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HomeMy WebLinkAboutMiscellaneous - 31 DANA STREET 4/30/2018 c� 0 nM A P F R E The Commerce Insurance Company1" Citation Insurance Company1m Commerce " Gore Road,Webster,Massachusetts 01570 INSURANCE- 508.949.15001 www.commerceinsurance.com April 23, 2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: BRIAN FAYE/TRACEY FAYE Property Address: 31 DANA ST Policy#: BDKVLT Date of Loss: 02/18/2015 File#: JXJT 19-HNYNT3 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. LISA LEAHY Telephone: (508)949-1500 Ext: 15846 Sr Claim Representative,Property Toll Free: 1-800-221-1605, Ext:15846 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. April 23, 2015 ice dam claim CIC 254 (Rev.4/95) MAIL 788 U Date.... .................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88ACMU`3� +4 This certifies that ................................................ ...........`...................................................... has permission for gas installation .. 0 lc. ...... C''-......... inthe buildings of..... �s...� ..:�................................................................................ at.....�-a' ..�D. ........ .................................... North Andover, Mass. Fee... Lic. No Z..�.? M GASINSPECTOR Check# -56(d.o ill � I •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `y CITY MA DATE fr► i PERMIT# U JOBSITE ADDRESS S_,; ' DOWNER'S NAME GOWNER ADDRESS TEL�� TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL PST RESIDENTIAL` '` CLEARLY NEW:2r RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES D NOD APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER �- - - -—:- - - - _ CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE1 :..__I GENERATOR, v�.l_ 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 LO INSURANCE COVERAGE _ 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2/ 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: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 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 m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with 11P rtinenk provisi n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME - LICENSE#� . SIGNATURE MP 0 MGF EjI JP 0JGF LPGI EI CORPORATION Ell#=PARTNERSHIP[J#=LLC E]# COMPANY 3- _ ' ADDRESS CITY %✓, _ STATE�ZIP 4;71 TEL FAX CELL :EMAIL l ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION IES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES A Y 1� 0 ' As > The Commonwealth of Massachusetts , - Departinent of lndustrigl Accielents Office ofluvestigations 660 Washington.Street .Boston,MA 02111 vww.mass:gov/clia Workers'Compensation Insurance Affidavit:Builders/Conti°actors/Elecfriclans/Phimber s Applicant information Please Print LeWhAl Name(Business/Organization/Individual)' Address: City/State/Zip: Phone#' Are y an em 'r?Check the appropriate box: Type of project(required): 1. I mployer with 4• ❑ I am.a general contractor and I 6• []Now construction loyees(full and/or part-time).* have ifted the sub-contractors ,2. I am a sole proprietor or parta.er- listed on the attached sheet 7• ❑Remodeling ship and'have no These sub-contractors have 8. ❑Demolition worldng for me in any capacity. workers'comp.insurance, 9. ❑Building addition [Nb workers'comp.insurance 5, ❑ We are a corporation and its 10.0 Electricalrepairs or additions X equired.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.EEO workers,comp. c.152,§I(4),and we have no 12.❑Roofrepaks insurancerequired.]; employees.[No workers' 13.❑Other comp.insurance required.] xAny appliomtthat checks box#i must also fill outthe section below showing theirwbrkers'compensation policy information. t'Homeowners who submit this affidavit indicating they a're doing all worX and then hire outside contractors must submit a new affidavit indicating such. i'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for any employees Below is the policy and job site information. 72surance Company Name% Policy 0 or Self-ins.Lic.#: Expiration Date: Job Site Address; City%State/tip: Attach a copy of the workers'comp ensationpolzey declaration page(showing the policy number and expiration date). Failure to secure coverage as requireduader Section 25A ofMGL o.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 Investigations of the DIA.for insurance coverage verification. X do Xzereby cert under flee paints andpenalties o fperjmy that the information provided above is true and correct. - Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 9 Issuing Authority(circle one): 1.Board of Health 2.BuildingDepartment 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 eraployee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or written." i i An employei 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 o£a deceased emplor the receiver or trustee ofyer,o 'an.individual,partnership,association or other legal entity,employing employees. I owe r t 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 ba 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 fox 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-contractors)name(s),address(es)andphonenumber(s)along with their ceztificate(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 thatthis affidavit maybe submitted to the Department of Industrial Accidents fox 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 reference number. In addition,an applicant thatmust submitmultiple permit/11cense applications in any given year,need only submit one affidavit indicating current policy information(if necess ary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has b eetl 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox p ermit not related to any business or commercial venture (i.e.a dog license orpermit 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 Gon ojjwoaltbLofwossac17u.:sPtts - DePart.ent d1ndus al,A,ccidenta OMW of13mstigaJoiM 6,90 Was •p n Stce�_t Boston,U.A 421.11 TQL 61.7-727.4900 e 406 ox 1-877- Revised 5-26-05 `ay, 617-727-7749 _ t�.a..pa$s,g4v�dia i r OF MA$SAW • tolMlasig Lei Ll BQAA O PLU-ABEFtSa ARU`lyASf ITTIE S k : ISSUES TNE ' F'OLlOW11�1B rL1,srENSE -1 C �S S33 A JUURNE�YM N "L y' �L"T !' 4 135 WA W� t Vai ORNRt?VER MA 01$45 3 i 248 ,146 Al- Cd le i) tir `y}}, �/'f' /7 t ✓�/ rte' F4' 4f „W ffi 'F 1 t t !i Y, ,f J4P,{ 15"G �: I Aik CIummerce InsurancesM The Commerce Insurance CCmpanySM C1c Citation Insurance CCmAanysM SM Members of The Commerce Group, Inca" CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500 www.Commerceinsurance.com March 28, 2013 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: BRIAN FAYE/TRACEY FAYE Property Address: 31 DANA ST Policyk BDKVLT Date of Loss: 03/25/2013 Filek CWMC03-YAWC89 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. SUSAN JOHNDROW Telephone: (508)949-1500 Ext: 15193 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15193 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above,by first class mail. March 28, 2013 water damge Co11II Crc COmpanles ....COME GROW WITH us CIC 254 (Rev.4/95) MAIL 506 Z t� a J U Date...`5...,' ....... NORTH 1 3:°•,;�``°�'_�"°o� TOWN OF NORTH ANDOVER FO 9 PERMIT FOR WIRING �,sSACHUSf This certifies that ...... ��Q...................�...................................................... has permission to perform ...... T� r....T.!............................................. wiring in the building of......... ......` .�z........................................ s at.......................................�........5.7 ................ .North Andover,Mw. i l bme Fee..— :.O... Lic.No. .✓7S/�.......... ..... . �z u...... ...� ............. ELECTRICAL INS CTOR Check # J'�� Official Use Only( Permit No. 3 a "�q Pu6Ue 540Y Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cade 527 CMR 12:00 (Please Print in ink or type all information) Date!;— �-6 Z,, To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number 04a4 Lr Owner or Tenant 0 Owner's Address :54m Is this permit in conjunction with a building permit Yes M/ No ❑ (Check Appropriate Box):�q89 Purpose of Building��i� �1����! Utility Authorization No. Existing ServiceI DOAmps Volts Overhead 91 Undgmd ❑ No.of Meters_L New Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters ,Number of Feeders and Ampacity Location and Nature of Proposed E ectrical Work v �t Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Co nd Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Ar a Heatin KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Heatinq Devices KW Local Connection t No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases Wiring _62.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I h current Liability Insurance Policy including Completed Operations Coverage or its substantial equival t YES:=)Nproof of same to the Office YES= NO = If you have checked YES please indicate the e by checking the appropriate box. INSURANCE = OND = OTHER =. (Please Specify) O p (Expiration Date) Estimated Value of Electrical Work$ I �' Work to Start Inspection Date Resquested - ough Final Signed under 6e P naltie perju FIRM NAME / LIC.NO. Lrkensee — Pq in signature LIC.NO,� /I c-,,-4 ,� I�Bus.Tel No.�(7 3 Address/I� Pn Pave) IX Lf 7 Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my.signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE (Signature of Owner or Agent) r Location No. Alis Date n z- NORTN TOWN OF NORTH ANDOVER O � R P Certificate of Occupancy $ s"A�M�S Building/Frame Permit Fee $ / � Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 15536 Building Inspect r ` TOWN OF NORTH; ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLINGON ft q� a w W= u V BUILDING PERMIT NUMBER: Q DATE ISSUED: _ f(,� _ O X SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 151 h&Vh Sr 140 Map Number Parcel Number r 1.3 Zoning Information: 1.4 Property Dimensions: Q Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R 'red Provided d � d' 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 /K On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Flint) Address for Service t. Sig re. ti Telephone 2.2 Owner o ecord: Name Print Address for Service: O z Signature Telephone SECTION 3-CONSTRUCTION SERVICES go 3.1 Licensed Construction Supervisor: Not Applicable ❑ ` \(>I Cow— 6)R,#5T0 �y Licensed Construction Supervisor: 46 95z�5' •t7,/ IM License Number Mn Address z S-06-03 Expiration Date Signatur Telephone �..� 3.2 Re istered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address ' �V ^`�✓� �� Expiration Date /z� Si nature Telephone i!d SECTION 4-WORKERS COMPENSATION(M.G.L.'C 152 81,25c(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..... No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s). Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: S&zatiD ZZeZ Z ,Sr3neL� i SECTION 6-ESTIM[ATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be l ) x � �I'IClLIIE+ O a !tom Completed by t applicant 1. Building (a) Building Permit Fee �'6 oaG Multiplier 2 Electrical (b) Estimated Total Cost of `¢f DDD Construction DBD 3 Plumbing Building Permit fee(A)X(b) 4 Mechanical HVAC .AO�Zs I a 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, / S/ni/ as Owner/Authorized Agent of subject property Hereby authorize [IIA-1 to act on My behalf,in all matters relative to work authorized by this building permit application. ,ZD v Z Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION V//Il 1, 6ZftQ ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 6e , tw- Pr' - ao Signature of O ent Date NO.OF STMZS SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DEVIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING - X MATERIAL OF CFM'vMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office or/nvesdgatlons 4 Boston, Mass. 02111 WorKers'Compensation Insurance Afdavit a1 Y Please Print Name: Location: City Phone am a homeowner performing all work myself. OI am a sole proprietor and have no one wonting in any capacity EUI am an employer providing workers'compensation for my employees working on this jab. GLom n name: A V1-9.d Address City /��4 ;f�Yi/,✓)/ .,�- 1 � dC� Phone#• ;7 7 Insutance Comnanv name: Address Gty: Phone# Insurance Co. Poll # Failure to secure coverage as rewired under Section 26A or MGL 152 can feed to the itnimition of criminal penalties,of a fine up to s 1,500.00 and/or one years'imprisonment as well as c ivo penafties in the form of a STOP WORK OAA and a fine of($100.00)a day against me. 1 understand that a copy of this s t may be forwarded to the Oftke of investigations of the DIA for coverage verification. I do herby certify under t p,r► a s,Yles of pedury that the!Narration provided above is true and correct: Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' 0 Building Dept ©Check If Immediate response is required Building Dept p Licensing Board Contact person: Phone# p Selectman's Office Q Wealth Department Outer RSA WORKMAN'S COMPENSATION cN3PECTlQN Of APE LOT zq LOT do r 0.00. { i , � I L 077 916 1 LGT c)7 LU W cc a=10,1000 S.F Ij LQT.Y8 ~ � I u 1 IY 24!x- O � L I j .ANA 5T`R EF T I f' nay Pun.f M6BD p.STK{9M�.LrfMC"MnK""+u.IEV7GWM�';.WD 15m 3cl:W FOR ww.AGE MM1n06f/das. 1 •`aD1[^'�Ri'.Tk:LfFaE'!:44 9CM�9fOVl.'.MQtDGUSg1 S?FSTAalA9. ll� ES E'X COUNTY 4PLAN OF LAND PL NO. OP-ED PLA;1 F.EFE9ENGi�� ' BK 4237 m. 138P;84`R"—" ' p� 'N +; CEHT NO. "" "- PG. -= NORTH ANDUV ERX i {{`"'°�y h > +?.rr a aK F+aacoc quP uaura.�ty as movm"-4 1 PKiILFAF LD FOR: f! .rare no,n viuke"a ft=ri p ay kb,-at e+a rm,e dcw*==an,x 3a fm wax+ e:erRq erw,mrTwfr,ecae-w 06.E Ct o CA -Lt Ma". --PEOPIRS MORTOWE CORP. I C,&vtW Leat The sn-im u aro ftB 1n 01 ^9 b 9Ra•b++ewing I s�L''1�� 1V�t STS[`_ S ';j F E."A—Nor-2—C m.Vms rb mew d rnPimW M=d. " FLOODHAZARD COMMUNRY NO 732998 I SOUNOARY MAP NO-2M3—c— r_FFECTIV tF�?I3 { SCALE 14-20 FEET 1 H OF MV. 7MvMAS 13AILUE&COMPANY C. LAND SURVEYING&RESEARCH - eaeLLce •,- !w.3a472 33 HOWARD STREET Rc 15TERE0 tJWC SURVEY READING,MA.01857 PHONE(781)944-2767 ` _DAA eLra�1°P FAX:1781)944-6112 i A ✓tae >`�r,„e.,�aon,ncal!/e of� ljaa;ac/a.:ells BOARD OF BUILDING REGULATIONS 11 License: CONSTRUCTION SUPERVISOR Number: CS 069505 Birthdate: 03/26/1973 Expires: 03/26/2003 Tr.no: 9692 Restricted To: 00 VINCENT J GRASSO _ 274 MIDDLESEX STS N ANDOVER, MA 01845 Administrator ./lre�.%�mm�eo�euralllr r�.,��t�iu.�xi HOME IMPROVEMENT CONTRACTOR Registration: 129047 Expiration: 6/28/02 Type: Private Corporntio Construction I Development &P'Vincent Grasso ADMINISTRATOR 104 Castlenere Place N Andover MA 01845 • 63,i?U;"2I^02 11: 21 979--E.37-01 4S 1INTERNE-1 1NSURAHCE Pe]E R2 � -CO-RD. CERTIFICATE OF LIABILITY 61VSURANC DATze/a,70 , °RCD)v Ci¢ THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION INTERMT I01;Uhmics AGENcL, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 522 CHICKLIP119G ROAD FOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE 0OVIERAGE AFFORDED BY THE POLICIES BELOW. NORTH AJTl'KNTR, HA O1845 I INSURERS AFFOIkD04000VERAGE lF.1l.4a6t� iNbuRER A: ARRELLA YROTZCTTON CONSTRUCTION SS DEVELOPHANT IIIC S•ISURERB: AMLLBI. FROTECTIOIR 733 TURNPIICR STREET, #223 ---� — �RS.d1REF C LIR11SL7.'X MUTUAL —� --- ------- NORTH AmovZR MA 01845- I tNauREltd: COVERAGES TFE POLICIES OF INSURANCE LISTFD OELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE 1501.1,^Y PERIOD INDICATED.N0T/yIT,-'3TAN0lWf4 ANY FEG UIREMENT,TERM OR.CONDI T;uN 01=ANY CON:RAGT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH'$CERTIFICATE MAY 9E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TJE PCLHEIES DESCRIBE:;HEREIN 18 SUWECT T40 ALL THE TERMS.EXCLUSIONS AND CONPITICINS OF SLIGH POI.ICIES-A.GGPFG.ATE LIMITS SHOWN MAY HAVE SEEN REDUC9D By PIND CLAIMS'. INBR, Fc4jcY IFpHPOLI IgIWE9ATION TYPE Of INSURANCE POLICY NUMBER ^' LIMITS �OWNCRAL LIAEMLI'ri' •••• - EACH OLC hkmiz is 1,000,000- A ;GOC!,000A L I( C]IAISlERr1AL GENERALLIABILITY 36000x3541 07,101/2001 107/01/2002 FIRE D,,,,AC,,E(Ar aneflre) 3 50 000 ?r,11 hLAIMS WADE Lm OCCUR UFD EY:P An Qno �----- 5,000 — LJl I PERSONAL&AMINJ!)R �S 11000,000 I i !GENERAL AGGREGATE 9 — 1 fiOO OC)0 j 0P.,41 ACrLREGATF.LNdIT APrPUES PER; e`'RODUG'S-COMPIOP AG", 4 °OLIGY I PNG- I C�I LOC �.._»._....._=— - I------ a rrnMORILa LIAItil)Tb II COIdl3 WO SIHVL9 LIMY $ A14Y AUTO 11000,000 � I ! f (Sm xcMenti _ I3 '1' ULOWNEDAJTOS 144501400001 0FSJ01/2001 08/01/2002SCOK.YIN.URY �1 i !iL+! SCHFOULC-U AUTOS I I Per voroan, .ff �VHIRED AUTGS - — I I BODILY INJURY NOK-OWNEDAUTOS --i I (ForOCd") —+ I I PROPERTY DAMAOF- S ??p�6.(aAt�E LIABILITY i I AUTO ONLY-FA ACCI4ENT LJi1 ANY AUTO I OTHER HAN EAACC S I !_40i— AUTO ONLr. ACsi S _ _�... ` E$gL;ApiiITY � eAG+t'J_GCUkkEtiGE S w i.J OCCUR i_.1 CLAIMS MAL)6 I I �.I - gEUATE- ----,$ - - _- i �f DE.Gucn9L=_ gE(E44TVJN 0 IS WORtSs:N:9 GGMVEN$AT!ON AND EMPLOYRRS'LIAOk,#Ty ---. � r, OTH- 1-316-312772-039 10/20/2001 10/20/2002 'E.L..ACHacclU�ttiT s ^ 10A,00p-,1 F,L:DIGLIAE-EA FMPL('Y-E- E L.OISEASE-POLICY HWY 13 ,. 500,000! OTHER i II XSCRIPTION O^OPRRAnONS)LOCATICMS)VENICLES)RkCLU870NS ADQEL;OY ENDDRBEMEMT/SPECIAL PRr)V1gjoN8 w CE tTIFICATE HOLDER �_-RrrgR;r CANCEILLATION �D<�ITiCNALIa9URFD:Iast�R[Re. TOWN or NIJllwa ANDOVER MA SHOULD ANY OF THIS AWWP Dl±ECRIIRlrD POLICIES BE CANCBLLRD RRFOAF THE EXPIRATION HLTZLDXNG L`EPARTAA£k'T DATE-HEREOF%THE ISSUtNQ MOURER WILL ENDLAVOR TO.14 L 41.8 DAYS VIRITTEN I 120 bWN STRZET NOTICE TO THE CERTIFICATE HOLAEIS'NA AED TO THE LEFT,BUT 0AILUR1=TCS DO&O LaAr WPOSE NO OBLIGATION Olt UAS IL,TY OF ANY KNO UPON THE INSURER,(TS AOEN"S OR 14ORTIY ilNDOV21k bfiL 41®SRI- REP blNTA.TIVE9. — ..� AUTNURI$'URIp BENT E AC,iITD 25-S(7197) RPO RATION 1983 GFX FORM U.=LOT RELEASE FORM ,�3-�,F � INSTRUCTIONS: This form is used to verify that all necessaryapprovals/permits es from Boards and Departments having jurisdiction have been obtained. This does not retie the applicant and/or landowner from compliance with any applicable or re q uire mentsVe . *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT LOCATION: Assessor's Map Number__Z�9_ PARCEL_ SUBDIVISION LOT(S) STREET ST. NUMBER�� OFFICIAL USE RECO. ENDATf NS OF TOWN AGENTS: Cop ADMINIS RATORDATE APPROVt:D /O DATE REJECTED COMMENTS WZI 114. j . TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWERAVATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm -- NORT#i 4Andoverow�r� o . 0 No. t", 9 9 A o dover, Mass., COCMICMEWICK 7 ADRATED PP? I BOARD OF HEALTH Food/Kitchen PERMIT T Septic System c BUILDING INSPECTOR THIS CERTIFIES THAT........ .! ..y... !�.�.y.......J.. ................................................................................. Foundation has permission to ~.. NG'eS�........... buildings on .... 1.............A..N. ..... .... .•......................I........... Rough to be occupied as..e.."t, �tpO ract 'iA44ASre..d 1"e Y �If01&r%4L 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 Inspection, Alteration and Construction of Buildings in the Town of North Andover. I C)/q 4 ' sat 09� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR C 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. SEE REVERSE SIDES Smoke Det.