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HomeMy WebLinkAboutMiscellaneous - 33 HAROLD STREET 4/30/2018 (2)_ - -_ _ -- - - - --- r - MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723.3800 Ma Only (800) 392-6108, FAX (800) 851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch.139, Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: MATTHEW GOSSELIN Property Address: 33 HAROLD STREET, NORTH ANDOVER, MA 01845 Policy Number: 1296269 Type Loss: Windstorm Other than Hurricane or Tornad Date of Loss: 03/14/2015 Claim Number: 334896 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1000.00 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 the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 3/18/2015 9212 Date..111,-?4? ///. . TOWN OF NORTH ANDOVER .�� '• °oma PERMIT FOR PLUMBING This certifies that ... -7Q—C14/Q-S ................. has permission to perform .... /oe6?yt".�orl ................. . plumbing in the buildings of .,l3! ............. ............. North Andover, Mass. Fee.? 1�•.4;1?Lic. No.. ��%. A71��9rs7..... . . PLUMBING INSPECTOR Check # _.c- L= [ns " i C,.,O„x&II, fame: f �}lll ���^. CE c° r Ori 3o,i tl.r�rLrft4aa� �i' Address: GI .� City/Town: t d� ElCorporation O V1�tate: G . Business Tek -c-1 '7Y L (L ElPartnersh- Name of Licensed Plumber: ��� Company INSURANCE r-rni�o�..� 1 have a current IiabilitLr,insuranEe policy or its su ntiai equivalent which meets the requirements of MGL. Ch, 142 Yes If you have checked Yes, please indicate Type of Covera e b checking the No ❑ g y g appropriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does have the insurance coverage required b C Massachusetts General Laws, and that my signature on this permre application waives this requirement. y hapten 142 of the >i nature of Owner or Owner's A ant Check One Only Owner ❑ Agent ❑ 1 hereby certify that all of the owledge and that all plumdetailng s and information I have submitted (or entered) regarding this Knbiwon k Pertinent prand installations performed under the permit issued for tt ovision of the Ma se State Plumbing Code and Cha P 42 oft neral r • Type o cense: :le y(mber Signature o Licensed P `.y/Town aster 'PROVED (OFFICE USE ONLY) ❑Journeyman License Number: •_� are true and accurate to the best of my in will he in compliance with all I FA . I MASSACHUSETTS UNIFORM APPLICATION ` FOR PERMIT TO DO PLUMBING City/Town: �- �� V MA. Date: Permit# Building Location: Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New:E] Alteration:0 ❑ �.,� Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES l� DEDICATED 1 W z SYSTEMS f�] w `n Ln z c w N 2 ~ Ln -lea �, " z Q w W � Z VV p O Q w w _z I- Z FQ- a Q cn ,e O LU Z y in Z= O a p. N W JL U. u X Q r f - ° Q = 2 O a L) '' N o° Z t- °x F- w in „w.r � Z a o 3 a Q x Ln LL x , Q Q w W o` w Ll LUl� 'SUB BSMT. Q m mo o LL C) s m >Q 3 P Ln 3 0 a N ¢3 BASEMENT 1sT FLOOR 2ND FLOOR RD FLOOR 4TH I FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR L: FLOOR [ns " i C,.,O„x&II, fame: f �}lll ���^. CE c° r Ori 3o,i tl.r�rLrft4aa� �i' Address: GI .� City/Town: t d� ElCorporation O V1�tate: G . Business Tek -c-1 '7Y L (L ElPartnersh- Name of Licensed Plumber: ��� Company INSURANCE r-rni�o�..� 1 have a current IiabilitLr,insuranEe policy or its su ntiai equivalent which meets the requirements of MGL. Ch, 142 Yes If you have checked Yes, please indicate Type of Covera e b checking the No ❑ g y g appropriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does have the insurance coverage required b C Massachusetts General Laws, and that my signature on this permre application waives this requirement. y hapten 142 of the >i nature of Owner or Owner's A ant Check One Only Owner ❑ Agent ❑ 1 hereby certify that all of the owledge and that all plumdetailng s and information I have submitted (or entered) regarding this Knbiwon k Pertinent prand installations performed under the permit issued for tt ovision of the Ma se State Plumbing Code and Cha P 42 oft neral r • Type o cense: :le y(mber Signature o Licensed P `.y/Town aster 'PROVED (OFFICE USE ONLY) ❑Journeyman License Number: •_� are true and accurate to the best of my in will he in compliance with all I FA The Commonwealth ofHassachusetts Department oflnd'ustrialAccidents Office of Investigationg 600 Washington Street Boston, MA 02111 5 www-mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/.1J+ lectricians[Plumbers m Iicant Information Name (Business/Organization/Individual): Address: City/State/Zip: Cr quire ] Homeowners pt17Phone #: G _i =277 - q I L/ .Are you an employer? Check the appropriate box: 1. El am a employer with (>' 4. ❑ I am a general contractor Type of projec required): employees (full and/or part-time).* 2111 am a sole proprietor or and I have hired the sub -contractors listed 6. ❑ Ne construction partner ship and have no employees on the attached sheget. t These sub -contractors have 7. emodeling working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. EJWe are a corporation and its 8. Demolition 9. ❑ Building addition required.] 3. ❑ 1 am a homeowner doing officers have exercised their 10-ElElectricalrepairs or additions all work myself. [No workers' comp, right of exemption per MGL c. 152, §1(4), and we have 11.❑Plumbing repairs or additions insurance r d. re uire q ] � no employees. [No workers 12-ElRoofrepairs � comp insurance re ' d 13.[] Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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. avlicndicat g such_ Xam an emptoyen Haat is providing workers' com information. pensation insurance for• my employees Below is the policy and joh site . 1 / Insurance Company Name. v r T 4 /'��% f-vr rl1 , Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:_ y c, S Attach a copy of the ,workers' com ensation otic City/State/Zip:�/c �. �,� Y p Policy declaration page (showing the policy number and expiration date). 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 civilpenalties 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 r ana penalties ofperjury that the information provided Offacial use only. Do not write in 1 is area, to he completed by city 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 S. Plumbing g Inspector //. is tr7eatd correct. Contact Person: Phone #: Date P— ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .,144...........�.. )Oed�.......................................... �..... has permission to perform �f/.................................. .................... wiring in the building of /.i%C K-,..... d/Lin S„ ................................... at .3.1''j......... ..r( ).4/.........t'. j ..................... . N Andove , r Fee ... I.y.�...-..... Lic. No..... .x.9... -4.9(..E ... ......... ................. E ALINS PECTRR Check # ,v 10564 ,gN /� / C.cclmmonwea& olMamachumtb RNKME °Uepad..t /5 ire S wkej ON NEW r` BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /b Occupancy and Fee Checked [Rev. 1/071 (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 IN INK OR TYPE ALL INFORMATION) Date: City or Town of: ()` th Ay1ac-,e.,,- To the ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) I Owner or Tenant 0 ,1 cA Telephone No. 97k- Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building /D W Z./1;4 !2 Utility Authorization No. Existing Service %00, Amps /2 0 / 2 (il)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: e e- � 6 c(,t-% Q Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LuminairesSwimmin 3 Pool Above ❑ In- ❑ g rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets ao No. of Oil Burners FIRE ALARMS I No. of Zones No. of SwitchesNo. 12 of Gas Burners No. of Detection and Initiating Devices ;• No. of Ranges I No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals: P Number Tons J.KW "' "'"''' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers I Space/Area Heating KW Local F1 Municipal El other Connection No. of Dryers I Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or E uivIlent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equi dent OTHER: Attach additional detail if desired, or as required by the InspeVoy fres. 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 completionn4, INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issuino the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. 1 CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under the ams andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: �.fie,� Gvoo�Jnr._i f��toC i-r� cLIC. NO.: 7yZ::-� Licensee:- (let, { !,t, L., �,r ,,,4/ Signature ��_ IC. NO.: (If applicable, enter "exempt" in the license number line.)Bus. Tel. No.: `�7 �' — ��,t1 ^ �t�� Address: Z % Z /(�tr..� 13c�►� oto,, Lett lff a,� 6 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 agqnt. Owner/Agent Signature Telephone No. PERMIT FEE: $ 3 F1 i -6"/Z f �, l c `; The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Tfashington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _pphcant Information Please Print LegMy r, Name (Business/Organization/Individual): (_,,�__ tC Address: City/State/Zip: Act,,%l r,,g 5�/9 6, Phone #: 7 -7 �- - Z C G - 'Z r" -t Are you an employer? Check the appropriate box: 1. El am a employer with 4. [:]I am 'a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2• am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub=contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. El We are a corporation and its required.] 3. ❑ .I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. Insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.7 Roof repairs 13.❑ Other luoccenon treoiv sheW_t "- wors-workaa Policy informadoa.meowners 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:�'!�!/�j•,� Policy # or Self -ins. Lic. #: ` Expiration_ Date: / Z/ Job Site Address: City/State/Zip: ZZ.1, g;,,�, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. _17 x _. _ 975 ^ zr— - 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be. deemed to be an employer." MGL chapter 15.2, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their cerdficate(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 tote city or town than the app licaluon for the permit or license is being requested, not the Depart-m—en_t 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 that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 4.06 or 1-8.77-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 mTwur.rnass.. govfdia Date. // 7 ") f . IN, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that A./ ........... has permission for ............. in the buildings of .......................................... at ` 32 -........... North Andover, Mass. *..—.. Lic. Check # 0,3 17/ 0 6625 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) �Q / I � 44 a0 c7 � 0 C"�" { �Jj l/e� Mass . Date Q �% I City, Town �i i Permit # Building T70. (� S4 Nameie4I, ty) Owner' s �047+C,+ Q.S�J: AT : Locationy�s� GNew ❑ V Type of Occupancy: IR P—S /' A, e A C (0-1 RenovationEl Replacement e Plans Submitted YesE] No ❑ (Print or Type) Installing Company Name Address —a=0 Check One: Ifre0._�l✓l0, C1 Check - ❑ Partnership _ Firm/Company Certificate y Business "Telephone � � 8 q OE q_ Name of Licensed Pluber or Gasfitter gym, 14 1, pe H I hereby certify that all of the details and information I have submitted (or entered) in above application arc true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed throwner or his agent that I do not have liability insurance including completed operations coverage. --- '- Si•n.tu of O m/A•'cnt . I have a current liability insurance policy to include compacted operations coverage. By _ Title City/ Town APPROVED (OFFICE use ONLY TYPE LICENSE: KPlumber ❑ 'Gasfitter ❑ Master 0 Journeyman Signature o icensed Plumber or Gasfftter t3(`I7 Lioense Number i : ■■■■■■■■■■■■■ ■ (Print or Type) Installing Company Name Address —a=0 Check One: Ifre0._�l✓l0, C1 Check - ❑ Partnership _ Firm/Company Certificate y Business "Telephone � � 8 q OE q_ Name of Licensed Pluber or Gasfitter gym, 14 1, pe H I hereby certify that all of the details and information I have submitted (or entered) in above application arc true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed throwner or his agent that I do not have liability insurance including completed operations coverage. --- '- Si•n.tu of O m/A•'cnt . I have a current liability insurance policy to include compacted operations coverage. By _ Title City/ Town APPROVED (OFFICE use ONLY TYPE LICENSE: KPlumber ❑ 'Gasfitter ❑ Master 0 Journeyman Signature o icensed Plumber or Gasfftter t3(`I7 Lioense Number -� COMMO E LTH O SSAUHC SETTS ISSUES THIS LICENSE TO TIMOTHY C HILPERT r 020 NORMAN ROAD s NORTH BILLERIC MA 01862-233 13647 nr fn, .- _ n 11/24/2008 21:46 9786671018 BRAINERD PAGE 02 COVERAGES THE POLICIES UP INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PI ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS C MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXC POLICIE6, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, NeaAbD POUCYNUMBER POUCYEFFECTNB FOLICYEXPIRATION TYPE OF INSURANCE DATE U MroD" X COMMERCIAL GENERAL LIASILM CLAIMS MADE LK OCCUR A GENT. AGGREGATE LIMIT APPLIES PEA PRO - POLICY M JF LO( AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS ti NON -OWNED AUTOS pARAGE LtABILnY ANY AUTO M ESS I UMBRELLA LIABILITY I1 OCCUR ❑ CLAIMS MADE DEDUCTIBLE RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPMETOPMAInNEIVEXECUMA OFFICEARA MISER EXCLUDED? Ir!A0. dlaerlbo bndor SPeCIAL PROVISIONS bUwr DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES!EXCLUSIONS ADDED BY ENOORSEME Plumbing Town of North Andover 146 Main Street North Andover, MA 01845 Attention: ACORD 25 (2001108) RIOD INDICATED, NOTWRTISTANOIN© ERTIFICATE MAY BE ISSUED OR .USIONS AND CONDITIONS OF SUCH LIMITS EACH OCCURRE C ! 600,000 OANAOETO D00CU S PREMIeW oocvrMea 50,000 MED. EXP (Arty one perMan) $ 6,000 PERSONAL & ADV INJURY sb 500,000 GENERAL AGGREGATE S 11000x000 PRODUCTS-COMPIOP AGO. 3 500,000 S COMBINED SINGLE LIMIT ! (Ea accident) BODILY INJURY (Par person) ! BODILY INJURY ! (Par ac0iden0 PROPERTY DAMAGE ! (Per accident) AUTO ONLY - FA IOENT R OTHER THAN EA ACC L AUTO ONLY., AGG S EACH OCCURRENCE 5 AGGREOATZ ! 8 9 3 wa erATw DINER TORY LIMITC E,L, CACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE Fs- E.L. DISEASE -POLICY LIMIT 5 E.L. 4T! SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE OCSCRIPED POLICIES BE CANCELLED BEFORE THE EXPIRATION bATC THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 $0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. (T'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENIATIVE Gordon C Brelnerd Jr, President Certificate # 6756 9) ACORO CORPORATION 1988 G v Date- ? � Y . y...... TOWN OF NORTH ANDOVER .� • PERMIT FOR GAS INSTALLATION SACHU5Et r 7 This certifies that ..... .... has permission for gas installation ., . f ................... . in the buildings of .. .4. F. 1� :r. ........................... at .............. . North Andover, Mass. Fee..3P .... Lic. No...I. ?! c-.( .. .... ..... GAS INSPECTORK ` Check # / l % f 1 6325 or MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) pot , Mass. Date 2007 Permit # L Building Location3 3 /� �-d /d ,7/Owner's Name Owner's Tel # Type of Occupency New M Renovation M Replacement IZI Plan Submitted: Yes ❑ No ri Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate Address 20 Cooper Streetx Corporation 2720 Lynn, MA. 01905 Partnership Business Telephone 339-440-8100 Firm/Co. Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr. Insurance Coverage : I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Mx No M If you have checked fes, please indicate the type coverage by checking the appropriate box. A liability insurance policy , Ex Other type of indemnity ❑ Bond M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check One: Owner Agent Signature of Owner or Owner's Agent I hearby 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' Womplianwi all pertine provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.BYType of License: Title x Plumber U City/Town Gasfitter Signature of Licensed Plumber or Gas Fitter Approved (OFFICE USE ONLY) x Master Journeyman License Number 13106 In di■■N■0■■ MEN ■■■�■■■■■■■■■■ Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate Address 20 Cooper Streetx Corporation 2720 Lynn, MA. 01905 Partnership Business Telephone 339-440-8100 Firm/Co. Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr. Insurance Coverage : I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Mx No M If you have checked fes, please indicate the type coverage by checking the appropriate box. A liability insurance policy , Ex Other type of indemnity ❑ Bond M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check One: Owner Agent Signature of Owner or Owner's Agent I hearby 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' Womplianwi all pertine provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.BYType of License: Title x Plumber U City/Town Gasfitter Signature of Licensed Plumber or Gas Fitter Approved (OFFICE USE ONLY) x Master Journeyman License Number 13106 O z O H U w a U) z_ cn U) LU O w OCL ch w U H LU Y U) z O H U w a z_ J Q z LL 0 z w LU LL O z_ r LL CA a O O 0 0 F - w a w O LL z 0 H a U J a a a 0 z O J_ m U- 0 O w CL r LU a z z_ D J_ D m LL O z 0 Q U O J w m D J CL a w F - z t9 W a w H a 0 w 0 v w a N z a 0 0 4 Location 3 � � 1? 01 `- — No. CY Date �b J�no NORT1y TOWN OF NORTH ANDOVER f 9 ' Certificate of Occupancy $ . °, .«mac_.. ,° • ;,s'^•° AMUSE � ( — Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C117 Check # ' 7 Building Inspector A 1.1 Property Addresg: 33 1�-.� X011 n 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. Public 0 Private ❑ 54) Zone 1.5. Flood Zane Information: Outside Flood Zone 0 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ JEl,11V11 L - rKuJrEKI Y Vwf'4EKbtUr/AU 1tIUICtZ ID AGEIN'I' 2.1 Owner of Record 3 3 Name Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: 3.2 Registered Home Improvement Company Name (03 -�0/a Telephone t., All ✓"�—Jt''/ 5 Not Applicable ❑ 0 License Number W-/00 Expiration Date Not Applicable ❑ mc G&() Reg tion Number �� Y%c�--- 0 ( V Expiration ate M M X z O 47 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ 1�4er ❑ Specify fJ Lt✓ t /t wS l Brief Description of Proposed Work: C2 51� 2-� <-- C2,5.', C-13 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Pennit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1 t C W v9yL'7 �1(�'% as Owner/Authorized Agent of subject property Hereby authorize 1 ^ C2��� to act on My b a u all matters�relative to work authorized by this building pennit application. 9 /O kf-' U Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, a � ( C- `� ,�110 F✓C�% 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 12 ) FLS i^7 Pri e j ?JIaS �uy Si ahue of Owner/A ent Date t NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1sr2 ND 3 SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH EY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE RICHARD FLUET CONTRACTING INC. 102 Bridle Path Ln. METHUEN, MASSACHUSETTS 01844 (978) 685-7010 To Stephanie Faber 33 Harold St N_ Andover,,Mass. 01845 INSTALL 17 HARVEY,WHITE,CLASSIC,INSULATED,TILT-IN,VINYL REPLACEMENT WINDOWS WITH LOW "E" GLASS,AND INGLASS GRIDS. $265.00 EACH TOTAL $4505.00 WORK TO INCLUDE;PERMIT,INSTALLING NEW WINDOWS,INSULATING,CAULKING,AND TRASH REMOVAL. WE ARE LOOKING FORWARD TO INSTALLING YOUR NEW WINDOWS FOR YOU. Extras or changes to be completed at a rate of per hour, per man. Unpaid balances subject to 1'/a% finance charge per month. WE Pq?O OSaE herep to feurn timate al and a�q�r7e conte 6(1T1r"ce1y8hlt Je�%ve specifications, for the sum of: 4,505.00 C1 1 I1C1 eU / dollars ($ ). Payment to be made as follows: 1/2 WITH ACCEPTANCE, BALANCE UPON COMPLETION. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifica- Authorized tions involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Note: This proposal may be Our workers are fully covered by Worker's Compensation Insurance. withdrawn by us if not accepted within ACCEPTANCE OF PROPOSAL —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: 30 days. r � .%irsir.»r�yrox<<u�rli%r r/.. !/rr.uar%trlJef�i Board of Building Regulations and Standa,ds w :TOME IMPROVEMENT CONTRACTOR { Registration: 106620 ' Expiration: 7/24102 Type: PRIVATE CORPORATION RICHARD FLUET CONTRACTING I Nkhard Fluet 102 Halle Path Lane,; ff Methuen, MA 01844 Adminwtramr BOARD OF BUILDING REGULATIOXS• .' License: CONSTRUCTION SUPERVISOR I r { Number: CS 050710 Birthdate: 04/22/1956 Expires: 04/22/2001 Tr. no: 8438 J ` Restricted To: 00 RICHARD A FLUET r 102 BRIDLE PATH IN -1 �. • METHUEN, MA 01844 Administrator IIIC L-�UI///IIUI/WCdll/l UI /VIdJJdGIIUJC!(S Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Location: 3 3 14-"0L41) City ti, t9 -) a k7 -A Phone am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Lompany name: 7�L l L t Address City'' Phone #: ((j I U Insurance Co. f-1���'1./ ix Policy.# Company name: Address City- Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andtor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under*th*Tins and pelae , jury that the information provided above is bue and correct. Signature =�—n�( �` -� �"�_ Date Print name r ' �� �� Phone # IM G 1? )0 /0 Official use only do not write in this area to be completed by city or town official' E:]' Building Dept []Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person._ Phone A- ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION N C U) ;� 0 co O co C: z O COD O .y O Q. CD C O G3 V _Cc CL CA O Q .CL CO2 C O C a CO) x o LE v a cn 9 o A m c U ro w 94 o PQ00 G'' � a W v W °° —Cd°° a o z c y O z w a cA cn o cn 0 co O co C: z O COD O .y O Q. CD C O G3 V _Cc CL CA O Q .CL CO2 C O C a CO) c o m c o s c y O c V V �c oc • , CL m c :z o 0: yaco. E Get CD c CD CLCD rn o=cr CD caE to v mmCL H CD C40 0 3 .-. Qf m O °C C C y O A O `Em *-4 y :O:mo c tnm� oC Z = O cm:S r c O c 'Cc� c y . 04 m H O O . V Z O O ; 01 O c Q m ; O i m c •O LULU c tV c m om. M ca CD 0 W ,E c V.�p 3 ca tom R cm O m ie coo O O 'd cm _ ` O ZZ CL .&. CIO 0 co O co C: z O COD O .y O Q. CD C O G3 V _Cc CL CA O Q .CL CO2 C O C a CO) Location No.. 7 !� Date S� TOWN OF NORTH ANDOVER J-'9' Certificate of Occupancy $ Building/Frame Permit Fee $ IT Foundation Permit Fee $ Other Permit Fee be -k,, v $ �5 Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Insp c or 7 / I 3 13 /27/99 11:36 25.00 PAID Div. Public Works w L c: a 0 z m a F W z U O O U O - U = V Ww c o w � � 1J - C z v Y w °lZ Y O O c' _ G N a W x ^O i...i d N z W Q o o J r O O C M� 7 _ ,.,, m ..7 ° F Z c N U F U O r W G y O a z F y a O w0 4 O V Z U Z z O z O U. O U U N z a: O O O O Z ZL S i O Z Z F cj O w z U O O r+^�1 O O H J Q O z � ' x w cn p a rn �MM m F, W z Z � O 2 LA U e w x y z 0 0 z fW < v w p a o p !- N EO- U C7 C7 o z z z o c c m c _ m 4 N H i m a 0 z m a F W z U O O U O - U = 1 z W V Ww c o � � 1J - C v a w °lZ O O c' _ G N a W x 1 imm o � cr- W z CL a m a w :c a a 0 W W Q c. CL :o CD ci ` imm o � cr- W z CL O w a 0 cn CD cr w w ccW m :c 0 c O Q c. CL :o CD ci 0, N m a N COCi O • H E � m V Cc Cc H O o �- .h Em Amo O = avo n i h o ; =:5 m 0 C v•yZ O O O C� p 0 CLC co •O �'-• : CL:5 O N W W C m• O C-3 m � O• F- La _ A m .8oy• O CL:z O w a 0 cn CD cr w w ccW Town of North Andover NORT1y OFFICE OF e,yOL COMMUNITY DEVELOPMENT AND SERVICES y�rOy�'ty`o ° . x. h'. 27 Charles Street x North Andover, Massachusetts 01845 9SSACHUS't WILLIAM J. SCOTT Director (978)688-9531 Fax(978)688-9542 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) 0 l cis", . ..... — =r• r,...,.... Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9.540w PLANNING 688-9535 w David Bennett 9 (508) 352-2446 NEPTUNE DEMOLITION P.O. YOX 910 GEORGETOWN, MASSACHUSETTS 01833 (508) 352-6210 TO Gene Fo�.arX........................ .......................................................................................:..... 33 Harold Street .......... ................ ............. .............................................. :................... ..... ..................... North Andover, Ma ..................................................................................................................................... M04129199 Page No. _ 1 of 0 10:52 AM D 2/2 pages J)ropo.gaj 14677 PHONE (978) 688-9566 DATE Aril 29, 1999 JOB NANE i LOCATION Demolish Garage 33 Harold St North Andover, Ma FAX PHONE (978) 688-3211 ARCHITECTS DATE OF PLANS Demolish_ and remove garage..and.foundatiom ....................,........... ,,........... ............ .......... ......................... .......... .......................... ........... ....................... .. aspose of„all debris caused by said work from site. (.....Owner to obtain all necessary.. permits and disconnects..................................................................................................................................... . for the sum ofTwo Thousand And 00/100 dollars $2,000.00 ......................................................, ....:.... . ............................. PAYMENTS TO BE MADE AS FOLLOWS: .............. ._ I ................Payment in full upon completion ................................................................ ... ASBESTOS OR ANY OTHER MATERIALS CLASSIFIED AS HAZARDOUS.'BY THE DEPARTMENT. OF ENVIRONMENTAL PROTECTION ARE NOT INCLUDED IN THIS CON TRACTOR.'PRICE., UNLESS SPECIFIED ABOVE. m material is guaranteed to be t as rd p -a d. es work a er to completed vet it a work- Authorized menlike manner arordng to standeM p-actices. Ary aneration or deviEtpi hcm :re Signature ab?ve x atta&ed specihcatcns invoNng extra costs A be executed only uoon wnttsn orders: and w II become an extra charge over and above a;timate. Ai Gifford R. Russell . owner ag'eeaems contingent upon strikes, accidents or delays bev?nd our control. Owrer zo cary tre. *o -redo and over necessar/ ins.irarce. % wo-kers are tUh� _o4ered oy Note:Thi9 proposal may be v cr<men's C?mpensation Ihsuraue• wilhdrawn by us t not accepyed within 60 days Arreptance of 3propoot _ The above or attached prices, specifications and conditions are satisfactory and are hereby Signature accepted. You are authorized to do the work as specified. Payment Wil be made as outlined above. �/ ^^ Dale of Acceptance: r �J Signature X LLJ N Li J D D G3 L 4,100 S.F. eml 44 r I I r I 45 S.F. 6 X0'7 74 10,020 S.F:. I �9 7,500 S.F.---� '7t a 5,000 S.F. 44 '?2 500 S.F. 43 ss 42 ca 12,000 S.F. 9,500 S.F. M ' i5 40 10,000 S.F. „ 15,000 S.F 38 • �, 39 � =17 62 a Sep. 1 r 'cl , 10,000 S.F. 10,000 S.F. 97 ao i 1101v 1 �Z �- I 39 8,575 S.F 86 AO r . i.. 5,000 S.F 66 J 4! O , JIMi I 1 I I I . 1 59 w w