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Home My WebLink AboutMiscellaneous - 285 RALEIGH TAVERN LANE 4/30/2018 (2)00 gm § rn 115 '%"# 5 - Date. 114014 ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that A.� .... .. ...... .................. has permission to perform ........... ............................. plumbing * the buildings of .................... (Zt.h, ort Andover, Mass. .. . ...... .......... . ... ... ... . atc7l'.1!&S ............... I. . . '***'****'* ... **"**'*'*'******'**'****"*'*' Fe& Lic. No. ,:56 V ... ................ . .... ............. ......................................... Check # ?P /UM��B�IN� li'N�SPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER MA DATEF��-18-2Q16 PERMIT # JOBSITE ADDRESS AVERN ROAD � OWNER'S NAMEJ JIMSCOTT POWNER ADDRESS I SAME - — TELI 978-790-5626 FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW: D RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YESE] NOE] I FIXTURES -1 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/OIIJSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHERI---- F77D F--71 INSURANCE COVERAGE: I have a current liabili!y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITYE] BOND F-1 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 [j AGENT SIGNATURE OF OWNER OR AGENT 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 i gompliance with 11 Pertin t viAn of.1he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I KENNETH J ROBERTS LICENSE # SIGNATURE MPE] jPn CORPORATION El # PARTNERSHIP[:]# LLCD#[= COMPANY NAME I ABSOLUTE PRECISION ADDRESS I P.O. BOX 1260 CITY [MIDDLETON — STATE F—MA-1 ZIP 1_01949 TELF78-767-1475 FAX CELL 1978-766-1475 1 EMAIL I KEN@ABSOLUTEPRECISIONPLUMBING.COM 0 — A b COMMONWEALTH OF MASSACHUSETTS PLUMB ERM? 5SF I TTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER� tu PO BOX 1260 MIDDLETON MA 01949-326o 22552 05/01/!6 223979 .,. " " �; il��l Llj COMM . ONW . EA - LT i OF MASSACHUSETTS ��e V -1v y .. 0, offm a KSF I TTERS klSsu�S T�kE FGLLQWtKG2 LICENSE LICENSED AS A MASTER PLUMBER� Lu KENNETH J ROBERTS P.O. BOX 126o N4 MIDDLETON MA 01949-326o 11934 05/01/!6 223978 COMMONWEALTH OF MASSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP z KENNETH J ROBERT U, ABSOLUTE PRECISION PLB. & HEATIN z 5 WILDWOOD RD' w MID.DLETON MA 01949-2133 3304 05/01/16 2o4671 1— 16 AC40RV CERTIFICATE OF LIABILITY INSURANCE DATE (MMID;YYYY) 7778/10/15 164.� ADDL JM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confL-r rights to the certificate holder in lieu of such endorsement(s). PRODUCER Circle Business Ins. Agcy, Inc 247 Newbury Street Danvers, MAL 01923 CONTACT NAME: Lori A. Cote PH FAX -4898 (ALM F)d). (978) 777-5619 (A/Q No): (978) 777 E-MAIL ADDRESS: LCote@CircleInsurance.net INSURERS) AFFORDING COVERAGE NAIC # INSURERA:Utica Mutual -EACH DAMAGE TO RENTED PRFMI1F1 (Fa occurrence) $ 50,000 INSURED INSURERB:Safety Property & Casualty INSURER C: Absolute Precision Plumbing & Heating, Inc. INSURER D: Po Box 1260 INSURER E: Middleton, MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBER: 2015-2016 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. INSR LTR TYPE OF INSURANCE ADDL JM SUBR VWD POLICY NUMBER POLICY EFF (MMIDDNYYY) POLICY EXP (MM/DDIYYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_x1OOCUR Lori A. Cote 4541084 7/8/15 7/8/16 OCCURRENCE $ 1,000,000 -EACH DAMAGE TO RENTED PRFMI1F1 (Fa occurrence) $ 50,000 ME D EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER F-xl POLICY [-] PRO- LOC ,ECT F PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANYAUTO ALLOWNED X SCHEDULED AUTOS AUTOS X NON -OWNED X HIREDAUTOS AUTOS 6218367 7/8/15 7/8/16 MBINED SINGLE LIMIT (CEO, .cdr't) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPE R'Y DAMAGE IP.r. �.dero $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGG RE GATE $ DED RETENTION $ $ AIORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If rs nder S6describe u D RIPTION OF OPERATIONS below NIA TATU OTH- I TWIPSI MITS I I FR E.L. EACH ACCI DENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICUES (Attach ACORD 101, Additional Remarks Schedule, if more space is recid red) CERTIFICATE HOLDER CANCELLATION @ 1988-2010 ACORD CORPORATION. All rights reserved. ACOR D 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: jkconstruction@comcast. net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN J. K. Construction ACCORDANCE WITH THE POLICY PROVISIONS. 24 Windsor Lane AUTHORIZED RE PRE SEN TATIVE Topsfield, MA 01983 I Lori A. Cote @ 1988-2010 ACORD CORPORATION. All rights reserved. ACOR D 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: jkconstruction@comcast. net Date ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... . .. .... .... ...... has permission for gas installation ........ ................ in the buildings of. a t . ............. No ........... rth Andover, Mass. Feq-?jq��-!'2 ...... U/c. No. d�� ... ...... . .......... (� ASiNSPECTORI/ . ........................ Check # '1�22 I It MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER I MA DATE 11-18-016 1 PERMIT# C' JOBSITE ADDRESSJ_285 RALEIGHTAVERN ROAD OWNER'S NAME I SCOTT G OWNER ADDRESS I SAME 78-790-5626 FAX F— _ __ ___ __ 1 TELFT - - __j TYPE OR OCCUPANCYTYPE COMMERCIAL[j EDUCATIONAL RESIDENTIALE] PRINT CLEARLY NEW: Ej RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES[] NOE] APPLIANCES -1 FLOORS- Bsm 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE F DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER LINVENTED ROOM HEATER WATER HEATER OTHERI All—AIL—A INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7, 1 OTHER TYPE INDEMNITY F-71 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 [:] AGENT SIGNATURE OF OWNER OR AGENT 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 at a ine�� of the Massachusetts State Plumbing Code and.Chapter 142 of the General Laws. O/z, PLUMBER-GASFITTER NAME H J ROBERTS LICENSE# 11934 SI G NATU RE MP ED MGF [:] JP [:] JGF [--I LPGIF–j CORPORATIONF # PARTNERSHIP[:]# LLC Ej# COMPANY NAME] ABSOLUTE PRECISION ADDRESS I P.O. BOX 1260 CITY I MIDDLETON STATE= ZIP j_qj_N9 .___=TEL 1978-766-1475 FAX 1978-777-5371 97�-766-1 TT --j EMAIL I KEN@ABSOLUTEPRECISIONPLUMBING.COM I CELLL --i t7l' 7 0 AC40RO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 12/22/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT AME: Andrew Atsaves c/o Artex Risk Solutions, Inc. 8840 E. Chaparral Rd.; Suite 275 PHONE FAX, -4266 IAIC, No. Ext): (480) 951-4177 (AIC No): (480) 951 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Scottsdale, AZ 85250 INSURERA: American Guarantee and Liability Insurance Co. 26247 INSURED INSURERB: Genesis HR Solutions, Inc. One Burlington Woods Dr. Suite 203 INSURERC: Burlington; MA 01803-4552 INSURERD: INSURERE: INSURERF: -PREMISES MED EXP (Any one Person) $ COVERAGES CERTIFICATE NUMBER: 16MA603806009 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE � ADDLSUBR INSD WVID POLICY NUMBER POLICY EFF (MM/DDfYYYYJ POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE F OCCUR 1 DAMAGE TO RENTED (E. 0..urr�nc�j $ -PREMISES MED EXP (Any one Person) $ PERSONAL & ADV INJURY $ GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO - POLICY JECT F LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY MBINED INGLE LIMIT $ ..c (CEO, id.n1S BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ FIR ER DAMAGE OP Z a d $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE I I RETENTION$ $ __7DED A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? F—] (Mandatory In NH) N/A WC 48-41-995-05 01/01/2016 01/01/2017 PER JOTH- x I STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 Ifyes,describe under DES RIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Location Coverage Period: 01 /01/201L 6 01/01/2017 Client# 1957 -MA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Coverage is provided for Absolute Precision Plumbing & Heating, Inc. only those co -employees 5 Wildwood Road of, but not subcontractors Middleton, MA 01949 to: CERTIFICATE HOLDER CANCELLATION Absolute Precision Plumbing & Heating, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 5 Wildwood Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Middleton, MA 01949 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/011 @ 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and loqo are reaistered marks of ACORD . - I ft The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 1UV . * www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information , Please Print Legibly Name (Business/Organization/Individual): filroL07F Address: /00- 1-z40 City/State/Zip: /*I --r-4 OIC -72--i /w� a/,? k9 Phone #:_� "79- - 7 7-r Are you an employer? Check the appropriate box: I.XI am a employer with S 4. 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.E1 I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity, workers' comp. insurance. [No workers' comp. insurance 5. We are a corporation and its required.) officers have exercised their 3. n I am a homeowner doing all work right of exemption per MGL myself. (No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. E] New construction 7. ORemodeling 8. Demolition 9, Building addition 10. Electrical repairs or additions I 1XPlumbing repairs or additions 12.0 Roof repairs 13. n Other *Any applicant that checks box n] must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new alfidavit indicating such. tConlTaclors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation inNurancefor my entplayees. Below is the policy andjoh site information. Insurance Company Name: 4AI ,eP- 1C19'-1 C1 IQ Ot-Vre t VA— 4 �/V 0/ —0/ —.2— 67 Policy # or Self -ins. Lic. 4: GI -1 C Expiration Date: Job S ite Address: &1_;1t/Z-_1VV7 2- 9 -'7 6- City/State/Zip: 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 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under flee pains, and_genq1ties opfperju at the information provided above is true and correct. / — / J- — .2— 0/t( Simature: Date: .01, Phone tk-d!S-,3 S Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitfLicense #. Issuing Authority (circleone): 1. Board of Health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person Phone #: 9373 Date. . �11�9114, - - - 140 TO I TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,ts,q US This certifies that has permission to perform plumbing in the buildings of ...... at . 24-49 Z� N h .,�Vtndovei, Mass. Feeln, - 9. Lie. No..7173... Check# S*6iv ,.� 3 W/ 0 PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C /)j . '. . A 1. . -,-. —1— MA DATE[ PERMIT # ITY F JOBSITE ADDRESS <—, OWN E R'S NAME GOWNERADDRESS TELI 30V FAX TYPE OR OCCUPANCYTYPE COMMERCIAL[' EDUCATIONALI 'i PRINT RESIDENTIALK CLEARLY NEW: I RENOVATION: REPLACEMENT.-;>� PLANS SUBMITTED: YES F— N CN/, APPLIANCES -1 FLOORS— BSM1 �2 3 .4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER T CONVERSION BURNER .... . ..... COOK STOVE DIRECT VENT HEATER DRYER .. .. .. ........ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ------ POOL HEATER ROOM / SPACE HEATER ........ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER .... ... . . . OTHER.. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER F AGENTI 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME MICHAEL H HOUSE LICENSE# 7173 MPi, MGF JP1 JGF- LPGI CORPORATION Iv 4 3377 C PARTNERSHIP LLC #1 COMPANY NAME! MERRIMACK VALLEY CORPORATION ADDRESS 15 AEGEAN DRIVE, UNIT #3 -689-0224 CITY METHUEN STATE MA ZIP101844 TEL; 978 FAX! *97'8-689-2206 CELLI 978-884-3427 EMAILI lliftle@mvalleycorp.com or srufter@mvalleycorp.com Ns 0 o Z LLI CL q* LLI I.- ui > 0- LLI > cc z LLJ .tl U) 04 z 0- 0. < Ns 0 Date... .................. r. �, � ; ��O, \�� TOWN OF NORTH ANDOVER A�.M 40q _6 PERMIT FOR GAS INSTALLATION This certifies that.. .. eZre ..... has permission for gas installation "/ XW4�1 in the buildings of ....... /6 ...... ....................... ,4?. . -j� /q Z6 at Z� North Andov7r J�� Mass. Fee..��.q�� Lic. ...... GASINSPECTOR Check # M/10 I rd ON P TYPE OR PRJNT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK A 4 4 4 - � ' / / CITY MA. DATE ��/O- PERMIT # JOBSITE ADDRESS lft� k_j� ��,rejWNER'S NAME I.. VVI I Nyz . L. . OWNER ADDRESS: F . .... ... TEL:13�7-,31 FAX: OCCUPANCY TYPE: COMMERCIAL E:1 EDUCATIONAL RESIDENTIALK NEW: RENOVATION: F-1 REPLACEMENT: PLANS SUBMITTED: YES NO)4 FIXUTRES -1 FLOORS— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/ AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL r=RVICE / MOP SINK Llroll-ET I URINAL— WSHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 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. LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY [:] BOND 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 [] AGENT SIGNATURE OF OWNER OR AGENT 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 applicatic� will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A cq-�) PLUMBER NAME: _MICHAEL HOUSE LICENSE # 7173 OIU14A I UKI: �MPANY NAME: MERRIMACK VALLEY CORPORATION I ADDRESS: E15 AEGEAN DRIVE, UNIT 3 CITY: [M#T�UEN STATE: F 'MA -1 ZIP: MW. FAX: L97�1-649-2206 ',TEL [978-- -P224 LL EMAIL: LEYCORP.COM U9 CE MASTER RE JOURNEYMAN CORPORATION M # � PARTNERSHIP [] # LLC [-] # 01 0 0 *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers'compensadon insurancefor my employees. Below is the policy andjob site information. Insurance Company Name:_,// -&/,6 Policy 9 or Self -ins. Lie. #: L71,A-ICIA 14A 9/ Expiration Date: lllh�JA Job Site Address: 4-4549 lel q City/State/Zip: Aymel d�pellg A� 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 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerii&y�nde �Ihp , s a d enalti at the infoor"an provided aboolv, is true a 4,65. Yu ry nd correct. Of Sig ature: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: The Commonwealth of Massachusetts fra Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): . 1711e:�zw-MIZwel—I t,116111ev Address: City/State/Zip: Phone #: 99 - Are ou an employer? Check the appropriate box: 1. W, am a employer with _-,go -"'- 4. E] I am a general contractor and 1 Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. El New construction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. F] Remodeling ship and have no employees These sub -contractors have 8. F-1 Demolition working for me in any capacity. [No workers' comp. insurance employees and have workers' comp. insurance.$ 9. E] Building addition required.] 5. E] We are a corporation and its I0.E1 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their ILE] Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.E]Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.)o Othereg&g Alt, employees. [No workers' )OL COMD. insurance reauired.1 7 v - *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers'compensadon insurancefor my employees. Below is the policy andjob site information. Insurance Company Name:_,// -&/,6 Policy 9 or Self -ins. Lie. #: L71,A-ICIA 14A 9/ Expiration Date: lllh�JA Job Site Address: 4-4549 lel q City/State/Zip: Aymel d�pellg A� 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 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerii&y�nde �Ihp , s a d enalti at the infoor"an provided aboolv, is true a 4,65. Yu ry nd correct. Of Sig ature: Phone#: 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 Person: Phone #: Date ....... . 'AORTH 0'0�� TOWN OF NORTI A V /ER PERMIT FOR GAS IN=ION This certifies that .................. CA 14 has permission for gas installation ................ in the buildings of . . ........................... at xP-�.).-. North Andover, Mass. Fee.c?-A-, Lic. No..q Check # 3 j hG�S� �INSPEGMR 6519 c (0, FIXIFURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Ot cityrrownd AJ - ;�� oL1E--1Z-,- I Date: 102LOel_0471 Permit#1 I I i k / -W `7 Building Locatij 110t9w /-IV I Owners Name: I TLI -3&-// Type of Occupancy: CommerciaIL] EducationaIF-I IndustrialL] 1nstitLAiona1F-j ResidentiaiM New:[--] Alteration:0 RenovationM Replacement:F—1 Plans Submitted: Yes No Ldnj 0 FIXIFURES 1z U) Lu w Lu cc 9 z U) 0 cc X W X 0 W W a P- Zj U) 1- cc 0 X 0 2 Lu W W. z Ir- 0 z z5W W lz wceol�-:) 0 W > I- U) M I" Z 0 W X 0 9L I.. j3 UJ cc X W >0W4z0-jI--9Oz-j0W W W z W X pl- z W W WF-Wuj ZLU>. 0 lz IX wc*:� MW0z0U)—>ZI-XQ--1 n9w 9 9 5 8 0 0 w z z W I--1, 5 LL 0 X X a. X I-- D > 0 % SUB BSMT. BASEMENT -i'57 FLOOR -iWFLOOR 3HL'FLOOR ,VH FLOOR 6'" FLOOR -i"'-FLOOR 7.. FLOOR —Ttt 8M -FLOOR Check One Only Certificate # Installing Company Name: I 1P, kle Z;Plvl<-()Ili L7 1 1, ' Corporation Address--JAVO S . 11MIA) S7=-CityrT0wn.11F5b State:FmAl Partnership Business Tel: 177T-1qd-3 -=Tsoo Fax: JY 2T -7 N �?3 Firm/Company FYI Name of Licensed Plumber/Gas Fitted A clih 3 jga�/� I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. f -Vi A liability insurance polIcyL/\j Other type of indemnity L1 Bond 0 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 Siqnature of Owner or Owners Aqent nerF-1 AgentEl By checking this box []; I hereby certify that all of the details and Information I have submitted (or entered) regarding this application am 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. Byl ype of License: /Z Plumber z Titlel Gas Fitter Sigrifature of Licensed 'Plumber/94 Fitter Mast" cityrrownl Joumeyman License Number: APPROVED (OFFICE USE ONLY) Lr installer PATRICK J. DONOVAN ASSOCIATES, INC. "CLAIM AND LOSS ADJUSTMENTS" P.O. Box 110 Wakefield, MA 0188o (617) 245-5540 FORM OF NOTICE 0 F CASUALTY LOSS TO UNDER MASS. GEN. LAWS. CHP. 1.39-.o TO: Building Commissioner or Inspector of Buildings City or Town Hall North Andover, MA 01845 RE: Insured: Paul & Betty C. Polverari Property Address: CZ85'�Rale - igh Tavern Lane' North Andover, MA 01845 Policy Number: PHO 0100 55 93 87 .Loss Type: Date of Loss: bur File Number: Pipe Burst February 8, 1996 WAP 22814 - I \0 OWN Claim�.'has been made involving loss, damage or destruction of the above - captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapt'Or 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws'" Chapter 139, Section 3B is appropriate, please direct it to the atieiihll�ion of the writer and include a reference to the captioned Insured, locatione policy number, date of loss and file number. Adjuster - Vern Laws Donovan Associatesg Inc. Wak I efield, MA 3/5/�6 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. z�,Itww Location - No. 2��2 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ S ,*Iect�r 15. 00 PAID Building Insp - 8033 Div. Public Works PERMIT NO. S 50 to &0 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE I M 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. OCATION PURPOSE OF BUILDING OWNEWS NAME NO. OF STORIES SIZE IWO 6WNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME ;9`1ZE OF FLOOR TIMBERS I ST 2ND 3RD PILDER'S NAME %0 09PAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF S`ILLS POSTS DISTANCE FROM STREET ,UISTANCE FROM LOT LINES - SIDES 1�r REAR GIRDERS AREA OF LOT FRONTAGE 4EIGHT OF FOUNDATION THICKNESS IS BUILDING NEW ,;IIZE —OF FOOTING x IS BUILDING ADDITION MATER:AL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM ;0 STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR ZDATE FILP 44 SIGNATURE OF OWNER OR AUTHORIZED AdENT F E E PERMIT GRANTED 03 3 PROPERTY INFORMATION LAND COST ga ,<ST. BLDG. COST fp,366 — EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTO -1H - C) 36 7 OWNERTEL.# j�L CONTR. TEL. # CONTR. LIC. # H.I.C. # BUILDING RECORD I OCCUPANCY 12 �INGLE FAMILY I_ S-ORIES MULTI. FAMILY __�_�FF'ICE'S APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE --- PINE 3 1 2 13 CONCRETE BL K. BRICK OR STONE HARDW D PIERS PLASTER DRY —WALL UNFIN. 3 BASEMENT AREA FULL 114 1/2 1/1 FIN. B M T AREA FIN. ATTIC AREA NO BMT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS CONCRETE EARTH B 1 2 3 DROP SIDING WOOD SHINGLES ASPHALT SIDING -�ARDVJ D ASBESTOS SIDING COMIAGN -;VSPH TILE VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR BRICK ON FRAME CONC.OR CINDER ELK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I I POOR NONE ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBIELI I A -�Ip MANSARD BATH (3 FIX.) TOILET RM. (2 FIX.1 TLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING DERN FIXTURES -M TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. '�TEAM STEEL BMS. & COLS. HOT W T*R OR VAPOR WOOD RAFTERS_ AIR CONDITIONING RADIANT H'T G UNIT HEATERS 7 NO. OF ROOMS GAS Oil B'M'T 2nd Ist I 3,d I— ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. V. f 11 pt 21 I/ t C\ r_4 ol R.7� :!711, r 0 FMM4 0 0 co WO en ui 6 CL z a cc cc, C.J C.) M.0 ca E 03 CL E E sj� Z cm C.0 4D cm 03 :ca* co C4) CO) at. (D 0 CO 03 cc cc co co C" COD cc, �Lj :5 u= mg 1; co CL= — = *_ cli LU E c; = o w &_ Q CO E cm C.3 0 0-00.s C*13 CL CD F m - " :s CA CL.- to E Ma CIO ff f 0 cm CD co :10 0 z 0 C/) z 0 U 0 lz 16:0-.4 :0 S, 6ml .0 Lel ts ca CO CM ca M 0 co CD 0 0 C* -0-1 C cc CD ca CD 0 C* cc 'a CO2 U_ LLJ U) 2-7 C) C-) CL I CD ZE CL t= LLJ LLJ LU cr LU 3: LU U) I 0 L2 4) cf) 0 C_ 0 E :2 u 00 c x .3 0 —co C: z 0 1:4 - > C/5 . ca U. 1 ZW PQ 0 Q) U) 0 C/) 0 FMM4 0 0 co WO en ui 6 CL z a cc cc, C.J C.) M.0 ca E 03 CL E E sj� Z cm C.0 4D cm 03 :ca* co C4) CO) at. (D 0 CO 03 cc cc co co C" COD cc, �Lj :5 u= mg 1; co CL= — = *_ cli LU E c; = o w &_ Q CO E cm C.3 0 0-00.s C*13 CL CD F m - " :s CA CL.- to E Ma CIO ff f 0 cm CD co :10 0 z 0 C/) z 0 U 0 lz 16:0-.4 :0 S, 6ml .0 Lel ts ca CO CM ca M 0 co CD 0 0 C* -0-1 C cc CD ca CD 0 C* cc 'a CO2 U_ LLJ U) 2-7 C) C-) CL I CD ZE CL t= LLJ LLJ LU cr LU 3: LU U) I 2. >( ZX /d I \ Aj 40 es-r-l*ou C-cr la't;j TGAGE -INSPECTION PLAN AT 2.85 RA L EIGH TA VERN L A NE NORTH ANDOVER MA. -NO -ESSEX. REGIS -TRY OF DEE9S-'8X / 991 PG 335 PLAN.- ;V6. Y.168 CER TIFIED T , 0.'. - GREA 7- WES TERN MORTGA &Z� CORPORA rION SCALE..] 60. DA TE.- JULY 2 41 1992 0 20.30 5'12,601 - 20,30 6' 23 WOOD FRAME WELL. LOT 18C 43.922 5 F J�f D DRAINAGE RAINAGE EASEMENr 19.4-16 /)DO NOT USE OFFSETS TO ESTABLISH PROPERTY LINES OR TO ERECT ANY STRUCTURE 2)PROPERTY LINES ARE DETERMINED FROM COMPILED INFORMATION TO BE USED FOR MORTGAGE PURPOSES ONLY CERTIFICA TIONS.* BASED ON My KNOWLEDGE, INFORMATION AND BELIEF, / HERE8Y CERTIFY THAT THE PERMANENT STRUCTURES INDICATED ARE LOCATED ON THE'GRCUND APPROXIMATELY AS SHOWN AND ARE CONFORUING TO THE ZONING SET6ACK REWIREMENTS OF THE TOWN OF NO A NO 0 VER WHEN C 0 N S TRUC TED A NO THA T THE S TRUC TURE SHO WN �f �O LOCXrED IN A FLOOD HAZARD ZONE AS PER FEMA. MAP, COMMUNITY NO 250098 EFFECTIVE DATE' 06 - 15-83 ZONE* C JOHN ABAGIS 8 ASSOCIATES PROFESSIONAL LAND SURVEYORS 137 CHANDLER ROAD. A ND 0 VER, MA. (508) 688-4699 NO. P668 Town of North Andover BUILDING DEPARTMENT Homeowner License Exeinution (Kease print) D ATEE 7- Z? JOB LOCATION umter . Street Address ,UL Section or town co�&q - 6 u3 Name HOME Phone Work, ?,hone PF E c - I/ M,-�'L_T.NG ADDRESS �Z&5 kal_c-�(Gfil :y/ Town State. 4D coce The current exemptLon for "homeowners" was extended to inclLude owner --.cz,,='e,d dweilin-1-s of six units or less and to allow Such 'nOMeCWnEr_-- to a ri e=zge an incilvidual for hire who does not possess a license, provia— t'ha-_ 'the owner acts as supervisor. (State Building Code, Section 109-1-1) D-77NI-70N OF HOMEO'wNER: Derson's' who owns a parcel of land on which he/she resides or intends to to S4 faMily dWel-- res e. on which there is, or is intended to. be, a one 'L 4 11 use and/or fa-rm tures accessory to suc.1 r L a--tached or detached str= C nS, -yenr s:ruC:'1.:res. A person who 0 tructs more than one home in a two - period shall not be considered a -homeowner. Such "homeowner" shall submi: to the Building Official, on a form acceptable to the Bulding Offic-4al. reSDOnS4 t' -a" he/she shall be Lble for all such work�performed under the d n g p e rm, i (Section 109.1.1) bul -1 L -.1 "horneowner' assumes responsibil-it,/ for compliance w` �Incerslgn -_1u_J1d,:;.n,-- 'Code and other applicable codes, by -'Laws, ruliems ar'-` -.-_a:ions. T LL ri e o hom thaL he/s"e understand -s t, I 4 ; lne--_� "'. iecwner" cer---'.L-. No A i-idove r 3u --' ]Ld in g Depar tm e n t m i n 1,"num ins z)ez t o n p roc ec u -- 2 s a ncl and t1 -a: hE/ShE Wil -11 COMOil/ wi,_h sald proc=CUras anu 7 -. - :;,- C L OFF 7L I , 2 Eee�. or. Lar-:-er, wJ L C 1 7 J, Cons- -EZ:-:Dn z �.a a g CL) . W MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTI (Print or Type) NORTH ANDOVgR Mass. Date building Location -444&-1w -Z�Pzoil Permit # — Owners Name_JWPZ New —I Renovation Replacement Plans Submitted F-1 (Print or Type) Check one: CertificatE! Installing Company. Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122 Address 5731 SO. -UNION STREET = Partner. LAWRENCE, MA. 01843 F-1 Firm/Co. Business Telephone: 978 685-8383 Name of Licensed Plumber or Gas Fitter mgrw LARosE I nsuranc�.:_ Cqverag Indicate the type of inS'Ulance coverage by checking: the appropriate.,boxv Liability insurance policy Other type of '.in'demnity F --j Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application joe5 not have any one of the above three insurance coverages. Signature of owner/agent of property .:Owner 17 Agent I hereby certify 1.4st All of (he details and infoctnXtion I have tubmitted (or enter . ed) in above application are true and acewate to the best of my knOvAedge and tlLat all plumbing work and instAllAdOt" MfOrmed under'I'ermit iuL*c4 [a.- this application will -be In compliance with all pertinent Provisions Of the hisizachusetis State Cas Coade and QApter 142 of Lhe General LAwa. By TYPE LICENSE: Title Plumber 'ture of Licensed Gasfitter- Sigf�a CitY/Town: Master Plumber or Gasfitter APPROVED (OFFICE USE ONLY) Journeyman License Number NUNN MEEMMMIMM MENEM IN IMEMEMIKE OMEN IMEMENO NX MEMO ARM MEMMINMEREEMMEM (Print or Type) Check one: CertificatE! Installing Company. Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122 Address 5731 SO. -UNION STREET = Partner. LAWRENCE, MA. 01843 F-1 Firm/Co. Business Telephone: 978 685-8383 Name of Licensed Plumber or Gas Fitter mgrw LARosE I nsuranc�.:_ Cqverag Indicate the type of inS'Ulance coverage by checking: the appropriate.,boxv Liability insurance policy Other type of '.in'demnity F --j Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application joe5 not have any one of the above three insurance coverages. Signature of owner/agent of property .:Owner 17 Agent I hereby certify 1.4st All of (he details and infoctnXtion I have tubmitted (or enter . ed) in above application are true and acewate to the best of my knOvAedge and tlLat all plumbing work and instAllAdOt" MfOrmed under'I'ermit iuL*c4 [a.- this application will -be In compliance with all pertinent Provisions Of the hisizachusetis State Cas Coade and QApter 142 of Lhe General LAwa. By TYPE LICENSE: Title Plumber 'ture of Licensed Gasfitter- Sigf�a CitY/Town: Master Plumber or Gasfitter APPROVED (OFFICE USE ONLY) Journeyman License Number 2825 Date. It ......... -TOWN OF NORTH ANDOVER lo 0 PERMIT FOR GAS INSTALLATION S CHU In This certifies that. ............. has permission for gas installation . . ............... in the buildings of .. F�-) R )� j ........................... at :2 S�J_./ )A.� el. oj-i ..... North Andover, Mass. Fee.-�;�. Lic. No../.'� �-..3 ... .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N2 2135 -like 10 01'. VA Date e�� ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that-.�. ............ a75777� ................ has permission �to ......... ..................... wiring in the building of%.. .......................... Nbrth Andover, Mass. Fee..&.?� ....... Lic. N . ......... 8 .... ............................................................... ELECTRICAL INSPECTOR 11/17/98 o9:21 15- 00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office use only Gibi Lfum=niuraith of Permit No. 3z;mrtmznT af ilublic —Aafitj Cccupancy & Fee Checked 3M (leave blank) BOARO OF FIRE PREVENT10 REGULATIONS 527 C -MR 12Aa I APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacriusetts E*-ec*ricai Code, 527 C.MR 00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (%X or Town of NORTH ANnOVER To the Inspector of Wires: The udersigned acciies 'or a permit to perform ricai Ncrk describ25,!zeIcw. e eiec* /V -- A, --I— Location (Street & Number) Owner or 'Menant Cvvner's Acic!ress Is zz:iis perrnit :n ccniurc-.:cn witti a building permit: Yes No 2C' (Check Apprccria:e EGx) Utility Aurr.crizaticri No. E.,csting Serilice Arnos -\/C;"s Overneac Uncgrric New Ser.,ice Amps —1-1/cits Cverr.eac Uncgma No. of Meters No. at Nie!ers Numcer ct =------ers ainc Arr.cac:,,/ arc Nat'.;ra co Pf-c=csec EeC*-:--zl %'Icrx alai t No. _gnnng Zuc:e!s No. s No. =f 7ranstcrrr-.ers KVA Accve— :n - 'No. v Loqnnnq �:Xcures Sw,rh"hing 2CV grnc. a-M.C. Generators KVA No. zit Emergency ,No. :1 cecc-c-2c:9 Cutlets No. =t Cil 5:uners Barer., �hlts 140. -t Sw.tcn Cutlets No. =r Gas -Z---rr!ers I No. --* Ranges No. =: A.r -znc. alai tons No. ::t ---isccsais Nc.=r atai s Tons -alai '40. X r-1snwasners ScaceiArea ?-!e2tira NO. V =r%,ers H.ea-,-,.-.a Cevices fi No. =? '40. of No. at 'Afater �eazers No. �+.,Cra Massace - ucs Badasts Sicns .40. ::t Mctcrs atai --4P �riPE ALARMS No. zt '-7znes No. �:t -etec*:on anc initiating ::avices No. ::t Saunc:nq Cevices i No. at ceit Czntainec 0e,ec--.cniScurczng Cevices ',zw Voltage 1,Virir,,C muntc:cai — other Cznnec*:crl — iNS�jSANCa =vE=AG-=. ?--.rsuan, za tne recuirements :r !.',assacn%;se7s ;Sneral I-aws I have a ".rent L-acitity insurance Pvic'/ -ric:uc:rq -Z.;rrc:etec Cceraticns Zzvefage or -is sucsantial ecuivaient. YES :: NO Z .have suorninec vaim =.cct ct sarne to :me Ctlice. YES Z NO :: it ycu nave cnecxec YES. :tease moicate :ne type at caveraqe zy Cneiaxing -.ne accrocriate zcx. INSURANC=- = BOND = O-,�E=; :: (Please Scec:ty) (Exciration -:)alai E-surr-atec; vaiue of E�ecmcai Worx S =nal Werx :a Star inscec-:cn Oxa Adcues'.ac: Rougn -er S;gnec ;ncer .Ie Penalties at . -ju 6'f -3-3� FIRM, NA.ME , ZZ" . a No. L--censee S, Af , 7416d —'_:C. NO. ACCress Alt. 741. No. CWNE:q*S 1NSUPANC�--- WAIVEP: I arm aware !Mal trIe t-;censee coes rat nave me insurance cz-verage or its suostantlal ecuivaient as re- Cusrec; =v Massachusetts General Laws. aric �hal nly signature an :,.:s =errr:t acotication waives this recuiremiElint. Owner Agent (Please ctlecx onel -etecrcne .140. _ PS=iMIT XSE S Sicrature ci Cwner --r Aqeritl