check # '3� 6 e 18575 Building Insp ct& (.,-Ir TOWN OF NORTH ANDOVER + i at Certificate of Occupancy $ Ape* MU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # '3� 6 e 18575 Building Insp ct& (.,-Ir TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIk RENRX&TF OR DEMOLISH A ONE OR IWO FAMILY WELLING BUMDING PEgi!4 NL'T'WE-R: DATE ISSUED: A- A A - -/9-/ 1 SIGNATURE: Ii I LILW44'i Building Commissio2Ehj=tor of Buildings Date I SECTION I- SITE INFORMATION 1.1 Property Address: NY MEa—wo-o-Cwtc 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zonin District Proposed Use 1.4 Property Dimensions: Lot A— (sf) Frontage (ft) 1.6 BUILDING SET!��CKS (ft) Front Yard Side Yard RM Yard ReqWred ReqWmd Provided Requimd Provided + 1.7 Water Supply M.r-1-C.40. Zone Information: Public; 0 Privatc zone Outside Flood Zone 0 1.9 Municipal SeweragoDispml System: 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT 2.1 Owner of Record WaAa Sow (/,I&/ 2J� 8�ruw 0/f ac - Name (Print) Address f6r Service: I Telephone 2.2 Owner of Record: I Name Print SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 'DAiz1?-61J MALT -Wo Licensed Construction Supervisor: #Y A011" AF t5x-r fi?Efl-kjP-,tj,&+ Address f/#'- 7uc-. Telephone 3.2 Registered Home Improvement Contractor vNive-Ij MAknmo Company Name Address Address for Service: Not Applicable 0 03 660YA, License Number F-/!5'-2(JG7 Expiration Date Not Applicable 0 /,-� Ll 9 C Registration Number �-/7 - a�00 Expiration Date I I SECTION 4 - WORKERS COWENSATION (MG.L C 152 & 25c(6) I Workers Compensation Insurance affidavit must be completed and submitted with this ;p—plication. Failure to provide this affidavit will result in the denial of the issuance of thhe milliding permit. Signed affidavit Attached Yes ....... X No ....... 0 SECTION5 Description Proposed Work (check appficable) New Construction 0 Existing Building 0 1 Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 f Other X Specify KIT—0006 I-V Ora - Brief Description of Proposed Work: TAJ Ob MCI, CARIALN -L XMCMAJaf SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by pennit applicant OMda USE ONLY 1. Building cc (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHOR17ATION TO BE COWLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT sou as Owner/Authorized Agent of subject property Hereby authorize -to act on I , in al mattwTelative to work authorized by this bailding penuit application. Si I Date SVeTfON 7b6WNER/AUTHORIZED AGENT DECLARATION ITMA49V /77" r /AA as Owner/Authorized Agent of subject .1 property Hereby declare that the statements and informiation on the foregoing application are true and accurate, to the best of my knowledge and belief ZKEAJ 191A MPe. Sidng��f Own�� Date NO. OF STORIES SIZE BASEN1ENT OR SLAB SIZE OF FLOOR TACERS Ist 2 ND 3 RD SPAN DMENSIONS OF SELLS DEVIENSIONS OF POSTS DMENSIONS OF GIRDERS HEIGHT OF FOUNDATION TIUCKNESS SIZE OF F0OTlNG X MATERIAL OF CBRVINEY IS BUELDING ON SOLD) OR FMLED LAND I IS BUILDING CONNECTED TO NATURAL GAS LINE Name The %Commonwealth of Mass�chuselts Deparbnent of IndushWAccidents Office of lnvest�affbns Boston, Mas�. 02111 Mike& Compensabw* Inwrdnce Afflbavit Please Print Name: LAqQ�Elj ./)2.4/ZI,4vo Location. 2AWIrkboo A) �Affb,&-n Phone #. 1 arn a homeoww perforuing all work myself. I am a sole proprietor and have no one working in arry capa*'. I arn an mooyer pruvicbV wwker& mriperisation for rny OWIO� working cn this job. 2FAGrUMM andfor ........... Date Print Offk:W use 0* do not wrle in Ws ame tD be Govkftd by dly w town drebr (WI'W TOYM -# 9-7,F- �7e-Kr6o 921� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: ZS 066342 Birthd ate: 08/15/19711 Expires: 0811512007 Tr. no: 2502.0 Restricted: 00 DARREN MARTINO 44 ADDISON AVE E)(T METHUEN, MA 01844 Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 124961 Expiration: 911712007 Type: Individual DARREN MARTINO Darren MARTINO 44 ADDISON AVE. EXT. METHUEN, MA 01844 Administrator F1 (,�e C6P DM Constructjo,7 Building with the QUALMY and CAamctcr of yesteryear. 44 Addison Ave Ext Methuen, MA 01844 (978) 685-3037 Estimate Submitted To: Michael and Katie Sullivan 284 Brentwood Circle N. Andover, MA 01841 We hereby purpose to furnish the matenals indicated and perform the labor necessary for the completion of Kitchen remodel.(See specifications sheet) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completion in a substantial worlananlike manner in the sum of Twenty-four thousand doilars-$UM.90 Payments to be made as follows: $5000-00 when work begins. Remaining payments as work progresses. Respectfilly submitted: Darren Marfinii Any alteration or deviation fftrom thfve sPn'eciffil ons involving extra costs will be executed only upon written order, and will become an extra charge Over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note -This proposal may be withdrawm if not accepted widiin 10 days. Proposal Date 9/14/05 ACCEPTANCE OF PRoposAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date: Signature: M NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: ,,,/is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Location of Facility) Fire Department Sign off- 1,lez, Dumpster Permit igna re of Permit Applicant' Date (A m m x m 4 m x cn m m CA Z CD 0 CL C2 CO2 C.) CD CD CL cr * =r CD CD 0 CD CD CA 5. CD a- 0 CA CD z CD CD 1* 10 -11 =r C�o -0 C*r 2L- So CA 0 CL C-) 0 0 m ca cp CLO .0 �oc z =r -O ra 0— CA = :: CD =r 06 CL =r M = CO fA CO) CD grm ca -0 0 0 z 0 La. cc,' -cab %U2 CL C3 C=,r c CD n Go 0 0 r 'A CL = w cr z co CO3 IE 0: CD Q a Or CD CD CO3 CD Ch) r CO co -OW CVS Cl) 0 C= 0= z m o z gi ::) S- M 0 PL ;z 0 C: (FQ CA z n cn I M 0=3 0 40i 1. VAO 0. SACHUS ate. . ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Af ";? " -- .'- . ........... .. ......... has permission for gas installation .... P.,41 ............ in the buildings of . .......................... at . . )-. F .1( ... ........... I North Andover, Mass. L Fee. Lic. NO` 1.c -'7 �GAS INSPECTOR Check#. / " e 1 ),- 5 'Z' 517 MASSACHUSEYTS UNIFORMAPPUCATONFOR PERM TO DO GAS FMI NG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS '2 <2 Building Locations Permit # 2 tin s N4me Z, / e� <: -, � � -7, Owner' New El Renovation Replacemeno-,,_ Plans Submitted El (Print or Name / Name of Licensed Plumber or Gas Fitter )Chec e: CerfifiFate Installing Company Corl Corp r rl I Partner. mi/Co. INSURANCE COVERAGE . I Check one: No I have a current liability InSUT4ancl,cy or it s substantial equivalent. Yes 0 e p "c" If you have checked ye s A5,please i cate the type coverage by checking the appropriate box. _y Other type of indemnity Bond Liability insurance policy [3 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent 0 wner Age - nt I hereby certify that all 01 tne cietaiis ana imormation I HdVU bUU111ILLE; ku, �11L�11 j .. — -FF—"--.. -- .-- -..- — -.- best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with ail pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. )wn ,OVED (OFFICE USE ONLY) lumber 13 P ' E-] Gas Fitter ElMaster :A� meyman Fitter .�—r , " �� f),/4 LI -0 MIM7MMMM -fS—T. FLOOR �2 N T -.—F L R FIE 0 0 R �4TH. FLOOR mw=— a Ire �@� 7TH. FLOOR i8TH. FLOOR (Print or Name / Name of Licensed Plumber or Gas Fitter )Chec e: CerfifiFate Installing Company Corl Corp r rl I Partner. mi/Co. INSURANCE COVERAGE . I Check one: No I have a current liability InSUT4ancl,cy or it s substantial equivalent. Yes 0 e p "c" If you have checked ye s A5,please i cate the type coverage by checking the appropriate box. _y Other type of indemnity Bond Liability insurance policy [3 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent 0 wner Age - nt I hereby certify that all 01 tne cietaiis ana imormation I HdVU bUU111ILLE; ku, �11L�11 j .. — -FF—"--.. -- .-- -..- — -.- best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with ail pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. )wn ,OVED (OFFICE USE ONLY) lumber 13 P ' E-] Gas Fitter ElMaster :A� meyman Fitter .�—r , " �� f),/4 LI -0 ,OPT" 00 .. ......... A14D � CHUS D D rn6 A. ate. .7/. e ;X TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ........ has permission to perform .................... plumbing in the buildings of ................... at. ............ North Andover, Mass. Fee. Lic. . ..... 1 PLUMBING INSPECTOR Check # 6630 9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Dt Building Location Owners Name A5�ee: ermit Ir TNoe of OccuDancy '4 �-'; �: �— Amount New 0 (Print or type) Installing Con Renovation 11 Name of Licensed Plumber Insurance Coverage: Indic� Liability insurance policy— Insurance Waiver: 1, three insurance FIXTURES Plans Submitted Yes No . 11 1-1 -Check Ae: 01 CQrtificate Corp. 13�- 10, Partner. Firm/Co. of insurance coverage by checking the appropriate box—. Other type of indemnity Bond have been made aware that the licensee of this application does not have any one of the above Signature Owner 11 Agent 11 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 Upqrmed under Permit Issued f r tW 1* 1 will be in compliance with all pertinent provisions of the M2!�sa�chus � 91t I �= PWmbing Code and Ch, aws. pe of Plum i License 'own ROVED (OFFICE USE ONLY License INUMS Master Journey man A 73b9 0* "40 T SAC14 Date�.-J-4..,(.0 ..... OF NORTH ANDOVER T FOR GAS INSTALLATION This certifies that Vr-'. has permission for gas installation Le . . . . . . . . . . . . . . . . . . in the buildings of ................ at North Andover, Mass. Fee.,� Lic. No. 1,:2.534 . ..................... j GASINSPECTOR Check # ( � & dK .X!,- 4 4 "Ihis certifies that . . 0. S . LI vx.�. �. .... e n . �. ... L c C— has permission to perform ... exo I .................... plumbing in the buildings of ... So. L -C L pljc�'A Jz- at.2g-� .. &Leez Tx)do/ ..... r- � tiz. -... North Andover, Mass. Fee. 0.#--.Lic.No./'q13() . ........................... PLUMBING INSPECTOR Check # /3(0k 87U2 % Date( -'i1.-.; - TOWN OF NORTH ANDOVER 04 PERMIT FOR PLUMBING SACHUS "Ihis certifies that . . 0. S . LI vx.�. �. .... e n . �. ... L c C— has permission to perform ... exo I .................... plumbing in the buildings of ... So. L -C L pljc�'A Jz- at.2g-� .. &Leez Tx)do/ ..... r- � tiz. -... North Andover, Mass. Fee. 0.#--.Lic.No./'q13() . ........................... PLUMBING INSPECTOR Check # /3(0k 87U2 UNIFORM AppLICATION FOR PER)UT TO DO PLUWING -MASSACRUSETTS . I (TYP a or print) NOP,THANDOYMMASSACHUSETO ))ate wners Name Building atidn 0— Aniolint LyLeofoc pancy Renovation Replacement plans Submitted Ye -5 Nc) El 0 El W-7 M, �-1 M FIXTURES 10-11P. W-11FRIEWSES ------------ checkone, certificate (Plint or typo) Corp- "int"O justalag CompanyName J)artner. El jAddmss �Fcol Name ofrlcens�d Plumber: verage oy checking the approO[ata box: cats e-Wm5;-of 11rance co Insurance Coverage: ladi th ms other type of indemnity Bond F1 Liability imurmw policy � [a 11 , ap-pli, 1714 L the undersigned, have been. made aware that the licensee oftb' -- �tlorj does not . We any on- of the abO ,Ins,irmce Waiver: threeinsurance, owner Agent tgnatur, atioril have submittO (or ed6red) in. abDve application are.true and. -accurate to the I limby mitit taat all Of the dataHs and inform s ed his plicatioRvillbein t1lat all plumbing work and installations performed undtrPermitls U fort aP best of iiaylmowledge and 1.1m�ing Code and Cliapter 142 oftho an6ral Laws- mcew saa) 01, compli ith all pertinent provisions ofthe Massa By: :IgLna 0 C-Glisc er Title ter [e joeyman Citynomm Um Gr �APPROWD (OU�cE USE ONLY The Omnzonwealth of Afassachmse& DCP7Phnenf qfrndusfHaUccidenty Ofil-Ce 0f)WVeSg-,aa0nS 600 Wasizington &reet -nostayl, -w 0 -?-11-1 Workers'Compenqation hasurance MUCT-avit: B.uUders/Co-utractorgXlertxicxans/P`lumbers -kinlicant -Information Please Pdnt Legib C119, Name AddreL-' City/State/Zip--4 P-4 Phonc q7 R- N' (01� :A -re You an employer? C�eck the appropriate bo 4. I am a g-c-heral contractor and I employees (fbil and/or part-timo).* 2. ETI am .1 Sole haV6 hired thb sub-cont=tOzg proprietor or partner- -ffit--d On tbLe: affiched sheet ship aadhaveno rroployces; These aul>-Colltractors ha:ve, worl6n�cr for me miany capacity. workers, COMP. insurance, Vo Viorkers, corap. ins�cq we are a corporation and its requiradj 3.0.1 am a homeowner doing all Work Offic= haV5 exbroised their right 01 oxe�mplioli per MGL Mysolf [No workers, comp. G. 152, VI (4), and we havr. no innimacerrquhl] T =Ployees- [No *orkers, gbmp. ias�ce, required -I TYP8 Of Project (reqitired): 6. E] Ne�, constuction. 7. El Remodeling S. IDbrnoli-don 9. B�ildi4g, Eddition 10 -El F-IrCHcal'repairs- or additions .1 I,bk Plumbing regairs or additions 12 -El Roof repairs 13.0 Other 3contzcbrs that chee� this box =-qub;,-L Doatmat-c- -4dst mi�mft a =,v iffikvit indinaf ad an addiliouZZ shct ShOwlu-� lei ---abf th. sub-rtmt=t.,.d th'- W111 -en, ing r=h. romp- PddCY informatim Iam an 6MPI,7Y-7tkdjSproVjdjg Workers' Compencaflonirrs7zirancefor MYOMP16yee'v Belo�' is Site lngUra= COMPiMy NainC: -PONGY # Or Self-ing. Lic. ------------- aTiragou. D tq 12 r ate 0 Job Site Address: 0 -crlkeo� CIp city/shlte/zip -ktfacha copy -of the workers, compensation policy iievlaratj.,QUPa,, (Sha -W ng the P(,ljCY nuraberand expirafion date). FailurE, to secure covmgc as required under Section 25A of M'C--L G. 152 can lead to the, imposition of UP to S 1, 5 0 0. 0 0 and/or one -yr, ar impris o TIM ont; as Well as c,:jVfl p onalti c s in th6 form or a Penaltir's of a of up to S250-.00 a day ajainft the violator. Be -advised that a cc) STOP WORK ORDER and a. fine py of this Statment M�Y b e forwarded to.the. Office of 111-ves6zatiom of the DL� for insurance coverag, -vrrMcatjojL -1 -do h.�reby thepains zzndp,�xdjj6s pf �;erju,31 th,,-t th-, i4formallor provided above*h y�-ua jind correct Officild zrse only. Do nat wri&irz thlsarea, to he co M,PL'tad hi, cii�, Or f'onin officia� City or Town. -PernribUcense IsSuinz Authority (circle one): L Board of Health 2. BuIldingy Department 3. city/Tpwn Clerk 6. Other Contact Person - 4. Elertdcallmspector E. Plumbing � Impe&tor Phone"i � �6 NUASSACHUSEITIS Us"RNI APPUCATON F OR PERWr TO DO GAS FnTNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS BUildin(TI-ocations Permit # Amount $ Owner'sName !Nuw Renovation Replacement Plans Submitted (Print or type Check one: Certificate Installing Co mpany Name— AJ�,, U Corp. Address ai &U, Partner.. rl BUSiIICSS'relephone aFirm/Co.. Name of Licensed Plumber or Gas Fitter Kf ]INSURANCE COVERAGE Check ont�� I have a current liability Insurance policy or it's substantial equivalent. Yes 19 N01:3 If you have checked yLs, please hAate the type covoragt� by checking the appropriate. box. Liability insurance policy Other type of indemnity Bond [so' 1 0 Owner's Insurance Waiver: larn. aware that the licensee does not have the Insurance coverage required by Chapter 1-12 of [fie Mass. General Laws, and that my signature on this permit application waives this requirLment. Check one: ' Signature or Owner or Owner's Agent Owner El A.cent 0 I hereby certify that all of the detailsand inrormation I have submitted (or entered) in aboveapplicatiDn are true and accurate to the- hc�,t ofni� knowled-e and that all plumbing work and installation,; performed mider Permit Issuod for this application will be in t. coin p Hance wii th all pertinent provisions oftheMassuchuselts State Gas Codcand Chapter 142 of the General Laws. BY: Title CityiTown APPROVED (-OFFICF USE ONLY) Si--natUrC Of Licensud Phi iber 0 GIS Filter Plumber Gas Fitter Mc 7 n s 777 7-7 Fe—r Master JOUrneyman 94 0 M 0 4 U A "I (n z z 0 JV% H z A 0 Cn ca 0 Cn > 0 0 U C4 IS UB -B A SEM ENT f I B A S R M E N T IST. FLOOR 2ND. FLOOR 3 R D F L 0 0 R 4T11 . FLOOR STH.FLOOR 6TH. FLOOR 7TH. FLO OR STH. F L 0 0 R J_—L-A I (Print or type Check one: Certificate Installing Co mpany Name— AJ�,, U Corp. Address ai &U, Partner.. rl BUSiIICSS'relephone aFirm/Co.. Name of Licensed Plumber or Gas Fitter Kf ]INSURANCE COVERAGE Check ont�� I have a current liability Insurance policy or it's substantial equivalent. Yes 19 N01:3 If you have checked yLs, please hAate the type covoragt� by checking the appropriate. box. Liability insurance policy Other type of indemnity Bond [so' 1 0 Owner's Insurance Waiver: larn. aware that the licensee does not have the Insurance coverage required by Chapter 1-12 of [fie Mass. General Laws, and that my signature on this permit application waives this requirLment. Check one: ' Signature or Owner or Owner's Agent Owner El A.cent 0 I hereby certify that all of the detailsand inrormation I have submitted (or entered) in aboveapplicatiDn are true and accurate to the- hc�,t ofni� knowled-e and that all plumbing work and installation,; performed mider Permit Issuod for this application will be in t. coin p Hance wii th all pertinent provisions oftheMassuchuselts State Gas Codcand Chapter 142 of the General Laws. BY: Title CityiTown APPROVED (-OFFICF USE ONLY) Si--natUrC Of Licensud Phi iber 0 GIS Filter Plumber Gas Fitter Mc 7 n s 777 7-7 Fe—r Master JOUrneyman