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Date ..... &1.�i .................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�4.' - I -e '411�4 0 /Lu
This certifies that ...... !..'? ...... . ........... 2 .............. . ............. CA ...............
... .. ... ..
has permission to perform ............................ q ................. I ........................................................
50,-c L VV-\ "
wiringin the building of ............. K ........................................................................................
ut ......... ........... IM ..#' Maw
..................................... . 4orth Andover,
.. . ... . ....... ..... ....
Fee ... ............ Lic. No . ................. ....................... IJ .1, CTRICAL .. IN . SPEc . roR . / ... .....
-� Ac"
Check
12284
C40MM0nWeajffi&
Massachusetts
i Official use TV
DeParhnent of Rre SerW'ces
BOARD OF FIRE PREIE"ON REGULA-noNS I Occupancy mdFee Checked
�Rev.lifqqj --------
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
1.11 "rk lo be perfomed M =40r&= with tile Massachusetts F-jectca C. C\,g -
(PLEASE PRNT ly.U�W 0 � F); 52, C2�M 12 00
,R TYP.E ALL BVFOP-VA Y7.0M,, Date:
City or Twit of: c, sp
T theTTn;�8—eto? 0 J'' VY
BY ft VOCadon tbe- mdadgted
-dves 1:11 bis or her intention.- pjE�� h
nouce orm -t e.eie=!C�� wo& de -,'bed below.
&�Noumalber)
CC Map: Lot:
L
��
Owner or Tount Telephone No
Owner's Address
LS tV6 Pwmk ift cIift wift a building peimit-, Yes Fn
LZ Building PeI
Purpose Of Building Utility Authorbation No.
Exisdft Service An" vous Overhe-d Undgrd I -o. of
Weters
New sa-vice, Vohs Overhead Uadgrd No. of Meter,
Number of Feeders and AMp&I
L*Cxdm and Naftre of Proposed Electrical Work-
)Oyv.�' , fAvd <Zi 1 11 !]1!!1' ad 7�)
nA 0 �ii I - .
d
Of Wir
Noof Recessed Pblures No. of CeL Susp. (Paddle) Fausl
[�� Of Lwtftg Outlets NO. of Hot Tabs I
No. of Lioft Fbftres In-'
swii� Pool ��p k
and.
No. of Recepoade Onfleft No. of Oil IMmers
No. of Switebts No. of Gas Burners
V�A_
No.
o
0
0
f
f
fC
L
T
P�
r
'o of Total
_4
No. of Ra"m No. of Air Cond. Tons
N6. of Waste Disposers Elest Pump I Namber I Tons H A -
Totals: I
NG. of Dbbwasbers Space//Area Regtmg KW i 60
[N*._Gf D"m Heatuag Appliances
No. of N"
KW Sips BaRASI�S
No. Hydrowassage Bathtabs NO. Of Motors Tow Hi
OTHER:-
A=claddErfo�dez:i.'#�des-eZorasre, byrhehzTeaorof;j
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the license(
provides proofafliabili-ty insurance including -completed operatice' coverage or its sulbstantiall equivalent. The undersigned ceftifies that
coveTage is in force, and bas mt! proof ofsame to the permit issuing office. /"N,
CHECK ONE: INSUR.A rEBOND D OTHER El (Specify:�
kS;= 95m)
Bstimawd Valuc of Elootti"I Work (When required by municipal policv.)
W0zk to sart -r 6 1� inspections to be requested in accordance withmEC Rule 10, and. Lpon oonwletion.
I CaytifY. wsder &epabs mdpmaftiew ofpedztyy, that the btfiormation on thisapplicadon is true and coMletp-
LIC'
F=M NAME: 4— li-,� &erafir- Mar,
L&enw-- LOP4:64n -Din& Signatare I C - N 0.:
in zk- HeanSe 'I )b7
(-frappHcable. enter Bus- TeL Na.- 5Z 1 -
AAdress: 'M AIL Tel. No.;
OWNZWSIMUI—W�WAIVER.- I am aware tlMlhe Licensee doeS nol have the iiabil=v =%—m— -0—rase no-117;;quir� by
By my sipatare below, I hereby waive fts requirement- I am the (checik one) C1 owner 0 "'.ar's ag�al.
==M— Telephone No- P.Egwr FEE, s
9
p
1)
A
COMMOnweaft of Massachusefts
Depan*xwt of Fir,.
semces Derm=ft No.
BOARD OF FIRE PREVEN110N REGULATioNs I occupancy and Fee Checked
9 �Rev. 11/991 (If -m- -------
APPLICATION FOR PERMIT TO PERFORM ELECTR
,kl) work to be p,,l h, accordance wrth lile M ICAL WORK
. assachusetts Electiao Gme 527 C -MR 12.00
rPL&'W PPXVT ly EVI OR YTPEALL LVFORMA 7TO.V,, Date: 11,
Cky or TO" ()f-. thi— -7— 11 -------
1?�Tector of M�el:
By thiS V9=110rt te UXkn*ftd eives
perform TheeieCMIMwork IdL�sccriibed below.
Loodu (SU -09 & Nmber)
I Map: Lot:
Owner or Tenant co -Irl Ra r Telephone No
Owner's Address
Is tVs Plel is cWtURCtiOR wft a building permit, Yes Building Permiv;
Purpose of Bundhtg Utility AuthorizationNo.
Elisting Service Amps Volts Overhead El undgrd No. of Nileters
New $amyce Amps Vohs Overhead El Undgrd No. of -Meters
Number of Feeders and Ampal
L*exdm and Natum of Proposed Mecarkm work. -If I
__11 L!aMieW7
01 WtoUowJng rabie -w be watwd by the bw
pel of Wh
ING- of Recessed Fhtures No. of CeIL-Susp. (Paddle) Fans
NO. Of Total
Transfor mers XVA
of Lwlftg ontiets No. of Hot Tabs
Generators KVA
No. of Lj0ftg Fbmwes Sw6wnjug Pool
0. of
9374& ff—BAL
Battery Ua�its
NO. of Recel Ondaft No. of OH Burners
FB?.E AIARMS No. of Zones
Lml Of Switdies NO. of Gas Burners
No. of Detection 7
amn d
7
ic�s
1gifting Devices
No. of Ranges Total
FNo_ of Air Cond. Tons
LNo. of Alerting Devices
'm
No. of Waste Disposers -Number I Taus JKW
of SeIPContabaed
Mll==
Devices
No. of Disbwwbers Space/Area Heating KW
Local 711 N;tr= C2 Other 60
LNo. of &-yers Heating Appliances
or, E-Quivalent
No. of Wall of No. of
ECW
DI Wiring:
ENoo.
Ballasts
No. of Devices er
No. Hydremasup Bathmbs N4
No. Of Motors Total HP
T MOM,
11 of Devim or Uat&mt
OTMPL
I
A=ch a&fir� de!aL? trdzjbv4 or as requir, by the Inspector of P
INSURANCE COVERAGE- Unless waived by the owner, no permit for the performance of electrical -ork may issue unless the licel
21 e�qiuvaj
provules pmof of liability inswance mclu(bng "completed operal coverage or its substand ent. The undersigned certifies tim
coverage is in force, and bas eiti proof of same to the permit issuing office.
MOND
CIMM ONE: INSUR.A El OTHER D (Specify:)
Bstimil Valuo 'Of Elell;trioal WO& (When required by municipal policv-)
wmktostart _7_6t) IUSPeOdOUS to be requested -in accordance -ithMEC
Rule 10, arid upon completion.
I cel under the pal =djW=hdff ofperjury, that the wf&rmatwn on this apphcation is true and con*laa
- -7 ?'n
— LIC. NO.; A bD2
License-- Signature
IC NO -
TeL'-No-:
bz the amense nw"ber am
L)J�,
Bus-
AAdzel PeAk M "q n n
AIL Tel. No.:
OWNEWS INSURANCE WAIVER-. I am aware diat 1he Licensee does noi have'rne; 1=WL-_ i=- --ruse -317 —q— by
By my signatare below, I hereby waive this requirement, I am the (cheer, one) 0 Owner 'L-1
=Z1.A9`e= Telenhome No- I PERMTT FE.E.- S
f Y\ Pn It
I
r,,,O 5w 7-J-141"Pe-7
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a
61 @
AC40RD CERTIFICATE OF LIABILITY INSURANCE
16..�
DATE (MMIDDIYYYY)
I 10/22/2013
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 poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). I
PRODUCER
EA Stevens Company, Inc.
389 Main St.
P. 0. Box 188
Malden MA 02148
NT CT
CNOAME� Wally Valdez, CIC, CISR
PHONE (781)322-2324 �IA_X
- 1C. ,0781) 397-7672
E-MAIL
ADDRESS: wallyva@ eastevens ins. com
INSURER(S) AFFORDING COVERAGE NAIC #
1 INSURER A:PeerleSS Insurance Companv
INSURED
Dinis Electric Inc
PO Box 3955
,Peabody MA 01960
INSURERB':The Netherlands Insurance �4171
INSURER C:Peerless Ins �4198
INSURER D:
INSURER E:
INSURER -F I I
COVERAGES CERTIFICATE NUMBER:2013-2014 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.
LTR
PE OF INSURANCE
ADDL
INSR
WVQ
POLICY NUMBER
(MM/DDIYYYYI
(MM/DDNYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
IDPRME
A AZE To RENTED
'IS ES �E. occurrence) $ 100,000
X I COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $ 15,00
A
CLAIMS -MADE 7X OCCUR
BP3918373 �8/2/2013
/2/2014
PERSONAL& ADV INJURY $ 1,000,00
3ENERAL AGGREGATE $ 2,000,000
�FRODUCTS
GEN'L AGGREGATE LIMIT APPLIES PER:
- COMP/OP AGG S 2,000,000
$
X PRO-
POLICY F7 JrCT F7 LOC
AUTOMOBILE LIABILITY
0 NED SINGLE LIMIT
'M"N" 'INL
C MBI identl 1,000,000
Ea acc S
'a a -,dent
OD'LY I NJURY (P
BODILY INJURY (Per person) S
B
ANY AUTO
RY
BODILY INJURY (Per accident) S
D
ALL OWNED FX] SCHEDULED
3918368
e/2/2013
8/2/2014
AUTOS AUTOS
NON -OWNED
•
0 TY D M
PRO ER A AGE
Per accident S
HIRED AUTOS AUTOS
Underinsured motorist BI solit s 100,00 0
n
•
UMBRELLA LIAB
X JOCCUR
EACH OCCURRENCE Is 1,000,00�
AGGREGATE $ 1,000,00
C
EXCESS LIAB
7
CLA
DED X I RETENTION$
8791524
8/2/2013
/2/2014
C
WORKERS COMPENSATION
TATU_
x I TOCRYS LIMITS FIR
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE I
E.L. EACH ACCIDENT S 500,000
E.L. DISEASE - EA EMPLOYE� s 500,000
OFFICER/ME BER EXCLUDED? L!_J
(Mandatory m NH)
N/A
C 3918369
8 /2/2013
8 /2/2014
E.L. DISEASE - POLICY LIMIT $ 500,000
If Kes
S6 describe under
D RIPTION OF OPERATIONS below
A
BPP
BP3918373
8/2/2013
8/2/2014
$33,530
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
City of Beverly
Attn: Building Inspector
191 Cabot St.
Beverly, MA 01915
ACORD 26 (2010/05)
INS025 oninns) ni
..W
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATWE
Thomas Cares, Jr/WV
W -I W00 -LU I VK%o%Jr%LJ %,VF -,r -%J ivi . I H I I V
Tho Art'jpn n�im� nnfi lr%nf% nra ranictararl mnrlec r%f ArilPr)
N
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LA
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www-mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nnilid-an+
Name (Business/Organization/Individual):
Address:
/State/Zii):
Phone#
Are you an employer? Check the a�p_ropriate box.
I am a employer with 7 4. am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. LJ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. El I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] f
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.'+
5. [] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insurance reauired.1
P1
Type of project (required):
6. E] New construction
7. El Remodeling
8. E] Demolition
9. 0 Building addition
10. ZElectrical repairs or additions
I I -[I Plumbing repairs or additions
12.0 Roof repairs
I ') - El Other
'o *Any applicant that checks box #1 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:
Policy # or Self-ins6 Lic. #:_-E C-�_ SA tA Expiration Date:
Job Site Address:__t9g/ 1� cLtA:� City/State/Zip:�0)0,4 er /q)
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certitv under the pains andpenalties ofperjury that the in rmation provided above is true and correct.
Sip -nature: Date: Y116�1 L
Phone#:
Official use only. Do not write in this area, to be completed by city or town of icia
T I
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 9:
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ko &-,t /'9-10 b\ r%-01
.......................... .............. ......
has permiss ion to h7 -L' -j 6 d -l -e
.................................................................. ..........................
wiring in the building of .... ..........................................................
fit ....... ........................... /LNorth Andover, Mass.
Fee2//5�-10 N 17-3o7
.......................... Lic. o . ................. ...........................
Checkit ELE6�cAL INSPECTOR
commonwealm am..,Whu.,
,tt
S offitial
Deparbnent of Hre sery'kes Permit No.
BOARD OF FIRE
PREVE"ON REGULA-noNS and Fee Checked
VO 17, 1%cly
APPLICATION FOR PERMIT TO PERF . ORM ELECTRICAL WORK
All work, to be pefformed in accordance with the.Massa�s F-1 *c2l Cote CxT,-C); 527 0,M 12.00
(PLEASE PRWr N EVK OR -FE ALL WORMA 7 joAg ect"
- Date: H/6
11q,
City or Town of: �we,( To the Inspecior ol, wires:
BY this applicadon the umderdPed gives notice of his or her intention to- perfonn the electrical work described below.
LACROOR tomw a Number)
Owner or Tenant 0�_,
Teiephone No!
Ut.
Owner's Address Ali; ffoc U".
b this Pus* IN cm*wtion with a building permit-, Yes NO %ilding Permito;
Purpose of Bafidjug; Utility Authorization No.
EtSdft Savice Amps Vohs Overhead UndgM No- of Meters
New Savice Amps volts Overhead Undgrd N o. of -Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical work:
of hheLbL2!LxnA WhLe -W be -w&i6d by dw 1)
NO. Of Recessed Fixtures No. of Cefl-Susp. (Paddle) Fans TOW
KVA
No. of Hot Tabs Generators KVA
NO. Of L*gbtbg Oudets ::::
4VN
Above
No. of LigUting Fbaeres Swimming Pool 011- M I
No. of Eawxgmcy Lhoit—mg
and. grlade Battery units
P
'eceptade
NO. Of on" CA No. of OU Darners
I
FIRE AIARMS lNe. of Zones
No. of Switches No. of Gas Burners No. of Detection and7E
Initiating Devices
No. of Ranges No� of Air Cond. Total
Tons jNo. of Alerfin Devices
No. of Waste Disposers E[W=1 Number J Tons JKW No- of Self -Contained
DetecdonJAlerfmg Devices
No. of Disbwasbers SpacelArea Heating KW
Local ther
'= El Other
No. of Dryers Heating Appliances KW
I
Security Systems:
No. of Devices or Eguhaleat
%J
N06 Of Water No. No. of
Kw of
Data Wiring -
Beaters sips BaDusts
No. of Devices or EguirAent
No. Hydromassage Bathtubs No. of Motors Total HP
Telecomxnunicatiovs'�Ylwbr.
No- f Devices or 9guivalent
OTf MIL_ 01,le CuAfL j('rD kj�oa
'c)0h noAd,
I J Attach addittonal derail rf desired dr as required by the bwpeaor of W
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee
provider. proof of liabift insurance including -completed operaxion7' coverage or its
substantial equivalent. The undersigned certifies that s
coverage is in force, and has exhib'�� proof of same to the permit issuing office.
r�
CHECK ONE: IiISURANCE S' BOND El OTHER El (Specify:)
LL"
(Expuatix)
0 Date)
Estimatad Valueof Elechical Work- (When required by municipal policy.)
work to Start: Inspections to be requested in accordance with IMEC Rule 10, and upon ooupletion.
I cm tify, u nde r the pa bts a ad pmable w ofpedu ry, that th e i72formmion o n th is apph
ca don is tru e an d compla M
FUM NAME: it) 6D ea+ fir
UC. �No.;_,�4
taitensee: Loria/7n —L)I n6 Signature
IC_ NO.:
Bus- Tel. No.:
.8,2w in the
(4r,,H.bk, nwnber line.)
ROMP,
P_UZtIQJ� Mq n L9 01-0
Tel. No.:
AAdress- -,391RIR Alt.
OWNER'S INSURANCE WAIVEP_- I am aware that &e Licensee does not hcrve the liabilty insurance coverage normally required by I
By my signature be -low, I hereby waive this reqniremem. I am the (check one) C3 owner 0 owner's ag�L
OwneriAgeat -
PERMIT FEE: S
Sicnature Telephone No-
9
f
1,
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
I www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual): eC4 f I C.
Address: ?Ll)b
City/State/Zip:
Phone
Are y u an employer? Check the appropriate box:
I . VI am a employer with ':::6' 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. [] I am a sole proprietor or partner- listed on the attached sheet. +
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
I workers' comp. insurance.
.5, El We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F� New construction
7. E] Remodeling
8. F-1 Demolition
9. EJ Building addition
10. �Iectrical repairs or additions
ILE] PI umbing repairs or additions
12.rl Roof repairs
131� Other,
'*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informatioh.
Homeowners who submit this affidavit indic�ting 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 their workers' comp. policy information.
I am an employer that & providing workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: A4 L) 0_/
Policy 4 or Self -ins. Lic. Expiration Date:
Job Site Address: C�q) MZ2�:�ffilg City/State/Zip:aA&.�t�- W
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure'to secure coverage as required under Section 25A of MGL,c. 152 can lead to the impositi6n of criminal penalties of a
fitle up to $1,500.00 and/or one-year imp�isonment, as well as civil penalties in the f6rm of a STOP WORK ORDER and a fine
of up to $250.00 a day against the Violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA forinsurance coverage verification.
Ido hereby certify,under thepains andpenalties ofperjury that the information provided above is true andcorrect.
ON/
-S)
Phone 4: �y I 's
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 Insp&tor 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
v
IR
Ln* =
LLI
LLJ
U-
LLI
Ljj
LLJ
.............
LLI
LLJ
LLI
Date..21�.zlA ................
...... ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
............................................................................................................................
has permission to perform ......
............................................................................................
of
wiring in the buildinj . ................... . .........................................................................................
.at ....... 2-9 kA-
............ .............................................................. North Andover, Mass.
Fee.�P .................. Lic. No.
................. .............. ....... L�M-
Check it 664
1 2161 vy\. 711-dl�
commonweafth of Massachuse
AWL it
Deparbnent Of Fire Services
BOARD OF F'Re PiMW-NTION REGULA-n()NS Permit -,o.
Oc"PanOY and Fee Checked
1 LPemft,
o- ?d
Oc7
_y
ev- 1291 _ Cleave
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All 'work' 15 be Perlormod in accordance with the Massachusetts Ejec`t"021 Code (--SC) 527 C�,M 12.00
(PL&ISE PP'WT -DV 'ZNZ OR lyPEALL EVFOR21,M 7TON,
ChY or Twn of: Date:
Pect i�
70 e- TO the Inspector 0 ev.
to
By t W s appi ic Won te M&Mi g EML4. L
91ves notke of his or her intendo
L4Cad9l1(8&ftt&Nvmber) Perform tile eiectrica" Work desclbed below.
Map- Lot:
Owner or TaLut
--fA4,J . )
Owner's Address
Telephote '10,'f �O2
Is this Perak ja coultemcoon wft a building permir- Yes
Plarpose Of Bwadjag NO 0 Building Perm"#
Ezisft Service Amps UdU%y Authorization No.
VOft Overhead 7 — — — — — — — —
------- Undgd No- of Meters
Vohs Overhead
Number of Feeden a" Ampedty ------ El Undgrd No. of.Njeters
and Natare of proposed Eleemw Work: I - N I -
ia-& -a MA3 OP,& —K—o �rjl.,-r
No. of Recessed
Fbftres
140. of U&Jag Outlets
No. of Lhgbftg Ftftrft
No. of Receptack 2!!!!! -3
No. of Swkthes
No. of Ces.-S� ftddle) FAns
No- of got Tgbs
swimming Pool=
No. of On Burners
No. of Gas Barners
ps
ta6k
Generators K -VA
FIRE ALARMS jNe- of Zones
of Alerting Devices
Data
Other
INSURANCE COVERAGE- unless waived by the owner, no permit for tL4w-rz uuuux7f = aerau g aesmea, or as required by the hzypeaor of W.
the performance of electricall work may issue unless the licensee
Provides Proof Of liabift inmrance including "completed operation7 coverage or its substantial equival ent. The undersigned certifies that s
coverage is in force, and has exldb�ibd proof of same to the permit issuing office.
cHEcK oNE: rNsui;LANcE E3 BOND ci oTHER i—I (specify:) ri
ULU-0 ab
Estix� Valut of Electical Work jLZQ (Whe. required by mmucipal Dolicy.)
Work to Start —nD
InsPectiow to be requested in acc(jrdance with VIEC Ruie 10, and uDOn oonwletion.
I ca tify, Unde r the pabis a ad Pe WMes OfPaju ly, tha t th e biforma tion on th is app lica don is tyu e and CoMpl0a
FJ[RMNA.ME:Zin),-:) Qf's+ac- LIC. -!40.;-.A
FPER3HT FEE: S (C
44 Ce -A
-I I
No. of Ranges
No. of Air con(L Total
No- Of Waste Disposers
Totals: I
NO. Of Dkbwasbers
Space/Area HeaUng KW
-of"
Heating Appliances KW
No. 01 vwuw
Heaters KW
NO- Of —No. of
- Ins Ballusts
No. Bathtabs NQ. of Motors Total HP
OTffEp--";z
ps
ta6k
Generators K -VA
FIRE ALARMS jNe- of Zones
of Alerting Devices
Data
Other
INSURANCE COVERAGE- unless waived by the owner, no permit for tL4w-rz uuuux7f = aerau g aesmea, or as required by the hzypeaor of W.
the performance of electricall work may issue unless the licensee
Provides Proof Of liabift inmrance including "completed operation7 coverage or its substantial equival ent. The undersigned certifies that s
coverage is in force, and has exldb�ibd proof of same to the permit issuing office.
cHEcK oNE: rNsui;LANcE E3 BOND ci oTHER i—I (specify:) ri
ULU-0 ab
Estix� Valut of Electical Work jLZQ (Whe. required by mmucipal Dolicy.)
Work to Start —nD
InsPectiow to be requested in acc(jrdance with VIEC Ruie 10, and uDOn oonwletion.
I ca tify, Unde r the pabis a ad Pe WMes OfPaju ly, tha t th e biforma tion on th is app lica don is tyu e and CoMpl0a
FJ[RMNA.ME:Zin),-:) Qf's+ac- LIC. -!40.;-.A
FPER3HT FEE: S (C
44 Ce -A
-I I
A
1
14
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office Of Investigations
600 Washington Street
Boston, AM 02111
W.MaSS.govIala
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
MiCant Infirmal-in.
Name (Business/organization/Individual):
Address:
City/State/Zip:
Phone #:- 9-? �_ - S!3 11 Q Ll r))
----------------
repu an employer? Check the appropriate box:
I I am a employer with '::6 4. 1 am a general contractor and I
employees (full and/or part --time).* have hired the sub -contractors
2.[] 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. El We are a comoration and its
. required.]
3. 1 am a homeowner doing all work
myself [No workers' comp.
insurance required.] f
officers have exercised their
right of exemption per MGL
C. 152, § 1 (4), and we have no
employees. [No workers'
I comp. insurance required.]
1Any applicant that checks box #1 must also fill out the section below showin fl,
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. �lectrical repairs or additions
I I - E Plumbing repairs or additions
12.El Roof repairs
13-0 Other
5 , , wor ers 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 their workers' COMP. Policy information.
I am an emDlover that is proviffisla utn�lf I
information. r" compensation insurancefor my employees. Below is thepolicy andjob site
L.
Insurance Company Name
Policy # or Self -ins. Lic. 4:
Job Site
e
Expiration Date:_
Ci�y/State/Zip:/U0,4/ArJn_JP
Attach a copy of the workers' compensation policy declaration page (showing the Policy number and expiration date).
FAilure to secure c overage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500-00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnvbstigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correc-
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#:
. MIM*
Ln
-;�t LAJ
U Z
LLJ
LLI
LL
tq
.
ALA
. .... ........... . . ......
. MIM*
Ln
LLJ
LLI
'IS
Date.. .6 —.�75�..t
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... k ....................
has permission to per .........
form
........................................................
wiring inthe building of ................... dkekll�A4--
at ..... oVI ... Mtd ......................... . North Andover, Mass.
Fee -&-5.7777*... Lic. No. 11.7 ........... j
Check #
Zj
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
dffi�cial
Use Only
Permit No. �f V-7
Occupancy and Fee Checked
Lev. 1/07]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
WORK
(1-1-MOZ J-M-Nj 11V INK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of hi perform the electrical work described below.
Location (Street& Number) AIARACAI ff( -Avl�
NPIN,
Owner or Tenant 6AR) *-DOUA, fi-,APJ,/ M -d— Telephone No.
Owner's Address —4**10t
Is this permdt in c -1781kh-06,2.2
onjunction with a building permit? Yes L-� No F] (Check Appropriate Box)
Purpose of Building rbw� Utility Authorization No.
E:dsting Service / '00 Amps lAo volts Overhead --------
t El Undgrd 2. No. of Meters J
New Service Amps Volts Overhead Undgrd El No. of . Meters
Number f Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Estimated Value of Electrical Work: �� 00 '0 u-ull y aesirea, or as required by the Inspector of Wires.
Work to Start &- /0 0 . (When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insunance including "completed operation" 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: INSURANCE [I BONDE] OTHER JR (Specify:) 121 0,,oVE
I cerdfy, under the pains andpenalties ofperju?y, that the information on this application is true and complete -
FIRM NAME:
Licensee:Ke, Signature LIC. NO.:
(If applicable enter 11exe t 11 in the licetup number line.) LIC. NO. -
Address: Bus. Tel. No.:
Aa 0 3 k73
*Per M.G.L c. 147, s. 57-617, security work requires Department of Public Safety "S" License: Alt. Tel. No.: 2LE���
Lic. No.
,,�OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. lv�ny signpire below, I hereby waive this requirement. I am the (check one) 0 owner E] owner's agent.
Owner/Ag
Signature Telephone No. flf- 615 -dud
t
I
0
The Commonwealtk of Afaysachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AL4 02111
www-massgovldia
Workers' Compensation Ins6rance Affidavit: Builders/Contractors/Electriciang/Plumbers
Policant Informati..
Nan�e (Business/organization /Individual): Ale
Address:
,4 cc /,z
CitY/State/Zip-*
_MA/(Y-0 (V C���o
Phone
Type Of Project (required):
6. [] New construction
7. ORemodeling
S. 0 Demolition
9. DBuilding addition
10. D Electrical repairs or additions
I LOPlumbing repairs or additions
12.[] Roof repairs
13.[],Other
OmeOwncrs who submit this affidavit indi t- Onpul-yinyormanon.
4connacton; that check this box r cating they are doing all work and then hire outside contractors must submit a new afrld&vit indicatinS such.
nust aftcb*d an Addition
car showing the n of the sub their,
me u-cofitmetm an worken;'comp policy information.
I am aA enWlayer jhX is prqviding:wor1jerS$ cOlVensadon iftsuraiwefor nF eMployeem
information. Below is thePONCY andjob site
Insurance Company Name:
Policy 9 or Self -ins. Lic. 9:
Expiration Date:
Job Site Address:
City/statelzip:
Attach a copy of the workers, compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of
fine up to $1,500-00 and/or one-year imprisonment, as well ELs civil penalties in criminal penalties of a
the form of a STOP WORK OR
I � DER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenafties ofperjury that the infor""on provided above is true and co
Signaturt
Date. A2, el 9
Phone k 6 4' '9 4'
Official use only. I& no, wrile in this area, to be contpleted by c4 or town ��off,.id
City or Town:
Perwit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. Plumbing I I nspector
6. Other
Contact Person: Phone 4:
You an employer? Check the appropriate box:
1 11 tim a employer
with
-part-time).*
4. 1 arn a general contractor and I
employees (fiall and/or
2.'L�f-i am asole Proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me.ii any capacity.
[No workem, comp. insurance
workers' comp. insurance.
5. El We are a corporation and its
required-]
3.[3 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MOL
myself. [No-worke'rs'comp.
C. 1,52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required -1
*Any applicant that checks bo)e # ust als I
T Ll out section below showing their workers' dom
Type Of Project (required):
6. [] New construction
7. ORemodeling
S. 0 Demolition
9. DBuilding addition
10. D Electrical repairs or additions
I LOPlumbing repairs or additions
12.[] Roof repairs
13.[],Other
OmeOwncrs who submit this affidavit indi t- Onpul-yinyormanon.
4connacton; that check this box r cating they are doing all work and then hire outside contractors must submit a new afrld&vit indicatinS such.
nust aftcb*d an Addition
car showing the n of the sub their,
me u-cofitmetm an worken;'comp policy information.
I am aA enWlayer jhX is prqviding:wor1jerS$ cOlVensadon iftsuraiwefor nF eMployeem
information. Below is thePONCY andjob site
Insurance Company Name:
Policy 9 or Self -ins. Lic. 9:
Expiration Date:
Job Site Address:
City/statelzip:
Attach a copy of the workers, compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of
fine up to $1,500-00 and/or one-year imprisonment, as well ELs civil penalties in criminal penalties of a
the form of a STOP WORK OR
I � DER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenafties ofperjury that the infor""on provided above is true and co
Signaturt
Date. A2, el 9
Phone k 6 4' '9 4'
Official use only. I& no, wrile in this area, to be contpleted by c4 or town ��off,.id
City or Town:
Perwit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. Plumbing I I nspector
6. Other
Contact Person: Phone 4:
-4
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide wo ' rkers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enter�rise, 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
owneir-of a dwelling house having not more than three apaxtments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair wk on such dwelling house
or on the grounds or building appurtmMt thereto shall not because of sucb employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every i state or local liednsing 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 n . ot 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
requir=ents of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation, affidavit completely, by checking the 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 (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' coyripiansation insurance. If an LLC or LLP does have
employees, a policy is reqiiired. Be advised that this affic * lavit may be 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 returried to the city. or town that the application for the permit or license is being requested, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number. listed below. Self-insured companies should 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 lnves�igations has to contact you regarding the applicant
Please be sure to fill in the perTnit(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 markea-by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fiftwe permits or licenses. A new affidavit must be filled out each
year. Wh= 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 Office of Investigations would like to dmk you in advance for your coopbration and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone ana fax number:
The Commonwealth of Massachusetts
Department of Industrial Accid=ts
Office of Investig,
ptions
600 Washington Street
Boston� MA 02111
Tel. # 617-727-4900 6xt 406 or 1-8.77-MASSAFE
Fax # 61 7-727-774�
Revised 5-26-05 www.mass.gov/dia
03/10/2014 09:14
9785219099
CARL BACKMAN
C4.55ic Machine
52 Rocb,7rnh,7ult socet
1-1,ivetbill, A4A oigi2
Ftotv: Od BIckm,3n
F6one:,978-521-8a,gy
Fax: Y78-521-,9oyg
AluMbet ofpqge5 incladIng covei-5heet
Commep
5.1
ZSr-/ c nuire,-c
L --31�szkniao
1: eq- 7 / N_n 11 rs 4 & I &I -
rAw-W,
lb
PAGE 01
..V
IN
10353
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that... ........ 4).e— - - - Ar - 0 ... Z --v .................... V ......
has permission to perform ...... ........... " e P.., 1 4.... �J/�
.......... ...... . ......... .
................ .......
plumbing in the buildings of ..... /C r" e�,j
........... ...... ... . !�7 .......
at..,,2—
....... 4�E ............................ I North Andover, Mass.
...............
Fee 0 Lic. No,2-6/
Check # 1,3 Z.-
..............................................
PLUMBING INSPECTOR
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CjTY 1 1 12
MA DATE PERMIT#.
JOBSITE ADDRESS achkA-4-0—WNER'S NAME
OWNER ADDRESS, TEL[ JIFAXE---- --11
OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL
NEW: 0 RENOVATION: Eq REPLACEMENT: B---�
FIXTURES -1 FLOOR- BSM
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS10IL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM F—
DISHWASHER FT
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
6THER F I
2 1 3 1 4 1 5 1 6
RESIDENTIAL 2 ----
PLANS SUBMITTED: YES Ell NO
7 1 8 1 9 1 10 1 11 1 12 1 13 1 14
A INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 9-- �00
IF-TOU CHECKED YES, PLEASE INDICATE THE7601 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY Ell BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [2 AGENT 101
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledg(
and that all plumbing work and installations performed under the permit issued for this application Will be in complianc with all P rt* t of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME trP�g--
C�q LICENSE# SIGNATUR�--
MP 01 ip 9--,
CORPORATION Flj# PARTNERSHIP P -A LLC U�
COMPANY NAME jj-�, .7-ji ADDRESS RA
CITY STATE ZIP TEL
=C� A� 4 Fin
FAX CELL EMAIL
m
LLJ
(mx
w
uj
U-
l4k
The Commonwealth ofMassachusetts
Department of IndustriqlAcclk�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
Uir www.mass.gov1dia
. Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Legib
Name (Business/Organization/Individual): I/Lo 0 0 J
Address: 40,P �V
Phone 4:
City/Stat 6 (`(4_71
YJ FJ -3 - 7 ? *?-(:D
Are you an employer? Check the appropriate box:
Type of project (required):
I -Q I am a employer with
4. EJ I am a general contractor and 1
6. EMe—wconstraction
employees (M and/or part-time),*
2. LL,?T am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. t
7. [2grmndaling
ship and'have no employees
These sub -contractors have
8. El Demolition
working for me in any capacity.
workers' comp. 'insurance.
5. El We are a corporation and its
9. E] Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10 -El Electrical repairs or additions
3. 1 am a homeowner doing all work
F1
right of exemption per MGL
11. E] Plumbing repairs or additions
myself. [No workers' comp.
C. 152, § 1(4), and we have no
12.El Roof repairs
insurance required.] t
employees. [No workers'
13FJ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they ftie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers'compensadon insuranceformy employees. Below isthepolley andjoh site
information.
Insurance Company Name:.
Policy # or Self -ins. Lie. 9: Expiration Date:
Job Site
City/state/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby e information provided bqeistr eandcorrect.
/ e , K r
Signature: Date:
Phone, 9: E�_
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 N:
Information and Instrutions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhire,.
express or implied, oral or written."
An employeils defined as "an individual, partnership, 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 be 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 the 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. Be advised that this affidavit maybe submitted to the, Department of Industrial
Accidents for confumationof insurance coverage. Also be sure to sign and date the affidavit. 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 required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should 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.
Pleas ' a be sure to fill in the permit/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 fature permits or licenses. A now 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any guestions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwalth. of Massachusetts
Department ofladustdal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel # 617-7274900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
6
0
Date ....... ; ..... �/z0.(meo*o0`-/-i0-"t . . ....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ................... / .................. �1�. ... ....... ..................................
has permission for gas installation ........
in the buildings of .... A4 .. ��
ats�P5J ......... ........ . ................ . North Andover, Mass.
Fee)6 .... . ...... Lic. No.Zq((P.o ...... Z
...................................................
GASINSPECTOR
Check #*7-z)
9.069/5-P
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I h4ve a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF C�� CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j 13OND
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.
117m]
CHECK ONE ONLY: OWNER El AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with aILPe Pnent prgyrsion ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'C= ,,, -7-
PLUM BER-GASFITTER NAME - or-na-5 _UQ-Vrz,,1-L0- I LICENSE #L:��jf7U-SIGNATURE
MP 0 MGF JP JGF LPGI
COMPANY NAME:
CITY
eV 5
FAX 11 CELLI -11
CORPORATION [J# = PARTNERSHIP
ADDRESS
STATE ZIP TEL
!z) W
,?-b -
LLC [J# =I
E
a,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITT NG WORK
CITY
MA DATE _L& PERMIT# 6-1
JOBSITE ADDRESS
OWNER�S NAME C!
OWNERADDRESS
TE __JFAX —7
TYPE OR
'PMT
OCCUPANCYTYPE
COMMERCIAL
EDUCATIONAL [j RESIDENTIAL
CLEARLY I
NEW:E1. RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES FO NOQ--
1z
APPLIANCES I FLOORS-
BSM 1 2
3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
Jj
DIRECT VENT HEATER
DRYER
L
FIREPLACE
FRYOLATOR
FURNACE
I
L j
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I h4ve a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF C�� CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j 13OND
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.
117m]
CHECK ONE ONLY: OWNER El AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with aILPe Pnent prgyrsion ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'C= ,,, -7-
PLUM BER-GASFITTER NAME - or-na-5 _UQ-Vrz,,1-L0- I LICENSE #L:��jf7U-SIGNATURE
MP 0 MGF JP JGF LPGI
COMPANY NAME:
CITY
eV 5
FAX 11 CELLI -11
CORPORATION [J# = PARTNERSHIP
ADDRESS
STATE ZIP TEL
!z) W
,?-b -
LLC [J# =I
E
a,
-"j ,
CD
0 w
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u w
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0
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1,
10387
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that...
has pennission to perforra ................. I ..................................................... �A
..........................
plumbing in the buildi . ngs of .......... i?:;%� [L—VA C- J
...................................................................................
at ..... .... 2 .......... ) .... I ............ 0 ....... VII.S.. ..... 5 ............ .... e ............................ North Andover, Mass.
Fee......... Lic. No. 2,,qlkQ. .4 . ................................................................
PLUMBING INSPECTOR
Check #
2�1-flH
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
MA
DATE
PERMIT#,
JOBSITE ADDRESS
OWNER'S NAME
3
OWNER ADDRESS TEL
P _ JJFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E9 EDUCATIONAL RESIDENTIALZ��
PRINT
CLEARLY NEW: RENOVATION: 2' REPLACEMENT: Ell PLANS SUBMITTED: YES EO NO
FIXTURES -1 FLOOR- BSM
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTE
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
67THE—R F
m���w
INSURANCE COVERAGE:
have a current insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES R-`N�00
IF YOU CHECKED YES, PLEASE INDICATE TH COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
41
LIABILITY INSURANCE POLICY ;;�� OTHER TYPE OF INDEMNITY D 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.
CHECKONEONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the pen -nit issued for this application will be in compllaDLce-voT all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME U lipmua SIGNATURE
----IILICENSE #
MP Ell ipa, CORPORATION F1J# PARTNERSHIPD# LLC
COMPANY NAME ADDRESS —J
C1 STATE PIT, I ZIP TEL
37,
N/- OVA 'A
FAX ]CELL[ JA,\%AV 5
11 EMAIL I
11
o
ce
w
IL
LU
F-
LU
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w
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0
IL
a.
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LL
Are you an employer? Check the appropriate box: Type of project (required):
.1.0 1 am a employer with 4. El I am a general contractor and 1 6. D NUw construction
em es (full and/or part-time).* have hired the sub -contractors
2. L4Wam. a sole proprietor or partner- listed on the attached sheet. t 7. QaZiliodeling
ship and'have no employees These sub -contractors have 8. E] Demolition
working for me in any capacity. workers' comp. insurance. I
[No workers' comp. insurance 5. El We are a corporation and its 9. E] Building addition
required.] officers have exercised their 10.E1 Electrical repairs or additions
3.01 am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. F1 Roof repairs
insurance required.] t employees. [No workers' 131� Other
comp. insurance required.]
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached anidditional. sheet showing the name of the stib-contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insuranceformy employees. Below is thepolley andjoh site
information.
Insurance Company N
Policy # or Self -ins. Lic. #:,
Job Site
Expiration Date;
Pty/State1h):
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required. under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or oner-year imprisonment, a's well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of ffie DIA for insurance coverage verification.
I do hereby cert&
p en alties ofperjury th at th e information pro vided ab o v9is tru 9 an d correct.
C)
Official use only. Do not write in this area, to he completed by city or town official,
City or Town:
PermittLicense 0
M
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
The Commonwealth ofMassachusetts
Department ofJndustrialAM6�ts
Office of Investigations
qu
600 Washington Street
Boston., MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansfplumbers
Applicant Information
Please Print Legibly
Name (Business/Organizationffndividual): 7�6 a2 -nf 06 _0
Address:
City/State/Zip:
U 1—,-2 � FT3
Are you an employer? Check the appropriate box: Type of project (required):
.1.0 1 am a employer with 4. El I am a general contractor and 1 6. D NUw construction
em es (full and/or part-time).* have hired the sub -contractors
2. L4Wam. a sole proprietor or partner- listed on the attached sheet. t 7. QaZiliodeling
ship and'have no employees These sub -contractors have 8. E] Demolition
working for me in any capacity. workers' comp. insurance. I
[No workers' comp. insurance 5. El We are a corporation and its 9. E] Building addition
required.] officers have exercised their 10.E1 Electrical repairs or additions
3.01 am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. F1 Roof repairs
insurance required.] t employees. [No workers' 131� Other
comp. insurance required.]
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached anidditional. sheet showing the name of the stib-contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insuranceformy employees. Below is thepolley andjoh site
information.
Insurance Company N
Policy # or Self -ins. Lic. #:,
Job Site
Expiration Date;
Pty/State1h):
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required. under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or oner-year imprisonment, a's well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of ffie DIA for insurance coverage verification.
I do hereby cert&
p en alties ofperjury th at th e information pro vided ab o v9is tru 9 an d correct.
C)
Official use only. Do not write in this area, to he completed by city or town official,
City or Town:
PermittLicense 0
M
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 and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhire,.
express or implied, oral or written."
An employeiis defined as "an individual, partnership, 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 shallnot because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local lie-ensing 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 requ-ired."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivi , sions shall
enter into any contract for the performance ofpublic 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 the 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. Be advised that thi's affidavit maybe submitted to the Department of Industrial
Accidents for confirmationof insurance coverage. Also be sure to sign and date the affidavit 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 required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should 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.
Pleas ' e be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/liceiise applications in any given yearreed 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 now 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 p* ermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho Comm.onwealth of Mossachusputts
Department of Industdal Accidents
Office of Investigations
600 Washington Street
BostoA MA 021 It
Tel # 617-727-4900 eyd 406 or 1-877,7MASSAFE
Revised 5-26-05 Fax # 617-727-7749
_wwwmass,gov/dia
C
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C. 1$.Ett
:1 -IC-OMM6NWEALTH OF MA
SSAC
MIR -
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MA�A I
TORSFIELD -
05/01/14
Fold, Then Detach Along All perforations
F),
Location
A)
No. To &3A"Ij Date Z,57�Ilx
TOWN OF NORTH AND19VER
Certificate of Occupancy $
Building/Frame Permit Fe $
e
AC Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
6 u ilding fnspecror
12/18/95 14:36 V4. 00 pAID
9470 Div. Public Works
PER'lfff NO.
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE I I
MAP 4-40. LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
ZON E SUB DIV. LOT NO.
LOCATION .4
RA &S VE
PURPOSE OF BUILDING ejov'<10to
R,
OWNER'S NAME VoAld.A WemM
NO. OF STORIES SIZE
OWNER'S ADDRESSvZqj MAMCWTiMS AVv�U&
BASEMENT OR SLAB bASA;MENT
ARCHITECT'S NAME 42-
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME 161-
SPAN
DIMENSIONS OF SILLS
DISTANCE TO NEAREST BUILDING
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION
THICKNESS
IS BUILDING NEW t4i
SIZE OF FOOTING
x
IS BUILDING ADDITION �l 0
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION vgs
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
yla
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE Y,"CS-
INSTRUCTIONS �j (+ 0*1= kTic, gPk�
SEE BOTH SIDES To MAKE -Gk�D;?alOs
OA
PAGE I FILL OUT SECTIONS I - 3 PlAy�[(T-CE 5'TojQnL&
IV%
PAGE 2 FILL OUT SECTIONS I - t2
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
DA
SIGNATURE OF OWNER CfR AUtHORIZED AGENT
IWO
F E E d!b A
PERMIT GRANTED
19
----------
DEC
3 PROPERTY INFORMATION
LAND COST
EST. B DG. COST
.iloo
EST. Of DG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
4OWNERTEL4 -61�4R-
CONTR. TEL. #
CONTR. LIC. #
t8*'- 4pateewwwa AQMPt%.
PLAS� :o
co��� m-koll Am, *�sw& X&
OF. PegAovqv — ItAeuydL INA
LAMY- CAN-� ft X*jk��
#
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY SiOkIES THIS SECTION MUST SHOW EXACT DIMENSIONS 0 . F LOT AND DISTANCE FROM
MULTI. FAMILY LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION
8 INTERIOR
FINISH
CONCRETE
PINE
HARDW D
3
2 13
CONCRETE BL'K.
BRICK OR STONE
PIERS
PLASTER
DRY WALL
—UNFIN
3 BASEMENT
AREA FULL
1/1 1/2 1/1
FIN. B M T AREA
FIN. ATTIC AREA
t!O 8 M T
HEAD ROOM
FIRE PLACES
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
V
I
3
DROP SIDING
WOOD SHINGLES
CONCRETE
-EARTH
ASPHALT SIDING
ASBESTOS SIDING—
VERT. SIDING
STUCCO ON MASONRY
�TA—RDVJD
COMIACN
ASPH. TILE
STUCCO ON FRAME
gRIU-UN"WASZ)F4RY
BRICK ON FRAME
ATTIC STRS. & FLOOR
CONC. OR CINDER BLK.
WINING
STONE ON MASONRY
STONE ON FRAME_
SUPERIOR IVI POOR A—
ADEQUATE I I NONE
10 PLUMBING
5 ROOF
GABLE
IP
IP
BATH 13 FIX.)
GAMBREL]
MANSARD
TOILET RM. (2 FIX.)
�L—A`Tl�
SHED
WATER CLOSET
ASPHALT SHINGLES
V
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
I
TAR & GRAVEL
L SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER EMS. & COLS.
STEAM
STEEL EMS. & CO[S--
T W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
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TOWN of NORTH ANDOVER'
AFFIDAVIT
Eine bFmmfft Qrtmctw law
A =]Mrt tD Pamik ApAicaticn
�M c- 142 A reqdizes dat the "r, - - r tstnr, tia:4 altemtim. muyaticr4 mpecir, uniMMi7atim, convecsim,
zqzuAmat, reMMI, dmialituxi, ar caBb=tdm of m adlaim to any pm- eastug a4o�4� bmld-
irg cmtYwirg at lewt cne hit mt mxe dm fcur deMirg u[dts ... cr to sbactices 4dch are adjacent to
adi residEFM cr hnldbV' be dxe by nWsteLmd catmrt=, with certm ecq*i=, alcrg Affi odEr
rmlirenmts.
Tvpe of Work:
Address of
Owner Name:
Est. Cost 171m
Date of Permit Application: 14, 9�1 ��_
I hereby certify that:
Registration is not required for the following reason(s): Fcr of Eire Use Only
Work excluded by law Fb7dt th.
-Job under $1,000 Date
.-;IA-;-- riot owner -occupied
145
=ainer pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLI% UM OWN PERMTIC OR DEALIM WM UNREIGISIERED ODNTRA=RS--
FOR APPLICABLE HOME RdW�DM WORK DO NOT HAVE ACCESS TO THE ARBMA-
TION PROMM OR GUARAN1Y FUND UNDER MGL c. 142A.
Signd u -d-- pemlties of perlmy:
I hereby apply for a permit as the agent of the owner:
Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply. for a permit as the
owner of the above p
/W1_V1 ZL
Date
Town of North Andover
� OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
KENNETH R. MAHONY
Director
Please print.
DATE Z�"
JOB LOC.�.TION
Number
"HOMEOWNER"
Name
PIRESEN'T 'MAILING ADDRESS
146 Main Street
North Andover, Massachusetts 0 1845
(508) 688-9533
HC%[EO�-VNEIR LICENSE E.X.E.MPTION
City/Town
Street address
ell �0/4
Home phone
S tate
"I. L�l
Section of town
Work phone
Zip code
The current exemption for "homeowners?' was ex*ended to include owner -occupied dwellings
a
of six units or less and to allow sucli Homeowner,,-: to encage an individual for hire who does
0 0
not possess a license, provided that the owner acts as supervisor. (State Building Code Sec-
tion 109.1.1)
DEFINITION OF HOMEOWNER,:
Person(s) who owns a parcel ot land on which he. -'she resides or intends to reside, on which
there is, or is intended to be, a one to six family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who. constructs more than one home in a
two-year period shall not be considered a homeow-ner . Such "homeowner" shall submit to
the Buildina Official, on a form acceptable to the Buildina Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
a
The undersi-ned "homeowner" assumes res7oonsibilitv for compliance with the State Buildin-
Code and other applicable codes. by.laws. rules amd regulations.
The undersianed "homeowner" certifies that he,,'sHe understands the Town of t%o. Andover
0
Building Department minimum inspec . don procedures and requirements and that he/she will
complv with said procedures and reauL-ements.
HUMEOWNER'S SIGNATURE
.-XPIIROVAL OF BUILDING OFFICLU
Note: Three familv dwellin-s 35,000 cubic feet, or larger, will be required to Comply with
State Building Co�e Sectionc' 127.0, Construction Control.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 689-9540 PLANNING 688-9535
Julie Partino D. Robert Ni Ifichael Howard Sandra Starr Kadileen Bradley Co1weU
w. -X,
Office Si
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V
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mun CIL 1M H Umwaw -permit No.
4
Eltimrhund Of 11U -2
hik ift Occupancy A Fee Chocked
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3M peave blank)
BOARD OF FIRE PREVWON REGUUMONS 527 OIR 12.00
APPLICATION FOR PERMIT -PERFORM ELECTRICAL"W ORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:0
(PLEASE PRINT IN INK OR TYPE ALL INFORMkhON) Date -
Q% or Town of I NORTH ANI)OVER To the inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 121 AS-LAC-4ugEM
OwnerorlbTm4u- LRL k NC_k2AAN_-t_1---
Owner's Address ��VF?W�E:
Is this permit in conjunction with a building permit: Yes No El (Check Appropriate Box)
L Puroose of Building Utility Authorization No.
Undgrnd No. of Meters
Existing Service Q 1) Amps 2AaJ_L2L_V0Its Overhead
New Service Amps -Vaits Overhead Undgrnd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Eec*rical Work
No. at Lighting Outlets :I No. of '7ransformers Total
KVA
No. of Hat 7,.;-.
1
i Swimming Pcoi At:cve— In- -7
No. of Lighting Fixtures g M 0. grnd. Generators KVA
No. at Emergency Lighting
-No. of Recectacie Outlets No- at Cil Burners Battery Units
-NO. Of Switch Outlets No. at Gas Burners FIRE ALARMS No. of Zones
lotat No. at Cetection and
No* ,I Ranges No. at Air Cona. I
ons Initiating Devices
L
No. of Disoosals No.of I ieat 7btai otai
Pumas '7ons KI.V No. of Scunding Devices
No. at eif Contained
No. of Dishwashers Scace/Are a Heating KW Detec-:cn/Sounding Devices
Munic;oa
No. at Dryers Heating Cevices ?CVV -Locai i " .'
I Connection
I No. of No. of Low Voitage
No. of Water Heaters KW Signs Sailasts Wiring
No. Hydra Massage -tubs No. of Motors -iotal HP
CTHER:
INSURANCE COVERAGE. PuNuant *,a the reouirements at Massacr-userts; general Laws
y inc!ucing Camc:etec C
I have a current Liaciiity Insurance Potic oeraticns Coverage or its suostantial equivalent. YES
have submitted valid proof at same to the Office. YES Z NO Z it you have checked YES. please indicate the type of coverage by
checking the appropriate box.
INSURANCE �_ BOND �_- OTHER :: (Please Scec-.ty) (Expiration Datei
1 1 -7<,) n
Estimated Value of E1117cal Work S CJ
Work to Start I Insciecion Date Recuested: Rough Final
Signed under the Penalties of perjury,
FIRM NAME LIC. NO.
Licensee T,\", -J P, Signature -D. L _UC. NO. Z ( 5ro 3
el ( Bus. -ei. No.
s s 26L 4 Li Alt. Tel. No.
Addre
CWNER'S INSURANCE WAIVER: I am aware that me Licensee does not have the insurance coverage or its 3ubstantiaf equivalent as re-
qu,,e,o - cmusetts General Laws. and that my signature on Vus permit application waives this requiremem Owner Agent
-a
s
by a
E . . - '4
P1.
ease one)
_ /�1'4? I YY Teteonone No. PERM[T FEE S
/(Sigriature of owner or Agent)
T2
2756
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that .....
ko
has permission to perform ....... ....... I ........... .......... Xkddflf.�U
wiring inthe building of .... 1?) MO. ............................
.......................
at ..... ;��/l ......... VV�-q-S$ ...... -A. ..................... . North Andover, Mass.
......... ........................................... ...... ............
FelNd,-00. Lic.Nod..::�9�-'�())
ELECTRICAL INSPECTOR
C 9- � 6 a
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN'G
(Print or Type)
NORTH ANDOVER Mass.
-S
4uilding Location Date ///9 9 /�
-5:r Permit
Owners Name e4r/ igAekw 4,k)
New 77 Renovation Replacement Plans Submitted
PIX; UP=IZ
(Print or Type)
Check one: Certificate
Installing Company Name _
061 rd N
L D oL6 = Corp.
Address MC-A00k]
-LANE
Partner.
N 12 6 (,cE
Firm/Co.
Business Telephone:
Name of Licensed Plumber
or Cas Fitter
81
Insurancp Coverag Indicate
t."e type of insurance coverage by checking the
appropriate box:
Liability insurance policy
= Other type of
indemnity = Bond Ej
Insurance Waiver: I, the
undersigned, have
been made aware that the licensee of
this application does njot have any one of the
above three insurance coverages.
-of property
Owner MXAgent 0
Signatu're of 6'wner/agen-t
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13ASEME111T
I ST FLOOR
ZHD FLOOR
3RD FLOOR
4TR FLOOR
:STKFLOOR
6THFLOOR
7TKFLOOR
STH FLOOR
(Print or Type)
Check one: Certificate
Installing Company Name _
061 rd N
L D oL6 = Corp.
Address MC-A00k]
-LANE
Partner.
N 12 6 (,cE
Firm/Co.
Business Telephone:
Name of Licensed Plumber
or Cas Fitter
81
Insurancp Coverag Indicate
t."e type of insurance coverage by checking the
appropriate box:
Liability insurance policy
= Other type of
indemnity = Bond Ej
Insurance Waiver: I, the
undersigned, have
been made aware that the licensee of
this application does njot have any one of the
above three insurance coverages.
-of property
Owner MXAgent 0
Signatu're of 6'wner/agen-t
0*4
I hctcby certiry that all of the dcuils and information I have submitted (or entered) in above application are true and accurate to the belt of my
knowledge and tlLat all plumbing work and InitAdations 7=rfo=cd undcr- ftn-xit izzutd foz this appLication wiU be in compLiance with ad pertinent
provisions or the Massachusetts Stale Gas rode and Chapter 14'. of the Cenerzi Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY1
TYPE LICENSE r
Plumber -,0— --U--icensed
Gasfitter Signature of -L
Mast-er Plumber or Gasfitter
ourneyman
Lit�ense Number
r
Date. .
'01 T ghAr
14- 41 19 3
TOWN OF NORTH ANDOVER
PERMIT FOR GAI.
T1
This certifies that ............
has permission for gas instmilatio ... ...... 1,
in the builLdA*ngslof ... . . .... ...... I .................. -
I
at .3 ............. North� Andover, Mass.
Fee. Lic. No.. . . ............ ...........
-GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
nAAS�AC'1oj--31z=S UNIFORM APPLICATION FOR PERMIT TO 00 G
ASFITTING
(Print or Type)
NORTH ANDOVER Mass. Date
�uilding Location NZU57
Perm -it # 0?
Owners Name C"qIQ 4ecleeloo-1
New :-K Renovation T] Replacement Plans Sul�mitted_,M
Fly llP=1z A1,dw#4-QaA
(Print or Type) Check one: Certificate
Installing Company Name lel-
F� Corp.
Address- E] Partner.
— IL9611 tozz 5P Firm/Co.
Business Telephone: 5-01? X15-17 '21X�l
Name of Licensed Plumber or Gas Fitter ,7-//-/
Insurancp Coverag Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy [Y�j Other type of indemnity D Bond Ej
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner F-] Agent F7
I hereby certify that ail of the dcuils and infoirnXtion I haye submit(ed (or entered) in above application are true and accurate to the best of my
knowledge and that &U plumbing work and LnicadAtions Peffornied Undex'Fetmit itmed [oz this appLicWon wHI-be-in compliance with all patinent
provisions of the Wssachusetts S(ateGas Code snd Chapter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
.TYPE LICENSE:
Plumber
Gasfitter gnatu f Licensed
Master Plumber or Gasfitter
Journeyman
L-1 License Number
111115711111311
(Print or Type) Check one: Certificate
Installing Company Name lel-
F� Corp.
Address- E] Partner.
— IL9611 tozz 5P Firm/Co.
Business Telephone: 5-01? X15-17 '21X�l
Name of Licensed Plumber or Gas Fitter ,7-//-/
Insurancp Coverag Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy [Y�j Other type of indemnity D Bond Ej
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner F-] Agent F7
I hereby certify that ail of the dcuils and infoirnXtion I haye submit(ed (or entered) in above application are true and accurate to the best of my
knowledge and that &U plumbing work and LnicadAtions Peffornied Undex'Fetmit itmed [oz this appLicWon wHI-be-in compliance with all patinent
provisions of the Wssachusetts S(ateGas Code snd Chapter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
.TYPE LICENSE:
Plumber
Gasfitter gnatu f Licensed
Master Plumber or Gasfitter
Journeyman
L-1 License Number
Date.....................
ORT01 TOWN OF NORTH ANDOVER
6
PERMIT FOR GAS INSTALLATION
�J OA
I ,VS C S
SS
This certifies that ........ .
............................. .......
has permission for gas, installation .......
in the buildings of ..........
..................................
at .... ..... �/ ............ North Andover, Mass.
Fee..��.,. Lic. No'? � �
..... ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
Bay State Gas Company
GAS INSTALLATION AUTHORIZATION
--Date
Issued toF-S-A., URI" Z,
- 146�
Address Q,u A&, 1164�� 1
For Installation of: /��Jq-s C'r
BTU Input aw
Restrictions
PERMIT ISSUED
BSG Representative
�-n
INSPECTOR
This Portion of Authorization To Be Returned to BSG.
Inspection Has Been Made of the Following Gas Equipment:
0 Heating System (BTU Input 0 Range
0 Water Heater 0 Clothes Dryer
0 Room Heater
Location
All Work Has Been Done In Accordance With The Massachusetts
State Gas Code And Is Ready For Use.
INS
4r
NO POsTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY CARD
FIRST CLASS PERMIT NO. 721 LAWRENCE, MA
POSTAGE WILL BE PAID BY ADDRESSEE
BAY STATE GAS COMPANY
ATTN: SALES DEPT.
55 Marston Street
Lawrence, MA 01B40