HomeMy WebLinkAboutMiscellaneous - 288 FOSTER STREET 4/30/2018 (2)C)D
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Commonwealth of Massachusetts Map -Block -Lot
104.DO068
-----------
BOARD OF HEALTH Permit No ------------
North Andover - BHP -2017-03 - 20 ----
--------------- --
P.I. FEE
F.I. 115"oz)
-------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John- DiVincenzo ------------------------------------------------------------------------------------
to (Construct) an Individual Sewage Disposal System.
atNo --2-8-8-F-O-STER--S-TREET
as shown on the application for Disposal Works Construction Permit N 2017
�m -------------------------------------------
Issued On: Jan -19-2017 BOARD OF HEALTH
----------------------------------------------------------------------------------
Commonwealth of Massachusetts
Map -Block -Lot
BOARD OF HEALTH
104.DO068
----------------------
Permit No
North Andover
BHP -2017-0320
-----------------------
FEE
DISPOSAL WORKS CONSTRUCTION PERMIT -------------------
Permission is hereby granted - John DiVince nzo
to (Construct) an Individual Sewage Disposal System.
at No - 2 - 8 8 F 0 STER S TREET
as shown on the application for Disposal Works Construction Permit No. B- HP -2-0-1- 3 ted January 19, 2017
LFri,�,--E ----------
Issued On: Jan -19-2017 ---------------- ------- j ..................................
-- -------------- --------------------------------------------------------------- BOARD OF HEALTH
North Andover Health Department
(ommunity and Economic Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 288 Foster Street MAP: 104. LOT: D0068
INSTALLER: John DiVincenzo
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
[I Contractor reports any changes to design plan
El FE)C��fing �e7p�t c ta�kp rope rly abando-n—edi
Internal plumbing all to one building s--ew7er
F1 Topography not appreciably altered
Building sewer in continuous grade, on
compacted firm base
El Cleanouts per plan
El Bottom of tank hole has 6" stone base
El Weep hole plugged
E] 1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
Water tightness of tank has been achieved by
visual testing
Inlet tee installed, centered under access port
Comments:
PUMP CHAMBER
Comments:
CONTROLPANEL
Comments:
DISTRIBUTION -BOX
Comments:
El Outlet tee installed, centered under access port
(gas baffle/effluent filter)
inch cover to within 6" of finish grade
installed over one access port
0 Hydraulic cement around inlet & outlet
F1 Bottom of tank hole has 6" stone base
E] Weep hole plugged
E] 1500 gallon Pump Chamber installed
El H-10 loading
E] Monolithic tank construction
El Inlet tee installed, centered under access port
El Pump(s) installed on stable base
El Alarm float working
El Pump On/Off floats working
E] Separate on/off floats
F1 Drain hole in pressure line
E] cover at final grade installed over pump
access port
Ej Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
E:1 Alarm & Pump are on separate circuits
El Alarm sounds when float is tripped
El Location of control panel: basement
El Alarm signal located inside: basement
Installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Application for Septic Disposal System
Construction Permit -TOWN OF
NORTH ANDOVER, MA 01845
Application is hereby made for a Permit to:
El Construct a new on-site sewage disposal system*
epair or replace an existing on-site sewage disposal system*
Repair or replace an existing system component - What? I
A. Facility Information
kuuiuzis or L01?F
TODAY'S DATE
$350.00 - Full Repair
$175.00 - Component
2, *TYPE OF SE SYSTEIVI*:
> Lj Pump WGravity (choose one)
***If pumEsy%tem, attach copy of electrical permit to application***
> YConventional System (pipe and stone system)
> Ej Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
> El Pressure Distribution S.A.S. (No D -Box)
> E] Pressure Dosed (D -Box Present) S.A.S.
> E] Does the system require an effluent filter? Yes- No
If yes, does plan specify make and model of filter.? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the MakeP
2. Owner Inforr
Name
ss (if different
y/Town
Email address
e -
Wha t is the Model?
State h1A_ Zip Code F75�
Tel6ph-onLrNum5er
3. Installer Information
- -1—A i��CCAX�
N aWe - P r � —<e " C—
Name�'of Company jr
4. Designer Information
Name
Aaaress
City/Town
O&eA- 171-kq <
Slate- ZipTCode— '
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best# to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
1 3fication
'or �Segic Dis� sal S�ste�m
011struCtion Permit - TOWN OF
ORTH DOVER MA 01845
i5A-�GE 2 �OF
A. Facility Information continued.
2�
RMQLB—U-11d-1—n2: - esidential Dwelling 01 []Commercial
B. Agreement
TODAY'S-dATE
$350.00 Full Repair
$175.00 COMponent
The undersigned agrees to ensure the construction and maintenance Of the afOre-described
E;nvion-site sewage disposal system in accordance with the Provisions Of Title 5 of the
, lon ental C
0 1 s well s
-1 the Local Subsurface Disposal Regulations for the Town of
No B do�tr. un d that until a final Certificate
th
t I
r st�ied system is not approved.
s e
a Hr r1tht:hrnstal Of Compliance has been issued by
Application Disapproved for the following reasons:
For offi,-. i i-.� �-.- -
fieeAttacbedp Yes No
Pro
2 jectManaget oh'ygatiOn fibim Attachedp Yes
3. Eum r, —
sgsteMP If so, Attacb coQV ofElect No
ricalp
enn,t Y
APP&can t teceived copy of es No
'Electrical Inspection Notes for Septic SY
Bandoutp stems, Yes No
4* Rev'elvedaPPron-d.ettez, affpaperwork-receivedP Yes No
Missin-or!'
Foundation A,--Bjjjjtp (new construCtion oniy):
PPTovedplan)
(Same scale as a Yes No
6 FIOOTPlansP (new construCtion only): Yes No
Application for Disposal System ConstrUction Permit * Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As . the North Andover licensed *installer for the construction for the septic system for the property at:
(Address of septic system) ans by
Relative to the application of4nsta_L_L_1�� ated (Engineer)
Dated /// 0 / ?
/____7_Tf`May's date)
With revisions dated
I understand the following obligations for management of this project:
(Unginal date)
(Last revised date)
1 - As the installer, I am obligated to obtain all permits and Board of Health approved plans p or to
performing any work on a site. I must have the approved 121ans and the permit on site when aW work is
being done.
2. As the *installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
in . dicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied ap,,aLinst me and/or
my compa".
a. Botiom of Bed — Generally, this is the first (is) inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be Present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (Or e-mail to: healthdept@northandoverma.gov) from the engineer must be
submitted to the Board of Health, after which *installer calls for an inspection time. Installer must be
present for this *inspection. With a pump system, all electrical work must be ready and able to cause
pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (otber than simple excavation) and I am required
to complete the installation of the system identified in the attached application for 'installation. —Iffirther
understand that work done by others unlicensed to install septic systems in North Andover can constitut
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, sigWficant fines to all persons involved are also possible.
5. As the installer, I understand that I mu-st be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached
b. Inspection of the sand and stone to be used
c. Final inspection by Board ofLlealth staff of consultant.
d Instaflation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wafl and other
components.
6. As the in-t5iller 1-1-* T ----I -I--
me of this obliggdo .
Undersigned Licensed Septic Installer:
0
ame —
A C-
6
Indover Health Department
munity Development Division
R SYSTEM CONSTRUCTION NOTES
LOCATION INFOR.MATION
ADDRESS:-'cW6T-6,'7-T10fZ-�) MAP: LOT-
INSTALLER:"-' �, kr\- D I V 0
DESIGNER: rMC)
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS C4
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
1, 0 3,,,),C) 11"-�
F-1 Contractor reports any changes to design plan
Existing septic tank properly abandoned
Internal plumbing all to one building sewer
Topography not appreciably altered
Building sewer in continuous grade, on
compacted firm base
Cleanouts per plan
F-1 Bottom of tank hole has 6" stone base
F1 Weep hole plugged
E:1 1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
E] Water tightness of tank has been achieved by
visual testing
E] Inlet tee installed, centered under access port
F-1 Outlet tee installed, centered under access port
(gas baffle/effluent filter)
El inch cover to within 6" of finish grade
installed over one access port
F-1 Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
F-1 Bottom of tank hole has 6" stone base
Weep hole plugged
E] 1500 gallon Pump Chamber installed
F� H-10 loading
Monolithic tank construction
Inlet tee installed, centered under access port
Pump(s) installed on stable base
F-1 Alarm float working
E] Pump On/Off floats working
Separate on/off floats
Drain hole in pressure line
cover at final grade installed over pump
access port
Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
Alarm & Pump are on separate circuits
Alarm sounds when float is tripped
Location of control panel: basement
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX Installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
11 C 0 2
Date.:;�..�I..�A.6 .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
I �� I
This certifies that..4-..l ..... AJ ...... f) r I aA e IL
.... . ......... i
.........
has permission to perform ........... (A.0 ......................... ........................................
plumbing in thn b
,,e, u� ings of .... * Q�In.o ...............................................................
at ..... ...................... North Andover, Mass.
Fee ... Lic. No. .... .....
............ ........................................................
PLUMBING INSPECTOR
Check #
0"
mam
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY NORTH ANDOVER . . . . . . . . MA DATE 1'1/30/15 PERMIT #d -10;W
JOBSITE ADDRESS 288 FOSTER ST. OWNER'S NAME[GO NC�Tl
OWNER ADDRESS TELL___________J[FAX
OCCUPANCYTYPE COMMERCIAL [j EDUCATIONAL El RESIDENTIAL ED
NEW: [I RENOVATION:E] REPLACEMENT: [�]
FIXTURES I FLOOR-
BSM
1
BATHTUB
CROSS CONNECTION DEVICE_
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND 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
ATER HEATER ALL TYPES
WATER PIPING
PLANS SUBMITTED: YES Ej NO[:]
2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES F71 NO El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITYE] BOND [D,
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 Y: OWNER [1 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 tr a c rat to the best
,c _9,�Ky knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co lia wg I e ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME [Aa /
N�N:OYES LICENSE # GNATURE
MPE] ip D CORPORATION Ell #F6-52-C----IPARTNERSHIP
LLCEI#[:=
COMPANY NAME WILLIAM GEDICK & SONS, INC JADDRESS E ST
CITY BURLINGTON STATE A ZIP [�1803 TELF7-81
FAX 781-273-2997 CELL 508-32C EMAIL
2kNr� 21 (1 1 6 iwA
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CONTROL # 0
IMPORTANT
dpl for
if your license is lost damaged or destroyed; is inaccurate; or
needs to be correct�d visit our web site at mass-gov/
instructions to ensure ihe proper mailing of your Renewal
Application and any other correspondence. and
This license is subject to Massachusetts General Laws
b and cannot be lent or
lulations. Your license is a privilege,
r% er penalty'bf law. Keep this
assigned to any person or entity und and/or
license on your person or posted as required by law
regulations.
41
Date ..........
.. ... .... .. ................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that R -A r,42,1.d (
................................................. ..... ............................
has permission to perform ........
leaw
.. .............................................................................
wiring in the building of ... C-10
at Z08 Z-= 2 '�;7--
................................................. 7Cr /
.............................................. North Andover, Mass.
Fee53--c9-!�—... Lic. No...1 2- 2-7 Z
............... ......... ?00� . ... .. ....... .. .......
rLECTRICAL INSPECTOR
Check # 17o
'7
Commonwealth of Massachusetts
m3mm
Department of Fire Services
BOARD OF FIRE PREVENTION, REGULATIONS
Official 1Vse Only
Permit No. /?�, &
Occupancy and Fee Checked
Rev- 1/071 (leave bla�k)
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 PPMTININK OR YTTEALL INFORAMT10A9 Date: / — f —16—
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 A
Owner or Tenant
Owner's Address
Is this permit in'conj unction with a building permit? Yes
Purpose of Building B&M&4v
No El (Check Appropriate Box)
Utility Authorization No.
Nti
Existing Service Zm— Amps IWlAd Volts Overheadnj Undgrd [j
New Service — Amps Volts Overhead [:] UndgrdF]
Number of Feeders and Ampacity
No. of Meters —/
No. of Meters
Location and Nature of Proposed Electrical Work: &M Am Akwe-141 1-4-r !L4 -1"A
Completion qfthejbllowln� table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
swimming Pool Above Ei In-
grnd. grnd. EJ
No—.7oTEm--ergency Lighting
B tt � U its
No. of Receptacle Outlets
No. of Oil Burners
�FIRE ALARMS
JN'o. of Zones
No. of Switches
No. of Gas Burners
No. of Detection nnd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
..... ......
JKW ..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [:] Municipal
Connection ElOther
No., of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total ]UP
Telecommunications Wiring:
No. of Devices or Eauivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Fun7res.
Estimated Value of Electrical Work: - A401401 — fflen required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COV19RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operatioif' coverage or its substantial equivalent. The
-undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSUIRM- CE X BONDE] OTMRE] (Specify:)
Icerfify, underthepalnsandpe�aldes ofperjury, thatfiteinformation on this application is true and complete.
FIRM NAME: . :2 04, xQ ZIA &W72P.4e-,ro R -s' LIC. NO.: 4122 72
Licensee: -.me,4trd A--4-Z1,P Signature LIC. NO. -
(Yapplicable, enter "exempt" in the license number line.) ]Bus.Tel.No.-. 7,V-/--272-�YjY/
Address: All 121)eh ^f ZLm ly,4 �IAR Alt. Tel. No.: -79/411 -.1 7-'ql —2 -
*Per M.G.L c. 147, s. 57-61, sec-urity 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) [I owner 0 owner'sagent.
Owner/Agent
Signature Telephone No. PtRWT FEE.- $
0 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance.with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit El
El Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PAR.T11AL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) El
Inspectors Com
,Tnents:
OA
Z—
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass n?
Failed
Re- Inspection Required D
Inspectors CommenY9
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
,a
The Commonwealth ofMassachuseffs
De - ofindushiqlAceldints
,partment
Office ofInvesfigations
6#0 Washington Street
Boston., MA 02111
www.mass.go-p1dia
Workeyg, Compensation Insurance Affidavit: 33uffders/Contraci
Name (BusinessJ0rganhat1onft&YiduaD:.
Phona4 / #/
Are you an employer? Check the appropriate box:
i. F1 I am a employer with —
4. E] I am a general contractor a -ad I
employees (fall and/ox part-time).*
have hired the sub -contractors
listed on the attached shoot.
2. 1 am a solo proprietor or partner-
ship and1aveno-employees.
These sub -contractors have
worMng form@ in any capacity.
F workers' comp. insurance.
We are a corporalion and its
[No work -ors, comp. insurance
officers have exercised.their
required.]
ADI am a homeowner Aing all work
3
right of exemption p or MGL
'ist comp.
'If. [No worke
Myse
c. 152, §1(4), and we have -no
InsaaacereTured..]
employek [No workels,
comp. insurance required.]
Type of project (required):
6. N6W cOnstraction
7. Remodeling
3. El Demolition
9. El Building addition
10.[] Electrical repairs or additions
uEl Plimbingrepairs or additions
12,Q Roof'repairs
13.E] Other
NA�qy applicant that checks box #I must also fffl out the sectionbe,16w showing their workers' compensationpoliryinforniation.
t -Homeowners who submit1his affidavit indjcat�gthqy Re doing allworVand then him outside contractors mustsubmit anew affidavit indloatffig such.
Tcontractors that cheAtbisbox. mnstaffached art9dditional sheet showirigtho name of the sub -contractors and their workers' comp.polloyinforination.
w is th j0h Be
-ram an emyloyer that isproviding 1porkers' compensation insuranceformy employees. Belo evolleY and s
information.
Insurance Comppy Name: -
ExpirationDato:
Policy # or Self -ins. Lic. V:
lob Site Address; Pity/State/Zip:
Attach a copy of t1te worke]W compensation -policy declaration page (showingthe polleyrimber and expiration date).
Failuratosecurecoverage.asre 4 dunder Section 25A ofMGL 0. 152 can lead to the imposition of criminal penalties of a
- Tme- orm of a STOP. WORK ORDER and a fmo
fine up to $ 1,50 0.0 0 and/or one-year impriso�ment, as well as civil penalties in the f b e. forwarde d to the Offic e -of-
of up to $250.00 a day against the, -violator. Be advised that a copy of tb-b statement MaY
Investigations of the DIA for iiasurance, coverage VOriflGation-
*N
It in mationprovided above is true anJ correct.
.1dollerebyceyt&uiiderille,�ainsandpenattlesofFe,-jurytllatt 0 fOT
— I - 4?,v X,,,,, , A� 4d_;�l Date: —16—
OfirMal use unly. Do not wrUe hz this area, to be cotqlefed by cl� 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
ContactPerson: - Phone
Information and IRS,*
Instructio
Massachusetts General Laws chapter 152 requires all employers to p o d, workers' compensation for their employees.
Pursuant r v! e
tothis statute, an ergPkeeis d0flucdas "...every person iii the service of another under any contract ofhjre,-
,Vvritte
express or implied, oral OT .U.55
An employeils defined as "an hadividualpartnershjP, association, corporation or otherlegal entity, q anytwo ormoro
of thofbrQoj�qg engaged in ajoint enterprise, andincludingthe legal representatives of aAcceasedemployg, orthe
receiver or trustee of an individual, partnership, as�ociation or other legal entity, employing eniployees. Mwever the
owner of a dwalling house having not more than three apartments and who resides there1q, or the o ccupaut of the
dwelling housoof another who employs persons to do maintenance, construction or repair workon such dwelling house
or on the grounds or building ap-purtenant thereto shall not because of such employment be deemed to be an employer.,,
MGL chapter 152, §25C(6) also states that "every state or lo'cal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to constiruct buildings W 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 sub 61sions shall
enter into any contract for the performance ofpilblic work until acceptable evidence of compliance with the insurance
requirements of this chapterhavo beenprosented to the contracting authority."
Applicants
Ploase:fi.0 out ffie worIcers, componsailon affidavit completely, by 61106king the, boxes that apply to Your situation and, if
necessary� Supply Sub-contractor(s) name(s), addross(es) andphono number(s) along with their cerocate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLp) with no employees o or the
members Or Partners, are not required to c workers, compensation u anr th that
ins r e
any If an LLTC or LLp does have
employees, a policy is. required. Do advised that this affidavit maybe, submitted to the Department of f
Accidents for conffimation of insurance c ndustrial
overage. Also be sure to sign and date the affidaylt. The affidavit should
b Bletumed to the city or town that th6 application for the, pormit or license is b oing requested, not the D ep' artment of
Industrial Accidents. Shouldyou have any questions regarding the law or if you are required to obtain a *orkarsv
compensation policy, please call the DePartraent at the number listed below. Self-insured companies should enter their
SOlf-Jusuranco R ' conse number on the appropriate lino.'
City or Town Officials
Please be sure, that the affidavit is complete andprintedlogibly. The, Department has provided a space at the bottom
of the affidavit for you to fill out in the eventtho Office of havestigationshas to contact you regarding the, applicant.
Please bo -sure to fdl inthOPOMIR/RcOnso number Whichwitl be
. used as a reference number. In addition, an applicant
thatj�ust submitmultiple pormit/11conso applications:h any given yo . ar, need only submit one af#davit indicating clm&.ut
Policy information (if necessary) and under ,job Site Addressl� the applicant should write "all locations in . (city or
to-wn).,, A: 6opy of the affidavit that has b ec'n Officially stan3p ed or marked by the city or town may b a provided to the
applicant as proof that a valid affidavit-is'on fdo�or future permits or licenses. Anew afff davit Mm't be, fflqd out each
year. Where a homeowner or citizen is obtaining a license or -permit not related to any business or commercial voutare
(i.e. a dog license oriermit to bum leaves etc) said person is NOT required to complete this affidavit.
T110 Office OfInvestigations'Would like to thank you in advance fox your cooperation and sh9uld y9u, have any question
please do not hesitite to give us a call.
The, Department's address, telephone mid fax number:
Tho CQin
. mow. ImIth of M-0 wardimo*
Department of fadusftia
I &cjdojj�a
()MQe 0f13RVeNffga-0o=
0 Wam-agm st��- t
Boston, MA 02111
TO. 9 617-7-27-4900 Qxt 406 or 1-877, AM
Revised 5-26-05 Fax 0 617-727-7749
-viwwwagovIcha
•
A
...war wF: � .. �`
}
f
Date... ... :� ......................
No 2475
TOWN OF NORTH ANDOVE:R
UT FOR NIVIRING
PEW,
0
This certifies that ....
....................................
,�gs permission to perform ...... I
'A 1, �- , . ......................................... -
ing in the building Of ....... .............................
North Andover, Mass'
.................................
at....... .................
Fee .............. Lic. No .--11.0..:��4 ............... jj� CTRICAL INSPECTOR
Z, Check # pjNK- Treasurer
WHITE: ApPlicant CANARY: Building -v -
I 11E, LA./lY1011VI vrrl:4�112 Ur I uince use omy
XPARTMNVT0FPUBL1CS4FM Permit No.
BOA)?DOFFMEPREY=ONREGULATIOAN527OfRI2'00
Occupancy & Fees Checked
UVA
APPUCATION FOR PERMU TO PERFORM ELE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS awmCAL CODE, 527 cmR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street �
Owner or Tenant
To the Inspector of Wires:
Owner's Address
Is this permit in conjunction with a building permit: Yes L��—J No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead M Underg und No. of Meters
Amps Volts Overhead I-1] Underground rl
Number of Feeders and Ampacity
New Service
Location and Nature of Proposed Elt
No. of Meters '
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
T�t_al
KVA
No. of Lighting Fixtures
Swimming Pool Above
M
Below
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. ofOil Burners
No. of Emergency Lighting Battery Units
No. ofSwitch Outlets
No. of Gas Burners
FIRE ALARMS
No. ofZones
No. of Ranges
No. of Air Cond. Total
Tons
No. ofDetection and
No. of Disposals
No. of Heat Total Total
- umps
Tons
KW
Initiating Devices
No. of'Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local Municipal
M
Other
No. of Dryers
Heating Devices KW
Connections
No. ofWater Heaters KW
No. of No. of
Signs -
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
0 1 FHER
PON
WeikiDSW InspectionDale;7oted
sign�undxTrRvakiessofpedur)�
FIRMNAME
Expuati D&
Rct# Fmal
I K"ITF-MR1 N. 41,14
I I . IF-// I If --W r- - V I- r, f fL- -, , X I f/IE.1 �I —AIL TU Nki
OWNER'S RR�E WAIVER, I amaw=ftttheLj=wdomrd thehm=WvMVorilssdAT9W4fN�as mqmWbyMwmdms& Gneral Laws
and drinTysgmbp-aiftpmntapphcabmVk'ACS this MWMinifft
(Please check one) Owner Agent
Telephone No. PERMITFEEL=L,—
N2 22- 8 2
0
Date ...... /A/
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ........
has permission to perform .... r ..... (7 ........ ... ...................................
wiring in the building of ..... T. �. no ....... ...................................
-�n� .... .......................
at ......... a.... ................... . NorthAndover, Mass��
Fee.I.L.Al Lic. No . .........
RICALINSPE&OR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
�,p
The Commonwealth of Massachusetts Wfice V60 ant
Nfelt U.
Department of Public Safety oce"fiefty 4 fee O"I"d
u,p BOARD OF FIRE PREVENTION REGMATIONS S27 CMR 12M 1 3/90 (leave blask)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All vArk to W performed in accoidance with the Mas"chusetu Elearkal Code. $27 CMR MOO
(pIXA.SE TRna IN nM PE ALL MORNMON) Date q161 _0
OR
AY
City or TowiL of 1Y &rk�Dvew__ To the Inspector of Wires:.
The undersiped applies for a permit to perform the electrical work described below.
Location (Street 4 Number) '1758 ?;-5�' 1 A/0 AdCbV_ev11_
Owner or
Owner I a
I— jk/6
Z�01� P>577-7Z� -:5-4 ,
Is this permit in conjurictLon with a building permit: Yes [E]--`N`O 0 (Check Appropriate Box)
Purpos* of Building Poel /9,4,7e -1— Utility Authorization NO.
ExUtins Service ____�ffs volts Ovtrhead 0 undird 0 No. of Meters
New Service Amps /Volts Overhead 0 Uodgrd 0 NO, Of Haters-
Niumber of Feeders and Ampecity
location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of got Tubs
Total
!:____�rswformers KVA
No. of Lighting Fixtures
SwL=Lnt Pool
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Faergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALAMS No. of Zones
go. of Detection and
InLtL&tLng..DavLces
No. of Sounding Devices
No. of Self Contained
DatectLon/Sounding Devices
Municipal 00ther
1,ocal 0 Connection
No. of Ranges
Total
No. of Air Cond. tons
No. of Disposals
No. of Heat Total Total
PUMPS Tons KW
No. of Dishwashers
Space/At" HestLat XW
No. of Dryers
Heating Devices XW
No. of Water Staters XW
No, of No. of
Sbans Ballasts
Low Voltage
Wirinit
No. Rydro Massage Tubs
No. of Motors Z_ Total HP tlx('� 3�4�
1
INSURANCE COVELUX: Pursuant to the requirements of Hassachusatts Gmeral Lelia
I have a current LlsbLIL Insuranc Policy including Completed Operations Cov rage or its substantial
equivalent. YES No 8 1 have au;:itted valid proof of sow to this offic:. YESO NO 0
If you have chockied IRS, please indicate the type of covers&* by checking the appropriate box.
INSURANCE J3 BOND 0 OMM 0 (PleAse Specify) MFgC!j4ANT-, . TN.(;-fTgAmr__y_ r.EQTIP q4?(-'
Estimated Value of Electrical Work S &f 0-0 tExpiration Vate
Work to Start Inspection Date Raquestedt Rough Lnal
Signed a.Aar the penalties of perjur,-:
FIRM 14AME LIC. NO.
Licensee GRE(;ORY TAYT,OR Simature AlUe" "Zt4iLAI LIC. NO.1 9 9 6 8 IF
Address 4 SAN MATEO DR. CHELMSFORD, MA 01 8�4 �gu . a,. No.--,-() s - 9 ; o - o n17
lei. No*
urance covers
OWNER'S INSURANCZ WAIVERs I = aware that the LLcensea does not have the ins i — so or to aub-
tantial equivalent as required by Massachusetts General Law$, and that BY 1116naturdl On this permit
pplication waives this Tequirement. Owner . Agent Mease check one) - � dd
Telephone No. PER= 3.
(Signature of Owner or Agent)
PE.::RTlFICATE:::A0F
ISSUE DATE (MM/DD/YY)
IN... 'X"
PRODUCER
. 3/27/00
EACH OCCURRENCE
$
THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMA ION ONLY AND
... - ..... I .................... ........ .......
.............. ..................
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
AGGREGATE
$
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
............ ........... ...............
POLICIES BELOW.
BYAM BROS INS AGENCY
191 PAWTUCKET BLVD
COMPANIES AFFORDING COVERAGE
LOWELLMA 01854
. . I . ... ..... ... I ... . ....... . ......... ...... . .......... . .... ..
......
DISEASE --POLICY LIMIT
......... .....
C 0 M PA N
LETTER A
MERCHANTS INS GROUP
......... ......... .... ...... .............. . . ... ... .. ...................
INSURED
COMPAN
LETTER Y B
GREGORY TAYLOR
............ ........................ . . . ... .... .... ... ... ................. ...................... ........
COMPANY c
LETTER
4 SAN MATEO DR
. .. ... . ..... . . ..........
CHELMSFORD MA 01824
COMPAN
LETTER Y D
............................. .......
COMPAN
E
LETTER
COVEf"Et:::::.
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.
.. ........... ....... -1 .......
CO.........
LTR TYPE OF INSURANCE POLICY NUMBER
-.1.1.1 ............... ... .. ... ........ ............ ..........................
POLICY EFFECTIVE TOLICY EXPIRATION:
DATE (MM/DD/YY) DATE (MM/DD/yy) ILIMITS
GENERAL LIABILITY
I ..... CCP6005900
3/20/00 3/20/01 GENERAL AGGREGATE 0 0, 0 0 0
X COMMERCIAL GENERAL LIABILITY
.......... I .............................. .. .$J,.o
..... .. ..... I .......... .........
.. .... ....
CLAIMS MADE � X OCCUR..
PRODUCTS-COMP/OP AGG.
........ .................. .......... ... .....
OWNER'S & CONTRACTOR'S PROT.
PERSONAL & ADV. INJURY � $5 0 0 0 0 0
.......... I ......... .. I ................................................ ......
EACH OCCURRENCE
..................
...........
F I R E D A MA G E A ny o n $ 1 0 0 0 0 0
MED. EXPENSE (Any one person) $ 5 0 0 0
AUTOMOBILE UABIUTy
ANY AUTO
COMBINED SINGLE
LIMIT $
ALL OWNED AUTOS
...... . ......... . .... ................ . .. .....
SCHEDULED AUTOS
BODILY INJURY
(Per person) $
HIRED AUTOS
...... ......
NON -OWNED AUTOS
BODILY INJURY
(Per accident) $
GARAGE LIABILITY
....................... ............ ..........................
PROPERTY DAMAGE $
EXCESS LIABILITY
EACH OCCURRENCE
$
UMBRELLAFORM
... - ..... I .................... ........ .......
.............. ..................
AGGREGATE
$
OTHER THAN UMBRELLA FORM
............ ........... ...............
WORKER'S COMPENSATION
STATUTORY LIMITS
AND
....................
EACH ACCIDENT
$
EMPLOYERS' LIABILITY
......
DISEASE --POLICY LIMIT
......... .....
......... . - ....
$
... ... - ........................
DISEASE --EACH EMPLOYEE
. ... ....... .
S
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS
'AN
PELLATI.ON..
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
0
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIAATION nR
A
Location C?,,88 e -C, �
No. 4135— Date cL03 -P-3
Z%a
Check # C:) P -8
1 6.�-�, 8 S
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ C;uo —
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
I
SO
mill
CAI,
NNW
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number CS 075506
Birthdate: 07/21/1972
Expires: 07/21/2005 Tr. no: 2164
�;onstrucuon Restricted: I G
I PETERJ MAHONEY
119 BURLINGTON ST.
LEXINGTON, MA 02420 Administrator
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Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesfigations
Boston, Mass. 02111
WOrkers'COMPensadon.Insurance Affidavit
Please Print
cily Phone
I am a homeowner performing all work rnyself.
I am a sole proprietor and have no one worldng in any capacity'
JZZ I am an employer providing workers! compensation for nvy employees worldna cn thL-. if*,
cornaM riame:
Address
PhD
Poluretosemmcoverage as reqt9redunder Section 2-5A or MGL 152 can-Jesdt&"bqxaWon ofcrkvkWpenarjMMa
arKVor one Yewe
understand that a copy of this. statenwd may tpe. krwarded to th& offce of
of the MA for coverag& verroca
I do hereby cwti5, W)der paWs and.penaffibs ofpe6my bW bNe kYWWtkwpvvA*dabov& is &w aw conec-L
Signature 7
'ej
Print r..-Ae�-ef *A CIX Dhr%"� 4,F
Official use only do not write in is area tD be cornpkited by city or town officiar
r
0
EjCheck,VkmnedWe respowe is required
Contact A
Selectrnan
rl Health Del
E] Other
6
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL 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 be disposed of in:
Wco6- U—�-'�) LC�Wpeu (2A
of Facility)
Signature of Permit Ap" t
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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Date ...................
...........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .....
I ................................. ................................
has Permission to perform .... : ......... .........
..........................................
w1ring in the building of ....................................
....................................................
at ..............
........................ ......
.......... ............. . North Andover, Mass.
Fed�� .................. Lic. No . ............. ................. ...
i�ECTRICAL INSPECTOR
Check #
4924
TNE COMMONWEAL 7H OFMASSA,
Department of Public safety
BOARD OF FIRE PREVENTION REGULA
APPLICATION FOR PERMIT�TO
AJI work to be performed in accordance witb the
(Please Print in ink or type all information)
Town of
The undersigned applies for a Permit to perform the electrical work described below.
Location (Street & Number_P4?80 Fd -5- Te- s -
Owner or Tenant
Owner's
Official Use only
Permit No. J71
CMR 12:00 Occupancy & Fee Checked
A ELECTRICAL WORK
Electrical Code 527 CMR 12:00
Date /-II) - �, 7
To the Inspector of Wires:
Is this permit in conjunction with a building permit Yes - No , (Check Appropriate Box)
Purpose of Building Z , J� le"2"
X Utility Authorization No.
Existing Service_6;2-�.Arnps_j�e Voits Overhead - Undgmd - No. of Meters
New Service Amps_Voits Overhead - Undgmd - No. of Meters
Number of Feeders and Ampaci
Location and Nature Of Proposed Electrical
1420 1! lnon!,�
f Ole,
�00 e
No. of Lighting Outlets No. of Hot h Total
No. -of Transformers KVA
No. of Lighting Fixtures Above In
Swimming Pool amd annd
No. of Switch Outlets _L0 of Gas Burners FIREALARMS No.ofZone
7 -
No. of Ranges No of Air Cord TotaF- No. of Detection and
Tons - Initiatino Deviner
No. of Diposal Heat Total Total
No. Pumps Tons KW No. of Sounding Devices
No. of Dihwah., SPace/Area Heatin NoJ of Self Contained
9 KW Detection/Sounding Devices
No. of Dryers Municipal Other
KVV Local Connection
No. Of Water Heaters KVV' . 0. ot No- of Low Voltage
Bailases Wirin
No. Hydro Message Tuds
.. j_2Npo. off Motqrs Total HI:
-OTHER: 4 /P/4c -Z4
e
�chuseftsGfnerai Laws
V INSURANCE COVER,111111(:�11: , : 1:11irsuarytto the reclit"111:iiiien6ts ofMa 4 --- I �'ll""I'll'"'Ilill��������l����������� -
I have a current Liability Insurance Policy including'Completed Operations Coverage or Its substantial equivalent yES NO .0,
have submitted valid proof of same to the Office YES= NO = If you have checked YES Pi
- AavA,!,indJjgte th tpe of coverage by checking the appropriate box.
INSURANCE = BOND = OTHER = (PleaseSpecify)
EstimatedValueof 170WI 40�� xpiration Date)
Work to Start Inspection Date Resquested
Signed und Rough II �e��.Final
Maer the P na es of
FIRM NA E
L L
IC. NO.
Licensee-
-!t- Signature LI
C. NO.
Bu. Tel No.
Address ZIP 02 �-e Aft Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that tibe�Lic�,e. �do�not �hle the Insuranci coverage or' substantial equivalent as requIred by assachusetts
General Laws. And that my signature on this permit application waives this requiremenL Owner Agent (Please Check one)
(Signature of Owner or Agent) Telephone No. PERMIT FEE
-2-�- cvUK6et,
C�-(o kA
ct P�
14CO c8aoov -ST-
05 (f�(Oc) 0 ��T
Vk
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Ihis certifies that . ! 14---K�I- -11-14:�-e--4--
..............
has permission to perform
.........................
plumbing in the buildings of . . . ?�:, -
at ... Ile14
................. North Andover, Mass.
Fe4-'.). . Lic. No/:;� -9 F/� . .... t A/'-
.............
PLUMP(N/G 1��
SPECTOR
Check #
5L5j
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
FOR PERMIT TO DO PLUMBING
f eLV-TF —,
,,Building Location Owners Name t I VV--% C'
14
'A
Date 3 Ov
Permit
Amount '3—Yj
Type of Occupancy
New 1:3 Renovation Replacement [:] PlansSubmitted Yes No
FIXTURES
(Print or type)
Installing Company Name 4-p— C�
Check one: Certificate
[]-�orp.
11 Partner.
0 Firm/Co.
Name of Licensed Plumber: R,C.VN f�'�C4L'
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy El-� Other tyW of indemnity 1.1 Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent 0
I hereby cer* 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 Massachusctts S 142 of the General Laws.
By: '91 -
Signapme or Licensea PRIZE=
Tide Type of Plumbing License
City/Town a.;t S- / -- a Journeyman
LICcnse NumBer Master
APPROVED (OFFICE USE ONLY
IL a
(0
L400 CY�)C-5-00 T�
V-
�a
u e
VE S
1P o -ta
101
AUb 2 2001
DER .0
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SYCOM Pumping Record - Page I of I
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fror-n-
Boards and Departments having jurisdiction have been ob'tained. This does not relieve
the applicant andlor landowner from compliance with any applicable or requirements.
FILS OUT THIS SECTlCN4t*,,
F -OZ.
APPLICANT -Tl,(C T" 66/11" PH'ONE
LOCATION: Aszessaes Map Nurrnber—LL� D
PARC=*.
SUSCIVISION LOT (S)
ST. NUMEER 2_8
CFFICIAL U,:za- ONL.
RECOMMENDA71ONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH CATEAPPROVED
-75>- J 41 DATE REJECTED
SEPTIC INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED_
ria
COMMENTS
PUELIC WORKS - SEYVER/WATER CONNECTIONS
CRIVE"WAY PERMIT
FIRE DEPARTMENT
R—ECENED EYEUILOING iNSPECTOR
CA7="—
Reyised 9�97 im
Insurance Adjustment Service, Inc.
139 Billerica Rd
Suite A- I
Chelinsford, MA 01824
(978) 256-3334
Fax (978) 256-3354
TO: Town Of North Andover
Board of Health/Building Inspector
N. Andover, MA 01845
9
Date: July28,2005
RE: Insured: Sharon Godbold
Property Address: 91 Meadowood Rd.
North Andover, MA 0 1845-5927
Date of Loss: 7/17/2o05
Policy Number: H012237268
Type of Loss: water/mold
File Or Claim Number: 24309
kECEIVED
AUG 0 4 2005
TOWN OF NORTH AM-oVr"
HEALTH DEPAF
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, Chapter 143, Section 6, to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, ease direct it to the attention of the
writer and include a reference to the captioned insured, locations, poli PI
number. cy number, date of loss and claim or file
Thank You for your cooperation.
Very y yours,
Scott O'Neil
Adjuster
Ext. 129