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Miscellaneous - 330 MARBLERIDGE ROAD 4/30/2018 (2)
Date........................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .............................. ......... . .............................. has permission for gas installation ............................... ............. in the buildin Of 12 ....... . ................... .................................. .. . ......... / ............................. �� ............... 7r, I r North Andover, Mass. at ................................................................................................. . Fee .3.6'..So ... Lic. No ................................. 4 ........................................................... .... .... ........ Check #iii/,;PASINSPECTOR 10141 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY - - MA DATE PERMIT # JOBSITE ADDRESS,3D OWNER'S NAME GOWNER ADDRESS TE 1 FAXI_-_ _ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:E] RENOVATION:0 REPLACEMENT: Q PLANS SUBMITTED: YES[:] NO E] APPLIANCES -1 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 0 -`.- DRYER- - - FIREPLACEp -, FRYOLATOR -..__ _1 ; ._ .--.-.. _. _ FURNACE - - -F - - ' - - - — - -- -- GENERATOR - - '0.-.._.i . GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNITOQO OVEN- POOL HEATER-- ROOM I SPACE HEATER T ._J .ROOF TOP UNIT TEST _ _ S _ _ - _ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER - ,.,,,// i - i 0 i _' _ 1 /j Vr F_ - _.__ 0 .._. _.._ _ _ INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO Q 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: OWNER E] AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Mark Adams LICENSE # M13049 SIGNATURE MP D MGF [__1 JP F71 JGF EJ LPGI E] CORPORATION E]# PARTNERSHIP F-_1# LLC [:]# COMPANY NAME: Mark Adams Plumbing ADDRESS 112 Fredrickson Road CITY I Billerica STATE= ZIP 01821 J TEL 781-275-6604 FAX CELLI Same I EMAIL 4 r o. COMMONWEALTH OF #WIASSACHuslft `s The Commonwealth of 1Mlassc chusetts Department oflndlustrialAccidents 1 Congress Street, Suite 100 ' Boston, MA. 02114-2017 °r 1-vww.mass.gov/d1a Sy Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers. TO BE MED WITH THE PERMITTING AUTHORITY. Name, Address: City/State/Zip: Are you an employer? Check&e appropriate box: Phone #: 1. ❑ I am a employer with employees (full and/or part-time).* I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will. be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet. Theso sub -contractors have employees and have workers' comp. insurauce.t 6.[] We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have nQ employees. [No workers' comp. insurance required.] Type of prosect ()Vequired): 7. ❑ New construction 8. [1 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12.. [( Plumbing repairs or additions 13.0 Roof repairs 14.E] 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. rContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is pi'dvlding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Policy ## or S elf -ins, Lic. M. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' coMpepsation•policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A cop of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. of —__ I / I do hereby cert that the information provided Official use only. Do not write in this area, to he 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 11 Contact Person Phone 4: 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 employes is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprise, 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 app uriena:nt thereto shall uo t 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 ok. renewal of a license or permit to operate a bui sini ss or to construct buildings in the combionwealtlt 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." .A.pplicants Please fill -out -the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) mame(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 Depai went 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' compensatioil 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 fiff 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1 -877 -MAS SAFE Fax # 617•-727-7749 Revised 02-23-15 www.mass.gov/dia Date................................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION V2+ This certifies that .............. ; ........................................... has permission for gas instalj�,! 15 m�A c-,- ation ............ ......................................... PA..P. LNj�— in the buildings of .............. A ............... ........ ............. . North Andover, Mass. Fee(C.K)"—'.... Lic. No. .fT�4 . ....... M. . . ................................................... GAS INSPECTOR Check# �(l h 15' 9449 \f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK U'r, 1 11 CITY N. Andover MA DATE 7131/2014 PERMIT # JOBSITE ADDRESSI 330 Marble Ridge Rd OWNER'S NAME �� q GOWNER ADDRESS I Same FAX TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL ❑ RESIDENTIALL) PRINT CLEARLY NEW:® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YESO NO❑ APPLIANCES 7 FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE i GENERATOR, GRILLE i INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER I I [ ROOM I SPACE HEATER ROOF TOP UNIT TEST i UNIT HEATER UNVENTED ROOM HEATER WATER HEATER [ OTHER Re lace 1 Gas Meters x and Associated Pi inq INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ i I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [Z] 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 ❑ 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 applicat4beliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Jose h Marino LICENSE# SIGNATURE MP0 MGF® JP❑ JGF❑ LPGI❑ CORPORATION Q# 3285C P ®# LLC ❑#� COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE = ZIP 01501 TEL 508 832-3295 FAX 508-926-4347 ❑ CELL 508-832-4=6EMAIL JMarino@RHWhite.com j 1 ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY I FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES r�C ® DATE (MMIOl5NYY)(I �.:�. CERTIFICATE OF LIABILITY INSURANCEP... 1 of z 08/29/2013 THIS OERTIFICATE 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 COVERAGI; AFFORDED 8Y 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 POlioy(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 eonferrights to the Certificate holder in Ileu of such endorsement(s), williQ of MRSSRChu Otte, Inc. c/o 26 Century Blvd. P. O. Box 305191 Nalghville, TN 37230-5191 R. H. White Construction Company, Inc. 41 Casntral Street P. 0. Box 257 AUhUrn, MA 01501 4 W..1 nrran.unvu4VYCKHhC NAI01 INSURER A: The ChAxtAr Oak FixA Ineuranc9 Company 25615-001 INSURERS:Trava:Lnrg property Casualty COMIPRny Of Am 25674-003 INSURER C:Nati*nA1 Union Firs Ineuranea Company Of 19445-001 INSURER D; Travelers Inda=jtyr Company I 25658-001 vveRHve0 CERTIFICATE NUMBER: 20267680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN [$SUED TO THE INSURED NAMED ,ABOVE FOR THE POLICY PERIOD [NQICA7ED. 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. A GENERAL LIABILITY X COMMPRC1ALGENERAL LIAB11.17Y CLAIMS -MADE OCCUR AGGREGATE LIMITAPPLIES PER; )3 1 AUTOMOBILE LIABILITY X ANYAUTO AUT0O8 NED AUT08ULE[ X HIREDAuTos X NON-OWNEi AUTOS X Co DedX Co11 Ded COMBRELLA LIAR I OCCUR X EXCESS LIAs II— CLAIMft-I VTC20co 97789948-13 9/7./2013 9/1/2014 EEAhGU CgqIOCRRENCE M U STAo IFIII I.n MED EXP (Any one person). PERSONAL &ADV INJURY GENERAL AGGREGATE PRODUCTS -COMPIOP AGG VTJCAE 977K955A,-7.3 /1/2023 9/1/2014 ISRM IN�osINGLFLIMIT BE8766140 9/1/201.3 9/1/2014 BODILYINJURY(Perpemon) IS BODILY INJURY(PeracaldeM) G DED IX IRETENTIONS 10,000 11 WORKERS EMPLOY RS'LI AILIT VTRX B 8205Ala5-13 9/1/207.3 9/1/207 4 X TION AND EMPLOYERS'LIABILITY YIN TAI;Y.U, D ANY PROPRIETORIPARTNFRIEXECUTIVEI :1 NIA VTC2xuB 8203,A71A-13 9/1/2013 9/1/x014 E.L.EAGHACCIDENT OFFICERIMEMOER EXCLUDED? I `�" JJ (Mvendolog NH) E.L. DIAEA9E-EA EM Ui�eae, ttel%�IUN OF UPURATIONS below FJ.. DISI POLIC TE Zvidence of =naurance Remarke 36hadula, I1 more ep eco 2,000,000 1,000,000 1,000,000 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORILI!D REPREaENTATNE Coag,:4197604 TPI:1694012 Ce7:t:20287680 ©1988-2010ACORD CORPORATION. All rights reserved, CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD r ��,, jj Date .. . �...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �— ( �� 3 N �--- This certifies that .......l...........�� ................ has permission to perf ornt......................................................... wiringin the building of..............................A................................................................. �U',4, u —='`........... , , North Andover, M ss. at .��. rt�� ............................1. — . Fee.. .:........ Lic. No. Iii .. ............. ........... 2 �� E AL INSPECTO Check # �� CTRIC 1 1 � c�"1-- t i vv\' IN 1 O 4 Commonwealth of Massachusetts Official Use Only 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 (PLEAS EPRINTININKORTYPEALLINFORMATIOA9 Date: S/ /L/ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her 'ten ion to perform the electrical work described below. Location (Street & Number) `3`�(j 1c l �� C Owner or Tenant G-1 V + G 1 n 9 Ale,—Aon Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (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 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ��,�t a Some- (2->--A +- /n o c,r H -c -r �- Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- rnd. rnd. TR—Elo. o mergency Lighting Battery Units No. of Receptacle Outlets 3 No. of Oil Burners FIRE ALARMS J.N'o. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number " -" Tons """' ........ KW '"""""""""' No. of Self -Contained etection/Alerting Devices No. of Dishwashers Space/Area Heating KWLocal o `J ElMunicipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E enk No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. ? No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _3 006 (When required by municipal policy.) _ Work to Start: :&/d/&I Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 ❑ (Specify:) Icertify, tinder thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ LIC. NO.: Licensee: j,,,TQ)rj j�ve Signature LIC.NO.: joclas 3 (If applicable, enter "exempt" in the license number lin . Bus. Tel. No. • one< CINJ 6t-77, Address: �-�� i=c)��cffl C,i M), - (0 1b.b Alt. Tel.No.: Gl *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 P ERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 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. G.L c. 166, § 32, an; electrical permit shall be 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 sball.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid 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 Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH S CTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co ments: Inspectors Signature: Date: FINAL INSP ON: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: —�o DEB WEINHOLD ... TOWN OF ME RI AC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): harm 45 00n 1 Address: -bn {- City/State/Zip: mTJAJ MA 6a lsG- Phone#: �' 1`7 _7A 73I 44/ Are you an employer? Check the appropriate box: 1. rN4am a employer with 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.01 am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[jlegrctrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ 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 anew affidavit indicating such. r tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: �/ i vl-i Grr, S e, I Policy # or Self -ins. Lie. #: �,/C UU 7 �J Expiration Date: 1 ef O Job Site Address: 3�Z_4 M c, f -h11 trVI t, -L City/state/Zip: N6 ,1-1 -Anek—,,, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 and iepalns andpenalties erjury that the information provided above is true and correct. Phone#: 4'f-7 `7/!!�,_734_/!V 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 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 employeiis 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 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who,has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) 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 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 GorxuonweaXth oMassachusPtts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 `1`e1, # 617-727-4900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 ww.m;ass,Vvldia LLOWING L'I<C MASTER E.LEC I 10525 Date .511 . ..... f ......... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I e- P� N c,--,. 0- , e, NoThis certifies that ......... ......... . .. ........... ............................................... "" (- e- V -v -cd -,e �'**'*****"*'*"***"*"**'*"* has permission to perform ....................... .......................................... ; ............... plumbing in the buildings of ........................... at ........ a?�o M Arlo- Lk j " ........................................................................ .... .......... . North Andover, Mass. Fee Lic. No. .... k.,Po .. ....... ................................................................. PLUMBING INSPECTOR Check it 6P * 19`l -1`i V. -r,- li-I -11 1 y I _-_....-! I _..._._.i_ -__i ..._.._ I .._.._...-I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES (xNO Fj IF fOU CHECKED YES, PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY F BOND F1 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-11 AGENT IFI 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 compl- ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'T PLUMBER'S NAME 05 arc.' I LICENSE # %GO/G SIGNATURE mpg, JP D CORPORATION [-Jl# PARTNERSHIP F# ® LLC COMPANY NAME ,/�a(c r'r� !°/ymbing ADDRESS CITY I Sgv STATE ZIP p (`30 (, TEL FAX — --III CELL $(- `��-a!_. MAIL cx�cJa��_Ply bid _i , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE S / y _( PERMIT # 16 V� JOBSITEADDRESS 330 .111,b�eh;�Q-Q OWNER'S NAME _ OWNER ADDRESS /'1_ b c d F' I TEL � IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL WK - PRINT CLEARLY NEW: FI, RENOVATION: REPLACEMENT: F PLANS SUBMITTED: YES F! NOF FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _...,__..1 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I 1 F-771 DEDICATED WATER RECYCLE SYSTEM DISHWASHER f i f 1—j i __.___I .---_._ I I I DRINKING FOUNTAIN _----_f .._---..1 -- (___--_E —_f __ _I ._.-----� -----� -----a ....-......._I -_-_.-_1 _-___..-.1 —f _..-..._f FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) MF ----I KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL I ..__ f 4I SERVICE / MOP SINK I f _..__f f I _...__.1 -__.71 TOILET I _-.. _! _ _1 f _.. I URINAL WASHING MACHINE CONNECTION I _ __.__.._S WATER HEATER ALL TYPES WATER PIPING OTHER _--- _ _� _ 1 f I ......_._._. 1 I ( I f .- .-.-_._( ....._-_ f f .-__..__I I i # I 111 t I f i I _-_....-! I _..._._.i_ -__i ..._.._ I .._.._...-I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES (xNO Fj IF fOU CHECKED YES, PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY F BOND F1 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-11 AGENT IFI 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 compl- ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'T PLUMBER'S NAME 05 arc.' I LICENSE # %GO/G SIGNATURE mpg, JP D CORPORATION [-Jl# PARTNERSHIP F# ® LLC COMPANY NAME ,/�a(c r'r� !°/ymbing ADDRESS CITY I Sgv STATE ZIP p (`30 (, TEL FAX — --III CELL $(- `��-a!_. MAIL cx�cJa��_Ply bid _i , O ❑ Z U) W CL iii w p t The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): d " l q (c_� o, -n o p) U rl h i n4 Address: W' 11,L7C><,�L City/State/Zip: o� u / U U 6 Phone #: G 17 775= 73r35 - Are you an employer? Check the appropriate box: J. PI am a employer with ( 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] 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.❑ Roof repairs 13.❑ 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 2ce doing all work and then.hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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: 33� l'1 arbl e,s, ar�� P7 d. ,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 requiredunder 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 DTA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. 6/7- 7-7s- -3315-- 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 #: 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 152, §25C(6) also states that "every state or loeal 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 -contractors) name(s), address(es) and phone numbers) 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 maybe 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 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 opMassac4usetts Department of Zadustrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel. # 61.7-727-4900 ext 406 or. 1-877-MA.SS.A88 Revised 5-26-05 Fax # 61.7-727-7749 ww mass,gov/dja A 01906- archadeck° America's Deck &Porch Builders"" September 3, 2015 Building Inspector Building Department Town of North Andover 1600 Osgood Street Bldg 20, Suite 2035 North Andover, MA 02472 RE: 330 Marbleridge Road Dear Sir, Enclosed is the installation report for the footings at 330 Marbleridge Road. It shows the bearing capacity of each footing exceeds the required design load. Sincerely, Jim play Cons ruction Supervisor • c 7t � -.kN t"d .. Archadeck of Suburban Boston • Telephone (781) 273-3500 • (800) 696 -DECK • FAX (781) 273-3536. 16 Adams Street • Burlington, MA 01803 nemass.archadeck.com • subboston@archadeck.net tech�oPWof Connecticut 4Q7. 5ping 5t. � Naugakuck, GI-. 067%0 MAPp!y QF POSTS Rota Head' O G�arbcr. ! I OMS 125 OMS 20Q OMS 250 r A 50 # Torque Depth 9 Type S!nklmm # Torquo � Depth #Type Sink/mm 1 1800 5'-0" 115871bs 2 1500 6'-0" _ — 1948.61bs- 3 1500 67-0Y —. -- -�- -- _ __ _ 9486lbs -- + 4 150a 6'-0" 9486lbs — — — — 5 1500 6'-0 �9486fbs 9486lbs I— — 7�_ 1504 6' 94861bs -- - 8 1500 's _ —..-i 94861b s — -- �— --�— — L Signature of installer: cooaiaoou j Xyd xa 90:T 6TOZ,'M 6o 0 W IV, AF� Ins W-10%2" ►i' W W 0 m m 3 C4- C4, C4, � O 3 3 6?34 Date.................................. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,nn This certifies that ......� 1 �r. - !?!?... /' ... . .............................. has permission to perform.....Q.o�-'4,5n ..................................................... wiring in the building of ....... E .% %` at ...........3... C)......./..:/..�. �4f1�... ���, orth Andover, Mass. .40 Fee....Lic. No. )qlq.1.71 ............................................. ..... . crRic • �� ���v INSPECTOR _. Check #J _ 6?34 1 11 -2113 -455 - Date.................................. °. ` o- TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..... A4)W4— wr?!r.?.... . has permission to perform ..... &v i_ ,6�g ..................................................... wiring in the building of ...... 4? ....U) /8iv"1; .7 !% �,� ......... 3 f "� ua4 e.kD.'f.'F... Ab, Orth Andover, Mass. Fee....ZQ.. Lic. No. p1!'.F..l g ................... ................. ..... . _-�CTRIC INSPECTOR ---�- VUR �y��%�z:ItZrs� ) 6?34 1 I —ze3-ds Date.................................. ° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING .�- This certifies that .�12�P�:�c��r�...�.r ..... .................................... has permission to perform .....6.oa...................................................... wiring in the building of .................................................. (-G 7 . Y!Y� ...................... 3 �%`� .. ... �, North Andover, Mass. at .................................. Fee .... Z Q. .. Lic. No. &1q.1. gl..................................... . • �A A� �� INSP� . Check ti ___ �! caY To: Peter Murphy Page 1 of 1 2005-11-23 11:33:42 (GMT) 18573733002 From: Mike Yawnick -� Commonwealth of Massachusetts umeta, use Un1y KA Department of Fire Services permit No. A', �H ..`, BOARD OF FIRE PREVENTION REGULATIONS Date Issued: 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) Bate: f t ! s ear City or Town of: �; Us T� firkl o -l-"- r 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) 3 W�i%t.�We -< � Owner or Tenant -5 ;'1 1' V i ,V 1' i1 ✓1 W IT� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No P--' (Cbeck Appropriate Boz) Purpose of Building DI/ie- I 1 F -)o � Utility Authorization No. Existing Service ?C�s Amps //0 ! 221�volts Overhead D-- Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work: (� yrs P �i t �) ( e-, C No. of Recessed Fixtures r No. of Ceil-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs . Generators XVA 75T No. of Lighting Fixtures Afim'e In- Swimming Pool nd. El annd No—.ergency Lighting Batt m Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. o€Gas Burners No. of Detection and, Initialing Devices No. of Ranges No of Air Cond. fool No. of Alerting Devices No. of Waste Disposers eat Pump Nuwber Tons hVi -- - _ No. of Self -Contained "Totals: Detection/Alerting Devices No. of Dishwashers Space/AreaHeating KW Local ❑ Nfunicipal ❑ Other Connection No. of Dryers Heating Appliances KW Security SJstems: 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: No, of Devices or F uivalent OTHER' Attach aaamonat aetaLt rf aesrrea. INSURANCE COVERAGE: Unless waived by the owner, no pt see provides proof of liability insurance including "completed open that such coverage is in force, and has bited proof of same to tl CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Sl Estimated Value of Electrival Wurk: 3 fi (When re Work to Start: 04 51��' Inspections to be requested in ace I certify, under the pains an�J/ penaMe�.j of per ury, that the informs FIRM NAME: r /CG �GJd �%� Grr�z r C— Licensee: G: qeSignatures (If applicable, en! r "exempt" in the license mrmher tine.j Address: `faYt�l; t ; 501'�iZlGt�, /d. OWN'ER'S INSUP-ANCE WAIVER. I am aware that the Licensee does nc Signature below, I hem -by waive this requirement I am the (check one) ❑ o. OwmerfAgent Signature 1 Insurance on File: Will Fax: Permit Fee: F1-2-6 tiro ifies To: Peter Murphy Page 1 of 1 2005-11-23 11:33:42 (GMT) 18573733002 From: Mike Yawnick Commonwealth of Massachusetts cmictat use my CS .: Department of Fere Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Date Issued: 4,_�. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEGA, 527 CMR 12-00 (PLEASE PRNT LV LVK OR TYPE ALL LVFORAMT10JV Date: l°t a-:Vor City or Town of: (70"-T� finew---r To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to periform the electrical work described below. Location (Street &Number) !3 CTE Owner or Tenant -.) L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No P----(CheckAppropriate Box) Purpose of Building ; vM- I 1 i -h --) . Utility Authorization No. Existing Service �?CTi Amps r'/G / 222 ,Volts Overhead D-- Uudgrd ❑ No. of Meters L— New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed .Electrical Work: Camntetion nfthe following tahle may be waived by the Insoecror of fYires. No. of Recessed Fixtures No. of Ceit-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs . Generators KVA No. of Lighting Fixtures Abnve ln-o. Swimming Pool d. arnd m o ergency Lighting Baffm Units No. of Receptacle Ontlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and t.:Devices No. of Ranges No. of Air Cond. _ ,Ti.00tal ns No. of Alerting Devices No- of Waste Disposers eat Pump Number Tons- _'V4 Na--. of Self Contained I'otats: Detection/Aledi Devices No. of Dishwashers Spacc/AreaHeating KW Local Mnniripal ❑ Otber Connection No. of Dryers Heating Appliances KW Security Systems: Na 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: No, of Devices orF uivalent OTHER: Attach additional derail . f desired or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no pennit for the performance of electrical work may issue unless the Licen- see provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and hasrxMbited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ( > (Expiration Date) Estinuded Value ofElcctricl Work: 3 G1� ` (When required by municipal policy.) Work to Start: CJ ,j1"fPainspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the paps and!penuMe. of perjury, that the Information an this application is true and complete- FIRM ompleteMRM NAME: el -,41-111- P-106 k C - LIC. NO.: A: / y/ ll Licensee: n7 i c�,r d LIC:. NO.: -)v--3 (lfapplicoble, enf r "exernpI- in Ike license number Itne.) Bus. Tel. Na• `7!0- 7 Address: roti dr5o�i YI✓� l tiZlet�.'�d- Zip: txtSf�fC� Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I run awure that the Licensee does not have the liability insurance coverage normally required by law. Dy my Signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ mvner's agent OwnerfAgent Signature Phoue:_ Insurance on File: Will Fay:: Permit Fee: Receipt b: Date: 1� C cy ,, To: Peter Murphy Page 1 of 1 2005-11-23 11:33:42 (GMT) 18573733002 From: Mike Yawnick Commonwealth of Massachusetts Urttcial Use My -', Department of Fire Services Permit No. � BOARD OF FIRE PREVENTION REGULATIONS Date Issued: — Z r 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 INF0RMAT101V Datta: P/' a� f or City or Town of: l +#N (IUC Th fiftAI-16-- r 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) 3:30 mo,Q - )e�__ _ Owner or Tenant U t Telephone No. Owner's Address t) t) is this permit in conjunction with a building permit? Yes ❑ No f(Check Appropriate Box) Purpose of Building Di/J � 1 * -�? � . Utility Authorization No. Existing Service :201C Amps //G' / 22Z volts Overhead a-- Undgrd ❑ No. of Meters L_ New Service Amps / Volts Overhead ❑ Uodgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature or Proposed .F."lectrical Work: Cont letion ofthefollawink table maybe waived by the InspeciarofWires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No_ of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs . Generators XVA No. of Lighting Fixtures Swimming Pool Above In- [3In- El o• o mergeney Lighting i red. Batt nits No. of Receptacle Outlets No. of Oil Bursters FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No.of Detection and lnitiafiu Devices No. of Ranges No. of Air Cond. ,Tl oottal No. of Alerting Devices Pio. of Waste Disposers eat Pump Number Tons _ R' - - No. of Self Contained I'oWls: Detection/Alert' Devices No. of Dishwashers Spacc/ArenBeating KW Local ❑ Mnniciral © Other Connection No. of Dryers HeathttgApplianeea KW Secnri h` Systems: No. of Devices or Equivalent No. of Nater kN No. of No. of Data Wiring: Heaters . Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or F uivalent OTHER: .411ach additional detail if desired or m required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the outer, no permit for the performance of electrical work may issue unless the Licen- see provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and hasgxhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE J3 BOND ❑ OTHER ❑ (Specify:) a TO (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: q 5/170 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains arr penaUtq ofpe„ fury, that the irrfotmallon on this apidiration is true anti complete_ FIRM NAME: G� , LIC. NO.: A: / Licensee:Signature 1. t_ G -- LIC. NO.• E: 1'77 (If applicable,enfr -exern t" in the license number line) Bus. Tel.N0.''2t'l-727- :L"S/ Address: �a�rl'J9; �15d 21 Ja; �ii'1/ e 114. Zip: G� I SSSD Alt. Tel. No.: "s/ - 2 OWNE,R'S INSUPL- NCE WAIVER: I tun aware that the Licensee does not have the liability insurance coverage normally requimd by Law. By my signature below. I hereby waive tiffs requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Phone: Insurance on File: Will Fax: Petmil Fee: Receipt q: _ Dale: �f.2-6.:= Commonwealth of Massachusetts amort use t.,nty Department of Fire Services Permit No. : ? BOARD OF FIRE PREVENTION REGULATIONS Date Issued: Z--Z,--.c> "J APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 1200 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /t /aV os— Cityor Town of: %i(XT� fffkl o-k--rTo 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) 3.�v Owner or Tcnaat � U h �fl / tt o r n �, �� Telephone No. Owner's Address( Is this permit in conjunction with a building permit? Yes ❑ No P -,f (Cbeck Appropriate Box) Purpose of Building �!/� l r7) Utility Authorization No. Existing Service :200 Amps 1166 / 22c/Volts Overhead D-- Undgrd ❑ No. of Meters L— New Service Amps / Votts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: !'amnletian nfthe fallowing table may be waived &- the bnsoectar of {Vires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs . Generators KVA No. of Lighting Fixtures Ahav ln- Swimming Pool ad. arnd o. o ergency Lighting Ba!10 Units Na of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatiu Devices No. of Ranges No. of Air Cond. Total ns No. of Alerting Devices No. of Waste Disposers eat amp Number Tons .. - _ ' _ _ —.._ ... '*- No. of If- Contained Totals: Detection/Alerting Devices No. of Dishwashers SpacelAreaHealing KW Local [I Municipal 0 Other Connection No. of Dryers Heating Appliances KW Se,01i ty 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 Motor Total HP Telecommunications Wiring- iringNo, No,of Devices or F uivalent OTHER: .411ach additional derail i,/desired or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licen- see provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has bited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) !v (Expiration Date) Estimated Value of Electrie;dl Work: 3c, (When required by municipal policy.) Work to Start: C1 51�P Inspections to be requested,in accordance with MEC Rule 10, and upon completion. I certify, under tlae pales anqpenaltte of per ury, that the information on this application is true and romplWe FIRM NAME: 192r /e'i G% %C' G'r7/� i C- LIC. NO.: A: / `// Y Licensee:i c.l7ce� %��tt' G�� Signature i �"�` LIC. NO.: k::-3 3'8 '77 (If applicable, enf t• "exern t- in the license number line.) / Bus. Tel. N0.• '7S1l- 7:27- %i-5/ Address: � roti �r 50� 19 ✓'c �;TIX -L 1 d- Zip: Aft. Tel. No.: 'g1.. 2 -1, Z-;/ OR'h'ER'S IN51TRANCE WAI VER: I tun aware that the Licensee dons not have the liability insurance coverage normally required by law. By my signature below, I hemby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Phone: _ Insurance on File: Will Faic: Permit Fee: Receipt h: _ Date: Cv Al N May 22, 2013 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 330 Marbleridge Rd, North Andover, Ma 01845 Policy Number: H3S21800291570 Underwriting Company: LM General Insurance Company Claim Number: 026056815-0001 Date of Loss: 2/26/2013 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, � 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect a lien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111, § 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Dates-� 2I.. � sw�Sr`rb'7Wc ti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....�........... C .. ^' + �+ has permission for gas installation `��! .. �� ..... . in the buildings of. ... ....................... . at .... .....�.. ... �.�— ........ , North Andover, Mass. Fee .�-�.(O .... Lic. No.L.3.32 N . ................... ... GASINSPECTOR Check # 8611 ` "0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK DIRECT VENT HEATER CITY A n ve r � MA DATE a` = c$ _ l3 PERMIT # OW l FRYOLATOR JOBSITE ADDRESS _____ OWNER'S NAME GOWNERADDRESS cS e �_�,__ _ _ TEL-��FAXz TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIALok CLEARLY NEW: El RENOVATION: © REPLACEMENT: Fj PLANS SUBMITTED: YES 0 NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 BOILER J . - -_ l == d14 BOOSTER WATER HEATER CONVERSION BURNER --- 111-- 1 L_J COOK STOVE 1 . _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE I _ : l�J _TI T _ =a- -- -- -- - ___u - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ nab OVEN POOL HEATER---_ ROOM /SPACE HEATER ROOF TOP UNIT I ' TEST _-. ! (� I L- . _. I .. I _ _ I A_ _J UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I E_ =TI _ INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 5,N00 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW S LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ( BOND f7j] ; OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [I AGENT t") 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 knowledge of my and that all plumbing work and installations performed under the permit issued for this application will be in co ance with rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME l�o�(iGc,yr�,{. LICENSE#- SIGNATURE MPMGF JP D JGF [] LPGI PCORPORATIONjj# _ j PARTNERSHIPQ# LLC [:]-f COMPANY NAME: " .� .._.-(� n� T4s S _ _lIADDRESS ADDRESS[ 70 _�^_4_.w_�eA_ 4SrQ . _---------------- CITY kJ ,� 1 1 STATE A-alZIP TEL - c t FAX—� CELL g'8'31 EMAIL P1. C-_�. .✓��ec;yn5. _. Cr'`� _ - --- - --. ... x - `�% O z o F U W a 4 - 0 Z O yri w �- F_ W OF a Z U w � 3 W 5 aco CL W W W co ra o a a a U J E,, a CL a lbe cn LL; = w F- w W F z O C F U - � n c�7 C7 is ,C M ., The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): P pQf? r, rv, C, Address: ' / City/State/Zip: G�/ pi- - , �,� t�'� 0)-Y1-1. Phone #: 6 1-7 9 �- `f 100 � Are you an employer? Check the appropriate box: Type of project (required): 1. [�1I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.R.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.[i Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Al Homeowners who submit this affidavit indicating they ate 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:. C, Policy # or Self -ins. Lic. % 3 0 S ..S 6 / ©6 Expiration Date: Cf/ Job Site Address: 3 0 rn qjr� 9-,�5e V_ City/State/Zip: A/or•k�, &\ apvim' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cert under the�nd penalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # V13 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 #' Informati®n 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 employeiis 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 152, §25C(6) also states that "every state or local licensing agency shall withhold the'issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (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 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 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 Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 604 Washington Street Boston} MA 02111 TO, # 617-727-4900 ext 406 or 1-877,7MASS.AFE Revised 5-26-05 Fax # 617-727-7749 www-mass.gov1dia is co Co' L 1.N' Cl) NW z uj o cn D < 2 LL att LLI > 0 CD < W Ln w > Ul Ui LLI LL CM .......... Lo6-,�tion " .� c No, Date TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ �'�s'••°''��' Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ 0 Other Permit Fee $ -- TOTAL $ �L Check # Building Inspector 1 1W -jai l■LUMQ.7■■M1Ua,RJCU9V41■LUCK 1.1 Property Addree/sss:��//''cc Q� TOWN OF NORTH ANDOVER 1.2 (Assessors Map and Parcel Map Number BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING film& IM BUILDING PERMIT NUMBER: DATE ISSUED: Frontage ft 1.6 BUILDING SETBACKS ft SIGNATURE: Building CommissionerA or of Buildings Date 1W -jai l■LUMQ.7■■M1Ua,RJCU9V41■LUCK 1.1 Property Addree/sss:��//''cc Q� 1.2 (Assessors Map and Parcel Map Number Number: Parcel Number O 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 ReqWred Provide ReqWred Provided ReqWred Provided b / 1.7 Water Supply M.G.L.C.40. 54) Public 0 Private ❑ 1.5. Flood Zane Information: Zone Outside Flood Zane ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PHOPER'1'Y OWNERSHIP/AUTHOICUED AGENT 2.1 Owner of Record �330�o� Name (Print) - Address for Service: 2.2 !Dwner of Record: Name Print Address for Service: 4 SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor Not Applicable ❑ �— _ sensed Construction Addres � Si re Telephone 3.2 Registered Home Improvement Contractor Company Name r.5 6(a93(9-7 License Number bc,o Loi %a Expiration Date Not Applicable ❑ 1a. 3 W(e> Registration Number l 00 &J, Expiration Dat If J SECTION 4 - WORKERS COMPENSATION (NVLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will rksult in the denial of the issuance of the buildine permit Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: A) PC9 I SECTION 6 - ESTIMATED CONSTRUCTTON COSTS I Item Estimated Cost (Dollar) to be Completedbypermit applicantr,., IS(I!NL'Ya , r 1. Building 000 (a) Building Permit Fee _ Multiplier 2 Electrical (b) Estimated Total Cost of / 00v. ^` 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 as Owner/Authorized Agent of subject property Hereby authorizep to act on My behalf, in all matters relative to work authorized by this building permit application. La !- Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 +, Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS 1 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE A J T "niyl U "I 1\L' LL' tx0L' 1' 11111Y1 3 ?NS TRUCTIONS : This form is used to verify that allnecessary approval /permits from (eit r ;. Boards and Departments having jurisdiction have been obtained. This. does not relieve the applicant and or landowner from compliance with any applicable requirements. • �wsasaarararaas�aaaaaaraaa0aaraaaaaa0aaa0aaaa2a0aa9wa00aaaasaaaawaaaaaaaaaaa APPLICANT/ !V G� o� GU? PHONE 00/) / �v I� of ASSESSORS MAP NUMBER DLOT NUMBER SUBDIVISION LOT NUMBER STREET A I CN SVD9 STREET NUMBER 3 3 D 'yaapsarseen rrraaaaarwrwas rawown ada anon a;*foo MOMS saaBoom aaaaaraaaa■awrssaaars■ OFFICIAL .USE ONLY I■swsarr■wars■■■Ransom swrsraaa'soa Owosso mom ■■swwwaaaaws_■rsaawaawaaa■■■an as aaa. RECOM�NDATIONS OF TOWN AGENTS �r■■e■■aaarasawsrasawarrarraawsasswwarasraawssrrraaaasraas■'a■ ■aaaaaaaasa DATE APPROVED 6 CONFER VATION A15MMSTRATOR DATE REJECTED COMOVMNT S DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR -'HEALTH DATE REJECTED DATE APPROVED, SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENDS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR - .TE 'ORD CERTIFICATE OF LIABILITY INSURANCEIDATE,MMIDD v RRARS 01/31/01 dOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kittredge Insurance Agency Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 276 W.Main St., P.O. Box 1129 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northboro'MA 01532 Phone o 5 08 - 3 93 =7744 i INSURERS AFFORDING COVERAGE INSURED Ferrari Pools and Patios, Inc. 107 Old Flanders Road Westboro MA 01581 INSURER A: CNA INSURANCE COMPANIES INSURERS: COMMERCE INSURANCE CO INSURER C: INSURER D: E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING _._..,.......... I ".11 -1-1 — I . � —1w., , r11J 1-1rIVA 1 Q -T oc 100ueu vK MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR - TYPE OF INSURANCE POUCY NUMBER DATE EFFECTIVE MM/DD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS GENERAL LU181UTY I 1 EACH OCCURRENCE !S1000000 A X COMMERCIAL GENERAL LIABILITY 2048660953 02/01/01 02/01/02 FIRE DAMAGE (Any one Are) S50000 CLAIMS MADE []XC OCCUR MED EXP (Any one Person) $ 5000 PERSONAL d ADV INJURY I S 10 0 0 0 0 0 I GENERAL AGGREGATE j$2000000 GEN'L AGGREGATE LIMIT APPLIES PER: _ I PRODUCTS - COMP/OPAGG $ 2000000 POLICY PRO. LOC I AUTOMOBILE UABILITY B ANY AUTO TBD 01/21/00 ; 01/21/01 COMBINED SINGLE LIMITS (Eeecadenl) 10 0 0 0 Q Q i ALL OWNED AUTOS X SCHEDULED AUTOS I j BODILY INJURY I (Per person) (. i ii X I HIRED AUTOS X ; NON -OWNED AUTOS I BODILY cc INJURY (Peerraccident) S I I PROPERTY DAMAGE(Per iI accident) I $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO i 1 ! OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS UABILITY I EACH OCCURRENCE 1153000000 AGGREGATE IS3000000 A iX OCCUR 1 CLAIMS MADE 2048661035 i 02/01/01 1 02/01/02 1 I$ DEDUCTIBLE I S X RETENTION S l 0 0 0 0 ! S WORKERS COMPENSATION AND I EMPLOYERS' LIABILITY A I I TWC ORY LATU IMITS 1 ER i 2048660998 i 02/01/01 ! 02/01/02 ! E.L. EACH ACCIDENT I s 1000000 1 1 E.L. DISEASE - EA EMPLOYEE] S 10 0 0 0 0 0 E.L. DISEASE - POLICY LIMIT 1 S 10 0 0 0 0 0 OTHER i i DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - '- -- Vnl\VGLLI111V14 SAMPLFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEEXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 30 SHALL Sample Certificate IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS, OR ,.0 UKU 25.5 (7/97) BOARD OF 13UILD1 GREGULATION i ukases: CONSTRWT10N SUPERVISOR Number. CS 069397 ' Birthdate' 06IQr'''�1964 BixMres: 060&'2002 Tr, no: 26732 Resbicted To: 00 JASON E WARD 107 FLANDERS RD WESTBORO, MA 01881 �- Admlnisbr-ator mo�r rn —NIVOm �. 0 r— m c * M D -� W rn�o m Xao � '0 O f?� r 3 r• N O O CO INA (71 N W C7 )-A I H Z X C) OU iU 'S rt 0) I.. rt o►-• o z ° O OO0 F 3 co (-�' DD o0 cort � O ?r (D � w rt c'* 0 O O n CO = M 0) '00 n (D P ct o rt t O• (A ;0 N O 0 CLO Ww(n � ort o CD a Cl) 7) C C/) 0 m y 'v C � d 'v O CD n Z CO) CD O. CZ � C• C. d :;• CO) aCc -0 O CD CD O CL Cr =. d CD Sr cc) O CSD C CD y� �. CD O CA O I CD rod ru • u m cn o� O —• y O Q H d O E ECOca O y. cs a es m 2 •� �•cp H o, = �' m yCL CL -o' T co = y O O m y p N O �m m S m �o = O y co C y = . 7 O to O O m C CL CD O y d y y d d :�C d CD �� y ?CA ICOIQ o �C*Ppo�m� 1 .��• •� � =m to00 CD �. o N G Wco m. cn X- O AS. o oll ro M171n rfl tz00 oKa r- r� Z � rb n d x y 0 0 c IT- 3 '! 45 Date ... e�l, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ G--CA.Ad. C. -A -0c ....... ..................... has permission to perform ........... ............................ wiring in the building of X.1./..1.. ..../ .......... :Wr� . .................................. ............................................. ..... 9 at ....... .30 NoMh Andover, --Mas Fee ....... No.,/f .......... .....�/EL'ErICAL INSPE R Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer F - 1 ne L.ommonweuiu► v,/ Ili UJJUt_jjL O Dcper:7ncnt of Public Sa/cry oc.uNncr L r., e1.ew e BOARD OF FIRE PREVENTION REGULATIONS S27 CMA 12-00 3/9p APPLICATION FOR• PERMIT. TO PERFORM ELECTRICAL WORK All Work to be pc-."rr-tcd in accordance With the Mace.ehusens EJec riul Code, 527 CMR 17-00 r (PLnASE P°L_E%M 74 INK, OP._ALL Pi='OR,/2AXION) Date C; ty O -Z Toe --a Of /' 'd^4' 14) otl4C TO the L speetor of Wires. She undersigned applies for a perrit to the eleccricAwork describcd below. c Loation (Street: & Nt=b,r) '33UAll /0IRIsL f- t g i—, /�z t\ Ager or Tea.an- -Zb 14 Al CV E X114 TUq- , Owner's Address Xj Is this peri: in conjunction with a butldllng P< _ice Yes WN0 ❑ (Check Appropriate Box) Asrpose o: Building � 7y1 r L, f/ Utility Aathor i=aCi0.n, NO. Existing Service A_ -Ps 1 D -o / 3L -Vo Volts C••'erhead ❑ Undgrd ❑ No. of Meer s _ N.ew Se:-riee Asps_ / Volts Cve:head ❑ Undgrd ❑ No. of Y.ete-s N=ber of Feeders and 1�pacityT`_ nn Location and .1L&ture of Proposed Electrical WorkWe RE /N64!!C/A)b P6 Z_ 4)W) aAJAICcT-eb SPA No. of Lighting outlets tic. o. }?oc Tubs I ` INo. of TrAr3!c =ers TvA �yA No. of Lighting Fixeures Svi—ix. Above Iz- I g Pool grad. ❑ grtd. ❑ I Gene: acors )CIA go. of Receptacle OutletsINo. of Oil 3ur-ers INo. of "-ergeney Lighting Bacte y Uni.s No. of Switch Outlets I No. of Gas Burners iirL-' ALA.ti"S No. of Zones No. of R.in es S r , Total INo. o_ Air Con... tons No. of Detection and Initiating Devices No. of Disposals Heatlo I No. of U--js local No, of Soundiag Devices No. of Dishuashers (Space/Area 'Keating 1Cl No, of Self Contained Detection/Sounding Devices No. of Dryers Ideating Devices Ka Local❑.ktmieipal ❑Other Conneetio^ No. of {tater Beaters No, of No, o: ISiens Ballasts Low Voltage Iuirine No. Hydro Massage Tubs INo. of Motors local F? I , Crr--- 7.: NSURANCE COVERA E• 'ursuan: to the requirements of Vass:chusects General 1.4 -as I have a current Liability :ns::rcnce Policy including C:=-_'-e:ed OYrations Co•.erage or its substantial equivalent. "ES ❑ NO ❑ 1 have submitted valid ?-:-of of sa=e to this of=fice. YES Q NO Q If you have e:: eked =1 1 please indicate the tyre of coverase by checking the a:propriate box./ INSMUCE have ❑ 0.r ❑ Olease Specify) l-tpirac►on ate) Esti=ted Value of Electrical Work S Work to Start. Inspection Date Requested: Rough WILL CAtZ. Final. Signed under the penalties of perjury: FIRM NAMftC- >9T� E c e- C L— / �-.IC. NO. Licenseeg�(tJ� lir i{ C� �� Signa cure c-��1' /l_"z6- ,etnc. NO. Address R Xt 8kfl , hk. A/ C //f ZAS)gje, .i(./ 14 Bus: Tel. No. `tZ45' ag I— 41-9 Alt. lel. No. OWN -EM'S INSIMANC's' WAIVER: I am aware that the License E o have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my s� iature on this permit application waives this require=ent. Owner Agent (?lease check one) do Signature( • Telephone No. p�,y� F -E S_7� Signature of Owner or Agent) Date. 9.. �r .` ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION i-1 This certifies that <' .......1 ........................ has permission for gas installation ... t . .:. {.... .. .'......... . in the buildings of ..!. ! ... .' . r ....................... at ! c15 < J? . , North Andover, Mass. Fee. e�� .:... Lic. No....`(?. t . ? . . ....... . iGAS INSPECTOR Check # D >" IJ �/ 37`16 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAST TTING (Type or print)Date/G`- / NORTH ANDOVER, MASSACHUSETTS Y I / Building Locations J 0 Permit # 3 ? k 6 NA� v Amount $ - c'�nOwner's Name �d� � �..P � New i Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) j-) Name Address & , ",�• /( /�o "/.ns.-1 MSFc/77- v Name of Licensed Plumber or Gas Fitter zrl'ew' C one: Corp. Certificate Installing Company Lj Partner. ❑ Firm/Co INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ( No ❑ If you have checked M, please indicate the type coverage by checking the appropriate box. Liability insurance policy 01 Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certity that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber L Y Z Er- Z ❑ Gas Fitter License Number Master 1't�l Journeyman ,3RD. FLOORi7TH. FLOOR (Print or type) j-) Name Address & , ",�• /( /�o "/.ns.-1 MSFc/77- v Name of Licensed Plumber or Gas Fitter zrl'ew' C one: Corp. Certificate Installing Company Lj Partner. ❑ Firm/Co INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ( No ❑ If you have checked M, please indicate the type coverage by checking the appropriate box. Liability insurance policy 01 Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certity that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber L Y Z Er- Z ❑ Gas Fitter License Number Master 1't�l Journeyman 4J Date. Z� ..... /r '1.... Of 4ORT01 A TOWN OF NORTH ANDOVER it "e — , 0 PERMIT FOR PLUMBING 41 SSA1. D C mus This certifies that ................ ....... .... .... has permission to perform ............................. 1� plumbing in the buildings of . ................... el ........................... Korth Andover, Mass. /fiIK Fe...... Lic. No .......... ... O-7 ............. PLUM G/ffNSPECTOR Check# h) 6691 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location /7,6 r��/q� Date � � i�cf Owners Name -%0 (, e 4"o Permi Amounts i Type of Occupancy /A' .` New Renovation Replacement Plans Submitted Yes No ❑ (Print or type)9�f / /-0/,— / Check one: Certificate Installing Company Name c[, Corp. Address � !�?� �� >�� %t�•�E'h �k /�/t o /�� � � Partner. Business'lelephoner 77 6 71 y7/7 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy S Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachusettsPlumbing Code and Chapter 142 of the General Laws. By: igna ure or Licenseaum er Title Type of Plumbing License 1a�G .36 City/Town License um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY J • • • I MMM MM 411W DO 001 -------MMMMMMMM --------------®--- /_. ------------------------- i M-M..M--------------- MMM Now M WMM MMM MMM- 1 M------------------------ 1 M-MMMMOMMMM WMMMMM-M-M W.11-110107300MMMMMMWMMNMWMMMMMM-- (Print or type)9�f / /-0/,— / Check one: Certificate Installing Company Name c[, Corp. Address � !�?� �� >�� %t�•�E'h �k /�/t o /�� � � Partner. Business'lelephoner 77 6 71 y7/7 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy S Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachusettsPlumbing Code and Chapter 142 of the General Laws. By: igna ure or Licenseaum er Title Type of Plumbing License 1a�G .36 City/Town License um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY I--- Date ... ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................. has permission for gas installation in the buildings of ....................... at North Andover, Mass. Lic. No.'q�.'3.......... IN PCT GAS CT R Check # M 6 6 5339 MASSACHUSiiJ M UNIFORM APPUCATON FOR PERNIlT TO DO GAS FIT ING I / (Type or print) NORTH ANDOVER, MASSACHUSETTS Date //pf Building Locations � � (`L� / �.4 sZ lev. Permit # 3 _ Amount.$ i� Owner's Name ;J o�n New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type) f CJW one: Certificate Installing Company Name IJ q Corp. Address / � M" `' ❑ Partner. usmess a ep e q ,7..- c/,)- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 4: C— �Z/,t/ INSURANCE COVERAGE• Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes P1 No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. y: Itle VED (OFFICE USE ONLY) �r, C-40e�- Signature of Licensed Plumber Or Gas Fitter Plumber / k 6 3 G ❑ Gas Fitter License Number Master Journeyman 0 WOMEN fST. FLOOR 7TH. FLOOR (Print or type) f CJW one: Certificate Installing Company Name IJ q Corp. Address / � M" `' ❑ Partner. usmess a ep e q ,7..- c/,)- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 4: C— �Z/,t/ INSURANCE COVERAGE• Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes P1 No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. y: Itle VED (OFFICE USE ONLY) �r, C-40e�- Signature of Licensed Plumber Or Gas Fitter Plumber / k 6 3 G ❑ Gas Fitter License Number Master Journeyman