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Home My WebLink AboutMiscellaneous - 336 CANDLESTICK ROAD 4/30/2018 (2)---0 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 24,200.00 m $ - $ 290.40 Plumbing Fee $ 36.30 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.30 Total fees collected $ 463.00 336 Candlestick Road 385-2016 on 9/25/15 Renovate Porch TOWN OF NORTH ANDOVER 0RTF/ Office of the Building Department r1 o� t.70 ,bgtio Community Development and Services o? 1600 Osgood Street, Bldg. 20, Suite 2035 '" 70 North Andover, MA 01845 � oar Ar 0 ��SSHCHUS��h Gerald Brown, Inspector of Buildings July 13, 2015 Brian G. Vaughan, Esq. Smolak & Vaughan LLP 21 High Street, Suite 301 North Andover, MA 01845 Re: 42 Jared Place and 366 Candlestick Road Zoning Determination — Exclusive Use Easement for Yard Dear Attorney Smolak, I am writing by way of follow-up to our meeting and discussion on July 9, 2015, at which I reviewed the proposed sketch plan that you provided showing an easement area to be located over the southerly portion of 366 Candlestick Road. You have indicated that the easement would be granted as an exclusive use easement in favor of the abutting 42 Jared Place. You have also indicated that there would be no alteration or relocation of existing driveways and no new driveways are intended to be constructed over this area. The easement is to be granted with the intent of allowing the owner of 42 Jared Place to continue to use the proposed easement area, exclusively, as though it were a portion of the yard for 42 Jared Place. This memo will confirm my zoning determination that the granting of such an exclusive use easement over this area (by the owner of 366 Candlestick Road in favor of the owner of 42 Jared Place) will not result in a zoning nonconformity with respect to either 366 Candlestick Road or 42 Jared Place. As discussed, if the fee interest in the property were to be subdivided and transferred (ie, with the dimensions of the lot to be changed and with a fee rather than easement interest in the area to be conveyed), then such an alteration would affect lot frontage and configuration and likely result in various zoning noncomformities. Such a change in the configuration of the lots would require a new plan, with Planning Board and likely Zoning Board approval. However, the mere grant of an easement over the area as detailed above would not require any such approval and would not result in any zoning nonconformity. Page 2 The grant of an easement will not alter or change any existing lot lines. So it should be noted that any setback lines or other dimensional zoning matters for the respective lots will continue to be determined from, and based upon, the existing lots lines of record and without regard to the easement area. No opinion is hereby expressed and no zoning determination is hereby made with respect to any future construction (if any) as may be proposed or conducted on either lot. I understand that at this time no construction is intended on either lot. But for clarity, if in the future any construction were proposed on either lot it would of course need to comply with all the applicable zoning and building requirements in effect at the time, which requirements would be applied with respect to the lot lines of record (ie, with regard to fee ownership lines and without regard to the easement area). Please contact me should you have any questions concerning this matter. Sincerely, Gerald Brown Inspector of Buildings Cc: File 0 Z Date ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... =,.'; ........... has permission to perform ............... ft7Z-1 5��t� ... 7 .... ............................... wiringin the building of .................................. . ..................................................... 2 `3 at . (V C.7.2, .. .... ... . .. ............ n— North Andover, Mass. F 5.- ee ...... .. Lic. No. 7oPY. ............ 4........ ELECTRICAL INSPECTOR! Check # z- 17) ^ I., e, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 � z z 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 ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ,W,1 C► 0WI..-S], c k_ Owner or Tenant Telephone No. Owner's Address S' E Is this permit in conjunction ith a building permit? Yes El ® (Check Appropriate Box)) Purpose of Building /Z" (-e 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: j Completion of thefollowing table maybe 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 Luminaires Swimming Pool Above ❑In- ❑ o. o mergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number .. ........................................""'.... Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local M"Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ dy s -e U . n � S {-✓' to -5 v C- LIC. NO.: -;14 Licensee: LTC. NO.: (If applicable, goer t"in the license number lineBus. Tel. No.:7 61- 9YV Address: KS)a©ID .- Alt. Tel. No. 25 f A 4 7 *Per M.G.L c. 147, s. 5f-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 PERMIT 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 shall -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 Chapter 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 M Failed EN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass [N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: =ol,Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Name (Business/Organization/Individual): S Address: !� W006 A" -e n City/State/Zip: %V D. lJdW r tit A Phone #:_7K—,F- Are :7K—,F- Are you an employer? Check the appropriate box: l.�am a employer with _employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 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.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ we are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.® Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. I t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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: (2" tl,�kc /C City/State/Zip:NO . 4K n a ky— AA -A Attach a copy of the workers' compensation 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby unde 'fie p s an pe a of perjury that the information provided above is true and correct. gionnfiir? bate' Aon! ey 3 r�d Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 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 cityor 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. 1 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 a N 4+ ^! m rq + `O v�Dq 8, U O U� •" � a 'S a 4-i �4 •� � a� o a Y -c� btI 00 A •O CC+ •.� Na 'O U C�' N •C) aF .n I-ipp N b• N U N❑ N N y Gp o Ri In m C o b q f N h O O Uro �1 C U N h0 I- o,no a N C N CJ 8 5� o 0 o It 3 m oy� cu oe� m c m g o G o a q .o o •O w O O wo Qi 2 y o W 42 O O O U Q U O cC cd .q C Cll. •� „b. 3 c °pins „ a� 40A °' � �A �w•a ,,.3ri ami �'a oGo m a� 41 o p X O Fy y eq N 0 Date.....(... TOWN OF NORTH ANDOVER PERMIT''FOR WIRING This certifies that ....... r.. ......... !!.. v( ..... ............................. has permission to perform ..............ku) ................................. . ........ .......... wiring in the buildg of ..................7r�.�C.................................. at ..... ....iL STic 6 , NorthAndover, Mass. Fee..................... Lic. No............. ............................... ELECTRIC INSPECTOR Check #Q� 10487 ®�r►rn®nwealth of Massachusetts Official Use Only J Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank 'a go- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date:ltl/pl/eZ;° 02 f City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice e of his or her intention to perform the electrical work described below. Location (Street & Number) 3,34 [ _"e15 YjG K Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No LJ (Check Appropriate Box) Purpose of Building & ,S /6& nce 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: a b �i'w n pra 2 Completion of the following table may he waived by the Inspector of Wires. No, of Recessed Luminaires No. of Ceil: Sus addle' Fans F'' �� 1 NO. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El 'In- .❑ nd. rnd. o. o Emergency T ng Batter Units No. of Receptacle Outlets No. of Oil Bi�vners FIFE P�A??oM5 No. ofZones No. of Switches • No. of Gas Burners NO..Inof Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum P . �1lxmber Tons - KW - No. of Self -Contained p Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail f desired, or as required by the Inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of lii�E te including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cozce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURP.N E ❑ OTHER ❑ (Specify:) I certify, under thns nd pef alti s of petyy, that the information of pplication i�'true and complete. FIRM NAl (/ wt 5 D i !�I t-1 t l �1 / / �%/r LIC. NO.: 9 �a Licensee: �d�en� ignLIC. NO.: Ifapplicab , enter "ezem " in tnumbline.)Tel. No.:Address: _ O . O Tel. No.: -7 S/— '7 FY9 :;: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 PERMIT FEE: S The Commonwealth ofMassachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street a.ult a Boston MA 02111 www tlzass gov/dia . Workers' Compensation Insitarance Affidavit: Builders/Contractors/Eleotricians/Plumbers Applicant Information Please Print Leaibty Nanta (Business/Organization/Individual): Address: City/State/Zip: Phone #: . Are you an employer? Cheek.the appropriate -box: ' I. ❑ I-am'a employer with 4. ❑ I am a general contractor and I 12.0 Type of project (required): employees (full and/or part-time).* I am.a.sole proprietor. or partner- have hired the sub -contractors listed on the attached sheet. t 6 New construction t ❑ Remodeling ship and have no employees These su&contractors haVe 8. [] Demolition working for mein any capacity. [No workers' comp. insurance workers' comp. insuranc 5. ❑ We are a corporation andts 9, 0 Building addition required.] l ] 3. ❑ I din a homeowner doing officers have exercised their 10. Electrical re ai ❑' p rs or additions iii work myself. [No vrorkers' comp. insurance right of exemption per MG! .c. 1.52, § 1(4),'and we have no 11.❑ PIumbing repairs or additions 12.[] Roof repairs required.] t employees, [No workers' 13 ❑.Other comp. insurance required.] showing their worked' t Homeowners who submit this afrtd vit Indicating they are doing allVwork and then hire outside contractors must sub mion policy oi anew affidavit indicating ContTactots that check this box mustrttnehed an additional shtshowi?g Fhe name ofthe sub conhactors and theft umr..at' cam . r , such. U p poacy land a➢sa eaaspivper that,pxoyidifag:tvorke inforrnsadom rS' co,peraseatiore arasaarapace for rvay empinyees: Belowis Ilse policy and job site Insurance Company N Policy # or Self -ins. Lic. Expiration Hate: Job Site Address: City/State/Zip: Attach a copy of the workers'.'compenstntion 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 maybe 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 t)ie information prnverled �hoye is true and correct. Sienature: Date: Ofjtciaf use only. Do not w. rye %n this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 6.Other 5. Plumbing Inspector Contact Person: Phone 4 . r 4 Date ........... ;•t`"-:° �o� TOWN OF NORTH ANDOVER P PERMIT FOR WIRING This certifies that .. .�.,?.eR e .... 1.... �. -'e / s L 4 Gc- ----------------------- has permission to perform ...... at ................................................ wiring in the building of ..�1 lr..... rnf1Q''Y` '"— ..................................... at .... 6 ...CAA .d�..,�T7.� t'� - .................. . North Andover, S. Fee.-35.' ee . ECTRICAL NSPE Check # 10781 Commonwealth of Massachusettts Official Use Only Department of Fire Services Permit No. 18-7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELETRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 71), 527 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7 1 City or Town of. NORTH ANDOVER To the Inspector of Wires. - By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location (Street & Number) Z y (n K„ A A L JC % A Owner or Tenant I A- C - Telephone No. Owner's Address S 4 -4n -c Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building_ Z c„ e p Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overbead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity lion and Nature of Proposed Electrical Work: .wrath additional detail y desired, or as required by the Inspector of Wires. Estimated Value of ctric 1 Work: �1� (When required by municipal policy.) Work to Start: '1- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RA E: 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:) 151Y 2 I certify, under the ns and p altie ,ofperjtt ,nth � hE information on this application is true and comp, te. FIRM NAME: U �,�t LIC. NO.: C Licensee: i Signature �,-----7 LIC. NO.: (Ifapplicable, enter `exempt" in the license number line) Bus. Tel. No.-, ' Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 Signature Telephone No. PERMIT FEE. $ ..........,,G ul.uww iaote m ne waived a the Ins ector o 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 Luminaires Swimming Pool AboveElIn- Elo. o mergency ig mg rnd. rnd. Battery Units No. of Receptacle Outlets Z No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of -Initiating DDts Devices No. of Ranges No. of Air Cond. TotaTons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number .Tons KW........... No. of Self -Contained Totals: Detection/Alertiniz Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances I{yy Security Systems:x No. of Water No. of No. of Devices or E uivalent Heaters KW Bal Si Bal Signs lasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: .wrath additional detail y desired, or as required by the Inspector of Wires. Estimated Value of ctric 1 Work: �1� (When required by municipal policy.) Work to Start: '1- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RA E: 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:) 151Y 2 I certify, under the ns and p altie ,ofperjtt ,nth � hE information on this application is true and comp, te. FIRM NAME: U �,�t LIC. NO.: C Licensee: i Signature �,-----7 LIC. NO.: (Ifapplicable, enter `exempt" in the license number line) Bus. Tel. No.-, ' Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 Signature Telephone No. PERMIT FEE. $ A - _ ELEMiCAL P PMT NO. ELEClMCALINSPECTOR�. " CTIONV Posed— Sailed--[ ] Re -inspection requizerY($50.00) Inspectors' omruepts: `. (Insp ecto s7 Signa a -• nolxfoals) pate Z. SINAL STP ON; — JPassedL [ Fafled—[ ] P%e-fuspeetion regi axed ($50.00) -• [ Inspectors' commients; -IEEE. (%spectors'signature no initials) `� �S / r� -V Date — .S-- /L t 3. Yi�TDER GROTTND INSPECTION: passedg[j Fafled—jl Re-iuspectionrequired ($50.00)Inspecments: (Inspectors' Slgnatare •- no initials) Date 5 IP SPECTION •- OTfMR: Passed -- [ ] I+ailed — [ ]- Re -inspection required ($50.00) [ 7 Inspectors' cozinm.ents: asp ectors' signature mo initials) Date D 0 OR TAGS APX TO DE TILLED OUT AND LEFT OST SITE IF THE APXA. TO BE )NNOECTED 18 NOT ACCESSIBLE AND A. RE WSPECTION OF -$50.0 018 TWO CMRGED. - 0 The Commonwealth of Massachusetts Department of Industrial Accidents 'Is f5ff Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Nam�}-e (Business/Organization/Individual): 4Gco !/ - C - Fct� &ki— City/State/Zip: Zort/�e l 1 , M4- U/a'hone #: 2r( Are you an employer? Check the appropriate box: 1. ❑ I 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. # ( 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 3.01 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1 0.� Electrical repairs or additions 11.0 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. t Homeowners who submit this affidavit indicating they aie 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 21, information. Insurance Company is providing workers' compensation insurance for my employees. Below is the policy and job site Policy # or Self -ins. Lic. Job Site Attach a copy of the workers' compensation Expiration Date: City/State/Zip: 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 civilTenalties 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 t i�-statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert de the pains and penal�ti'ofperjury that the information provided abboove�'s ttr7,e�, nd correct Signature: r Gi - Date: / / / / 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 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 ofIndustrial Accidents Office of Investigations 600 Washington Street Boston., MA 02111 Tel. # 617-727-4900 ext 406 or 1-877MASSAFE Revised 5-26-05 Fax # 617727-7749 www.mass.govfdia 9377 Date .. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that V ...�' e-..... �` . p .'7 has permission to perform . . `.. .. . ........ plumbing in the buildings of at ........ ��-, North Andovet, Mass. Fee .T.Q "':' .. Lic. No. . fA L MBING INSPECTOR Check # �%Yl.. 14 r, Op MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT' TO PERIFORM PLUMBING 'WORK r� jr TYPE 011 PRINT CLEARLY OITYl �Iglzl'I 4/vb0c/ MA DATE O//� PERMIT It JOBSITEADDRESS 1336 C�IrvD�eS�/C ,� I OWNER'S NAMEI OWNERADDRESS I I TELT 1FAXI I OCCUPANCY TYPE COMMERCIAL ( I EDUCATIONAL 1 RESIDENTIAL ( NEW ( I RENOUATIQN: (1 REPLACEMENT: ( ( PLANS SUBMITTED: YES ( ( NO] ✓( ffXTURES T FLOOR-' . 13SM 1 2 3 4 5 B 7 a 9 10, 11 12 13 14 BATHTUB _.. GROSS CONNECTION :DEVICE I' DEDICATEO SPEdIAL WASTEZYSTEM DEDICATED GASIOIUSAND SYSTEM D CATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ' .. :.1........_...:_... _ ..._..... 1_._... ...., .... _ ......_. ........., ._... __ .w.:..i .. ....i .:........ DEDICATED WATER RECYCLE SYSTEM DISHWASHER . . DRINKING FOUNTAIN I FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY I i ROOF DRAIN j 8}10WER STALL 1- I SERMOEIMOP SINK I . ; ._ .... , . .. . - .. ,... _ .... l ...... V. TOILET i. I .. i A, - — URINAL i-- -. - WASHING MACHINE CONNECTION -- — WATER HEATER ALL TYPES WATER PIPING A)THER — a 1 INSURANCE COVERAGE: I have a ctirrent.liabilit ihs0r8i1ce policy.br its suiistaortal equivalent vrhich meets the reggirenients of MGL Ch. 142. YES (NO ( 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COUFRAGEBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ( BOND �. G OWNER'S INSURANCE.WAIVER: I am aware iliat the licensee.rloes not Piave ihe-itisurance cpveraUe required by Chapte> l V of the Massa husett Laws, and that:tny sicJnature on tins penliit applil atipn tJaives this regtlireinent. CHECK-ONr0NLY:. OWNER ( AGENT j SIONAl URE OF WN .Ft OR AGENT 1 hereby certify lhal all of the detail an rrifonnallon I have submitted of entered regarding jl is applicaliori atd true and accurate to the best of my knowledge and that all plumbing work and Wla1fdrions performed under the permit issued for this application will be in compliance vrillz all Pe 'neni provision oflho Massachusells Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ,'A 04 i P g0 U ko e0 9' S jLICENSE 11 Iol 5o'/6Z IGIGNATURE MPI I JP I wr 9 50 y�— CORPORATIONI III 1PARTNERS11IPj (!1( J LLC COMPANY NAME I TA M -P $04t eo►S I ADDRESS I Cr P;hP S�- CITYI FrANel r /'1 STATE I yk% 4 i ZIP I C),9_63'&' I !ELI '61 /- 33 s- .13 1 t> I FAX I I CELL I .. I EMAIL I ... i . i The Commonwealth of Massachusetts Department of lndustriqlAccldits Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrgariNation/Individual): �TA v" 1'' e o V rZ s Address:— I/-) S� v City/State/Zip:_ Phone #:_ (p /7 -335 - > 3 > -b Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ElI am a general contractor and I 6. New construction ' ❑ employees (full and/or part-time). � have Hired the sub -contractors 7• ❑Remodeling 2, 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. 9. ❑Building addition [No workers' comp. insurance 5. ElWe are a corporation and its 10.E1 Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp, insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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 Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 cero underyke pains and penalties otperIffPy that the information provided above is true and correct. Sianature�✓1.%C.t > l�afie�T ��/�s� 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. CitylTown 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 ofhire,• 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 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. Tran 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 confiirmation 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 (ifnecessary) 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 Massachmetts Department of Industrial Accidents Office ofInvestigatitons 600 Washington Street Boston, ice. 0211 t Tel, # 61.7-727-4900 txt 406 or-1.-S77�,UA.SS.AFI E Revised 5-26-05 Fax # 61.7^727;7749 wWw.xaass.govNia N2 2514 Date...... j... . ..... ... ...... '0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING Ais certifies that.......................... .. .................................. t has permission to perform .............. .........6....................................... wiring in the building of ........................................... North Andover, Mass. . ..... ..... ....... Feed ..... I ......... Lic. N ......... / ... i�ECM-ICAL-INSP-ECTOR ................. Check # A-'-) 3� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Date. ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. ,/y/ChQ 2 ./-1e174 ..... , ... . f . has permission for gas installation kqaolce !! " in the buildings of .. �c� . !?...... ................... at... ` ....... Fee.. . . Lic. No.?V-M... GAS INSPECTOR Check # d�'gi 7949 Q NLASSACHUSErIS UNIFORM APH ICATON FOR PERiNIlT TO DO GAS FMING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date / Z,/ 71 i,1 Building Locations (.A'1 LIe Ir c�, $2j Permit # Amount Owner's Name �,Q eft 1Y'M),ber► New 1z Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) 1 Check one: Certificate Installing Company Name Al Corp. Address le? o C% F� ��/ Cc�jn�i Partner. Butirness Icephone Gj7�— �7J �jp/ Firm/Co. :Mame of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ITNo If you have checked �, please indicate the type coverage by checking the appropriate box. ILJ13 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 nt� knowlcdve and that all plumbing work and installations perfnrm :d uniler Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1421 of the General Laws. Title City/Tow \PPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber // G 9 i Gas Fitter Ocense Number Master Journeyman w d o H z x a z F F z z Fj z C w E� C z x .. W r as j z w O z t~ n; O > a CIO) C SUB - BASEiM ENT A F BA SEM ENT Lx 1ST. FLOOR 2 N D. F L O O R 3 R D. F L O O R 4T II . F L O O R 5 T H. F L O O R t 6 T H. F L O O R 7 T H. F L O O R 8 T H. F L O O R 1 7— (Print or type) 1 Check one: Certificate Installing Company Name Al Corp. Address le? o C% F� ��/ Cc�jn�i Partner. Butirness Icephone Gj7�— �7J �jp/ Firm/Co. :Mame of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ITNo If you have checked �, please indicate the type coverage by checking the appropriate box. ILJ13 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 nt� knowlcdve and that all plumbing work and installations perfnrm :d uniler Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1421 of the General Laws. Title City/Tow \PPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber // G 9 i Gas Fitter Ocense Number Master Journeyman 4e . 4, The Commonwealth of 1Vlassachusetts Department oflndustrial Accidents Ofjtce of Investigations, 600 Washington Street Boston, MA 02111 yY www.naasvgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors!Electricians/PIumbers Qicant Information Name (Business/Organization/Individual): �W ► c L" Address: City/State/Zip: 1N } A c-) ZI f 2 Phone #: Are you an employer? Check the appropriate box: 1 • ❑ I am a employer with 4.❑ ' Ontractor employees (fall and/or part-time).* 2 am a sole proprietor or and have hired ub contra tso I listed partner- F s ship have on the attached sheet. t and no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its 3. ❑required.] I am a homeowner doing all work officers have exercised their right of exemption Myself [No workers' comp. per MGL c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp insurance 475>»/ 90)if Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roofrepairs A 13F1Other I *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy mformahon. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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' comp inensation insurance for my employe formation. es Below is fire policy and jab site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I- do hereby Cert fy under the pains anJpena[ties Ofperjury that file iF1fOPl1latlon pYOVide[l abOYe is free anfl COYYBCt. „---� I - _"A `7� - —tea 2->8--7-7) -q-P)e ✓��`«� uae oncy. Lo not write in illis area, to be completed bycity or town official City or Town: Perm41rL IssufgAuthority (circle one): ense ff 1. Board of.Health 2. Building Department 3. City/Town Cleric 4. Electricalxnspector. n 5Plumbing ec 6. Other g Ins p for f �,-/ ?// 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 doomed 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 nny 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been pros ented 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) andphone numb insurance. Limited Liability ers) along with their certificate(s) of 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 referent§ 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 town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the or applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner 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 NOTrequired 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: Tlxe COl`nMOTMean- of IVIrassachusetts Depaxtinent of Industrial Accidents Office of fnvesagatlons 600 Washington Street Boston;MA, 0211 Z Tel. # 617-727-,4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mas&g.ov/ilia 11111; C..U1V MU1V16 r' 4L.La"i' UP 1l14& #C-ffULNEJ I's unite use only DEPARTAfEAT OFPUBLIC&4FETY Permit No. BOARD OFFIREPREVEN77ONREGUTATIOAS527C fR12.E00 Occupancy & Fees Checked UVAS`UCATI®N FOR PERA4ff TO PERFORM ELE CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date O Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant To the Inspector of Wires: Owner's Address . �a4 VV, Lo— Is this permit in conjunction with a building permit: Yes rM No (Check Appropriate Box) Purpose of Building W 7`- j ( yU a- Utility Authorization No. Existing Service Amps AJ, ldy&olts Overhead ® Underground r—M No. of Meters New Service Ampsa / Volts Overhead ® Underground ® No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 41 7 QLILZE 7 C -ep No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total .. i .EIS• �:':" KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground El grourid 17 No. of Receptacle Outlets ^ p� No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FILE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Irtitiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW ® Connections ® No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER OR .. i .EIS• �:':" I - a FIRM NAME /� I�oa�seNa Ixen9ee � 1l _ �� l�,sn /%Z %� sigIxenseNo �s / Business TeLNa � j Arlr§C At TeL No. OWNER'SINSURANCEWAMT,IammmhtdrLx=to the h==oris suhstmtat astetundbyNtssadas&CanalIam andth�rtrysigt>�taecalthi;peat�aon�vai�esthis tequi. (Please check one) OwnerED Agent El Telephone No. PERMIT FEE $ 'E,1 Y Date � :. � .. G. ` ;. N° SG0i 04 ,,OR .� �' tio TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� This certifies that ..., ...�. .! !'' `. ' ...... .... ............ . has permission to perform .... �.. S .......................... . plumbing in the buildings of ................. at ....... . , North Andover, Mass. Fee .. .... Lie. No... .. .-7.`' �............. ... ate ...... . / PLUMBING INSPECTOR Check # f f WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) . NORTH ANDOVER, MASSACHUSETTS Building Location 217 � Owners Name Type of Occupancy f -P S Date C/— % —40 0 Permit# 7 (S 3V Amount / o New F1 Renovation 13-1" Replacement E] Plans Submitted Yes F� No n FIXTIREESS 'oil ---I (Print or type)) J Check one: Installing Company Name V/ / G � P S / d' / � M Corp. Address 7D Moo)( �� y✓ ��5 �-3— Partner. . Business Telephone i b" — 31, 3 $" 0-1irm/Co. Name of Licensed Plumber. Pci�- Y (,(-4 7Gi Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond R Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mqs§achusetts Sta Plumbing Cod Cha r 142 of the General Laws. By: algnarUM 01 LlCenSedum er ~ Type of Plumbing License Title 3 % 9-5'-- City/Town License Mumber Master Journeyman n APPROVED (OFFICE USE ONLY 1�' J 5 J 8 Date .: .................. pF NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION 9 • This certifies that .. !.-...` . �, E . _, r? ¢ / has permission for gas installation ...f-� s . ............... in the buildings of . at ........... North Andover, Mass. Fee../..;..:". Lic. No.. ........ ............. -- .... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer s > MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO FITTING t Type or print) Date g — +9- X20 O'O NORTH ANDOVER, MASSACHUSETTS Building Locations 3 Chi hd / S��CK ` Permit # 3 Jw d— Amount S / Y-7— Owner's Name New ® Renovation [:� Replacement ❑ Mgjd ew Plans Submitted ❑ ;Print or type) j/ Check one: Certificate Installing Company dame / �9 �i S lL 14. ❑ Corp. 4ddress 7a �4�/� C11 %%� ❑ Parmer. 3usiness Telephone \lame of Licensed Plumber or Gas Fitter D-�irm/Co. NSURANCE COVERAGE Check one: have a current liability Insurance policy or it's substantial equivalent. Yes ❑--- No ❑ f you have checked yes, please Ind' to the type coverage by checking the appropriate box. _lability insurance policy12/1'Other type of indemnity ❑ Bond ❑ Dwner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the vlass. General Laws, and that my signature on this permit application waives this requirement. Check one: ❑ iienature of Owner or Owner's Agent Owner ❑ Agent hereby certify that all of the details and intormarion I have submitted (or entered) in above application are true and accurate to the )est of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in :ompliance with all pertinent provisions oFthe l lassachus7c�s State Gas Cocjt and �pter1 12 the General Laws. Bv:3 gnature of Licensed Plumber Or Gas Fitter Title Plumber 7� -ity/Town ❑ Gas Fitter )cense Ivumoer ❑ Master -APPROVED wi i:IcE USE ONI.Y) �Joumevman IST— FLOOR ;Print or type) j/ Check one: Certificate Installing Company dame / �9 �i S lL 14. ❑ Corp. 4ddress 7a �4�/� C11 %%� ❑ Parmer. 3usiness Telephone \lame of Licensed Plumber or Gas Fitter D-�irm/Co. NSURANCE COVERAGE Check one: have a current liability Insurance policy or it's substantial equivalent. Yes ❑--- No ❑ f you have checked yes, please Ind' to the type coverage by checking the appropriate box. _lability insurance policy12/1'Other type of indemnity ❑ Bond ❑ Dwner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the vlass. General Laws, and that my signature on this permit application waives this requirement. Check one: ❑ iienature of Owner or Owner's Agent Owner ❑ Agent hereby certify that all of the details and intormarion I have submitted (or entered) in above application are true and accurate to the )est of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in :ompliance with all pertinent provisions oFthe l lassachus7c�s State Gas Cocjt and �pter1 12 the General Laws. Bv:3 gnature of Licensed Plumber Or Gas Fitter Title Plumber 7� -ity/Town ❑ Gas Fitter )cense Ivumoer ❑ Master -APPROVED wi i:IcE USE ONI.Y) �Joumevman The Commonwealth of Massachusetts FOR OFFICE SE ONLY rm y Peit No. { Y Department of Public Safety , 5 '= Receipt No. .' BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 ' �h V APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work will be performed in accordance with the Massachusetts General Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date S ��>%� Tr-" City or Town of A;4-11 To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work describedbelow: Location (Street and Number) .2 Cc.r dl -e- / 8, c.0 Map: Lot: Owner or TenantZone: Owner's Address S a- m e-- Is this permit in conjunction with a building perm,it? Yes l� Nn ❑ (,Check Appropriate Box) Purpose of Building Reside " e P -- Existing Service -1 ot2— Amps /16 / a- 2 o Volts Utility Authorization No. / Overhead 11 Underground E? No. of Meters New Service Amps / Volts Overhead ❑ Underground ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work a A" No. of Lighting Outlets ) 2. No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above grnd. ❑ In-grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emerg. Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self -Contained Detection/Sounding Devices No. of Ranges No. of Air Cond. Total Tons No. of Disposals No. of Total Total Heat Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of Signs No. of Ballasts Local ❑ Muncipal Connection ❑ Other No. of Hydro Massage Tubs No. of Motors Total HP 1 Low Voltage Wiring OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts Gener,4Aaws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O ❑ I have submitted valid proof of same to this /office. YES ❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ 3 00 o Work to Start Inspection Date Requested: Rough �%/�� / Final Signed under the penalties of perjury: FIRM NAME Walter B. Stockwood, Inc LIC.NO. A4622 Licensee Walter B. Stockwood Signature EE3 3 4 4 Address 31 Sixth Road , Woburn, MA 01801 Bus. Tel. No. 781-935-8181 Alt. Tel. No. 781-729-0994 OWNER'S INSURANCE WAIVER: I am aware that the Licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner ❑ Agent ❑ (Please check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Location y" No. % Date Np"T" TOWN OF NORTH ANDOVER D Certificate of Occupancy $ �sscHuSE<t' Building/Frame Permit Fee $ �- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ l5� Check G � _Building Inspe N° v J U Date...: .......1:................ V �10R711 °`�"`° :•_""° TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................ %:..... :�^.::�.-.�.. .J....... �. has permission to perform -'• � � • � ' � wiring in the building of:.:.....:'..:.: ��1--"" ......................................................... at......-:...........:........................................................... , North Andover, Mass. Fee.,711 ................ Lic. No......................................................................... ELECTRICAL INSPECTOR 05/15/98 14:59 WHITE: Applicant 75.00 PAID CANARY: Building Dept. PINK: Treasurer 1.1 Property Address: 1.2 Assessors Map and Parcel ✓ /D(. Map Number Number: L-- 0 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 Name Print Address for Service: Signature 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION.2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Own r -of Record )1191the (Print Address for Service ja,me Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 'L/(25 oa 7B3zd�--f Not Applicable ❑ Licensed Construction Supervisor: _ �77 License Number S � ddre Telephone 4 5 piration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Addj=Ls E apiration Date Signature Tele hone 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) , C�I.Addition ❑ Accessory Bldg. ❑ 'IDemolition '" ❑ 1 Other ❑ Specify Brief Description of Proposed Work: ; SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant � iFFICIAI tkONLY ` � M 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+51 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT I, --�m � —[, (�►c_.ws S as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, �O 4-� CJ I,' ¢ � as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief / l - Print Si e of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T VIBERS 1 ST2 ND 3 RD SPAN DIN ENSIONS 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 1. 0die l d)lt p9.M2UM a� /�%au�ac/riar/�a NOME IMPROVEMENT CONTRACTOR Registration 131252 Expiration, 6/21/02. Type; DBA STAR CONSTRUCTION C011PANY ROBERT NILLIAMS 49 MAIN STREET ADMINISTRATOR NEST NENBUR MA 01985 o��/�ao:iac�,uaetta BOARD OF BUILDI G REGULATIONS ilcensc CONSTRUCTION SUPERVISOR 1 Numbei: CS < 007832 f Birthdate 04/18/1954 Expires 04!18!2002 Tr. no: 19904 d" L Restricted To 00 ROBERT E WILLIAMS 49 MAIN ST'""�.%�✓ T - WEST NEWBURY, MA 01985 Administrator ! 1 I 6 6 Z x a o w u b o w C U v v) O z A as o co b O w a O c� v C �C U C W. aa o Ow —bb p w co x 0 w a W p w cn G w H m—co a G w a w G w o z co v -� O cn g O L# , On O O E CD L O O v co Q. O y Ia� cm O C'o —MM pW W O � � � L cc O d cmQ y O cc CD ca ts CD C..1) Na C _c CL COD 0 U) U) w w fr w U) c y- 0 CD c c O i C CO) • i� CO V_ V CLC ev ea. O ;= O � m H � EQ :mC O n ' � h O L . C r O O cm 1 y R di h coca cm m J c • C � CID H A -gy m o.v y m C O Q 0. C ' Q y O ♦ C,2 C � O O. O m C vCD Q W C Cc -o --� 79:5 •d1 Mo y... ev �... O.t C LU 'E o .. v H CD c m c COD a m'� o'O_ _ !p H t ON .o. o`.�'O CIO g O L# , On O O E CD L O O v co Q. O y Ia� cm O C'o —MM pW W O � � � L cc O d cmQ y O cc CD ca ts CD C..1) Na C _c CL COD 0 U) U) w w fr w U) Town of North AndoveroIt NORTH Building Department r0 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax(978)688 -9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit y / 7 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Maio 616ptl-1 611 e eC'e reWPg 441*� Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: --31.3 /Zl = am a homeowner perfo In I work myself. aI am a sole proprietor and have no one working in any capacity v I am an employer providing workers' compensation for my employees working on this job. Company name S T a�cJS-�izJ ✓��, Address �f 9 ho /J-7 Insurance Co. ;of— -i Policv # 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 and/or 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 the pains and penalties,& perjury that the information provided above is true and correct. S Print name �o�e �.�) , 1 �� a.Vtl S Phone # 27P -343-7U-7 Official use only do not write in this area to be completed by city or town official' ❑ 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 4) ca 0 4Id� 00 6t It i Q ��++>++ Q 6% 69 6% fii 64 6% 69 U- m' it c O a — E m a) m °' Z Ui U LL O a U E� N o 0 Oo E a— LL U U ai Z ul c o 0 0 0 c 0 3 vc' co a- 0 ~ v c (D a� CO Q U m Li O cn 3 o f N z 0 f m 0 a z' Ir aC W L a' L N Z 0 1- U z fn N t o c W N a N F 1 W ] 0 0 c J J F LL 4 m W 4 W t7 l N {L E i Q U i 1 0 I(WL LU w U LU 3 o ci o q 0 0 m I N W Z Y u {W o F x W- z < Z J O _ O W d KC m < Z N o W f W V O N < ; m z 3 z 3 Ix 0 i J O O Z W - 0 0 0 Z Q N W N N m W Z 0 W 0 O 0 U 0O G O U. z Z G mm m J J F QN O K F < i 0Z Z Z 0 '� W J N0 F- Q l7 Z ' 0 z = u N z Z U Z U Z U 0 m ILK LL IL 0 W 0 W 0 m Z 4 Z O 4 0 0 4 J Z O Z O Z O Z O N d 0 W W LL 0 W $- tL O W 7]] 7 Ix O N N Z < I N ! m m m m N d Z m to y p Z I N N N N 4. J M x W � K < • K Z _ 0 Jm Iix � 0 u 0 J ' 4 N ZN _ Z VI Q '41 �� Q W l0 v z W 0 Z Z 4 �C O O y W m < U. m _Z oi J (A 0 Z J Ul tonm m ,. Z Z I O z 0 � F W j O H IL- < CMS W K F O F K 0 W q) W I C O < I W Z< Z I I 0 O W Z<< U O J U. Z W a Z < Z O < N Z 0 H W LL 0 Z O d < ~ K K N W 0:0 u F W z u u Z z J w O O J O O j J J m 4 0 O � Z V Z z u O F 1- F to y<1 m m m J < < N 0 0 0< m o o < N N N; m z 0 f m 0 a z' Ir aC W L a' L N Z 0 1- U z fn N t o c W N a N F 1 W ] 0 0 c J J F LL 4 m W 4 W t7 l N {L E Q U i 1 0 LU w U LU 3 o ci o o �n£DTGi G1 ,Do y Q D D Ll 160 nwH�^mDD�pn 0 0 0 c c y m v O p> A xIZD a 0 �° W �on '^ n z 0 zzn,l n,. �xoov om a o. Qn n�_O m r n° x, _ 2 2 p z z 0 0 6' 1 2 p 0 0 _a zx Zm 0 �s nA3 ZZZ`^ozZvo JOjZD 3O� G1O °' H �w 0 O C l�- NNm3Z 0 30pm0 3p m Da T Z m� M = ti Z n 0 iIIIIII IIIiIIIIIIIIII I I I I nn H 2 7C D D D n 2 fl HOD DO tD zm 3 '� T T 0-zz C O 2 v.� Tp D0 .� p v+o A 3: f•1 = 3 0 2 f1 D a Z` O n m Z ZDO otlp ,� 13-C0 =O ` n '-ZTOw�{O� Z�-ix3 �xT x !A �c p>Z � N F A m° x Z Da N x O F I I I I I I I I I_ T=_ II II i I — LU II1 I Iillill� ILII I I I I I' IIIII" � >02 Nr� Zm mn n'" -1 DO NZZ SOC X -N•{ 3ntn 0�0 N0: pm x Ion NO S �Z _ mox 'OZ zo C m�0 r- Ncm v r 000 Zq 2 -1G)r "a (1)-1 �o �> ?�Z m A =o O Ol �o mD n2 In mm �m DO 3 E FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** ¢+ � APPLICANT: �i4CK �'tLF,cJ /�I DDE�t/ Phone V - -,T5'10` �" LOCATION: Assessor's Map Number Parcel Subdivision Street Lots) CAA1O4F k- Ry - St. Number 33 ******************** ***Official Use Only************************ RECOMMENDAT NS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments /; Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector MAY 3 1 1996 t Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date .,.IJ 11 - L ,I i C p. t3 N b yy on b y -08 (�(�J� 3 O� 0 0) O •� D '0 .E O C O O O N C O V fn E V,O N :8 pN- N E C O o N O �oo fi C)co Joos .S�Eo \ yo�Ln 1� `-�o �_ �� F yd cn E a � N—•rn a v W v t, o a'i ll y m` ti ` ovi ��d ov a�`5 a o- a r c E0 i s v_ W:s31: m v�E cc�.v ami � °' ^. v) 006 ig -2 C1. ? m E c� ` o of E c o �.o o .N u> c c o o 'o c a v o~ c o T I— c c 0 3 s o �.L N N ,O O O C U Z �� d C y O d M .- O -pU 1 w ' U pO Loco�'ooa�pA� ooUiv�o_ E,SEy rnrn C..') 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C rd cn cn C E3 91 o ?5 a C7 ►� w y 0 0 c 1 1 1 UMU- -10" 1-i0[1E IMPROVEMENT CONTRACTORS 'REG-[5'1RAT101'4 eoard of Building Regulations ar)(A Sf-andard�� rare Asj-�J-)(jrton Fllace , Room 1301 Boston, 0210C1 0'01f." T(: (,) N 1" R A CTO R Registyation 1.16e2104 Expirat.ion 02/12/97 Type, — Pk""I.VATE CorRPOFRAIJON TAMIL -Y POOLS -- PATIOS INC C. GIANOF"OUI-OS • 92 S BROADWAY LAWRENCE MA 0164.3 PAID ERIE; DEPARTMENT OF PUBLIC SAFETY ONE AS�IBURTON 1301 BOSTONO."MA,02108—, 1RM618 AUG 16'95 CONSTRUCTION SUPERVISOR LICENSE.—., D.P.S. Number: Expires: Bjkthd-te--- CS 010330 07/19/1997 07/19/1960 w,sM Restricted To: 00 -� �. � r "� tsar. WILLIAM C POULOS Detach bottom, fold sign on 92 S BROADWAY a and laminate license card. LAWRENCE, MA 01843 Keep top for receipt and change ,/of address notification. � 07. Restricted To: 00 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - None Number'. Expires: Birthdate. 1A - Masonry only S .-010330; 07/19/1997 07/19/1960 1G - I & 2 family Homes Restfictedlo: 00 Failure to possess a current edition of the Massachusetts State Buiildinq Code WILLIAM C POULOS is cause for revocation of this license. 92 S BROADWAY LAWRENCE, MA 01843 _. cation 3 4 y No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee J ' • — Other Permit Fee [MAY: 2 jewfggnnection Fee $ ----� Water Connection Fee $ /L a- 4 TOTAL ! / 9 $s •A/- q , /, ��3 V Building Inspector 0. 6085 Div. Public Works F ,Location No. -` Date 0 TOWN OF NORTH ANDOVER Certificate�Q�pancy $ 3 1cp1� ii��11st Fee $ 'TKO" 'nation Permit Fee $ ' Other Permit Fee �p�Q0�7� Sewe o �tio $ $ -- Water Co' nnpciion"P'ee TOTAL r Building Inspector Div. Public Works A -0T 4[3 Location 3.3� •-�- �' 1-ee 0.) _ / /•- 93 No. 'a Date /9 TOWN OF NORTH ANDOVER F A Certificate of Occupaty $ Buildin /F� $ s�cHusE�� Ford If ee $ �J,4 Other Permit Fee $ Sewer Connection6Fej*'6 $ --� �/(9 Water Ctroctiu Fee , ,.--$ . TOTAL >7 'uu�illding Inspector JZ 3�9b-\ 11 /> YI/I / Div. Public Works W a !N1 � 8 m } 0 a C C Z 0 W 0 a u L W u 0 J uu 0 J ik f W V u < H j m W m W m W M �- W N (') m N IL X IiW ma 3 G Z 0 I m oc0 0 O u Z 0 I d IC N d 5 m 0 H ag W IL Z O 0 Z IL 0 Q a.0 Z 0 0 ] J N ' Q 0 r W i N i t11 1 / q 0 m m W Z x U x 0 Z J O W J J LL IC O s o z 71 E N x U Z LL 0 O Z < O J < m E � r l z 0 0 Z � 8 m } 0 a C C Z 0 W 0 a u L O m U u 0 J uu 0 J a J f W V u < M j m W m W m W M � (') w Co J � i 1 fA Z 0 � 1 Z 1 1 U 7 � 1 M1 O W N z M N o I ] 0 ZZ O 0 Z I 0 m F UU W W m m ] f m 1 � � a 0 0 - J �J m J J n F W 1 F F LL 0 N m W W w 13 43 I U I F 1 U w m n n W i 3 <p i N� �^ m 0 0 y y ^O p p �! � m D�� O p mIZ _- D v p 11 (l D 3 N D O v D m M 0 0 c c m w m O D A r 0 O w 0 0 >M clz moa ~ m m m m 8 x n H r). 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N x 0 m c m D N n N p, y ° 0 0 0 0 D N 0 p; - O m m m m x= Z Z p Z Z Z Z O N N 2 Z 0 r c N m m v Z D z ; n 3 Z o Z N 3 a m O N; 3 Z „ Ov N�N3 O ;om30DN ZC) y 3 0. p �< Om Dv mZpm ZOO Gl T 0 p p m Z N ~ 0 ? z 0 Z -�w _ DN D Dnx n "" -D� c 3::2 c0axv� ON 0 �yOD om y' SOD p0 l0 0mzz T{NAz, OD C i D m x 0 c !2n x 3 0 v _ o m m o D 3: mr)m" Dn A rzo zr13 rpo Z ^ 0 T N * m F) -� y 0 < Z Z x v F Pe T r) A Z ~�'° T I_ LSO Z DD III I°.0 x jizom a 0 11-" I I-= II I I I IIIIIIIW SII IIIII` � ' >01 �yN N NDN zm �mn ADZ COX D �0, 0 0 IAC)* _.< mim • mx C� -1ZD IN0 .. .,>. jf. z O m-3 v0m �mm C 0 NCZ arm � 1 ' rao Z 0 r Tog D*D 70 ` m I ?�z n ' I0. C ,. 0-4 . v ID Oz , In mm mm t 00 a o FORM U - LOT RELZASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction t have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. *.***************Applicant fills out this section***************** APPLICANT: l��C��-dL Phone LOCATION: Assessor's Map Number Parcel Subdivision Lots)�� Street ��—�/ St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: 17 Date Approved atl-5— Comments Conservation Administrator ejDate Rejected Date Approved 3 q2 Town Planner Date Rejected Comments Date Approved Z Z Health Agent Date Rejected Comments Public Works - Bywater connections 'ga1 driveway permit ,�fr��o a� //"W , �raceaf �Z/Z z �kC Fire Department G�,�� '- Received by Building Inspector Date FR I I jr-, ,�""� .•-'fit",........ »�-----^-„ . �...,-�,,....� - COMMQ, E;.iTH :iipXTMENT OF Pusuc JAFE•ry O1;r y,O COMMONWEALTH AVE. MASSACht SETTS 90STON, MASS. 02215 ti I;- EXPIRATION DATE CONSTR.IS 1pERVicGp RESTRICT 3dS' ? EFFECTIVE DATE LIC -NO. T .. ticnEi `/01 /1986 r,4 i9(4 AFiORERT E 13ATCPFLDER � i ea DUREN AVC ! SS -WcpuU N NA 0,1301 - PHOTO TLASTHG OPR ON• �, , FEE: . i7 i, HEIGHT: NOT VALID UNTIL SIDNEO BY L"U NSEE AND OFFICIALLY �} i STAMPED'. OR SIGNATURE OF INE COMMISSIONER } .I DOB: t� 11 I THIS DOCUMENT M15T 7 CARRIED ON THE PF"ON OF I SIGNATURE OF LICENSE w�F THE HOLDER WHEN :'NGAG O ' ;QTHER8 RgHT THUMB 1�� EO IN THIS OCCUPAi,ON '}.f COMMISSION 'ER CERTIFIED FOUNDA T/ON PLAN LOCATED /N No. ANOpfERI MA SCALE /"= 40' DATE • • sl w h* Scott L. Giles R. L. S. 50 Deer Meadow Rood North Andover, Moss. 0 �6 i y Q 0 LNAYV 2 1 1-78 g . �FUIt_DING DEP� � C�►�ST�c-fC. �Ap �RT� / VERT/FY SHAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF -THE BUIL DING /NSPEC TOR ONLY SHOWN COMPLY AND SUCH USE /S FOR THE W/TH 7HE,2ONIA16 DETERMINATION OFZONING 8Y LAWS OF CONFORMITY OR NON- CONFORM/TY 1110• 6!20\ ER. , A• WHEN CONSTRUCTED. WHEN BUIL r Ir } m ° C 071 z d m c � Z GO)• w CO) T 'O Z c� � CD Z T CCD O z rD t7 rttz r O d o E� wC W W .� CL CD WC l n CD O M z Cl) CD D m D _ CZ O m z o CO CD z CO) 10 m CD n CD CA 'C 03 O� O O y O C CO) n CD O r� CD CD y CD CO2 CD MM O "*1 a m C 4 r c'+ C I;_, - Idy C ? cIR o d s Z O N o cr N novo y »CS n m n o c�n� 3 m C- . Z • M ?-co vi � ^:co N T CD C �o CO) C CO)r 03 •o > :Eco, CD eo cc t 00 �oC°� a � CD SCD 1 C-)= c c. ��•�y. o W= N N n d Q •� N W co r� ® N ra NQ _. ^ Nco f\ Jl go t m .••r CO) J O n U �C .••' o o .. CD O •CA p :` �Oco � � O of Y Q � N S co LE Ct al d � . dt too CP CD m r� P� •'� r i0 y 0 9 a ID � I �vD �- iF'w 0 ,r 0 -z- 1, Q 2-4 ^.1 s cn O ° 071 z d m c � Z GO)• w cp �. 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Z � o'•o t%� � O� .-► 0 .Oi m O TI m aim y _� pZ CCD, ..� C C y� um nY ca CD y 0 co c o, m m m�� O y � 01 y y C d C CL C43 m CD N y�� 0 �. mC CDC yCD t� sz Kipao� CD0 . m CD �0 n nt m LE °c CD A o� y M. m c cn M O CD d Ec G ar C: 71 W w �• a- Ctrl• n Q "�°° Al� _`�V�,N-54 � G a tz n O a cp n y p rl a � 0' �.., dGOD Upt V o r �' 1 v� CA y 0 9 O C e Location --32 f No. i` Date '67"1%5 T ar 1113 12328 TOWN OF NORTH ANDOVEI� Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Buil ing Inspector Div. Public Works Location -a2 i No. x Date 3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ a• Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL .$. Building Inspector Div. Public Works R W C.i C N ^ N F X O H A Q F o � 0 z k w W k c ¢ 3 k ¢ 3 IC J LLj A Q a = z ii ti Z r O ° 'J F+�1 Z z m W r C O Z - w z z F. o -_ i z u z o 0 Fp � O z C O z Z z LU z U� w z w W ¢ i < z m m m W r a d in C O p w N H o O m z CO U z w u t a ¢ � o zz LLI LLI V — � Q " z r w azw LLI _= w m y _ F 1`` 0O Ouj w w Q w w 3 o F u Q w z Z'� z c o z z a 0-0 z z a z o° z z z w w w z F w wz z z Q C 5 L ' m C C G Q " ^ " �♦ w J c LU LU a G V Cd LU LU nr a L `z C c F d z a z o Vfv F -IN I LU L;j U1S cu, u k u a O C m m m u c• Ln � F .� x z z x LU w w J c LU LU a G V Cd LU LU 05110 vw Pi SIZ1aVH ,'M I s I n u I 38J 96/CO/10 UOTjPlTdx3 IVnQlAlaNI OdAl 506201 UoTlel3ST898 861JV81NOJ 103A0? K 3NOH Hill VR 'OHYNAVI is InKlyl It SlllVH A 038! go 101 pajolilsou 06101100 666101190 H9996 so ,olvpqljil 1sojldx3 ioqlnN 3SR3311 HOSIAHMS N0I19a8ISN03 r. A131VS 311111d 30 IN3NINU30 11 The Commonwealth of Massachusetts w �T - ( Department of Industrial Accidents office 811080120fis --_ = 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit 0 I am a -sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors 1 the following workers' compensation polices: below who have 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. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct �+ Signa T �i1��. Date t Printname /_^C Phone # ,official use only do not write in this area to be completed by city or town official city or town: permit/license q 0Building Department oLicensing Board O check if immediate response is required oselectmen's Office pHealth Department contact person: phone #; FlOther (revised 7/95 P1A) V I Town Of North Andover Building Department 146 Main St. Town Hall Annex 508-688-9545 APPLICANT: Project: of tit RT#t 1 44�eo o �+ t` p 33G GfNbl---E RE: , o to fes• Title of Plans and Documents: �� DATE: Please be advised that after review of your Building Permit Application and Plans that your Application is DENIED for the following reasons: Zonina Use not allowed in District Not in conformance with Phased Development Violation of Height Limitations Sign exceeds requirements Violation of Setback Front Side Rear Insufficient Lot Area Insufficient Parking Violation of Building Coverage Insufficient Open Space Use requires permits prior to Building Permit Sign requires permits prior to Building Permit Form U not complete by other departments Not in conformance with Growth B -Law Other Remedv for the above is checked below. Dimensional Variance Special Permit for Watershed Review Special Permit for Site Plan Review Special Permit for sign Complete Form U sign -offs, Copy of Recorded Variance Information indicating Non -conforming status Copy of Recorded Special Permit Other Other Plan Review The plans and documentation submitted have the following inadequacies: 1. Information Is not provided, 2. Requires additional information, 3 Infnrmatinn rmuira_s mnre clarificatinn 4 Infnrmatinn is incnrrer•.t 5 All of the ahnAip # # oundation Plan Plumbing Plans Subsurface investigation Certified Plot Plan with proposed structure Construction Plans 116 Affidavit Mechanical Plans and or details I Plans Stamped by proper discipline Electrical Plans and or details Framing Plan Fire Sprinkler and Alarm Plan Roofing Footing Plan Plans to scale Utilities Site Plan Water Supply Sewage Disposal Waste Dis osal Other 41 ADA and or ABBA requirements _19 1 Administration The documentation submitted has the following inadequacies: 1. Information Is not provided. 2. Requires additional information. 'A Infnrmatinn rxruirac mnre rlarifiratinn 4 Infnrmafinn is inrnrreM F All of fha nhr # # Water Fee State Builders License Sewer Fee Workman's Compensation Building Permit Fee Homeowners Improvement Registration Building Permit Application iHomeowners Exemption Form Other I Other The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan Review Narrative" shall be attac ed hereto and incorporated herein by reference. The building department I r in all plans and documentation r the ab file. You must file a Vied 'g permit application form d in the ing process. Building Dep ff a ment Ol igna ure Applica ion Re ived App tion D If Faxed Denial Sent Referral recommended: Fire Health Police Zoning Board Conservation De artment of Public Works Planning Historical Commission cc: William Scott 6 A w a z � w p w p w U a: w w w cw w" cn o cn cn 5 c a .cam O2.9 :a CL cc cc C o : oA Coi 1 m 48 c z CD q `:yam E (((`//', O " �y GO cm O m vJ 10 �z f'3 CA Ey W O COD U n� m m y O O m W cya S W W mgra m � y z `o m c C y o c c w W 0 4::S= =D w mug*' .. C.. • F... MA dt c° C Z W •E V p V y O a CM C.) 5 _ a ` ti o f- CL. m > .1.1 14 pa 0 E Z a O h C C C=D c caCD Q A2 CD m m CD CD CD 3.0 CD Cm C i QL-a cc, , o a. M:,ta ca CD cc C C.3 .5 'p as c Z m V CD CL N! Co C C _c CL H 0 ✓IASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING or print) 1VVKI rl ANDOVER, MASSACHUSETTS Date 2 Z- 19 9S, Building Locations �� CA �- �5 1 ` � Permit # O9 -4P- 7 Amount $ Owner's Name New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company Name t ST -sI? 4jZS( t-4AvL-T FLVW13t+y 6. (Qc�- ❑ Corp. Address 420 LL I N 4�a H A-dw V C 'f X12 E ❑ Partner. Business Telephone ^7 � J � ,��.y,_ y(o � g Firm/Co. Name of Licensed Plumber or Gas Fitter �E re., Ap, S� n! Ay L) INSURANCE COVERAGE Check one./ I have a current liability Insurance policy or it's substantial equivalent. Yes 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 She Gas Code and Chapter 142 of the General Laws. ity/Town ROVED (OFFICE USE ONLY) Q Pgnature of Licensed Plumber Or Gas Fitter lumber 2-Z- —( ❑—Gas Fitterlcense um b e ❑ Master journeyman Zwz �L. z CG F zrA i C F cox] n W c7 `L W a z -� C "r % w cw. L "' F: c, .N. w w W L yi C W i - cw. U W .� cam. � z -C r >, rn z C Z o Cn ., F SUB -BA SEME NT BASEM ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4T H. F L O O R 5T H. F L O O R 6T it . F L O O R 7T 11. FLOOR 8T 11. FLOOR (Print or type) Check one: Certificate Installing Company Name t ST -sI? 4jZS( t-4AvL-T FLVW13t+y 6. (Qc�- ❑ Corp. Address 420 LL I N 4�a H A-dw V C 'f X12 E ❑ Partner. Business Telephone ^7 � J � ,��.y,_ y(o � g Firm/Co. Name of Licensed Plumber or Gas Fitter �E re., Ap, S� n! Ay L) INSURANCE COVERAGE Check one./ I have a current liability Insurance policy or it's substantial equivalent. Yes 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 She Gas Code and Chapter 142 of the General Laws. ity/Town ROVED (OFFICE USE ONLY) Q Pgnature of Licensed Plumber Or Gas Fitter lumber 2-Z- —( ❑—Gas Fitterlcense um b e ❑ Master journeyman 8 6 9 Date ../,� ? / 7 ...... . A w „ORT#1 TOWN OF NORTH ANDOVER 0h`4„ao p PERMIT FOR GAS INSTALLATION Ln This certifies that /a?:cc has permission for gas installation ....... in the buildings of ........................ o at ... . , North Andover, Mass. Fee../ ?.,.... Lic. No.. ,�. /. 2. ....... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: `2-5 -01 3-3� G�I�s�ici Ro� (example: left front of house) �ro�� mouse DATE OF PUMPING: Ct "ZS d 1 QUANTITY PUMPEDI'S 06 GALLONS CESSPOOL: NO YES SEP IC TANK: NO YES NATURE OF SERVICE: ROUTINE -7EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: r, l -- :� .. ED -