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Miscellaneous - 308 MASSACHUSETTS AVENUE 4/30/2018
308 MASSACHUSETTS AVENUE � D - - -- - ._--- -- -- - -- - - - -- --- I 2101016.39'0000.0 �" �� Date....... . s , "� NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ss^CHU This certifies that 'v �D�U ..... ................... .y. ........ .... ` ....................K7n4/1- ........................... has permission to perform (. wiring in the buil g of........ T �!9.11��. ......................... ,�ot3X69S� at.... .............................................. ......°.................6CMICALIiNS�P�EiC�MOR North Andover,Mass.� Fee . Lic.No. Or7.C/.��....... {.... ..... ...EL Check It �. 10408 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§.3L,the p j permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed• (� on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.01 c. 166,§32,an electrical permit shall he issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shallbe limited as to the time of ongoing construction.activity,and maybe.deemed_bythe,Inspector_of_Wires abandoned-and-in-,valid-if-he— or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 andlexter ded0by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote j&growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certainpermits-and licenses concerning the use or development ofreal property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was . "in effect or existence"during the qualifying period beginning on August 15,2008-and extending'through August 15,2012. the 8—PermitrDate Closed: **Note:)Reapply for new Permi r ❑Permit Extension Act—Permit ate Closed: �J 411- Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) :O� g y C Owner or Tenant � � rn ® Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes SaoNo ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters j Number of Feeders and.Ampacity / `\ Location and Nature of Proposed Electrical Work: L � �� A 1&Aj y ✓L f2W d Com letion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SNo.of Tot2lusp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ICDA Above In- o.o Emergency ig g No.of Luminaires Swimming Pool nd. rnd. Battery Units -— le Outlets No.of Oil Burners FRE ALAP. Na.of Zones No.of Receptac No.of Switches No.of Gas Burners No..of Detection and Initiatin DevicesNo.of Ranges No.of Air Cond. 'TToonsl No.of Alerting Devices A Heat Pump I Number I Tons J.KW No.of Self-Contained No.of Waste Disposers Totals: - Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW 5�'�` ocal❑ Connection ❑ Other No.of D ers Heating Appliances ICW Security Systems:* Dry No.of Devices or Equivalent No.of Water KWNo.of No.of Data Wiring: Heaters Signs Ballasts. No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: `" Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 roof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covers is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: G�� L LIC.NO.: n - Licensee: �ye 1/�-� Signat LIC.NO.: afapplicable,enter"exempt"in the license number line.) Bus.Tel.No.• - Z 0r/Z Address: t A/)J4 � � Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent 'r.11% X., PERMIT FEF. $ The Commonwealth ofMassachusetts >^i ! Department of Industrial Accidents : : Office of Investigations '°°•'� 600 Washington Street Boston, MA 02111 t ' www.i=s.gov/Via . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nairie(Business/organization/individual): Address: !LJA, City/State/Zip: — i� / Phone#:_. �� -41� 7 7,Areyouemployer?Check.the appropriate box: ' r7. E] f project(required):employer with 4, ❑ I am a general contractorand Iees(full and/or part-time).* have hired the sub-contractorsNew cotistructiort. . .sole proprietor.or partner- listed on.the attached sheet Remodelingship and.have no employees These stL&contractors have . Demolition working for me.in any capacity, workers' comp.insurance. g ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required_] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 airl a homeowner doing all work right of exemption per MGL 11.(]Plumbing repairs or additions myself.[No•workers'comp. c. 1.52, §1(4),'and we have no 12.[]Roof repairs insurance-required.]t employees. [No workers' comp. insurance required.] 13.❑.Other *Any applicant that checks boa'#l must also fill out the section below showing their workers'bompensation policy information. t 140meowncrs who submit this a r{f-idavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additior_a)sheetshowing.►_hey, of the subcontractors and their uiorkers'comp-policy infar�a6on. I OR an employer that is,prgviding:workera'coa pensakort faasurance for m3'employees: information Below is thepolicy and job site ' Insurance Company Name: Policy#or Self-ins.Lie..#: Expiration Date: +� Job Site Address: City/State/Zip: Attach a copy of the workers'.'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- fine up ta.$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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cn fy under the ppenalties of perjury that tite information provided above is true and correct Pho e#: 1ci a only. Do not w.rye%n Mis area,to be camnpl�ed by cuy or town officiaL City or Town: _Permit/License# issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.El*nspedor 6.Other Contact Person: Phone#: Date.. 11........................... NpnrN r I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION BACMUS� This certifies that ..............:.................................................................................................. �0.✓L�ti� has permission for gas installation .... ................................. in the buildings of r� ........ ...... ......................................................................... . at.. ..... c ?......�`X''..e l`S' Q- North Andover, Mass. � Fee............"...... Lic. No. ...... .............. f k. GAS.INSPECTOR k Check# 9201 F ►" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE3/24/2014 PERMIT# G ��.,.._. l 7, JOBSITE ADDRESS 308 Massachusetts Ave OWNER'S NAME GOWNER ADDRESS I SameTELL-- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ® ® RESIDENTIAL® CLEARLY NEW: RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES® NDE] APPLIANCES-1 FLOORS- BSM 1 1 2 3 1 4 5 6 7 1 8 9 10 11 12 1 13 14 BOILER LER BOOSTERED CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ,,ROOM/SPACE HEATER ROOF TOP UNIT 'TEST 'UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ------------------------------------- Replace 1 as Meter x and Piping as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERE] 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 corfipliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. < if PLUMBER-GASFITTER NAMEJoseph Marino LICENSE# 8736 / S NATURE MP El MGF JP® JGF LPGI® CORPORATION Ej# 3285C PART SHIP®# LLC®# COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE MA ZIP 01501 =TEL (508)832-3295 --� FAX 508-926-4347 CELL 508-832-4614 �]EMAILJ JMarino@RHWhite.com IJ G R . ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIONNOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# i PLAN REVIEW NOTES i i I t r I I 'rt I EALTH OF MASS ,V*80 "':PLUMBERS AND GASFfT`FE.RS= C01 AS-A.MIS T E R P.k I-SUES T}1NSE GTON ST W`aRGEST`ER MA 05/01/14 =•G;OittilUlUNWEALTH OF€U9ASS/�Cl�US:E`L U. €LUNfBERS AND GASFI7TRS --ENSE'D AS A JQU.RNEYM�4N=':f?l.UII yiT UES THE ABOVE"LICENSE TO-s•"" -s:=- ___ "-= .} J_DsE'PH'-D N➢ARr to • __''3��Fi4F2�RT=NGTON ST -• __�- - _ -- -v;! STE R MA 05/01/14 I I i 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 �C a® -- CERTIFICATE OF LIABILITY INSURANCE Page 1 Of 1 08/29/2013' THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(Pes)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 notconferrig hts to the certificate holder in lieu of such endorsement(s). PRODVCER CONTACT 9villiq o£ Masadchueetts, Inc. c/o 26 ftntu Blvd. PHDNE AX P. 0. Box 305191 No_Exi); 877-945•-7378 F _No): 888-46_7-2378 -MAIL Na v ah s11e, TN 37230-5191 .D.OR ce t:1 ' 0 5191 E;�s: J: fs,catpe.@w•illis.corn INSU1ER(8 AFFORDING COVERAGE NAICtf INSURED INSURERA: The CbAXter Oak Pira Inauranpg Company 25615-001 R, R• White Construction Company, Inc. INSURERS:TrRVGIArg Property Casualty co oi' Am 25674-003 0. Box P. 0. Box 257 41 1 Street INSURER C.Nati=Al Union Piro Ineurancm Company o£ 19445-001 Auburn] MA 01501 INSURERD;Travelers indmmnity Company 25659-D01 INSURER F,; COVERAGES INSURF,R F. CERTIFICATE NUMBER:20287fiB0 REV1310N NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IJJJL NSR TYPE OF INSURANCE DD' 3UB MM POLIGY NUMBER POLICY EFF POLICY EXP A GENERAL LIABILITY LIMITS VTC2000 977RD948-13 9/1/2013 •9/1/2014 EACFIOCC,URRENOE F_ 2,000,000 $ COMMfiRCIALGENERALLIABILITY TO RENTED CLAIMS-MADE OCCUR Et!'o eurencrf ,� 3 o a -Q.0 o MEDEXP(Anyone ereon 10_000 PERSONAL&ADV INJURY $ 2 QL),Q,000 GENERAL AGGREGATE S 4,000 000 GEN'LAGGREGATE LIMITAPPLIES PER: - PRO PRODUCTS-COMPIOPAGG $ 000 000 POLICY LOC AUTOMOBILE LIABILITY vT3CAP 977K955A-13 9/1/201,3 9/1/2014 $ OMBINEDSINGI,F,LIMIT ' X ANY AUTO ecordenI) $ 2,000,00a ALLOWNED SCHF,DULED BODILY INJURY(Per person) S AUTO$ AUT08 BODILY INJURY(Peraccldent) $ X HIREDAUTOS X NON-OWNED Co Defl AUTOS X X Coil Ded eracddenl Q C UMBREL IAS 7C OCCUR R 1=xcEsa Uaa 838766140 9/1/201,3 9/1/2014 EACH OCCUR RENCF CLAIMS-MADE $ 5,-000,000 DED $ RETENTIONa 10,000 AGGREGATE $ $,000,000 D WORKERS COMPENSATION TAr{YII, S AND EMPLOYERS'LIABILITY Y�N VTRKUB 820SK185-13 9/1/207.3 U - D ANY PROPRIETORIPARTNERIEXECUTIVEbNIA VTC2KUB A20A71A-13 9/1/ p]3OFFICER/MEMSEREXCLUDED7 E.L.EACH ACCIDENT .I1,000,-000 MendOtorfdvYtlnNH) E.L.DI2EASE-EAEMPIOYFE $ 1,000,000 u���W11 I IUN ud UNGRATIONS below E.L,DISEASE-POLICY LIMIT S 1.000,000 DIESEL RIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ATIsch Acord 101,=AddIfa..j Remark,31hedu14,if more ep sea is squired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCEI.I.ED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, EvXCOnce Of Ingurance AUTHORIZEDREPREaENTATNE coll:4197604 Tp1:1694012 Cert:20267680 ®1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 9 67 Date. .�av D:rho TOWN OF NORTH ANDOVER : ...r -...,�. 0 PERMIT FOR PLUMBING ,SSACMUS� - -- f This certifies that . .�bQ.;�'" . q/'! . . . . . . . . . . . . . . . . . . has permission to perform . . . 1a',. . . . . . . . . . . ` plumbing in the buildings of . . /`>!/ . . v .. . . . . . . . . . . . . at. . . -11,m�?1. . . . . . . ./. . .�. 04� North Andovver, Mass. Fee. G��r.,dU.Lic. No.. 2.�.!.�0 . .11?keA;5 . . . . . . . . PLUMBING INSPECTOR Check # i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /�o ) 4v �� A� MA. Date: permit# Building Location: 3 D� Owners Name:na1(i�$ Type of Occupancy: Commercial❑ Educational ❑ Industrial Institu ' • ❑ tlonal ❑ Residential New: Alteration: Ar ❑ radon:❑ Renovation: Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES cr DEDICATED 2ti z SYSTEMS � cn O O Z aw = w w 2 Z 'cr¢ v U O ❑ co Z ¢ ¢ w C7 fG a p m vi 0 t in Q 0 ,e ON n—Z ❑ N H w , ❑ ¢ 0 � pp-. w W V Z O O _ nm W y J `� 2 uX—. S Q ¢ m 1' cndf¢ O F- U ¢ a ¢ T w w m O ❑ O O 2 cn 1- w LuW w _ F ¢ m m O z — ❑ O 1 O d -SUB BSMT. O U BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR �rH FLOOR 8'FLOOR Instaliir� cr,Ipam,_ / )) ' }' ._�C�cf�l )�u3ati •lI� "°' e.r p�;tii.�¢r Address: 6 El Corporation qy 7"7 City/Town:��_ State:��`I Business Tel: �77-7P/ El Partnership Fax: Name of Licensed Plumber: ❑Firm/Company �er v�Gsvn INSURANCE COVERAGE: 1 have a current lia�Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.942 Yes If you have checked Yes,please indicate the type of coverage by checkingthe � No❑ appropriate box below. A liability insurance policy- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee Massachusetts General Laws,and that my signature on this permit application waives this requirement. doesnot aVe the insurance coverage required by Chapter 142 of the Check One Only ii nature of Owner or OwneCs A ent Owner ❑ Agent ❑ 1 hereby certify that all of the details and Information I have submitted(or entered)regarding Phis application are true and Knowledge and that all plumbing work and installations performed under the permit issued for this application will be i Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, a ate to the best of my n compliance with all d Type of License: fIe ❑Plumber Signature of Licen ed umbe `Y/Town aster ]� 'PROVED(OFFICE=USE Journeyman License Number: L0 i The Commonwealth ofMassachusetts Department ofIndustriallccidents Office of Investigations 600 Washington Street Boston,MA 021X-1 SY www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name(Business/OrganizatiorAndividual): Address: �jc U_�-- City/State/Zip: MC6(-1'Wt-qC Mc, 01,y6.0 Phone#: [insurance an employer?Check the appropriate box: a employer with 4. Type of project(required): ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction a sole proprietor or partner- listed on the attached sh et. t 7• ❑Remodeling and have no employees These sub-contractors have ing for me in any capacity. workers'comp.insurance. $' ❑Demolition workers' comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition IL ired.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions lf p § [No workers'comp. c. 152, 1(4),and we have no ance required.]t employees.[No workers 12.[:]Roof repairs comp,insurance required.] 13.[1 Other *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached sheet showing the name of the sub-contractors and their workers'comp.policy or I am an employer that is providing�anadditioflal rs'compensation insurance for my employees. Below is tlae otic andjob sit information. P y J e Insurance Company Name: Policy#or Self-ins.Lie.#: - Expiration Date: . Job Site Address: • Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex it Failure to secure coverage as required under Section 25A ofMGL 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 maybe forwarded to the Office of [nvestigations of the DLA for insurance coverage verification. fP J �' I do hereby certdf under the pains and penalties o er'u that the information provided above is true and correct. +i nature: ` Bate: none#: — 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electric 6. Other al Inspector 5.Plumbing Inspector Contact Person: 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 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 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 apartinents 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 insuranc6 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 r ° 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'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 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. Please be sure to fill in the permit/license number which will be used as a referencd number. In addition,an applicant that must submit multiple permit/licease applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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: The�o�.-n,ax�wEalth of�ass�.chusetts Aepaent of Industrial Accidents ®flee of Investigations 600 Washington Street Boston;MA,02111 Tel. #617-727-4900 ext 406 or 1..877•--1-.SS.AFE Revised 5-26-05 Fax#61.7^727-7749 10/28/2011 10:21 GOULD INSURANCE 4 19786889542 NO.196 D01 OP.(D:AILS f'r DATE IMM/DDnmrYl CERTIFICATE OF LIABILITY INSURANCE 10!28/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDf=R.' THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUbEB BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEN, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not confer rights to the Certificate holder in lieu of such endorsement s- PR000CER 978-368-2364 NAME: cT Could arket Square nca Agency,Inc. 978-388-8578 ��A o " Nal, Amesbury,MA 01813-2494 AD REBS: PR UER CUSTpM f-R ID A;JUDSO-1 ._. ..__.... INSURERS AFFORDING COVERAOE _ NAIL p INSURED r Robert Judson,Jr INSURER A:Merchants Insurance Group 6 Locust Street INSURER 13 � Merrimac,MA 01860 INaURER C; INSURER 0. INSURER E: N9URER F; COVERAGES CERTIFICATE NUMBER; REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INERUN -'RK-Ir0k 1 TYPE OF INSURANCE DmimaPOLICY HUMBER IMMID6 E M /ICY E UNITS GENERAL UAUIUTY EACH OCCURRENCE _ $ 1,000,00 A COMMERCIAL GENERAL LIABILITY BOP1067402 06/02/11 05/02/12 AGI y6TE6 ~^ j�,EMISE31Ea DCCuf 0gL6) $ 300,00 7 CLAIMS-MADE L OCCUR MEO EXP(Any ono vermn) S�. 6,00 X Buslnese Owners PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGR_CGATE $ 2,0_00,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 6 2,000,00 J POLICY PRO• 71 LOC $ AUTOMOBILE LIAVILITY COMBINED SINGLE LIMIT $ (Ee aGoldenq ANY AUTO BODILY INJURY(Por pera0n) S _. ALL OWNED AUTOS BODILY INJURY(Pe/eeclaent) 5 SCHEDULED AUTOS PROPERTY DAMAGE tUREO AUTOS (Per ottidaM) _+ $ _ NON-OVMED AUTOS _ $ S UMBRELLA UAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLC $ RETENTION B $ WORKERS COMPENSATION 1nIC S7ATU- OTH AND EMPLOYERS'LIAHILFIY ANY PROPRIETORJPARTNERIEXECUTfK-YN/A E.L.EACH ACCIDENT $ OFFICERNEMBER EXCLUDED? I4andwary In NNI E.L.DISEASC-EA EMPLOYEE $ Ir yyes.do>acribe ulMer ESCRIPTIO 0 -RAT NS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I L.00ATIONE I VEHICLES IAIlach ACORD 101,Addlllonal Remeraa 6019dule,If mora apace la roqulrod► Plumbing&Heating CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE: EXPIRATION DATE THEREOF, NOTICE WILL IjE DELIVERED IN Building Department ALCOR NCE WITH THE POLICY PROMS10 S. 1600 Osgood Street N.Andover,MA 01546 AUT EO REPR TATWE ®1988-200® ORD CORPORATION. All rights reearved. ACORD 26(2009/09) The AGORD name and logo are egistered marks of CORO i T"y gSACHUSE�S-`'� Mot. �o�R1EYMAN 3 1 SSD AS A >a S THE ABOVE LICENSE TO LOCUST ' ST GO 1` �4 1 j4 01 a.. Xt1A . g477 10067 MORTq TOWN OF NORTH ANDOVER PERMIT FOR WIRING SA US 4 This certifies that ...........................................................e .. ........... has permission to perform wiring in the building of................. .............................. at.....>.3. ........................ North Andover,Mass. Fee... L i c. o. 1-7. .............A, 0 - . . RI N N* .P' Check # V/ Yl r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 9105] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL WFORNIATION) Date: 4/11/10 City or Town of North Andover To the Inspector of Wires By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 308 Massachusetts Avenue Owner or Tenant Thomas Trepanier Telephone No. (617)856-1152 Owner's Address 308 Massachusetts Avenue f.�/ e&tt--t, 1.1V Is this permit in conjunction with a building permit? Yes [J No in— (Check Appropriate Box) Purpose of Building Dwelling Utility Authorization No. 10788946 Existing Service 100 Amps 120/240 Volts Overhead Undgrd[] No.of Meters 1 New Service 200 Amps 120/240 Volts Overhead UndgrdNo.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Upgrade 100 amp service to 200 amp Completion of thefollowing tableTM be waived b the Inspector of Wires. No.of Recessed Luminaires No.of Cei1.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above o No.of Luminaires Swimming Pool - o.o mergency Lighting rnd. grud. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatinal Devices ' No.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers eat m umber ons o.o e ontained Totals:: . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local F' MunicipalEl Connectionothe' No.of Dryers Heating Appliances KW ecunty ystems:* a No.of Devices or Equivalent No. Water No. KW o.S' s Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wir►ngg: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: n/a (When required by municipal policy.) Work to Start 412011 Inspections to be requested in accordance with NEC 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 insurance 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 perniit issuing office. CHECK ONE: INSURANCES BOND 0 OTHER R (Specify:) 1 certify,under the pains and penafhies of perjury,that the information on this applica o is true and complete FIRM NAME: Jose h C Mahoney -Licensed Electrician '` LIC. NO.: 1718JR Licensee: Joseph C Mahoney Signature LIC.NO.: 1718 (If applicable,enter"exempt"in the license number liihe) F Bus.Tel.No..--A603)347-8969 Address: 3 Topp an Rd Kingston,sto NHNH03848 � AIt.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,I hereby waive this requirement. I am the(check one)C]owner Q owner's a ent. Owner/A a.....gent iv 1 FFRUIT FF.F. S S.4 r:_... r � _ � . . - F ., M• r. : . � � � � I � , �����- � ��J � l d� .. �� � i +.�- '_ ..._ � q � � _. 1f, i f.. �.. I . .. � � i . i F` The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations Y SOD Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Letibly Name(Businessiorganizationllndividualy: Joseph C Mahoney Address: 3 Toppan Rd City/State/Zip. Kingston,NH 03848 Phone#: . 603 347-8969 Areyou an employer?Check the appropriate box:. 'I ype of project(required)': 1.❑ I am a'employer with 4. n I am a general contractor and I employees(full and/or part-time),* have hired the sub-contractors 6. p New construction 2.® I am a sole proprietor or partner- listed on the attached sheet. 7. Q IZernode_lin9 ship:and have no employees These sub-contractors have :g., ❑Demolition working for me in any_capacity. employees and have workers' insurance.: `9. 0 Building addition [No w6rkers comcomp.insurance p- required.] 5. [] We are a corporation and its 10.f Electrical repairs or additions 3.❑ .1 am a homeowner doing all work officers have exercised their I.I.[].Plumbing:repairs or additions myself.[No workers'comp. right of exemption per MGL 12n.Roof repairs insurance:required.]t c: 152;§.1(4),and we.have.no employees..[No workers' 13.❑Other comp:insurance required.] .Any-applicant that checks box#t must also till but the:section below showing theirworkers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all woilC and thenhire outside contractors must submit anew affidavit-indicating,such. 4_ontra6tors that eheck:this box frust attached an additional sheet showing.the name of the sub-contractors and state:whether or not.those:entities have employees.If the sub-contractors Piave employees,they must provide their workers'comp.policy number. I f an employer that is providing workers'compensation insurance for r y employees. Below is the policy ar d'joh.site in ormattom Insurance Company Name: Policy#orSelf-ins..Lic.#: Expiration Date;. Job Site Address: All Jobs in the City/Town of City/State%Zip:North Andover.MA 01845 i Attach it copy of the workers'compensation policy declaration page(showing policy xp the olio .number and a iration:date . ) Failure to secure coverage as required under'Section.25A.of MGI,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.DTA for insurance coverage verification. I do hereby certify under the p/ains�r£d'penalties of petinoy that the information provided above-is true and correct Si ature: '✓ Date. 4/11/10 Phone#: (603)347=8969 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 oue): 1:Board of Health Z.Building Department 3.City/Town Clerk 4:Electrical inspector 5.Plumbing Inspector &Other Contact Person: Phone#- 9604 _ Date..6?%?"5 .P.f. .... f NORTII TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4 i. . ,. �s � SACMUS� --� / This certifies that .. .I.G.G.I!�-�r I3 On S 1 has permission to perform .... �CI'�vST..t- � .. wiring in the building of..... .61!1'1,,.,' „r J.,^ f . at.... *......V �VG .............qIh ndo v. er,Mass...... ........... Fee. C0......... . ....l A ......... Check # ELECSPE _ Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Srf 2 5-(/D City or Town of: NORTH ANDOVER To theInsp orec of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 306 Mft5s �tyG Owner or Tenant —Vom IN N Q�Ate Telephone No. Owner's Address S¢imiE Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) a� Purpose of Building � Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ 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 following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. grnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones (,.. No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: -* - .. . ......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: i No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1 5 0© (When required by municipal policy.) Work to Start: '9/Z SJ ID Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER"informatt fy:) I certify,under the pains and penalties of perjury,that then o tis plication is true and complete. FIRM NAME: � L\C#�L ��ilTl'�CTLIC.NO.: UZC�'J Licensee: Signature LIC.NO.: \ZA (If applicable, enter "exempt"in the license tiLimber line) Bus.Tel. Address: 1- 'd�A 0i11 Alt.Tel.No.:SIQ- �y-�3t3 �-►I *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's Owner/Agent PERMIT FEE: $ Signature Telephone No. •' , � r ��� � � � �- ���J G' `� �� _� �,-� s' The Commonwealth of Massachusetts r Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 4 ,Y• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �h(��1 �-�►� V��1 1 om S Address: 'E�k S 0A(>0 L- City/State/Zip: til {�� SSS S Phone#: TV- ��� ' 1Z.�i 1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. $ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in an capacity. workers' comp.insurance. .; g Y P tY• 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ 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 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: ` City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 here yertify u er th ains and penalties ofperjury that the information provided above is true and correct. Signature: Date: 2S lo Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date :? NpRTM TOWN OF NORTH ANDOVER," p� «•° ,x,'60 � 3: ��`w -••..'• of PERMIT FOR PLUMBING ,SSACMUSE� 1 . This certifies that . . . . p) r.``. . . . " `.�r.`.'�. . . �``.. . . . . . . . has permission to perform ?/—/.. . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . at . . . . . . . . . , . , North Andover, Mass. u � Fee.y?. . . No.. 2 `?.(!°. .�� (PLUMBING INSPECTOR Check # Y/ 8409 MASSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING (Print or Type) /V 4AiJbv�i� , Mass. Date A 25 20 b Per it # Building Location /,P7,53 4 v Owner's Nam Type of Occupancye5 New 0 Renovation Replacement❑ Plans Submitted: Yes 0 Nox FIXTURES B.P. # 'SEWER# SEPTIC # z I � LQ z ¢ W } o ~ z p z cnUj wLU to _ L to in u_ z Z a U z � m c=n w >- ¢ N U) z a .. Il U Q V)) iCL n > H z a O cn z z U _ m = o o g oz a0 LL oa < 0 m o 0 SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR X 5 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name _ i20���-- Jvdirm Jk / Check one: Certificate Address b L06V-6 j ST 0 Corporation /11 enn*m hL f h(4 g06$6(9- Business Telephone_ 9 `�f�� 7y 0 Partnership Name of Licensed Plumber or Gas Fitter_ b.(T- 9-V,&r,, 0 Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes ❑ No if you have checked es,.,piease Indicate the type of coverage by checking the appropriate box. i A liabilit f insurance policy 0 Other type of indemnity 0 Bond ❑ OWNER' IN URNkAVERwam aware that the licensee does not have the insurance coverage required by Chapter 142 oft a assand that my signature on this permit application waives this requirement. Check one: Sign tur of wAgent OwnerA Agent 0 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 the permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title Signature of Lic sed umber 67 City/Town Type of License: 0 Master APPROVED(OFFICE USE ONLY) Jo u r n e y m a n License Number 2-6140 i �\ The Comnmonwe¢lth Of Massachusetts Department o f Industrial Accidents Office of£�vestio ations 600 Washington Street -BostOn, AL4 62111- Workers' Compensation In Affidavit:An licant Information vit: Builders/Contractors/Electricians/plMbers Please Print Legibly Name (Basin :a tion/Individual): R�jJe( J Address: ocvs -- 5T— City/State/Zip: T— City/State/Zip Phone �� Are you an employer?Check the appropriate boa: 1.0j am a employer with am a Type of project(required); employees(full and/or part-time ).* 4• ❑ have hirede the ral contractor and I 2� I am a sole proprietor or sub-contractors 6• ❑New construction partner- listed on the attached sheet 1 7. Remodeling ship and have no employees These sum working for me in any capacity workers contractors have g• ❑Demolition [No workers' comp. insurance 5. ❑ Weare come•insurance. 9. required•] a corporation and its ❑Building addition Officers have exercised their I O❑Electrical r 3.7.I am a homeowner doing all work right of ex repairs or additions • myself. [No workers' comp. c. 152 �mption Per MGL 11.❑Plumbing repairs or additions insurance required.] t 1(4).and we have no employees. [No workers' 12❑Roof repairs A,ny�?ir_ t fat�� y comp.insurance required•] 13-D Other homeowners who submit fhis- mus! o c the secs beioa s^oY W..Z affidavit indicating they are doh al work an "Contractors that checit this box m=at�:.hed an rdditionai sheet show' o a then hire ourside coatractnr z4VW - -u submit a new affidavit indicating such. m,the name of the sub-contractors and then wotkecs'co I am an employer that is providing workers'compensation insurance for my employees Below, ' noIicy � infornaation, ►+ rs thePolicy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Job Site Address: Expiration Date:, Attach a copy of the workers'compensation policy declaration as City/State/Zip: Failure to secure coverage as required und„or Section 2 p ae (showing the policy number.and expiration date). SA ofMGL c. 152 can lead to the fine up to$1,500.00 and/or one-year imprisonment, as well as civil imposition of criminal �n Of np to $250.00 a da a ivil penalties in the form of a STOP WO Penalties of a Y against the violator. Be advised that a co RK ORDER and a fine Investigations of the DIA for insurance coverage verification. PY of statement may be forwarded to the Office of I do hereby certify under the pains and penalties o er , �_ fP JmJ thrrt the information.provided above is true and correct Siffiature: Phone#: — c1 cJ� Date._._ ( ..' Official use only. Do not write in this area, to be completed by city or town o f1iciaL . Cita,or Town: IssaP ermitLcense#rAuthority(circle one): I. Board of Health 2.Buildinb Department 3. Citv/Town 6. Other Clerk 4. Electrical Inspector 5.PI umbinb Inspector Contact Person: Phone #: Information alt d Instructions Massachusetts General Laws chapt;-r 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute;an employee is defined as"...every p�zson 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 enterprise;and including tie Iega1 representatives of a deceased employer, or the receiver or trustee of an inaiviaual,partnership, association o>e-other legal entity,employing employees. However the owner of a dwelling house having not more than three apartnz encs and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte;�ance,construction or repair work on such dwelling house or on the grounds or burlaing appurtenant thereto shall not be:cause of such employment be deemed to be an employer." MGL chapter 152, §25C(�also states that"every state or 1o.ca1 licensing aDency shall withhold the issuance ar renewal of a license or permit to operate a business or to c onstruct bw'Idings in the commonwealth for any applicant who has not produced acceptable evidence of co=npliance with the insurance coverase 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 irn:�1 acceptable evidence of compliance with the inc�ranCe requirements of this chapter have been presented to the contracting authority." APPIicants Please fill out the workers' compensation affidavit completely,by checlang the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s), addresses) and phone numbers)along with their certificates}of - inc�ranre. Limited LiabrTity Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the ` members or partners,.are not required to catty workers'comp easadon inau_rance. 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 far confirmation of in�ranre coverage. .Also be slate to si„�n and date the affidavit. The affidavit should be ret'i:uued tb the city Or ttl�nrFi that the ap pllcBuOn for the p�rL�2Tt'or 1:Cen.°►LS be1ng r�gk2Bu�.�d,dlQt f�"e L'^Ja�L.T';e:lt Of lndustrial Accidents.. Should you have ane questions regardii.g the law or if you�'e re�^irired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter tireir self-inc�ranCe license number on the appropriate line. City or Town Officials • Please be sure that the affidavit is complete and printed legrbly, The Department has provided a space at the bottom of the affidavit for you tn f II out in the event the Office of Im�estigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple perrnitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under`.`3ob Site Address"tine 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office ofInvesfigations would Lt`ke to thank you in ad�'aace 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...... 'T'he Ceam;�onweatttc oaf Ma�cachusetts. Dep�artrnent of Fndt��ttial Accidents Office of Inve�bs>�Q>as . 640 VJsshin�n Street Bastion,MA 02111 Tel. � 617-?2.7-49fl0 ext 4Q6 or 1-S�-M4�S:A.FE Faa, �61?-7?.7-i 749 Revised�-26-0� ��u�u�.�ass..aov/ciia DEC'7AAM 50 CONCORD STREET, NORTH READING, MASSACHUSETTS 01864 978-470-2860 FAX 978-470-1017 April 26, 2002 Town of No. Andover Department of Health 27 Charles Street No. Andover, MA 01845 RE: Asbestos Abatement 308 Mass. Avenue Dear Sir or Madam: Dec-Tam Corporation will be performing an asbestos abatement project at the above referenced location. This work is scheduled as for June 10, 2002 through June 10, 2002. Any applicable local, state and federal agencies have been notified of this work. Please let me know if you have any questions. Sincerest regards, Brent Morgens Sales Estimator BM/jmp ASBESTOS ABATEMENT "; LEAD ABATEMENT INDOOR AIR QUALITY www.dectam.com E-mail: dectam@aol.com Commonweaith of Massaebusetts EX'E M PT Asbestos Notification Farm— ANF-901 ASbesfoS Abafemenf Oescripfion 1. Facility location: INSTRUCTIONS Name w°p` adders 1.All sections o1 this __Po a `9-���� 0 fa Oy;— q-/,�_ 1, form must be completed CltylJoan zipaxk Ie/en/rane g� In oder to with Ure Department of Environmental iYlraflstlrenvrksllabrapon7bulld/ngnama,1,,wrnp,lloo,room Protection notification requhemerds of 310 CMR 2, Is the facility occupied? ®Yes ❑No 1.15(len working days Prior notification is 3. Asbestos Contractor: required ofanyabatenea• projecQ;and the Dec—Tam Corporation 50 Concord Street Oepariment of Labor Nacre Add= and Industries notification mquirements North Reading, MA 01864 o1453CMR6.12 (len ellylT— (978) 470-2860 days prior notification is np code Telephone requiredolANY AC000035 abatement project greater. Written than three linear or D11lkensal ConlrrdTY14(wlllen/rorbalg Square feet). 4. On-Site Project Supervisor/Foreman: 2. Submit Original Form � To:. Name Commonwealth of DUCedlgcallonl Massachusetts 5. Project Monitor. Asbestos Program P.O.B.120087 LOU Boston,MA 02112- Nana lid 0087 DLI Caraacatran 6. Asbestos Analytical Lab: 3.This loan maybe used lot notifying the Same as 5 U.S.Environmental Name DLl cemnralronl ProleclionAgency Region r_ [� 1 t ; Iofasbestos demolition/ 7. Project start date 1l /y 1 /Oenddate f>/tD/�specilicworkhours(Mwn.-Fri.) ! (Sat.Sun.) renovation operations subject to NESHAPS(40 CFR Subpart M). 8. What type of project Is this? (circle one): demormon roper. ordno other(explaln) caoau,rusoumy 9. Describe the asbestos abatement procedures to be used (circle): provarog oncmrun runcaManmaa rJaamp iullitauo 1l encapsulaf/on dhpural anlY other taxplaln) naodeod oats 10. Is the Job being conducted ®indoors ❑outdoors? 11. Total amount of each type o1 As estos Containing Materials(ACM)to be handled on pipes or ducts(linear 1l.) or DINsurfaces(square ft.) to be removed,enclosed or encapsulated: linearlsqua-eyf�eet boiler,breaching,duct,lank surface coatings.../U` V grermai,solid care pipe insulation...... corrugated or layered paper pipe insulation.,.._/ insulating cement.................. —/ spray-on fireproofing....................._/ boweUspra r coalin cloths,woven kbr/es..................... 1'e gs.............. I tensile board,wallboard............. other(please describe)...................._/ 12. Describe the decontamination system(s)to be used: 13. Describe the contain erizallon/disposal methods to comply with 310 CMR 7.15 and 453 CMF 6.14(2)(g): _Wetting material with amended water and o1ar; @ in double Sn , 1 prelabeled bags to be transported to an approved landfill in a sealed _ lockable trailer. 14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency: Nanhg nrnFPnnlrJal rua Data VIA ulbodta/lon Warwrl --- llama of&lDffiaw Nfle Dale ofAafhonrallon wallerl 15. Do prevailing wage rates apply as per M.G.L,c.149,§26.27,cr 27A-F to.this project? ❑Yes ®No Faclllf,,Description 1, Current or prior pse of facile i 2. Is the facility owner-occupied residential with 4 units or less? ®Yes ❑ No 3. Facility Owner. a r !b%" mks, (" NJQWQ_ Name Address IIJ CMO n Bp code Telephone 4. Facility's Owner's On-Site Manager. Name Addf= Clry/Town lip rode Telephone 5. General Contractor. Supplemental Staffing may be provided Name Address by: Methuen Staffing,Inc. 2 Charles Street chyyrown 2to Godo Telephone Methuen,MA 01844 New Hampshire Insurance WC5825620 12/28/0, Conlraclor's Workers Comp.Insurer Polluyl Exp.Dale U. What is the size of the facility? PO (sq ft)�L (I of floors) Asbestos Transportation and Disposal 1. Transporter of asbestos-containing waste material from site to temporary storage she(11 necessary)to final disposal site: JOB Rolloff P.O. Box 6037 Name Address Chelsea, MA 02150 (617) 387-1495 c/ryyroun Zip mrle Tolopho m 2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site: Same as above Nacre Address Nate:Transfer chy/Too Zlpwde Tolephone Stations must 3. Refuse transfer station and owner(if applicable): comply with the Solid Waste Division repula- Nacre Address lions 310 CMR 18.00 C111YA00 Zip code Telephone 4. Final Disposal Site: Southern Alleghenies USA Waste Systems !era➢m Name timers Name 843 Miller Picking Road Address Davidsville PA 15928 (814) 479-2537 chylown Zip code Telephone Certification The undersigned hereby states,underthe penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledgeandbelief. Prhd Nems Auh)orlred Slpnaluro Tkb Note:Contractor must sign this � Dar—Tam C:ornm-atinn (978) 470-9860 form for DLI PashoNrl➢e Fleprosnnlln➢ Tomplxno notification purposes 50 Concord Street North Reading MP 01.864 Address Clly/Toxn Zlp Cale Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)710 yes ❑no Sticker i(from front of form): E /ciC GA S't� V N° 22 I J Date.., -.1.....:..: ..`l' NORTI�1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING sS^cmUSE� This certifies that .. `............. ............................................. has permission to perform .: � - �-.4,..... wiring in the building of... ..:............ .North Andover,Mass. Fee/--/.C'%..... Lic.NoZ:4�.... _ f;� ..3. 1J f v ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer N2 a Date. ..................... 2-- 5 NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ITS CHU This certifies that ...... ............ ....................................... has permission to perform .�..... .. wiring in the building of....Z4' - 'A-. .......................................... ............. ........................................................... .North Andover,Mass. 4 a/' . ....... ......... .......... .............�:................... Fee ...... Lic.No ./`/, ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THECOWONWE4LTHOFMAS 4 Office Use only DEPARTMENT OFPUBLICS4MY = Permit No. BOARD OFFIREPREVEN770NREGMTIONS5raffl12* —"——'-- Occupancy&Fees Checked APPUCATION FOR PERMIT TO PEUORMELEI=, CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date�— Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 6 /qg SS /d tic Owner ot+eaartp ..�..—moi ■ wn.r�.—�i��rrr�r��r�� Owner's Address Is this permit in conjunction with a building permit: Yes M No 12 (Check Appropriate Box) Purpose of Building ly //ti Utility Authorization No. �— Existing Service Amps / Volts Overhead Underground M No.of Meters New Service �^ Amps / Volts Overhead Underground No.of Meters �— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA and ound No.of Receptacle Outlets / No.of Oil Burners No.of Emergency Lighting Battery Units y 4 q No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal a Other Connections No.of Water Heaters KW No.of I No,of Signs Bailasis e No.Hydro Massage Tubs No.of Motors Total HP G9'HER IrMMXCOvWf R19Mrt8Dthetagtm=U1s use0sGataW Lam Iha,,ea=utLiabtk'yhmo=Pbtrynid%Car e Cote-�ecrksskatMegmalat YES NO Ihmest.km edvandploofofsameiotheOT=YESFJ IfjutmedvdwdYFS,plemmdc*thetWcf'wwaFbydxckirgthe bcx INSURANCE O BOND OII-IFR F-1 (PmeSpeafy) Expiration Date Estimated Vah;eoff3e U%A Wak$ WodcDSta<t Aw h�ionl� / Ra# Feral �.ioatsee �I y Sz Sigr>a�re Lioas9eNo / Business Tel.No. A-- 10d 4,f a o� l��ov ek AIL Tel OWNER'S UNISURANCRWAIVER,IamawatethattheLio m the it anoecarargporzshZrAWepydiatasm4iffedbyNbmadwsettsCrataalLaves aad�atmysi�tseonthsp�epp�rws�esthis« rr�. (Please check one) Owner a Agent Telephone No. PERMIT FEE$ Location 1 Q �"( >�t A14— No. Date c t NORTH , TOWN F O ,.o , 0 NORTH ANDOVER . o ? s 3 L O O . , Certificate of Occupancy. $ L0 f Building/Frame Permit Fee $ 4 Argo�sEt Foundation Permit Fee $ cM —Oftr Permit Fee $ S U i Sewer Connection Fee $ _ Water Connection Fee $ TOTAL Q$ j Building Inspector I 9774 Div. Public Works x PERJiIT NO. PAGE APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. MAP id0. LOT NO. 12 RECORD OF OWNERSHIP IDATE (BOOK .'PAGE ZONE SUB DIV. LOT NO. 1 LOCATION /--5 — PURPOSE OF BUILDING pn OWNER'S NAME �r-v4 NO. OF STORIES A SIZE - OWNER'S ADDRESS �7oC� /.�n •� BASEMENT OR SLA ARCHITECT'S NAME _7 (� SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME ,/.- ��LC71LKL SPAN - DISTANCE TO NEAREST BUILDING (� DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES —SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS . IS BUILDING NEW SIZE OF FOOTING % IS BUILDING ADDITION MATERIAL OF CHIMNEY • IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMEVrs OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY - IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDESi�W EST. BLDG. COST / J PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.� y�J Y(/ Iv EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS t - 12 SEPTIC PERMIT NO. ELECTRIC METERS 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 FILED �YtLDINa INS'P[C`TOI ;Fr G T OF O ER OR AUTHORIZED E OWNER TEL.# c(oRMIT GRANTED \ CONTE.TEL# �V ✓/V 19 CONTR.LIC.# v l / ,.. H.LC.lI / off 7 vr BUILDING RECORD 1 OCCUPANCY 12 I ANGLE FAMILY _ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM `MULTI. FAMILY LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES GA - - - -• — APARTMENTS - ,- -' RAGES. ETC. SUPERIMPOSED. THIS REPLACES L - CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW O PIERS PIASTER _ DRY WALL _ UNFIN. 3 BASEMENT - 17 AREA FULL FIN. B M'T' AREA _ l/ 1/7 V4 FIN. ATTIC AREA _ NO B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 1 - 4 WALLS I 9 FLOORS CLAPBOARDS 8 t 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING COMIAC COMLAC �— ASBESTOS SIDING N _ VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _. ...... .. BRICK TN MASONRY ATTIC STRS. b FLOOR ' BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR (� 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 TILE FLOOR TILE DADO g FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. j TIMBER BMS._COLS. STEAM i STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS GAS I 7 NO. OF ROOMS OIL I - - B'M'T2nd _ ELECTRIC Ist 13rd I NO HEATING i i r M ` U ?� b CA: `fV Z m b o co - a F ' y 4, ''�''����.,� �� �•r.�.•;�i+�Y.uc+�� �"`i��nc���� ck+�s+�+..s M���"x� ,w.�,e ',s�,,,��,_'' .�g'u t y r.. •a"�»*'x#'°�"� !6, �',x• ryA}u . .3 �..;�7' r.r"r xr 3 5° ti'..r, ^' i«� '-n-r,a. .: �, {' r FORTH 4. ��/1 T0VM of ' �. f 1 No. r& z - .�s_ -w COCMICMEWICK AERATED PP5 - ---------- -- - - 15 FIMR 01VI IT T ;> +.N THIS CERT IFIES THAT.............................. ..... . ..p. N....L.01... �................................. .............. .......,..,... - j has permission to nest.. - .b.�,. ...... buildings on ........... ��A. ........ j. ..... tobe occupied as....................................................�..,�,t. �r.....�f?�" ........ _ .............. c ... .._. provided that the person accepting this permit sha(I in ev respect conform to therms of the a� office, n to the provisions of the Codes and By-66' - ws relating to the Inspection, Alteration a is t : �[iuri of this o e, a d p Y 9 P r Buildings i.1 the Town of North Andover. VIOI_F -,-IO N of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES I] 6 MONTHS U'' LESS CONSTRU( ;TION ST LID �cci:panty Permit Require( to Occ4py Building is play in a Conspicuous Place on the Premises — Do Not No Lathing or Dry- Wall To Be Done - - ---- Until hispected and Approved by the Building Inspectc,y. Location e?, No. Z - Date EE N°RTS TOWN OF NORTH ANDOVEq F p Certificate of Occupancy $ + Building/Frame Permit Fee $ "AVIDEta Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ B TOTAL $ O�f Building Inspector '`` 9825 DIV.Public Works PEbt�iiT N APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE MAP 4J0. LOT NO. 2 RECORD OF OWNERSHIP IDATE (BOOK ;PAGE — ZONE I SUB DIV. LOT NO. �— 1 S.5 PURPOSE OF BUILDING .._ .. :.....: OWNER'SONA E }h,� • `a:—• NO OF STORIES SIZE -t --' - OWNER'S ADDRESSy& t5�1 BASEMENT OR SLAB C/ U ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2NO 3RD BUILDER'S NAME .}-�'`>. (� 2� �� ` 5 SPAN - — DISTANCE TO NEAREST BUILDING - DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES —SIDES REAR ' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION l� MATERIAL OF CHIMNEY IS BUILDING ALTERATION BUILDING ALTERATION UyN Rf [ ,�6L�f [ PC 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 GAB LINE 3 PROPERTY INFORMATION INSTRUCTIONS , I`� ( �/(� LAND COST SEE BOTH SIDESEST. BLDG. COST ` ... .. .. _ ._ - EBT. BLDG. COST PER SQ. - - PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 /U� 9--�� / V 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 FILED BUILDING INGP=CTO! TPERMIT E OF NEI OR AUTHORIZE NT }# OWNER TEL AI RANTED CONTR.TEL# �19 `F� CONTR.UC.X .:. .-: .. H.LC.N _ �4ORTlq F Tovm Of dover No. JK -} — Zo �' H 3 r dover, Mass., 100 2COCHICHEMCK � ADRATED FPa,`�� 1 5� BOARD OF HEALTH Food/Kitchen Septic System PERMIT T -- BUILDING INSPECTOR THIS CERTIFIES THAT ..:.............................1��.�'— O�l�p............(..R.�./..r7..�! .�... ... .......................................... Foundation has permission to erect... Quildings .......` 5............ .Jy. Rough tobe occupied as ..........................................................., iiU.�..(�. ...... �`�/! ................................................... Chimney provided that the person accepting this permit shall in every respect conform to th arms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIWSTT ELECTRICAL INSPECTOR Rough Service ILDING 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det: i r I HOME IMPROVEMENT CONTRACTORS REGISTRATION j Board of Building Regulations and Standardsi One Ashburton Place, - Room 1301 r Boston , Massachusetts 02108 I HOME IMPROVEMENT CONTRACTOR j Registration 102097 Expiration 06/30/98 Type - INDIVIDUAL I HOME IMPROVEMENT CONTRACTOR Registration 102091 Type - INDIVIDUAL JOSEPH P . BRADISH , JR I Expiration 06/30/98• 9 Moulton Drive/ Box 448 I E . Hampstead NH 03826 I JOSEPH P. BRADISH,. JR I t, Moulton Drive/ Box 448 G� E. Ham stead NH 038 I ADMINISTRATOR P 26 57597 I c _Q w u D _ • :MAr 9 1496 a ij � ✓,/e �oorvmanurea�/ o�✓�ac/:.u�etts I 1 57897 uv- ra S: LET'add"C: S09r( - .•