Loading...
HomeMy WebLinkAboutMiscellaneous - 301 SUMMER STREET 4/30/2018 (2) 301 SUMMER STREET 210/107.A-0170 0000.0 i Date. A NORTH 3?04.� •°;;._1�a0 TOWN OF NORTH ANDOVER, PERMIT FOR PLUMBING/ 49 ,SSACHUS� - �3i This certifies that . . . . . t ' . .�. . . . . . . . . .? .. . (f . . . . . . . . . . z has permission to perform . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . � plumbing in the buildings of . . 1�:. . . . . . . . . . . . . . . . . . . . at . . . i. (. Sc , North Andover, Mass. Fee,, . . . . .Lic. No.. Z ,C:3. . . . . . . . . . . . . - -. . . . . . . . . . PLUMBING INSPECTOR Check # ' 834 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS d Date Building Location 3 > SU/PJ M� 5TOwners Name S?,llb •7f4y/ Permit# Amount Type of Occupancy New RenovationReplacement ® Plans Submitted Yes No M FIXTURES rA aCn I E� SIMM $ri411i ,1FNj' IS'I:FLOOR r M FLOOR 3WIFLOOR 4IH HDM 5IR FLOfR 6TH HDCR 7M HIM SIH Rfm 1 #1 (Print or type) Check one: Certificate Installing Company Name �t*U_Olf4Al o Corp. Address /lop, /SOX ® Partner.• A1/4 Business Telephone ® Finn/Co. Name of Licensed Plumber. Insurance Coverao: .Indicate-the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ® Bond Insurance Waiver I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumb�e and Chapter 142 of the General Laws. By: signature of Licensea Fiumner Type of Plumbing License Title 0 3 City/Town ►cense um er Master Journeyman APPROVED(OFFICE USE ONLY Date. 77/.L . ..... r * NORTH 1 3�0 e ` TOWN.OF NORTH ANDOVER/' / • - PERMIT FOR GAS INSTALLATION .� • �a i °^• o�''��y SAc HUSEt This certifies that . . . . .!.e . . . . .l4. v . . . � f has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . .. C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ./. . .� E x �:z .'. . . . . ., North Andover, Mass. Fee, . . "" Lic. No:.z.`.f )- . . . . . . . . . . . . . GAS INSPECTOR Check# , ) 7064. MASSACHUSE ITS UNIFORM APPUCATON FOR PIItMIT TO DO GAS F MNG (Type or print) Date NORTH ANDOVER,MMSACHUSETTS Building Locations 30/ J U M oir� ST Permit# s7-e V d I ��/�pC Owners Name Amount$ New❑ Renovation ❑ Replacement �( Plans Submitted ❑ rA a 0 C z0 z a p YJ F y 0 W Gv� R'i U d Z F a a' > . Cw7 H x C F W Q Q pp Gam.: rig C'j O x 3 A ta7 U a0G > 0 0 F SUB-BASEM ENT BASEMENT 1 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Cmc one: Certificate Installing Company Name, T 11/4 G L DL1 Corp. Address . d 63 d X S 7,R, .� ❑ Partner. GI w oz e,n1 r e Business Telephone 9 7 rf to b'S' 9 So`� �__ ❑ Fum/Co. Name of Licensed Plumber or Gas Fitter 7'V d,i ars INSURANCE COVERAGE Check one. I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ Ifyou have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the insurance coverage required by Chapter 142 ofthe Mass.General Laws,and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ r hereby certify that all ofthe details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Glias/Code an Chapter 142 ofthe General Laws. • - By: Signature of Licensed Plumber Or Gas Fitter Title ® Plumber a Y f 33 4 City/Town 0 Gas Fitter License Number ❑ Master APPROVED(oFFia vsE ONLY) ® Journeyman r Location , '" L No. Date t • I ,40R71y TOWN OF NORTH ANDOVER Ottt�■° , �.y O? • '• 00� p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ sAcHusO Other Permit Fee $ RECEIVED RAMEMIRection Fee $ Water Connection Fee $ JUN % was $ No.Andover Collector Building Inspector Div. Public Works PER111T NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP i-40. LOT NO. 2 RECORD OF OWNERSHIP IDATEiPAGE ZONE I SUB DIV. LOT NO. ��� �'� vI ,I LOCATION PURPOSE OF BUILDING OWNER'S NAME ,�,^ NO. OF STORIES SIZE �+ OWNER'S ADDRESS _ d/, _- r - BASEMENT OR SLAB ARCHITECT'S NAME �/> SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 6� I� SPAN DISTANCE TO NEAREST BUILDING o DIMENSIONS OF SILLS 94 DISTANCE FROM STREET Gr ,/� "' POSTS DISTANCE FROM LOT LINES—SIDES REAR �s "' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS - IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION ky IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD'OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE ..p INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST r PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE&FLED +\ � BOARD OF HEALTH 1 R O O ED AGENT �'I OWNER TEL# Qf �j F E E � . �-'C� CONTR.TEL.# CONTR.LIC.# PLANNING BOARD PERMIT GRA BOARD OF SELECTMEN BUILDI I ECTOR BUILDING RECORD 1 OCCUPANCY '12 _ SINGLE FAMILY I S-ORIES THIS SECTION MUST SHOW..EXACT'DIMENSIONS0F LOT�AND DISTANCE FROM �. MULTI. FAMILY OFFICES _ 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 _ 3 1 2 13 CONCRETE 81.K6 PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 'L 1/1 °/, FIN. ATTIC AREA _ No B M FIRE PLACES _ HEAD ROOM _ MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D _ ASBESTOS SIDING _ COM/ACN VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I-I POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ r" TILE FLOOR TILE DADO " 6 FRAMING 11 HEATING ��----— ---•---— I 4 J 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 GAS OIL E'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING' t " i1 1 Date....1.2.. .1..9.7.06 �. 4 + kORT" TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,sSACMUs� �/` .. This certifies that ................. ................�...............�. ... ............................ has permission to perform ............. SsST�� ................. ............... wiring in the building of.......... u- ................................................. ��/�1 5.7 ,North Andover,Mass. Fee... �. .. Lic.No. �� ..4e ..... ... ...... ELECTRICALINSPECTOR Check # _� 7106 -M"'\ Lommonweairn or massacnusetts utticial Use unly Department of Fire Services Permit No. lzb lo BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupancy and Fee Checked 9/051 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC ,5271 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ,� pfv City or Town of: NORTH ANDOVER To the Inspctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrica work described below. Location(Street& Number) 30f Owner or Tenant /Ci/¢, e rl 00K -VWIfi j Telephone No.�k �9,2 Owner's Address Is this permit in conjunction with a building permit? YesNo ❑ (Check Appropriate Box) Purpose of Building S/yam � j /L� Utility Authorization No. Existing Service+� Amps / ?�yOVolts Overhead nn�Und rd � Lg ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA L No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- ❑ o.o mergency ighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of.Detection an Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eat um m er K Totalsuons o.oSelf-Contained Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipaI . ❑ Other Connection No.of Dryers Heating Appliances KW Security ystems: No.of Devices or Equivalent No.o KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP a ecommunicationsWiring: No.of Devices or Equivalent f OTHER: Estimated Value of Electrical Work: ��1� Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: 4/Vz�& Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE AGE: 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 that such co verin force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) /certify,under the pains and penalties of perjury,that lite information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: /f 2 — /,vC�� y�! Signature LIC. NO.:6LK� (If applicablT ter "exempt"in the license number line.) Bus.Tel. No.: Address: Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ f' Date. .4. �. .. .... .. NORTH TOWN OF NORTH ANDOVER • . PERMIT FOR GAS INSTALLATION � r • V �9SSAfHusEt Y This certifies that . . . r .;�.f !�`1'. . . . . . . . . . . . . . . . . . has permission for gas installation . .TJ r.�. . . . . . . . . . . . . . . . . . . . . in the buildings of . . 5. !. !' t.. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . .. North Andover, Mass. Fee.•7P.,. ' Lic. No.. AS INSPECTOR Check# 5674 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) , &)nl2TH k 60-V CL , Mass. Date Permit #_�� 7 Building Location 301 Su"h t z ST Owner's Name.TONN &W JC,/ SW i 1=T h� -- QOETH A000V6F- NA Type of Occupancy Y2 C-5100iTIAL- New ❑ Renovation ❑ Replacements Plans Submitted: Yes❑ No ❑ N a N W N Y Z Q N N N U CC }. (n a: N d O N W WW U m f" Z Vl 0 _ J O W ~ Q CC Z O r W 4 ¢ O O F m of4 y W O a � m' OC N O W a = z f' O > W N !L' W Z U W N W 6 cc cc WF. C C7 f- 2 j F- X W W O O > W }- U J ��. W Z q W Q � F' >• N pp Z O 2 W O 111 X < W > OC W D Z, < W Q Q O O W O W P SUB—BSMT. R BASEMENT ISTFLOOR 2ND FLOOR I 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # AddrCss 55 MARSTON STREET DC7 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 7 b'6 8,7-110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have aY usrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accurAte to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ BY T e of License: Plumber Signature of Licensed Plumber or Gas 0— Title Gasfitter Master License Number 374.5 City/Town Journeyman _ APPROVED(OFFICE USE ONL BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION FINAL INSPECTION SKETCHES FEE �1 N0. ~ APPLICATION FOR PERMIT TO DO GASFITTING NAME ZE TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE -�9 GASINSPECTOR Locationp R ,) No. ®a Date �ORTh TOWN OF NORTH ANDOVER 3? � •BOOL F ♦ » Certificate of Occupancy $ ScMus t� Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ o f Check # 16525 L/ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMrOLIISHH'A ONE OR TWO FAMILY DWELLING :.:.. ;..- x % � � •;� .�,.�,,..�.�,�. s�. ;,x ��`#+di`V?�, ��'�.'ilai� -.*?R.�'.��. � � 2�-':si'�� �„�c P �, ^d c BUILDING PERMIT NUMBER: DATE ISSUED: r SIGNATURE: Building Commissioner/InspectKi of Buildings Date SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: / /b Awcl6upa 4'i ss Map umber Parcel Number O 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dian d Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner oor . SLUT I\ ,. - t —jo f gum C�c S�r Name(Print Address for Service: \ -3 S2 Q 2... Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Si na re Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Lice Construction Supe ry or: Not Applicable ❑ Licensed Construction Supervisor: SO -7 ,5-9- O 75 00Ckn n rwc C(/t /C- License Numbermn Add (/ -200"1 )4 0o Expiration Date Signature TelephoneU < r 3.2 Registemd Home Improve ent Contractor Not Applicable ❑ v Companyame ( Z !9 5 ©s rn 7 6' C°6c- J,A# WC- 01 RC7L� � l ,/�l,(� Registration Number rM Add re �j � ���` Ct L�� Expiration Date ( ^z Signature Telephone Yw SECTION 4-WORKERS COMPENSATION(RG.L C 152 § 25c(6) 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 of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) t7-' Addition 0 Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: Cpi&p c l6 A4 t& qcvcV SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 00 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e) X(b) 4 Mechanical HVAC D 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 I, ,as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf.in all matters relative to work authorized by this building pernut application. Signature of Owner Date SECTION 7b OWNER/AUUTHORIZED AGENT DECLARATION I, ,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 beh Print Nan Signature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T1IVIBERS IST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I-Il-EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHNWEY IS BUILDING ON SOLID OR FILLED LAND IS 13UILDING CONNECTED TO NATURAL GAS LINE ♦�^_�IT�{+'�.=�"� � / t'� T e V®F�CirQJ" as Y S/Y/ t'!a���Y Y Yl.�ir.+/1�'���A��'I 1= a r 71 Board of Building Regulations - g One Ashburton Place, Rm 1301 Boston; Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/02/1949 Number: CS 075364 Expires: 10/02/2004 Restricted To: 00 RONALD P GAGNON 75 COCHRANE CIRCLE METHUEN, MA 01844 Tr.no: 3673 Keep top for receipt and change of address notification. , t �7?I3 - ..' BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 075384 Birthdate: 10/02/1949 x Expires: 10/02/2004 Tr.no: 75384 Restricted To; 00 RONALD P GAGNON r 75 COCHRANE CIRCLES / . METHUEN, MA 01844 Administrator J �. _ w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ,a Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: 4&A),%q A 6 400 Location: C; SS Phone # V� 3 S Z I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address city Phone# Insurance:Co. Pollee# Company name: -7A--i Address �ify' ( ►r`� c �' 0114 11�-U Phone Insurance.Co. tins Poli # -7 P `1 �"°� q2�4S3 Failure to secure coverage as nequired under Seddon 25A or=152 can lead to the imposition of criminal penalties ora fine up:to$'t.5(0.0p and/or one years'imprisormeint-s_welLas_ciW penaluesinibelcun-faSTDPY OM ORDERmd_afi eWA$IM-W) liayagainst w. 1 Office understand that a copy of this statement may be forwarded to the of Investigations of the DIA for coverage verification. I ob hereby certify ! the pains and na/hes of perjury that the informal W provided above is true and correct. 9 Si nature A10 Date Print name �A.) t Pte1 y��fi Official use only do not write in this area to be completed by city or town official- City or.Town PerrniY icemina. 13 Building; Dept E)Checlr if imrr►ediate response is required p Licensing Board E] Selectman's Office Contact person: Phone# Health Department E] Other 1Yavelers WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE POLICY NUMBER: (7PJUB-928X453-1 -03) INSURER : THE TRAVELERS INDEMNITY COMPANY OF ILLINOIS 13579-MA INSURED'S NAME : GAGNON, RONALD DBA TRISTATE PROPERTY MAINTENANCE ANNIVERSARY RATING DATE : 06-20-04 RATE BUREAU ID: 000153689 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 015400395 ENTITY CD 001 GAGNON, RONALD DBA TRISTATE PROPERTY MAINTENANCE 75 COCHRANE CIRCLE ' ME THUE N, MA 01844 CARPENTRY-DWELLINGS-THREE STORIES OR LESS 5651 IF ANY 10.62 ------------------------------------------------------------------------------------ MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ NONE LOSS CONSTANT (0032) 50 ADD FOR POLICY MINIMUM 328 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 378 EXPENSE CONSTANT(0900) 122 4.50% MA WC SPECIAL FUND AND TRUST FUND 17 TOTAL ESTIMATED PREMIUM 517 DEPOSIT AMOUNT DUE 517 DATE OF ISSUE: 07-03-03 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST NORT1y . Town of Andover No. oar) _ �. �o t- LA o � dower, Mass., COCHICHEWICK ADRATED S 4 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........::.rwgP.... ...........ts.. .t ` e.. ...................................................................................... Foundation has permission to erect.... '�.1?...IP....... buildings on ....� ........5.r.. .�...�.`4r!........ S Rough .. .... . .. .... ..... ..... ... . . to be occupied as .. ........7"Id. C ................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspect"o , Alteration and Construction of Buildings in the Town of North Andover. '� L'O © PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. �y Rough PERMIT EXPIRES 11 V 6 MONTHSELECTRICALUNLESS CONSTRUCTION AR S ELECTRICAL INSPECTOR Rough ............ .. .. ................ . Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE