HomeMy WebLinkAboutMiscellaneous - 29 BLUE RIDGE ROAD 4/30/2018rri
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. .. . ...... .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... ) ................................
has permission to perform
wiring in the building Of ... . ... i-.,
. . .........................................................................
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......................
at .... ................ . North Andover, Mass.
...... ...... ... ... .............
Fee ... 12 . ............. Lic. No. 2��9)0 ....................... LECTRIC . AL .. IN . SPECTOR ......................
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r Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Offici I Use Only
PermitNumber tc�10-1
Occupancy and Fee Checked
.9/05
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527CMR 12.00
(Pleaseprint in ink or type all information) Date: 12/2/2015
City or Town of- North Andover To the inspector of Wires
By this application the undersigned gives notice of their intention to perform the electrical work described below.
Location (Street & number) 29 BlueRidge Rd
Owner or Tenant Jeremy Finkle Telephone No. 978.502.8443
Owners Address
Is this permit in conjunction with a building permit?
Purpose of building
Existing service Amps
New service Amps
Number of Feeders and Ampacity
Location and nature of Proposed Electrical Work:
YES
Volts Overhead LJ
Volts Overhead El
NO Ll (Check appropriate box)
Utility Authorization No.
Underground E] No. of meters
Underground El No. of meters
Install 33 solar panels on existing roof. System size of 11.055kW
Completion of the following table may be waived by the Inspector of Wires
No. of Recessed Luminaires
No. of Ceil. -susp. (paddle) fans
No of
Total
Transforiners
KVA
No. of Luminaires Outlets
No of Hot Tubs
Generators
KVA
No. of Luminaires
Swimming Pool Above BelowE]
No. of Emergency Lighting
Battery units
No. of Receptacle Outlets
No. of Oil Burners
Fire
Number of zones
Alarms
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating devices
No. of Ranges
No. of Air
Total
No. of Alerting Devices
Cond.
tons
No. of Waste Disposers
Heat pump
Number Tons
KW
No. of Self Contained
Detection/Allenting
No. of Dishwashers
Space / Area heating
KW
Local
�
Municipal
1:1
connection E]
No. of Dryers
Heating Appliances
KW
Security Systems: *
No. of devices or Equivalent
No. of Water
KW
No. of
No. of
Data Wiring:
Heaters
signs
Ballasts
No. of devices or Equivalent
No. Hydro massage Bathtubs
No. of Motor S
Total HP
Telecommunications Wiring:
J-
No. of devices or Equivalent
Other: ISOLARINSTALL
,,nsurance Coverage: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee
provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies
�hat such coverage is in force, and has exhibited proof of same to the permit issuing office.
Check One: Insurance 0 Bond 0 Other (Specify): 07/23/2016
Estimated Value of Electrical Work $30,000 (When required by municipal policy) (Expiration Date)
Work to Start: Inspections to be requested in accordance with MEC rule 10. And upon completion.
I certify, under the pains andpenalties ofperjury, that the information on this application i uean omplete.
'o
Firm
Name: United Solar Associates, LLC Lic. No.:
Licensee: Dan McGrath Signature: Lic. No.: 20616A
(If applicable, enter "exempf' in the license number line) City of Leominster contractor Bus. Tel.. No.: 855-786-1776
Address: 452 Pleasant Street, Second Floor, Malden, MA 02148 : Alt. Tel.. No.:
* Security System Contractor License required for this work: If applicable, enter license number here Lic. No.:
Owner's Insurance waiver: I am aware that the licensee does not have the liability coverage I am the (check one) Owner F] Owner's Agent
normally required by law. By my signature below I hereby waive this requirement
Owner/Agent Telephone
Signature Number Permit Fee: $
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
AvOicant Information Please Print Lezibly
Name (Business/Organization/Individual): United Solar Associates, LLC
Address: 452 Pleasant Street, Second Floor
City/State/Zip: Malden, MA 02148
Are you an employer? Check the appropriate box:
Phone #: 855-786-1776
1. r7l I am a employer with 5 employees (full and/or part-time).*
2.n 1 am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3,R I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.F-1 lam a homeowner and will be hiring contractors to conduct all work on my property. Iwill
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.M I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance. -
6. F We are a corporation and its officers have exercised their right ofexemption per MGL c.
152, §1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. E] New construction
8. E] Remodeling
9. El Demolition
10E] Building addition
I lf� Electrical repairs or additions
12. F1 Plumbing repairs or additions
13.E:]Roof repairs
14. E] Other Solar Install
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
� Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-Contractors 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' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: TRAVELERS
Policy # or Self -ins. Lic. #: 7PJUB-5B50763-8-15
Expiration Date: 7/23/2016
Job Site Address: 29 Blue Ridge Rd City/State/Zip: N.Andover, MA 01845
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification�.
I do hereby certify und� J -a7ins,,ndpen , 7sp y that the information provided above is true and correct.
r
Signature: V� Date:
44.855-786-1776
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#:
I
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
1
TYPE OF INSURANCE
12/8/2015
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(les) 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
UUN I At; I
Asset One Insurance
-NAME:--
PHONE FAX, -625-8290
JAIC, No, Ext): 714-625-8204 (A/C No): 714
L -MAIL
ADDRESS: ara@solarinsure.com
575 Anton Blvd., 3rd FL
INSURER(S) AFFORDING COVERAGE NAIC #
MED EXP (Any one person) $ 10,000
INSURERA: Westchester Surplus Lines Insurance Company 10172
Costa Mesa CA 92626
INSURED
INSURER 8: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERK 25674
INSURERC: American Zurich Insurance Company 16535
United Solar Associates, LLC
INSURER D:
452 Pleasant Street, Second Floor
INSURER E:
1
INSURER F:
Malden MA 02148
COVERAGES CERTIFICATE NUMBER: 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. NOTVVITHSTANDING 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
AUULbUbK
INSD
WVID
POLICY NUMBER
(MMIDD/YYYY)
(MMIDDIYYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
_7 CLAIMS -MADE ^I OCCUR
1600 Osgood St., Building 20, Suite 2035
G27527966 001
11/10/2015
11/10/2016
EACH OCCURRENCE $ 1,000,000
UAMAI, 1011tN11-07-
ES (E. occurrence) $ 50,000
PREMI;E
MED EXP (Any one person) $ 10,000
& ADV INJURY $ 1,000,000
'L AGGREGATE LIMIT APPLIES PER:
POLICYFX] PRO-
JECT LOC
OTHER:
-PERSONAL
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 2,000,000
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
L
1
GUMIJINEL) bIN(3Lh LIMI 1 $
(Ea accident)
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
I Y UAMAUI:
J�-r'zd"dent) $
$
A
X
UMBRELLA LIAB [X�DCCI
EXCESS LIAB
U R
C
CLAIMS -MADE
G27527966 001
11/10/2015
11/10/2016
EACH OCCURRENCE $ 5,000,000
AGGREGATE $ 5,000,000
___
_F
, DED F RETENTION$
$
B
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE —
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) FYI
If rs
S6 describe under
D RIPTION OF OPERATIONS below
NIA
7PJUB-5B50763-8-15
7/23/2015
7/23/2016
X1 PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
C
Property
ER07771654
5/26/2015
5/26/2016
$522,302.00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
%) 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of North Andover
Attn: Building Department
AUTHORIZED REPRESENTATIVE
1600 Osgood St., Building 20, Suite 2035
North Andover MA 01845
wlte W4
I D;101_119� I
%) 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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MALM, MA OWMI
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Mmssachuseds - DOPVncmt Of Pubfic S2"
Board of Building Regulatons and Standartft
(i.n%trimsin Suiwmi-sr I J, F.,rUl*,
Licemm: CSFA404876
DANIRLJMCGRATH
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114BOYLS70M
MAMINMAOR48
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commsiom 0911150116
ELECTRICAL UNLIMITED JOURNEYPERSON
DANIEL j MCGRATH
114 BOYLSTON ST
MALDEN, MA 02148-7931
LIC. I AEG NO E-FECTIVE ER15190
LC.01"933.E2 10/01/2014 09/30/2015
4'
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STATE 01,7CONNECTICLIT
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DANIEL) MCGRATH
imBOYLSTONST
NIALDEN, MA 02148 -?931
u(- iW_NO. _____TFMTNC
ELC.OM1855-El 08131Y2015 09/3012016
I TH OF MA8649MRSU&m.
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
AS A -REG JOURNEYKAI ELICTIM"
DANIEL J MCGRATH
114 BOYLSTON ST
RA 02148-7931
RALOEN 112
11461 8 07/3iW_6- affaw
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MCC of Commmer Afftirs & Busineft Reptatiom
ME IMPROVEMENT CONTRACTOR
stmOon: 168524 Type:
MUM 317/2017 IndWust
DANIEL MCGRATH
DANIEL MCGRATH
114 BOYLSTON ST
MALDEN, MA 02148
Undersetretary
STATE OF MAINE
MW OF p"FLjsaa & ANAWK REWUrON
ELECTRCww ExAmMM BOARD
LICENSIE I 1111360020M
DANIEL MCGRATH
MASTER ELECTRICIAN
ISSUED Aug25,2013 ExpmSAuj31,2015
JAMES A. CLANCY
PROFESSIONAL ENGINEER
601 ASBURY AVENUE
NATIONAL PARK, NJ 08063
(856) 358-1125 FAX: (856) 358-1511
Date: September 28, 2015
Re: Structural Roof Certification
Subj: Jeremy Finkle Residence, 29 Blue Ridge Rd., North Andover, MA 01845
We have provided a review of the house roof construction of the above named property in regards to
verifying the capacity of the existing roof for installation of a new Solar Panel Array.
We have found the residence to be of wood frame construction bearing walls with a rafter framed roof
system. The Roof I and 2 are of 2xI0 @ 16" o.c. rafter framed construction with 2x8 collar ties @ 32"
o.c. and is sheathed with 1/2" ext -ply sheathing and a single layer of composite shingles.
The existing roof structure bears directly upon the exterior stud framed wall system. The existing
rafters as installed meet (MA 780 CMR) IRC -2009 design span ratings with sufficient capacity to carry
the 4#/sf additional load imposed by the proposed solar array per the details below.
Installation of solar rack systems shall be as follows:
Each panel row shall be supported upon 2 mounting rails. Rails shall be screw anchored
through roof and directly to rafters or purlins below. Rail attachment points to rafters shall be
staggered each row with exception to the first fastener row from the gable end which is
attached to two adjacent rafters/trusses with Stainless Steel fasteners.
Rail attachment to roof shall be fastened 16-32"o.c. at corners and 48" o.c. through the field.
Rails are to be placed at 24-48" o.c. on the roof.
When installed per the above specifications the system shall meet the required 105 MPH wind load and
50 PSF ground snow load requirements.
Should you have any further question or comment please feel free to contact our office.
Respectfully,
%k OF
AMES A.
LANCY
0 o.46775
James A. lancy
ST
Professional Engineer
AL
MA License # 46775
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Residential Solar Energy System Installation Agreement
6 Cit*v.— Jeremy Finkle & Tanya Gould
��t�- 29 Blu4* Ridge Rd., N. Andover, MA 01845
i7inl' (978) 502-8443
L;""A?CWn1,-.:r, National Grid
44.1, !
BLUESF I HOME Snil�.Pl
(Ratail tristalknerit Sale AgnismeM - Sub*j to Stift Regulation)
Fmot: finkle.jeremy@gmail.COM
Residential Regular Rl
PV"' of 'Zodulf_ 32 1 Thermal ft of P4rich,
Ice
fvt
t. ('!Jton%trurt.�n
lrr,�d D=umort Dc,-,-�-ry � 21 " - �� t;n
Amourt R 16296-23008
PVS'J�AL'M 5119 (M'D() 10.72
"'! %*r .1 -
4 -4u',, f nc-r;' it F!17Lc', f-",,"`u'__cturcF & V0dt1;1!, SunPower 335w, Black Fs11mztrdPVProdtjct..�n 14,842 k.'..iij
opti� yc�'r)
mizerej A
c Auto SREC Rcportin,, Permit-, In.'Lluded
o oic 2 larEdg* W/D�C
r 2 x SolarEdge W/DC Optimizers re-. :3 No Yc' :3 No
DAT/L0cus Coll 10yr Reporting I '-I Check box ifAddLr,_4umntt1,�chc-d
Iti.,dunn�:aU*�;;�,tVCorrp�,.Irripariefout,�,,4* (�f_,Ijj . rncbc
ro dr,d. you wV1 not h.Tp-- po4,Lur dxrm-, -in outzZe I
The Preliminary System & Total Price shown are based upon esthnat&L When you sip this Agreement you have a RkIA Cancel. When that
right Expires (Section 1q), Installer will provide a Final System Design. See al System Design Process (Section 2�
FI02nced.Tot�,IPr,,[,
Down Pi j=c rit (cp:�cq Cash: Totil Price i
, zjj $
U—h Tot-I'Lo-n Amou-t$ CDnf 0
Payment Schedule
SAC Lo,.,n A&jrct -. t�, 112 S $8,728 Initial Dc.,po-.A (15 pj4d with th.-. mritract
-1 yt'� 0 No lnclufL, St -t2 Tz% CrAq (Est Amt.) $ $29,093 2 " Payment (507-1 for -,poc-if ordLT ,quipment
* SAC Loon must be paid within 13 days 13 months 0 $14,547 3 "' Payment (25z'). b��--forc Stirt D-tte. upon invo.ce
r.vducLd Into rt. --.t Ra!�' I c - n fi?',) s torif 1" $5,818 4' Payment (bi!aric.A. upcn r�ajf:Et Compli tion
RIL Rau.- 1.5 r1l TV'r.1 r!L t4onit!'g Pi:ynwnt $ I
0 Pr incepl h -. JccL% S, -I- -, Tzx Exc-npt or EJ S,,L!s T.:x cmount, inciLded in Total Price $
If, due to existing conditions a municipal authority will not issue a permit or the utility provider will not permit interconnection, and the coff ective
measures needed will cost more than $1,600, upon notification of same by Installer, Customer shall have ten (.10) calendar days In which to
cancel this Agreement by notifying Installer. Within seven (7) days of such cancellation, Installer shall rqur all rids paid by Customer, save for
fees paid to the municipality and for engineering studies, upon which this Agreements libevoid. linitbitl
Massachusetts Home Improvement Contractor Registration Number 166151, expires April 29, 2016
TWU 111412y L49ILCI 6113 agracment rr it nas oeen signed by a party thereto at a place other than an address of the seller, which may
be his main office or branch therecit provided you notify the seller in writing at his main office or branch, by ordinary mail
posted, by telegram sent or by delivery, not later than midnight of the third business day foll 97 sfnl�jl of this agreement.
See the attached Notice of Cancellation form for an explanation of this right
I was Informed of my Right to Cancel and provided with two Notices of Cancellation (initials & date)
NOTICE TO BUYER:
1. Do not sign this Agreement If any of the spaces Intended for the agreed terms to the extent of available Information are
left blank.
2. you are entitled to a copy of this Agreement at the time you sign it
3. You may at any time pay off the full unpaid balance due under this agreeme�lt, and In so ftng you may receive a partig rebate
of the finance and Insurance charges. I
Thisag ement, signed as a sealed Instrument, can only be,changed bya writingsighed- by both parties.
Bluesel mom Solar I nr-, Deal" 100 Date: Custo
7 15 'r
/12/ 4.
7'
'ska" "0" Sol*,. ftv-, WOW cAirivrimp ft* V? An Setastian on" The terms of this agreement are contained on more than one pagc
j,181) 2614130 Suft 42M guft 12
;F- ISM 83"M' watitm MA 01WI
This Agreement is by and between Customer and BlueSel Home
Solar, Inc., for the purchase and installation of the System
described herein. The terms, rights, obligations, and warranties of
each party are governed by this Agreement.
1) Definitions
a) "Agreement Date" — The latter of (i) the date on which
Customer and Installer sign this Agreement; and (ii) the date
on which Customer is provided a fully signed copy of the
Agreement.
b) "Balance of System" — The items, equipment, and materials
needed to install the System not specifically described in the
System section on the first page of this Agreement.
c) "Business Day" — Any day of the week other than Sunday.
The following holidays are not Business Days: New Year's
Day, Martin Luther King, Jr.'s Birthday, President's Day,
Memorial Day, Independence Day, Labor Day, Columbus
Day, Veterans' Day, Thanksgiving Day, and Christmas Day.
d) "Change Order" — Any amendment to this Agreement and/or
changes to the System, reduced to writing and signed by both
parties.
e) "Commissioning" — In the case of a photovoltaic solar energy
system, connection of the System to the electric utility grid.
f) "Contract Date" — The first Business Day after the later of (i)
the expiration of the Right to Cancel; and, (ii) the System
Lock -in Date.
g) "Customer" — The person(s) named in the Customer section
on the first page of this Agreement that has contracted with
Installer for the installation of the System as defined herein.
h) "Effective Date" — The first Business Day after the expiration
of Customer's Right to Cancel.
1) "Final System Design" — A plan based upon Customer's
needs and Site specific criteria prepared after the Solar Site
Assessment that, upon System Lock -In, will become the
System to be installed at the Site.
j) "Final System Price" — The cost of the System as shown on
the Final System Design.
k) "Installer" — BlueSel Home Solar, Inc. with a principal office at
600 West Cummings Park, Suite 4200, Woburn, MA 01801,
which address shall be used for all written notices.
1) "Mailing Address" — The address to which any notice, invoice,
or other written communication provided to Customer should
be sent.
m) "Permits" — Namely, the building permit, electrical permit,
and/or plumbing permit issued by the local permit issuing
authority. Other permits (e.g., conservation commission,
planning board, historic commission, etc.), are not usual, and
are not included in this definition, but may be required.
n) "Preliminary System Design" — The solar energy system
and/or other equipment, system(s), and improvements,
described in the Preliminary System Design section on the
first page of this Agreement, and the Balance of System items
as defined herein.
o) "Project Completion" — Installation of the System and final
approved inspection of the System as required by Permit
issuing authorities, typically within four to five weeks after
Project Start Date.
p) "Project Start Date" — The date on which Installer begins to
install the System.
q) "Right to Cancel" — The option of Customer to cancel this
Agreement, for any reason, until midnight of the third
business day after the Agreement Date, as described in the
Notices and Signatures section on the first page of this
Agreement, and as described in the Notices of Cancellation
form delivered to Customer with this Agreement.
Residential Solar Energy System Installation Agreement
The terms of this agreement are contained on more than one page.
r) "Sales Representative" — The person with whom Customer.
primarily dealt prior to the signing of this Agreement and who
acted on behalf of installer.
s) "Site" — The address, identified in the Customer section on
the first page of this Agreement, at which Installer shall install
the System.
t) "Solar Site Assessment" — A review of the Site that may
include, but is not limited to, measurements of the location
where the System will be installed, a review of the existing
surface and structure intended to support the System, a
shading analysis, and a review of the Site's existing electrical
and/or plumbing systems.
u) "System" — The solar energy system and/or other equipment,
system(s), and improvements as shown on the Final System
Design and that will be installed at the Site.
v) "System Lock -In" — The date and time upon which the Final
System Design is deemed accepted by Customer.
w) "Total Price" — The cost of the System as shown on the first
page of this Agreement.
2) Final System Design Process
a) Within fifteen (15) Business Days of the Effective Date,
Installer shall:
I) Conduct a Solar Site Assessment, if one has not already
been conducted. Customer will provide access to the
Site at a mutually acceptable time in order to conduct the
Solar Site Assessment.
ii) Based upon the information obtained during the Solar
Site Assessment, confirm the Preliminary System, and if
necessary for technical, structural, dimensional and/or
other reasons, alter the Preliminary System.
iii) Prepare and deliver to Customer the Final System
Design, which shall include at least:
(1) The quantity, manufacturer, and model of the PV
Modules or Thermal Panels;
(2) The quantity, manufacturer, and model of the PV
Inverter, if applicable;
(3) Description of other components and equipment not
included in the Balance of System;
(4) The Final System Price; and,
(5) The projected PV Production of the System in the
first year after installation of the System, if
applicable.
b) If elected on the first page of this Agreement, Final System
Design may be delivered by email, of which Customer shall
acknowledge receipt.
c) If email delivery is not so elected, Final System Design may
be in person, by regular mail,.or by another means agreed
upon by the parties. Customer shall acknowledge receipt of
the delivery of the Final System Design.
d) If either,
i) the Final System Price is more than the Total Price; or,
ii) the projected PV Production of the Final System Design
is less than 95% of the PV Production of the Preliminary
System as shown on the first page of this Agreement,
then System Lock -in shall occur at 11:59 p.m. on the fifth (5 th)
Business Day after delivery of the Final System Design to
Customer.
e) If Final System Design differs from Preliminary System
Design in either of the manners described in Section 2)d)
above, Customer may cancel this Agreement in a writing
mailed to Installer, postmarked prior to System Lock -in. To
insure such cancellation is properly received, it is also
suggested that Customer inform Installer of such cancellation
by telephone or email prior to System Lock -In.
Page 2 of 4
f) If Final System Design does not differ from the Preliminary
System in either of the manners described in Section 2)d)
above, then System Lock -In shall occur upon delivery of Final
System Design to Customer (which will, in all cases, be after
the expiration of the Right to Cancel).
g) Unless Customer cancels this Agreement prior to System
Lock -In as described herein, if any terms, price, and/or items
included in the Final System Design differ from those on the
first page of this Agreement, those terms, price, and/or items
in the Final System Design shall govern.
h) If Customer cancels this Agreement pursuant to Section 2)e)
above, the obligations, rights, and duties of each party are
canceled and this Agreement shall be of no further effect.
i) Upon System Lock -in, this Agreement, including the Final
System Design shall become binding upon each party, and
may be amended only by a Change Order.
3) Installer Obligations and Responsibilities
a) Within fourteen days of System Lock -in, Installer will file
applications for the Permits, Grid Interconnect Application,
and other paperwork related to the installation of the System,
and it shall be the obligation of Installer to obtain these.
b) Installer shall provide and install all equipment, components,
and materials included in the System, as well as the Balance
of System, in a professional manner according to standard
industry practices.
c) Project Start Date shall be within thirty (30) days of receipt of
all permits, grid interconnect authorization, verification of
receipt of deposited funds, but not before the signing of this
Agreement and transmittal to Customer a copy of this
Agreement signed by all parties.
d) Project Completion is typically within five (5) weeks after
Project Start Date.
e) Delays beyond the control of Installer such as, but not limited
to, inclement weather, shipping delays, delivery delays,
structural analysis and/or improvements, and lack of access
to the Site, may affect time periods identified, and such
delays shall not be grounds for breach of this Agreement by
Installer.
f) Installer shall, upon request of Customer, provide evidence of
insurance for general liability and workmen's compensation.
4) Customer Rights, Obligations, and Responsibilities
a) The fee(s) for all permits are the responsibility of Customer
and shall be billed to Customer by Installer separately. If
"Permits Included" is checked in the affirmative on the first
page of this Agreement, the cost for a building permit,
electrical permit, and plumbing permit is included. Other
permit fees remain the responsibility of Customer.
b) If required by municipal permit issuing authorities, a structural
analysis of the Site may be conducted by a professional
engineer. The cost of the structural analysis and required
improvements are the responsibility of Customer.
c) In the case of a Cash purchase, as may be indicated on the
first page of this Agreement, Customer shall comply with the
Payment Schedule.
d) Customer shall cooperate in a timely manner with all requests
of Installer to complete and/or sign any documents related to
the installation of the System, including, but not limited to,
permit applications, Grid Interconnect Application, and
documents requested by financing entity, as applicable.
e) In the event that Customer is financing the installation of the
System and the Final System Price should change in
accordance with the terms of this Agreement, Customer
agrees to perform all steps required of the financing entity
needed to perfect the financing of the System.
Residential Solar Energy System Installation Agreement
The terms of this agreement are contained on more than one page.
f) Should Customer secure any construction -related permits, or
deal with unregistered contractors, Customer shall be
excluded from access to the Guarantee Fund under MGIL
142A.
g) Customer understands and agrees that Installer may include
Customer's name, Site Address, a description of the System,
costs, energy savings, and other information relating to the
System in reports, studies, testimonials, Web sites, and
marketing materials.
5) Installer Representations
a) Installer Federal Employer ID Number: 47-2714223
b) Installer Massachusetts Home Improvement Contractor
Registration Number: 166151, expires April 29, 2016
c) Installer Massachusetts Construction Supervisor License
Number: 5813, expires January 3, 2016
d) Unless noted otherwise, this Agreement shall not create a lien
or other security interest in the Site.
e) The System will:
i) Comply with all manufacturers' requirements,
ii) Be installed according to manufacturers' recom-
mendations,
iii) Meet all applicable requirements of the applicable current
state building code, and the National Building Code 2008.
iv) Comply with your electric utility company's interconnection
agreement
v) Utilize photovoltaic modules certified by a nationally
recognized testing laboratory as meeting the requirements
of UL 1703 all, as applicable.
6) Customer Representations
a) Customer is authorized to contract with Installer to install the
System.
b) Customer warrants that the statement concerning whether the
Site is the Principal Residence or not the Principal Residence
of Customer is true and accurate. Installer may rely upon this
statement in determining whether to collect sales tax on the
System. Customer is responsible for any sales tax owed.
c) Customer shall make the Site available to Installer at mutually
acceptable times for the purpose of installing the System, and
for any purpose related to the installation.
7) Information About Home Improvement Contractors
a) All home improvement contractors and subcontractors shall
be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170
Boston, MA 02116
Phone: (617) 973-8700
b) If you want to verify the registration of a contractor or if
you have questions or need additional information
specifically about the contractor registration component of
the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Bureau of Building Regulations and Standards
One Ashburton Place, Room 1301
Boston, MA 02108
Phone: (617) 727-3200
c) For assistance with informal mediation of disputes or to
register formal complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General
(617) 727-8400
Page 3 of 4
8) AfbkmdO"
a) Installer and Customer hereby InUIVORY agree in advance that
in the event that Installer has a dispute Concerning this
contract. the contractor may submit such dispute to a private
srbdrstion service which has been 8PP(Oved by the Office Of
Consurner Affairs and Business Reft?n and customer
shall be requW to submt4iskl� 9 nition as pro in
MGL c. 142A,
142A
*Mil 5
7
L
Customer ate:
Installer ate:
,e I a
s above apply only to the
NOTICE,. The sign s he
, th. . Of P
agreement of the Pa.' to allemeate dispute resolution initiated by
Installer Custormt may initiate alternative dispute resolution even
where this section is not signed separaft by the parties,
9) Disctslyntirs
a) Although Installer has endeavored to provide Customer with
accurate projections and estimates and has based all
estimates and projections of PV Production, electric utility
company rates, the value of solar renewable energy credits,
and other financial ftems are not guaranteed or assured.
Customer is encouraged to conduct Its own research on
these matters.
b) Financial Incentives for solar energy systems change
fr"uently. Customer's qualification for and recelpt Of
Incentives depend upon numerous factors. including, but not
limited to Customer's approval for the program, availlibilitY Of
funding. and Customers tax situation. AN financial incentives
discussed or presented in other documents by Installer are
presented as estimates for general information and are not
intended as tax or financial advice. Installer strongly
recommends that you consul your financial and tax advisors
to determine the applicability of these incentives to you(
project and individual SkwtiOn.
10) Wgffar" Terms and Conditions
a) Installer shall repair and replace components of the System
during the ten (10) years following the Project Completion in
the event of:
Detective workmanship.
System breakdown except for the components of a date
acquisition system,
IM Degradation in electrical output of a solar photovoltaic
panel of mom than the manufacturer's rated maximum
degradMW dudN the Installer's warranty period.
b) The warrenty covers the System, including PV modules and
inverters, and provides for no-cW mpair or replacement of
the System or system components, indudkv any associated
labor. except for damage to the System caused by acts of
God and misuse or abuse of System components. Normal
labor Charges Will apply after the I 0 -year Varrardy period. .
i) Termination
a) Upon System Lock -In. Customer may only termirtate this
Agreement for substantial breach of & material section of this
Agreement.
in order to effect termination under this Section I O)b),
Customer must notify Installer In writing Of b Intent to
terminate, and clearly kMn* the substantial breach
Of & material section of this Agreement.
I,) Upon receipt of CUSIOMY's "OtfC8t`V'. ' `� "
acknowledge receipt Of the not*aWn W4 ftroe L*_1
(10) Business Dar to cure Me "&W
in In the event that ImUller dM nOt cu're LnSWRT s"al
cease git work on the irwalation of te Sys* -m aft
provide Customer with d original Permift, receii;VS
for items offtfix"d And $M:kW Wdered for "
System, and shall set* its b0couil w1h CugW'_-'ff
for any W-ONW01 exPeInses paid On C4a"*"'
behalf.
112) MISCOW901,13
8) The captions of the sectionS Of this AgirSernerd We fOl
convenience and shelf not be construed as subsuftive
language of the Agreement.
b) The Uvws of the commonwealth of Massachusetts shell a"
In Interpreting and enforcing this Agreerrient.
c) Should any section or sections of the Agreement be deemed
unlawful or unenforceable. the remaiftV sections SW
remain in full force.
Your BlueSel Home Solar, Inc- Sales Representative is.
Name: Dave Judelson
Phone: 781-704743
Email: djudeftorebtuesel-com
DO NOT SIGN THIS AGREEMENT IF ANY SPACES ARE BLANX
THE REMAINDER OF THIS PAGE IS INTENTIONALLY BLANK.
Resklen"41 Solar Enerp Sydem Installation Agreement Page 4 of 4
The t0m% of this agreernent we coiritsined on mom OW one pop.
[You are being provided with two copies of this form, one for you to use, if you choose to cancel, and one to keep.]
NOTICE OF CANCELLATION
Customer(s): Jeremy Finkle & Tanya Gould
Site Address: 29 Blue Ridge Rd., N. Andover, MA 01845
Date of Transaction: 7/12/15
You may cancel this transaction, without any penalty or obligation, within three business days from the above
date.
If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable
instrument executed by you will be returned within ten business days following receipt by the seller of your
cancellation notice, and any security interest arising out of the transaction will be cancelled.
If you cancel, you must make available to the seller at your residence, in substantially as good condition as when
received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions
of the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days of the
date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you
fall to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so,
then you remain liable for performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written
notice, or send a telegram to:
BlueSel Home Solar, Inc., 600 West Cummings Park, Suite 4200, Woburn, MA 01801,
not later than midnight on: July 15th, 2015.
I hereby cancel this transaction.
Date: Customer's Signature
[You are being provided with two copies of this form, one for you to use, if you choose to cancel, and one to keep.]
NOTICE OF CANCELLATION
Customer(s): Jeremy Finkle & Tanya Gould
Site Address: 29 Blue Ridge Rd., N. Andover, MA 01845
Date of Transaction: 7/12115
You may cancel this transaction, without any penalty or obligation, within three business days from the above
date.
If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable
instrument executed by you will be returned within ten business days following receipt by the seller of your
cancellation notice, and any security interest arising out of the transaction will be cancelled.
If you cancel, you must make available to the seller at your residence, in substantially as good condition as when
received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions
of the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days of the
date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you
fail to make the goods available to the seller, or if you agree to return the goods to the seller and fall to do so,
then you remain liable for performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written
notice, or send a telegram to:
BlueSel Home Solar, Inc., 600 West Cummings Park, Suite 4200, Woburn, MA 01801,
not later than midnight on: July 15th, 2015.
I hereby cancel this transaction.
Date: Customer's Signature
8L
4Chan Ord r to Residential Solar EneM Sy—ftern Insta— I n ntract
_ge
This Change Order modifies the Residential Solar Energy System Installation Contract I*twe*W.
Customer: Jermy rinkle Tanya Gould
Installer: BlueSel Home Solar, Inc.
Site: 29 Blue Ridge Rd., N. Andover, MA 01845
Contract Dated: 7/12/15
Change Order M This is Change Order Number 1 to the original Agreement.
Modification(s) to In the event that the terms of this Change order conflict with the terms of the original
Terms of Contract: Agreement or of any Change Order previously signed by the parties, the terms of this Change
Order shall control. All other terms of the Agreement and of previous Change orders shall
remain in full force.
Adjustment(s) to Final
System Price:
il-ueSel Home Solar, Inc. by:
This Change order Is to adjust the System from:
32 x 335w SunPower Panels (10.72kw DC) to
33 x 335w SunPower Panels (11.055kw DC) (just below the Net Metering Cap)
Change in cost:
From $59,186 to
$59,904
bite: cuAomer:
7/16115
WWW66W.M& 17.bn&"aftnD** 4WV1LcWW*"PWk 7mtwmolthisChwaod4wpkaftorWWAV*omem&WgnI
261-W30 Sak*A=
5M)SO41MI Sul* 12 thwoftww&A
WAMSOLOM Soxwoh, MA 02W3 'AM
ch"" Order: Pat* 100
BLUESEL HOME SOLAR
ammordK SWUM _n Contnct
This change order modiftes, the Residential Solar Energy System installation Contract between:
Custo"Wer.
jorasy rinklo r, Tanya ftuld
liftsumer-
efueSel Home Solar, Inc.
Sftr
29 bluo Rid" Rd-, N- And"Wrl MA 01845
Contract Dekkk
7/12/15
Chmp Order M
This is Change Order Number ?,to the original Agreement.
Wto
in the event that the terms of this Change Order conflict with the terms of the original
Tenn of Contract:
Agreement or of any Change Order previously signed by the parties, the terms of this Change
Order shall control. All other terms of the Agreement and of previous Change Orders shall
remain in full force.
This Change order Is to adjust the System from:
Add a Une-Skle Tap to accommodate the current requirements.
Adjosbuent1s) to Final
Svitem Prior
Change in cost
Une Side Tap is $400
From $59,904to
$60,304
Date:
Custonw:
Date:
9/11/15
4 Z4
I If If 1
oft"Nameow'V&
VMS 17 an 8 o - Imi Dom OW W Currenirw FWk Tm twm of thk Changs Odw, p1m tho orWnal Agrownent and any
0640" Stft 12 64AO 42W prevkos CharVe Ordw% we contakied an more then one pop.
9-- d Ad WA 02M VVbburn.MA018W
ch'Wa'awpo"4146.1s Change Order Pag* 1 of I
I
I 12 u'- L
Date..7/2,05—
... I ........ I ...... .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
J:— 12-1 c -
This certifies that ........................ ............... .. ..... . .......
has pemiission to perfonn ......
plu in the uildings of
.... . .... ............................ ...........
(2 J, N o r th A n d o v er, Mas s
. . .................. ..
...........................
Fee ........ ............ Lic. No.
..................... .................................................................................
Check #4-735 - PLUMBING INSPECTOR
ob
This certifies that
Date ....... V ..�/ 57 .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�� C'- e- ;--�b &r� C -, e—
................................................ ......................................................
has permission for gas Mstallat*
..............................................
inthe buildings qf ...... ...............................................................
at ... 7 .5, . North Andover, Mass.
...........
Fee -N"—..... Lie. No....,.�).!! .......... ....................................................................
GASINSPECTOR
Check #
'I L L", � .). Mk
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I I MA DATEI -11,1115- 7PERMIT# 100V G'
JOBSITEADDRESSI 1A Pvt flo6d 1OWNER'SNAME1 &.Ad
GOWNER ADDRESS I 2-q Qje- t4ft TElf JFAXI
TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL F-1 RESIDENTIAL
PRINT
CLEARLY NEWE RENOVATION: Ell'- REPLACEMENT: PLANS SUBMITTED: YES[] NO[!]/
I I
APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
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 F—
V
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES F1 NO
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [Z] 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.
e4� 6— /;�� CHECK ONE ONLY: OWNER E] AGENT
SIGNATUIIE OF O&ER 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 with all PedirtenLamvisLan-of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I Eric C. Foster JLICENSE#EL�� qSIGNATURE
MP F-1 MGFEI jPF-1 JGF[:] LPGI[:] CORPORATION F -J# PARTNERSHIPFI# LLC [--I#
COMPANY NAME] Eric C. Foster Plumbing & Heating ADDRESS 1145 Stedman Street
CITY [Chelmsford I STATE=ZIP101824 :]TEL 978-256-597 __j
FAX 1978-4524711 1 CELL1508-328- EMAILF�ric@ecfplumber.com
'ASF I TTERK.
ISSUES THE FOLLOW Rd
LIC
9.NSED*.`- A JOURNEYMAN PLUMBER
ER:I:.�-. t FOSTER
PO BOX,: 1-99
W t. S- t - F (Ok' 0 MA 01886-0067-'
174-*7,"I:�'�,-:'.'05'/01/.1.6...:'�:-,-.,��'� 204282
s
SOMMONAEALtii OF M
0 i is
'0
GOAUMMR: D
PLUMBER*S11I.I.Aft -d-ASF I TTE-R-S-.,:
ISSUES THE FOLLOW
N)a
t # AS A TR PLU14BER
...ER,I.Cl;.t FOSTER
Po -BOX: 1-99
E'S '6RD M 0 1886-000*7'
204283
§�Axif solumall4a
OF MA S...-
-SSACHUSETT
DIVISION OF PROFESSIONAL LICENSURE
-.1BOARD-Of
PLUMBill
ISSUES THE FOLLOW IRP` �:t I 't E NS E,
REG.T,�T-,-ERID AS,A..PLUMBING CORP -'-
FOSTER
?LUMBING S HEA
Tj It
P=_% IL99
W AD 01886
31 c
2o4280.
The Commonwealth of Massa ch usetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, AM 02114-2017
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNUTTING AUTHORITY.
Applicant Information Please Print Ledb
NaMe (Business/Organization/Individual):
I - -
Address: b:be � M,CAJC� bt
City/State/Zip:
t 1,
,_ Thone OM - 2-57<:> - `5 T1 (o
LC
Ar on an employer? Check the appropriate box: Type of project (Tequired):
I am a employe r with Q__ - emp
.7.: loyees (ffill and/or part-time).* 7. E New construction
In I am a sole proprietor or partnership and have no employees workirrg for me in 8. Remodeling
any capacity. [No workers' comp. insurance required.] 9. Demolition
3.. [_1 I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.F_1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers' compensation insurance or are sole ll.E] lectrical repairs or additions
prop'netors with no employees. P
2 Plumbing repairs or additions
5.FJ I am a general contractor a ' nd I have hired the sub -contractors listed on the attached sheet. 13.Fl Roof repairs
Thes'e s�b-contractors have en�ployee's and have w�rkers' comp. insurance.1
14. Other
6. n We are a corporation and its officers have exercised their right of 'exemption per MGL G.
a' � '' �6es. rNom�orkers' comp. insurance required.]
152, § 1(4), and we h ve no eppl
*Any applicant that checks box 41 ' must also MI out the section below showing their workers' compensation policy information.
Tl Homeowners who submit ihis af , fidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such-
tContractors that check this �ox must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-c6n6ci6rs hav e* employees, lhe� must provide their workers' comp. policy number.
lam an employer that ispioviding -workers' compensation insurancefor my employees.' Below is thepolicy andjob site
information.
Insurance Company Name:
Policy # or S elf -ins. Lie. #: F. Z 5-(0. Expiration Date: kAjo
Job Site Address: 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi er t ains andpena ry that th e information Provided above is true and correct.
r 7
_.�
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#:
Information an d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ep&yees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
expres's or implied, oral or -written." I . I
An employer is defined as "an individual, partnersWp, association, corporation or other legal entity, or' any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill- out -the workers' compensation affidavit completely, by checking tho'boxes that apply to your situation and, if
necessary, supply sub-'contractor(s) name(s), address(es) and -phone, number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. De advised that this affidavit may be submitted to the Depaltment of Ifidustrial
Accidents foi confirmation of insurance coverage. Also be sure to sign and date the aifidavit. The affidavit should
be returned to the city.or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are reiqiiiired to obtain a workers'
compensatiori'policy, please call the Department at the number listed below. Self-ffisur6d companies sh.ould'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number -which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Date I)A � �,
Town of North Andover
Your permit has been sent back to you for the following reasons:
1) Check amount incorrect / �- 1�-
2) No copy of current license
3) Insurance Binder not on file or
4) No Workers' Compensation Insurance Affadavit Form
Please call with any questions 978-688-9545.. Fax 978-688-9542
Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover
Website under Building Department.
MailingAddress:
1600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845
0
.....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
. .................... ... .... .... .. ...
..............
has permission to p erf orm e
wiring in the building 0I O -LM-
..........
'V ........................ S . . . ................. �"*-**-*
......... ......
at ............................................ V'L ......... (e4 ....... rth Andover Mass.
Fee Lic. NOP59'�'
P ................... ................. .... .... . Zjw" /I.—
EL-11-1-1 I -P. -D
Check# �2154
VIK
ir
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank)
I "IV
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code pvffiq) 527 CMR 12.00
(PLEASE MWINHK OR TYPEALL HFORAMTION) Mate:
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
By this application the undersignedLgives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) & I y 9— rk- jit— d C
Owner or Tenant TAI\) J�ov(d 0 Telephone N46—M) 320— 17f
Owner's Address
Is this permit in'conjunction with a building permit? Yes [I No F1 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service J-p2o _ Amps -1�tf Volts Overhead Undgrdn No. of Meters
F— 120 /�Z
New Service — Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Kk,�AA 4�66vi
Completion ofthe following table mav be waived bv the Inspector of Wires.
No. of Recessed Luminaires
S
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above El In- Ei
grnd. grnd.
No. of Emergency Lighting
Battei�y Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE AL
of Zones
No. of Switches 3
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat pump
Totals:
Number I
I .................
Tons
..........
I KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
r-1 Municipal
Local El Connection El Other
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wirm .
No. of Devices or Eguiva nt
OTHER:
Attach additional detail ifdesired, or as required by the Inspector of Rres.
EstimatedValu fple,tric 1W I ork'p.�0�10 (When required by municipal policy.)
0 OP
Work to Start: � 1 15'- Inspections to be requested in accordance with NEC Rule 10, and upon completion.
INSURANCCCOVERAGE: -Uhless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation7' coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSUR-A-NCE [I BOND El OTHER El (Specify:)
I certify, under th ndpenalties ofperjury, that the information on this application is true and complete.
lriAeA-r/ C
FIRM NAME: TZ LIC. NO.:
Licensee: n V,-T-Akt(A Signature /vi LTC. NO.:
(Ifapplicable, enter "exempt" in th license ni ber line) ot,k�- Bus. Tel. No..4-0-'�- 3 rl fS1 d
I
e
Address: "9LO A -r CT Qw-w- I j� , ktA-4�-k�t W- el. No.:
0 L61 Alt. T
*Per M.G.L c. 147, s. 57-61, security work reAuires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAYVER: 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 El owner's agent.
Owner/Agent
Signature Telephone No. PkRMITFEE.- $
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 20 10 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
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass N
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass R1
Failed M
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed 7- 17-
Z -T- ection Required D
Inspectors Comments:
Fg-b
e4- 4
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
V IV
k .
The Commonwealth of Massachusetts
0, Department of IndustrialAccidefits
I Congress Street, SWte 100
Boston, MA 02114-2017
www.mass.gov1dia lignbers.
ders/Contrletors/FIee-triciaiiifP
Workersi Compensation insurance Affidavit: Buil 1. .
TO BE FILED WITH THE PERAUTTING AUTHORITY
Name (Business/OrganizationAndividual):
Address:
�X�jj � _ --.r -_
1.1
Phone, #:
Are you an emp!oyer? Check the app�opriate box:
1.594 am a employer with hill d1or part-time).*
__��PmPloyecs
2.F] i am a sole proprietor or partnership and have no employees working for mo in
ally capacity. (No workers' comp. insurance required] insurance required]
3.Fj I am a homeowner doing all work mysey. [NO workers' comp.
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
pi
proprietors with no oyees.
S.F] I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
�;�*e employees . and have workers' comp. insurance.t
These sub -contractors
6.F1 We are a corporatiq4 and its ' office rs have exercised their right of lexemption. Per MGL c-
152, §1(4), and We have n� mpldye;�. LNo workers' comp. insurance required.]
31-( - 9) 1 �_
Type ofproject ()required)'
7.
8. Wemodeln -9
9. Demolition
10 Building addition
ll.E] Ejec�ricg rep*s or additigns
12_,� Q. Plgmb�ing rep airs or additions
110R.b6frepairs
14. Other
3. policy information.,
*Any applicant that chec-k§ box #1 MUSE aLSO — - -1 — __ __ - affidavit indicating such
I ..., . . cating they are doing all work pd then hire outside contractors must submit anew
I Homeowners who submit. thi,s.affidavit indi sta 9 �the q T, fhosQPnOes�have
1, 1 '1 �n additional sheet showing the name of the sub-,otractors and t wh r r ot
tContractors that check this b6k must attache —her
must provide their workers' cOMP. Policy R
employees. If the sub -contractors have employees, they
elow & thepOliqv and)oh site
I am an employer that is prOVIding Wrkevs 5 compensation insurancefor MY enplbYees- eTq,7 aq(
information. f tAV4_q101qL_
K 6 o f -&JL MA f
Insurance Company Name: �Oi!K,
Policy # or Self -ins. Lic. Expiration D*:
Job Site Address: C_ City/State/Zip:_ 0 "UN— tiou date).
Attach a copy of the workers' ompensaqon policy declaration page (showing the policy number and expira
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation p . unishable by a fiAb 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. A copy of this statement may be forwarded to the Office of fnVestigdtions of the DIA for insurance
coverage verification. th t tile informationprovided b true and correct
7doher�ehycertlfy under thepains andpenalfies ofperju'Y th
7, ov7,
Of to he completed by city or town official,
fleialuseonly. Do not write in this area,
City or Town:
permit/License
Issuing Authority (circle one): i
1. Board of Health 2_ BuildingDepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
6. Other
Contact
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enip�dyees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of W6,
express or implied, oral or written.,,
An employer is'deffibd as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enf6rprise, and including the legal representatives of a deceased employer, or the
receivef0r, trust66 6fan individual, partnership, association or other legal entity, employing empl6yees�. - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair -work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to oporate a business or to construct buildings in the commonwealth for any
applicant who:has not prod -aced -acceptable evidence of compliance with the insurance coverage ieq'W`red."
Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall
enter intp any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of thi I s chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the Workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
nece�sary, supply sub'contractor(s) name(s), address(es) and phone number(s) along with their certificateb) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If anLLC o'rLLP does have
employees, a policy is required. 1�e advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city.or town that the application for the permit or license is being requested, not the Department of
IridustrialAccidents. Should you have an y* questions regarding the law or if you are required" to obtain aw6rkers'
compensatiori policy, please call the Department at the number listed below. Self-insured companies sf�ould enter their
self�insuranc'e license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "fob Site Address" the applicant should write faU locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-A4ASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Location C;)(:� 1?d —
No. 15 Date :2
TOWN OF NORTH ANDOVER
0 r- �' f r -
I j --e , j
1-30
Building Inspector
'A
Certificate of Occupancy $
CHUS
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
0 r- �' f r -
I j --e , j
1-30
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
WELDING PERNUT NUMBER: DATE ISSUED: 0
SIGNATURE:
Building Commissionerfln��tor of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
Z61 'BLuft-
1.2 Assessors Map and Parcel Number:
0G5 0� 9
Map Number Parcel Number
1.3 Zoning Information:
Zoning Di�Uict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.5. Flood Zone Information:
I.Mater SupplyM.G.L.008"" 54)j
Mic 0 Private 0. :1 -1 . I Zone Oatside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSIUP/AUTHORIZED AGENT
2.1 Owner of Record
zo(
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
U k /,j LA,�--(
Licensed Construction Supervisor:
a o) cr y /u - AJ06 Car-
Addre
2. -1 1�7 0
-gignature Telephone
Not Applicable 0
CS C)S5zU0g
License Number
A)
Expiration' Daeb
3.2 Registered Home Improvement Contractor
Qu i l' -(LA -t4 -4 R 'i A)V
Not Applicable 0
wo Q,9
Company Name
3LI —1 a%A)% t ,u C,)G,) (, fl- 0
Registration Number
� -&51
Addre I
/,4�— V—,,, 76 - 6 07- -1.5' 0
Expiration I)a
Signature Tele�hone
T
M
z
0
R
0
z
M
go
0
aan
M
G)
r-
-t .
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) i
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes ....... )5 No ....... 0
-SECTION5 Description of Proposed Work (check afl applicable)
New Construction 0 1 Existing Building [I I Repair(s) 9 Alterations(s) & I Addition 0
Accessory Bldg. 0 1 Demolition 0 1 Other 0 Specify
Brief Description of Proposed Work:
-�'VRA,q_ L"A-rr'_1L -AW#6-e-.P 6&&L 6,,vl�l-1 �,o f -A/ -I- Uj1-T71 0,eu_1jrdfA0
I'l-i5m -rge— 6�tvr y, -,p 600c
I SECTION 6 - F.STIMATFD C.ONr%TR1TrT1nN rn4ZT.q I
Item
Estimated Cost (Dollar) to be
I OFFICIAL USE ONLY
eKf_-k Ik N_\
Completed b permit applicant
-
I . Building
115(- 0 00
(a) Buil ding Pen -nit Fee
6,
D13.4ENSIONS OF POSTS
-
Multiplier
3 y,'o
2 Electrical
3000
(b) Estimated Total Cost of
'2 X
MATERIAL OF CHFVMY
fn A-5d'v AY
Construction
17d c 110
-3 Plumbing
—
Building Permit fee (a) x (b)
.4 Mechanical (HVAC)
2-42-4
-5 Fire Protection
—
6 Total (1 +2+3+4+5)
"7 D-0 00
Check Number
bhullun /a OWNEK AUINUKIZAHON TO HE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize �_k i NADT-tA L( 0 it 1v L-AqQ to act on
My behalf, in all matters relative to work authorized by this building pennit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and inforination on the foregoing application are true and accurate, to the best of my knowledge
and belief
'.' VY I- A-�-A
Print
Date
�/z /0
NO. OF STORII�S
SIZE
BASEMENT OR SLAB
eKf_-k Ik N_\
-SIZE OF FLOOR TIMBERS /0
INI 2 ND 3 RD
-SPAN
/6_/ 12 -
DIMENSIONS OF SILLS
6,
D13.4ENSIONS OF POSTS
ltlZL ' Z -A -(-e- Y 5
DIMENSIONS OF GIRDERS
3 y,'o
-HEIGHT OF FOUNDATION
THICKNESS
-SIZE OF FOOTING
'2 X
MATERIAL OF CHFVMY
fn A-5d'v AY
IS BUILDING ON SOLID OR FILLED LAND
17d c 110
IS BUILDING CONNECTED TO NATURAL GAS LINE -IL!5
I
Print
�� I L c —)IEL (Z- S
2- cl -B (—cj (-L, 9 �
Ci!y �-k k - Phone
am a homeowner performing all work myself
am a sole proprietor and have no on6 working in any capacity
am an employer providing workers' compensation for my employees working on this job.
Go
.mpa-n,v name:
Add
�Citv, Phone
C-OMRM-n-ome:
Addre.99
P—ttQne—*-
Failure to secure c&mrage as required under Section 25A or M& 152 can load to the WVWWon of criminal penalties. of a fine UP to $1 SM 00
and/or one yeam' imprisonment as won as dvil penalties In: the form of a STOPWORK ORDM and a fb* of (SIOD.00) a day against '
understand that a copy of this statement may be fonvarded to the Office of Investigations Of. the DIA for cmerage v&VIcaUm. me. I
/ do hetby cerdfil under the
Signature.
Print name -
WwMatIM PMWCOW aNwe is fte Wd correct
E)ate
Official use only do not write in this area to be completed by city or town. officiar
oCheak Yirnmedibte response is requked Buildng Dept
Contact person: Phone
T,W WORKMAN'S COMPENSATIOM
179
Ej
Building Dept -
El
Licensing Board
0
Selectr�an Is C)ff/c e-
0
Health DePartment
0
Other
1b
1 0 wim- fl,
1111'.1i
t
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
055288
NumbkCS
Birthdate' 03/0-'5)1960
18344
Exp�lrej: 03105004 Tr. no -
TIMOTHY R QUINLAN
34 TRINITY CT strator
NO ANDOVER, MA'bi 845 Administrator
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration.- 111089
QUINLAN & RAND-"BUILI
1 �, ;
TIMOTHY QUINLAW""
34 TRINITY CT
N ANDOVER, MA 01845
ip
Administrator
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton PlaceRm 1301
Boston, Ma. 02108
N valid w ut signature
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N2 2 7 0 Date.. ...............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..................................................................
......... I -?A z�e"I'
.........................................
has permission to perform,.-,,,�� ... ........
wiring in the building of
. ............................................................
........ �... -/& ................... . North.Amdover, Mass.
at ..... li� ...... ...............
Fee.. 42 ......... Lic. No ..................... ......................................
ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
DEPARTMENTOMBL[MMY
Permit No. c�976o
IPA BOARD OF FM PREYEWONREGM TIOAS 527 CM 12 0 1 Occupancy & Fees Checked
APPUCATION FOR PERW TO PEUORM ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat-,- 11
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street &Number) 2_1 6L,..)6 9-c6&&
Owner or Tenant Z176L6"-k:A
Owner's Address 'Sin��c
Is this permit in conjunction with a building permit: Yes [3*No M (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead Underground M No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Wtv,6 J00-0-4 JA,:i�� L. -J S —m -t4—,
No. of Lighting Outlets
No. of Hot Tubs
k
10,-3 hq)ecficnD*Rapested
No. offransformers
Total
of,
FIRM IN, 1AME %-,,AAA-r-- L—Le6—ANL4
fA-f
KVA
No. ofLighting Fixtures
,-A -
Swimming Pool Above
El
Below
Generators
KVA
ground
ground
No. of Receptacle Outlets 71-�
No. of Oil Burners
No. ofEmergency Lighting Battery Units
No. of Switch Outlets
No. of Gas B umers
FIRE ALARMS No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. ofSounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local Municipal
M
OthJ
No. of Dryers
Heating Devices KW
Connections M
No. of Water Heaters KW
No. of No. of
gns
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER -
I
I ha%tlaamutLiabi*hvL==PbhLynidTCaTpktOLerzfmCmaagcrdsWmbntdeqmaknt YES NO
lha\,eabnodvaMFiuofc(samlotheOffix YES ff�ou hawdtedW YES, p1e%emdc&theWofw&aWbydrdgthe
INS�NCE BONDF�
oTHR El
WorkoSwt
10,-3 hq)ecficnD*Rapested
Signed under -Er
of,
FIRM IN, 1AME %-,,AAA-r-- L—Le6—ANL4
fA-f
Expirzfm Dale
E0T"edValuedbmtncalWcik
Rough C,4�� Final
LiWWNT. /11 e—s-1,L
Lm=.LA��� SO==
Lt+J-100"b 44 03 BusinessTel.Nh
AILTdNo.
OWNEP,'SNRiANUWAMIR,I.amaWdWffiltcLimwdmM
and dvtmyWWncn1his pennitapplicabonv"icsthis MquMiTifft
(Please check one) Owner M - Agent 1:1 Telephone No. PERMIT FEE,$�
3 7 6
Date....
'y TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
P- p ( 4"1 A 0 C t '- (,- C 1 (7 ( ( C-( /
Thiscertifies that .............................................................................................
has permission to perform ............ / .............. . (I ..............
. ... ... ........................ ... .
...................... to Z
wiring in the building of ..... a�,�� .......... Al'o,
e (( 4 1) 61 *
at .... �/.(t .............. ........ ( .................. . North I ve�
14
................
Fee..'.—/. (0-0 Lic. No. .....
Check # ) -1 11;1 CAL INSPECMR
Official Use Only
Permit No.
VO4V---e 4;V-A�- 1-49, Occupancy & Fee Checked_
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Tovvn of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number_�� �L,) �PQ
Date j 1-16 1-b-7 — -
To the Inspector of Wires:
OwnerorTenant
Owner's Address
Is thispermit in conjunction with a building permit Yes No 0 (Check Appropriate Box)
Purpq,e of Building L,®r,-, i -b LT -1 V14— Utility Authorization No.
EAstW SerAce-----------�AmPs---------Ycits Overhead El Undgmd 0 No. of Meters
New Service Amps_____ --Yob Overhead 0 Undgmd 0 No. of Meters
Number of Feeders and Ampaci
Location and Nature of Proposed Electrical Work A4 (--A�fl
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts "ssachusefts General Laws
I have a current Liabill' !jy Insurance Policy including C9m E I NO=
have submitted v pieW Operations Coverage or its substantial equivalent Y r a
,qWproof of same to the Office YESV'NO = If you have checked YES please indicate the type of coverage by checking the app opri tebox
INSURANCE )P,'BOND OTHER = (PleaseSpecify)
(Expiration Date)
Estimated Value qf Eiqdn(.al Work$
Work to Start Inspection Date FtesqvestedA—),1 �O�—Rough _Final
Signed i
FIRM N) LIC. NO. A4 X—:51 f.
Bus.TelNo. fon.,4�.
PLA,-,—jVJ,1q _AltTel.No
OWNER' INSURP—CE WAIVER: I am aware that tfie Licenses does not Have the insurance coverage or its substantial equivalent as required by M chusetts
General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. _L___PERMITf EE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets 90
No. of Hot fuse
No. of Transformers KVA
Above 0
In 0
No, of Lighting Fixtures o
Swimming Pool grnd 0 gmd 0
Generators KVA
No. of Emergency L:ighbng
No. of Receptacles Outlets -3-0
No. of Oil Burners
Battery Units .
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KVV
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases,
I Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
I ---
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts "ssachusefts General Laws
I have a current Liabill' !jy Insurance Policy including C9m E I NO=
have submitted v pieW Operations Coverage or its substantial equivalent Y r a
,qWproof of same to the Office YESV'NO = If you have checked YES please indicate the type of coverage by checking the app opri tebox
INSURANCE )P,'BOND OTHER = (PleaseSpecify)
(Expiration Date)
Estimated Value qf Eiqdn(.al Work$
Work to Start Inspection Date FtesqvestedA—),1 �O�—Rough _Final
Signed i
FIRM N) LIC. NO. A4 X—:51 f.
Bus.TelNo. fon.,4�.
PLA,-,—jVJ,1q _AltTel.No
OWNER' INSURP—CE WAIVER: I am aware that tfie Licenses does not Have the insurance coverage or its substantial equivalent as required by M chusetts
General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. _L___PERMITf EE $
(Signature of Owner or Agent)
C-
Location,;�4�
No. — .441& �- Date
TOWN OF NORTH ANDOVER
a 0 -.*..
Certificate of Occupancy $
Building/Frame Permit Fee $
CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERMIT NUMBER: Y6? DATE ISSUED: 9�
SIGNATURE:
Building Commiisionerhnspector of Bodings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
— � . I?,
Zoning Dii—x ict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
'3c> 3o
1
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone In tion:
Public 6 Private 0 zone Outside Flood Zone 4
1.8 Sewerage Disposal System:
Municipal W On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print)/ Address for Service
n Telephone
Sig at
2.2 of Record:
Name 'nl Address for Service:
q
Signature TI h
SECTION 3 - CONSTRI 'VICES
3.1 Licensed Construction Supervisor:
�q (Quimc^l
LicensIr-onstruction Supervisor:
3� N. �-
,ss
Address /J U/' 70
1 4.,�
§lrnature' Telephone
Not Applicable 0
05� z1z 6
License Number
:315-)
Expiratioh date
3.2 Registered Home Improvement Contractor
OU iw L AP a- Phm 0 73 (, I L 19 (t
Not Applicable 0
Company Name
Registration Number
oo
Address
C"44 6 8Z- 1570
Expiration Date
Qn-ature / Telephone
09
M
z
0
0
z
M
90
0
Mn
M
z
G)
I SECTION 4 - WORKERS COMPENSATION (MG.L. C 152 § 25c(6) I "
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s)
A
ions(s) 0
Addition 0
Accessory Bldg. 0
Demolition f
Other [I Specify
Brief Description of Proposed Work:
-s' (6)
" 'Z 'SCECTWAJS 6�- t*'_'S-VAJL< ID(LI-ILL * gkfLA-tfL Ld ct"-a
kolt 4 U N_4WA"1AL—, 'DCLCAC�VG- OPLlt *
W LACk_
f- 0_4� J E_ (�LL- t—FOSI-5 *- .56,UO's 4- q-CJ'q UA'_�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIALUSKONLY
1. Building
(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 AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 'J as Owner/Authorized Agent of subject property
Hereby authorize ion QV �0( V% -to act on
My behalf, atters relativ to w onzed by this building permit application.
t - 00
Signature of 6"Amer Q_'*2:, Date'
SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION
1, 62,d k,�,J L�Af,( as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
___h j�j,
Print ame
Si ature o wne��ent
NO. OF STORIES
Date
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TBiMERS s, Z.�,lu 2" _Keo 3RD
SPAN
DIMENSIONS OF SULS
Z-,- L
DIMENSIONS OF POSTS
'/ lq�et -,-,
DIMENSIONS OF GIRDERS
Y'-0
HEIGHT OF FOUNDATION
THICKNESS /6
SIZE OF FOOTING
G X Z-(
MATERIAL OF CHIMNFY
C4 c
IS BUILDING ON SOLID OR FILLED LAND
5C�L,
LIS BUILDING CONNECTED TO NATURAL GAS LINE
-/ cx_ S
BOARD OF BUILDING REGULATIONS
W'42* 4w -w License: CONSTRUCTION SUPERVISOR
Number: CS 055288
Birthdate: 03/05/1960
Expires: 03/05/2002 Tr. no: 235
Restricted To: 00
TIMOTHY R QUINLAN
34 TRINITY CT
NO ANDOVER, MA 01845 Administrator
39
CA 1P di
FORM -, U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT -�gAt-iQ 6Q\LQC-1(& PHONE 7 0
ASSESSORS MAP NUMBER (oS— LOT NUMBER — � k 6A,
SUBDIVISION
LOT NUMBER
STREET Z9 STREET NUMBER
OFFICIAL USE ONLY
asoffinamememeen
RECOMAIENDWONS OF TOWN AGENTS
in
DATE APPROVED
CONSERVATIONADNffi,11STRATOR
DATE REJECTED
CONUVENTS kk U-Z-Kvuj� (o
CONMINTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERA41T
DATE APPROVED
FIRE DEPARTNIENT
DATE REJECTED
CONOAENTS
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
TOWN PLANNER
DATE REJECTED
CONDAENTS
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR - HEALTH
DATE APPROVED
SEPTIC INSPECTOR - HEALTH
DATE REJECTED
CONMINTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERA41T
DATE APPROVED
FIRE DEPARTNIENT
DATE REJECTED
CONOAENTS
RECEIVED BY BUILDING INSPECTOR
w -PLO
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GILLETT
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TheCommonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Narne* 62ukM(-A-N A— (24-,JS� 'B,-LLVf-,M
Location:
CitV Phone
F7am a homeowner performing all work myself.
rl�--Zll am a sole proprietor and have no one working in any capacity
I r_1
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone#:
Insurance Co. Poligy
Company name:
Address
City: Phone #:
Insurance Co. Policy #
MMM60M
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of cjiminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100. 00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DLA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signatu —Date.
Print name
Official use only do not write in this area to be completed by city or town official'
[]Check if immediate response is required Building Dept
Contact person- Phone
FORM WORKMAN'S COMPENSATION
hone #
Building Dept
Licensing Board
Selectman's Office
Health Department
Other
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Date
CT�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
fFrame Permit Fee $
ion Permit Fee $
Other Permit Fee
.4ftewer connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
Div. Public Works
PER]= N
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
t./PAGE I
Mkp +40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
ZONE
SUB DIV. LOT NO.
LOCATION
AcuaR-lAoc,c-
PURPOSE OF BUILDING
OWNER'S NAME
NO. OF STORIES SIZE _SCjC-,�0 ,,g_F7T
OWNER'S ADDRESS
BASEMENT OR SLAB
v
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST,2A to 2NO
3RD
BUILDER'S NAME J5#Z4)qH
SPAN A/
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES
REAR
GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE 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 OKCODE
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 TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DAT FILED
916NATURE OF OXER OR AtJTHORIZED AGENT
F E E ; 1) 0
0 OWNER TEL.
4)� CONTR. TEL.#
PERMIT GRANTED
CONTR. LIC, ft 020
Z, 19
-4 -'A IN 2 1 -
dog � -// 2 Y
6YS"�;-
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING RECORD
OCCUPANCY 12
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.
P-=
WIES
MULTI. FAMILY
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
CONCRETE
8 INTERIOR FINISH
1 13
P-1 -N —E 2 —
HARDW D
PLASTER
EONCRETE SL —K
BRICK O� STOWE
�IERS
-�RY WALL
I UNFIN.
3 BASEMENT
TREA FULL
FIN. 8 M'T* AREA
'/' 1/2 '/.
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
—90AR
9 FLOORS
EL A P DS
DROP SIDING
WOOD SHINGLE�
B
1
2
3
CONCRETE
EARTH
ASPHALT SIDING_
ASBESTOS SIDING
VERT. SIDING
HARD\'.t'D
COMIACN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON -MASONRY
ATTIC STIZS. &
BRICK ON FRAME
CONC. OR CINDER BLK.
I
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR POOR
)�DEQUATE NONE
10 PLUMBING
5 ROOF
GABLE
GAMBREL
11
HIP
MANSARD
BATH (3 FIX.)
TOILET RM. 12 FIX.)
WATER CLOSET
F "LAT
SHED
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
G S
OIL
B'M'T 2nd
Ist I 3rd
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.
P-=
FORM U - LoT REMEM]g FDRK
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,,
regulations or requirements.
****************Applicant fills Out this section*****************
APPLICAM: 5gligN fi'?/7Cb/67(-(- q7 --
5 -ge
Phone 53
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street 8Lu Zz- ki
St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator Date Approved ------
Date Rejected
Comments
Town Planner Date Approved
Date Rejected
Comments
Health Agent
Comments
Date Approved
Date Rejected
Public Works - sewer/water connections
- driveway permit
1/'F--i�reDepartment
Received by Building Inspector Date
9
'A,
Page No. of Pages
2_1�
65 tUildrjood Road
ANDOVER, MASSACHUSETTS 01810-5731
(500) 470-19-83
PROPOSAL SUBMITTED TO
PHONE DATE
R!Z-I)qlq M/7,cl/:�I-_( (
�7 5-- A40-3 I /,// t/A
STREET
JOB NAME -
;� � 8wt�=7 P'll 06 E- Ira.).
CITY, STATE AND ZIP CODE
JOB LOCATION
�� a) //7,4?
S141y", u
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby submit specifica-tions and estimates for:
/,-k/-S774(-(_,9-7-70/1J Or d� CCtNT-C-:,e-
-5JWQC-L) 48Y C)Q"E-4e-- WILL 81Z7
pu_, r-1-1 11 E je + E=- C -T )I
4,("rttl4q:� /,/ W(, 7-iA, 3&- '431- gee C,/y 4v e 42
0 -FIJI E
19P fropou hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
W H F-Aj dollars ($ /�k(_j CJ 6,
Payment to be made as follows:
All material is guaranteed to be as specified. Ali work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifica- Authorized z�r?
tions involving extra costs will be executed only upon written orders, and will become an Signature
extra charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within clays.
Araptaturr of Proposal- The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: /– 1q- 15 — Signature
PRODUCT1183 Inc- Groton, Mm 01471. To Order PHONE TOLL FREE 1+ 800-225-6380
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OFFICF-S OF:
APPEALS
11L]IIX)ING
CONSERVA110N
HEALI"H
PLANNING
Town of
NORTH ANDOVER
DiVISiON OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
120 Main Street
North Alidover,
(VI-ISSMIMSCIIS 0 184!1
((; 17) fiH5-4775
In accordancc with the PrOvisio"S of MGL c 40, S 54, a condition of Building Permit
Number — — is that the dcbris resulting from this work shall be
disposed of in a properly liccased solid waste disposal facility as dcfincd.by MGL c III, S
150A.
Tle debris will be disposed of in:
F-1
(Location of Facility)
Signature of Pcrinit, Applicant
'/9's 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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