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HomeMy WebLinkAboutMiscellaneous - 338 BLUE RIDGE ROAD 4/30/2018ift Date .... .. . .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ........ / .......................................................................................................... has permission to perform ...... .... . ................ . .......................... wiring in the building of....... ;, /-I ............... /.( . ........ at .....3 -?r ( /I ................................................... .. ........ 4.2 North Andover, Mass -r ........ .... Lic. No.411,31, ................. ................. R, ................ CTRICAL INSP4�: ...................... Check # Commonwealth of Massachusetts mum Department of Fire Services , BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /Z- Occupancy ZOccupancy 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 (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPEALL MFORMATIOA9 Date: J74 *ie .S`-/ 2,a l d/ 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) 33&- 131tic 1;-:tAS t Pci — Owner or Tenant 124 %,( -}- kc,�, % e I , -f-W S %— Telephone No. Owner's Address S 4 0" c at 3 C ky e Is this permit in conjunction with a building permit? Yes N No ❑ (Check Appropriate Box) Purpose of Building .s 1= (D - 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: yet ISC c C.kq•,-Srr KL fc- 4 t h Cmmnletinn of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA NS. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o Emergency Lighting Batte Units Battery Nq. of Receptacle Outlets No. of Oil Burners FARE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g 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 Hydromassage Bathtubs No. of Motors Total HP WirinNo. TelecommunicationsNo. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. ,Fstimated Value of Electri 'al 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F1 BOND ❑ I certify, tinder the pains and penalties of perjury, FIRM NAME: _ O t WI et) L��ec i�rr )THER ❑ (Specify:) that the information on this application is true and complete. aL A LIC. NO.: 14,13&(0 Licensee: MtC k*91 j3erwieCJ Signature LIC. NO.: 3(oS1 (If applicable, 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: 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 Signature Telephone No. PERMIT FEE: $ 3 ❑ 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 F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS ION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: �. I Inspectors Signature: er Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com r The Commonwealth of Massachusetts Department of Industrial Accidents 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/OrganizatiorAndividual): Address: City/State/Zip: Phone #: 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ai a 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' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date:, Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 rine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 oz permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office ofIavestigations 600 Washington. Street Boston, MA, 02111 Tel, # 617-727-4900 est 406 or 1-877rMASSAFE Revised 5-26-05 Fay, # 617-727-7749 wwwanass,govldia PERMIT FOR GAS INSTALLATION This certifiesC"� ���'`� l�AtP 4�✓tt that .................. ...,!.......... has permission for gasj4utallation ...... '?!" .g, , , , , , , , , a14 in the lzu 1 Ings ...� �t S-} ............................... . at . �,"'.. , North Andover, Mass. Fe , . Lic. No... � .. . Ww GASINSPECTOR Check # 8716 VA _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY DATE PE I # v 1 PR "12 JOBSITE ADDRESS /,� 19 OWNER'S NAME G O�NER ADDRESS TEL la � - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NOX APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESX NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY /9 OTHER TYPE INDEMNITY F-1BOND❑ 3q X//� OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compjiance with all Perti n v' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME Michael H. House LICENSE # 7173 SIGNATURE MP)K MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION X# 3377C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME MERRIMACK VALLEY CORP. ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-815-4523 EMAIL VA UO W F O z z 0 F U w a z a a z Yr C l Z z O a �rl W � ~ W O W O W rA U) W ' CL W p; w fx o I z W a W N .� O 0. a a a r U J F °' IL D) w s w I-- u. w F O z z o F \ U \ W w z a c� 0 a The Common*ealth ofMassachusetts DeParlmeW of lndM$&W Acddents Office Oflave *adons 600 Washington Street Boston, Mass. 02111 Workers' Compensation InsuranceAffidavit Bn App1 ers/Contractors/El Applicant Information ectricians/Plumbers Name (� City/State/I 3.D ion an employer? Chirac the I am an employer with employees (full and/or part time). I am a sole proprietor or partner- ship and have no employees working for me in any qty. [NO workers' comp. msw"aaoe I am a homeowner doing all work qulf nsi insurance comp. t 5.0 Phone: I am a general contractor and I have hired the sub-contracxors listed on the shed sheet, Thesesub-contractors have employees and have workers, comp• insurance. $ We are a corporation and its office m have exercised their � of mon Perm MGL c.152, § 1(4� and we have no employees. [no workers' COMP. insurance requ;r�ed,j _ `AaY aPPticant that cheeps tax ql meat abo fill oat the section bdory 7.� 9 10III v_ tSomeowaps�submh � atlidavit+rtvmlmrs' :Comacxors that ebech this baa mast i � am � as =and tbea hire oaW& p0�' mlormatiaa. Qnt an employ that is the sobcon&aftrs hm Mack M—W -t o terse eame n 00Otrnctors rad � "tdMMWM bm �yem inforna*& kers colt pn umiee for , Below is the Insurance Compal wr,.r_. t1, �' I Pty m�! job side Type of project ( �lrM 6.0 New co u uction 7.0 Remodeling S. f I Demolition 9.0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. CG Roof renai, c 13. --- - --r., -- &.W ••vncers• compensation policy declaration page (showing the policy number and Failure to secure coverage as required under expiration (date Up to $1,500.00 and/or one year ' On 25a of MGL 152 can lead to the imposition of criminal rmPrisonrrtent as well as civil penalties of a fine $250.00 a day against violator. Be advised that a penalties in the form of a STOP WORT{ ORDER and a fine of DIA for coverage verification. copy °f maybe forwarded to the O#tice f In I do herby Wxial use only 000*0Y that the �-e ° Yesttgat Ons of the above is true and eorrea Do not wrote in this area to be completed by eft. or town o,,�icial City or Town: Issuing AuthorityPetm /hicense #' 1.lioard of Heath 2. (circle one): 6. Other lig Department 3. City/Town Clerk 4. ElecI Iftspector 5. Plumbing Inspector Contact person: Phone #: 0 Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ...................... 4� ....... . ............................ � .. . . ........... ..... W— has permission to perform ... & vaj�& wiring in the building of ............... y ......................................... at ..................... .North Andover rWS. Pte.. 7� Lic. No. .............. .... LECrRiCALINSPECTMR Check # 14448 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1� L BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 1200 (PLEASE PRINT IN INK OR TYPEALL City or Town of: By this application the undersi ed gives not Location (Street & Number) 43-66 Owner or Tenant Owner's Address TION) . _ Date: To the Inspector of Wires: of hisior her intelition to perform the electrical work described below All Is this permit in conjunction with a building permit? Yes Telephone No. No ❑ BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A" o,,,,,, D,,., --F K;—,n I No. of Meters No. of Meters uuucrlurzu, uetuie J aesirea, or as required by the Inspector of fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: pections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same th pe issuing office. CHECK ONE: INSURANCE t BOND ❑ OTHER ❑ (Specify:) fie I cert, render the pains and p a ties of erjury,liat the information on this p ication is ue and complete - FIRM NAME: J G t � LIC. NO.: 55533) Licensee: , I�,� 4j4 Signature LIC. NO.: (Ifapplicable, enter " empt" 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" Licen LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. $yny signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature e(`t �cz Telephone No. PERMIT FEE: $ r v ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL J 1. ROUGH INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: 'Signature - no initials) Date /W e'D .. 4 /' C, 2 8k6 LVO P 3 DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Date �/ ?/ ; , 7 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... n 14.1) } has permission to perform .....t . 4�.-...1).'- '................... plu 'bing in the buildings of ..` �.1'. t �.� `-�.................... at"./] �T �� ..... '� . ,� .. ��.................. .North Andover, Mass. Fee. 3.1 .�!7.6.:.. Lic. No.. .� ! 6... . �- .�. ......... . PLUMBING INSPECTOR Check # t/ 0? f,52 .•" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 0 Date JCI1 neGt.J Permit #_�� c1 L Amount o V-0Type of Occupancy T New 1:3 Renovation] Replacement 1:1 Plans Submitted Yes No FIXTURES (Print or type) (�1 Check one: Certificate Installing Company Name 7c� (- jz-) f' 1�jC1 �%f,� 11 Corp. Address _o IN Z 7�AC040tu1 Ili. 61 �n� Partner. Business Telephone �r�•'� _ �• � — cl p� Finn/Co. 6 Name of Licensed Plumber: 60-N Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity 11 Bond ❑ insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I Owner 1:1 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 ins 1 ons p ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach State P u mg ,Ctode and Chapter 142 of the General Laws. Title D (OFFICE USE ONLY Type ofPlumbing License 26165 cense Num5er Master Journeyman phi 4 Ic Date. x%1.9/4 . P. . TM ,1O TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,, r,o ''`•c5 This certifies that ... !G.'� .. �,! . �.......... • • .. . has permission to perform .. !'�� h ` ° r/!� " '............... plumbing in the buildings of . C %� D S ........................ /P. .........`j.... North Andover, Mass. FeeLi c. Nolf�?<<!.. ......`!_. �..1! �''��, ......... �� I PLUMBING INSPECTOR Check � � 7654 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING .ype or print) %a%--' 4 N/114 JI..),?— MASSACHUSETTS ouilding Locations a: �I y�=�� �G` Zc�� Dat—k C( Date, � Permit # Amount (/ 7 Owner's Name t` U `ACAL 4 New Renovation r—Lle" Replacement [:] Plans Submitted rl FIXTURES (Print or type) Check one: Certificate Installing Company Named G a l i n s k y P l u m b i n & H e a t i n Xi Corp. Address P . O .Box 1701 ❑ ppm., NavPrhi 1 1 MA ni Rm Business Telephone 978-374-1743 Firm/Co. Name of Licensed Plumber: Stephen C. G a l i n s k y Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity D Bond rl Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p rmed under a it Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Cod pter 142 of the General Laws. By: Signature o (cense PlumDer Type of Plumbing License Title City/Town Llm4"Umber Master ®x Journeyman El APPROVED {OFFICE USE ONLY _ J I icy : ......................... (Print or type) Check one: Certificate Installing Company Named G a l i n s k y P l u m b i n & H e a t i n Xi Corp. Address P . O .Box 1701 ❑ ppm., NavPrhi 1 1 MA ni Rm Business Telephone 978-374-1743 Firm/Co. Name of Licensed Plumber: Stephen C. G a l i n s k y Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity D Bond rl Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p rmed under a it Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Cod pter 142 of the General Laws. By: Signature o (cense PlumDer Type of Plumbing License Title City/Town Llm4"Umber Master ®x Journeyman El APPROVED {OFFICE USE ONLY Date. ..� �Gi\...... AORTPI TOWN OF NORTH ANDOVER ;.+ PERMIT FOR GAS INSTALLATION This certifies that .. ��% ! ��.'.%....�� . C�. ....... has permission for gas installation.. in the buildings of ....................................... at . M ` .). t .4 :r......... , North Andover, Mass. Fee. 2.)./.'. Lic. No. yL.. I .... .... .. om ....... . GAS INSPECTOR Check # 3 v (iEi%,f1 I " MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or 'Type) (� �? F /"i/`a„1 0a , ,Mlk Date 0 4 6 �a ©©�� �t Pcr�mit, >r Building Location �% P1 U&- 1—r�+` Owner's Name �/ kl� o / o i Type of occupancy Owner Tel# / New ❑ Renovation 0P'—Replacement ❑ Plan Sutrmittcd: Yea ❑ No t� FIXTURES Installing Company Name Check one: CerWicate Address t / o S0 u-rM I / l r7/ lV ST " ❑ Corporation p, o Partnership Business Telephone 9� �0�3 " �3� •/' '. �(Flrm/Co. Name of Licensed Plumber or Gas Fitter I'/ I C 14 P t L Q R y S C INSURANCE COVERAGE: t have a current AabMy insurance policy or Its substantial equMient which rrteeft lira requirement of MGL Ch. 142. YesNo 0 If you have Led M, please Indicate the type ooverage by chsddng Ute appropriate box. A uablttty knuranoe potiq * Other type of IrXWMITy ❑ Bond 0 OWNERS INSURANCE WAIVER: I am aware that ate Iloenaer. does ffif jm the ktatnnov coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this perrnft applicattbrt walM thts nqukerrter>L Chad one: Owner ❑ Agent ❑ Signature of Owner or Owrtefa Agent I hereby certify that aA of tM details and Information I have knowledge and that aft plumbing work and Inst hillorn performed under tM peMnent orovlalons of the Massachusetts State Gas Code and Chapter 142 r BY rale City/Town APPROVED (OFFICE USE ONLY) h above appAatlon are and accurate to the best or my issued Ibr Qtle.gWo* i wwdl by t g2a►gana with ab Type of Ucense:- "00 •Plumber Sign re of Ltensed Plum titer -Gas Mar -Master License Number d • Journeyman Location No. =*2 �A Date /° " !'qs • _. ,0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # •� �v6 //` '--Building Inspg ,or 1.1Property r' tv( 1.2 Assessors Map and Parcel ,/ o Map Number r Numb:/0 / 7 Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lat Ares Fronto ft 1.6 BUILDING SETBACKS t9t Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply AGI..C.40. 54) Public 0 Private 0 1.5. blood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 31 I IVA Z - rKVYEx l Y V WAEMbIUVAUTHUHMED AGENT Historic District: Yes No 2.1 Owner of ReW�,w(AKWIL — 3 r �d � ' Name (Print) Address for Service : Signature Telephone 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor. Address Signature 3.2 Regis Telephone 761`937S_f4-D Not Applicable ❑ License Number P//?/o - ? Expiration Date Not Applicable ❑ Registration Number Expiration Date 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 ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ 1 Existing Building 0 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: 1 SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Itef/5Wbrs Estimated Cost (Dollar) to be.; Com leted b rmit a licant t)FFICIAL°USE (L�ti.Y , _ �' 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) IS -D l 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS NT OR C9NTRACYOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby au to act on My beh f, in all m tters re f ork authorized by this building permit application. 0 pplicatin.o 3/O / Si ature of L9 Date /, J SECTION O NER/AUTHORIZED AGENT DECLARATION 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 Print Name of Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 SPAN DEV ENSIONS OF SILLS DIN ENSIONS 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 z t Q o C O � C w O N t C V V �n 0 aC = o 4,4. `oma Ea 02 o o CL N E� m o Ocm C �m ocp Z 3 N C C � � � m 'Z C N co N Eo ILL) N O O WAD a � IA Z c � o a ` C = m • o � o to O F- ,.. W C* CO �w'flt_ N • .cm n 0 S eNe a`=� E— z sa0m E ir MoN N CDm Co C m O CD ��C 1`1 m Z O Z O 0 v O �A E Z C. O CO) Q C I Ccm O•— y Q O •E m m � Z r Z O.a �3 'O O Q L m O CL. cmQ CA c ev C. O co Z ,�) C: CD C.y O C C • C c CO2 C W W W 19 W o a a w G�12 w (n '" c1 a w rx v .9 U w" i•J Q. O rs: w W a°G u. C� a° w" �:+ w rA ogi z �l cn o C O � C w O N t C V V �n 0 aC = o 4,4. `oma Ea 02 o o CL N E� m o Ocm C �m ocp Z 3 N C C � � � m 'Z C N co N Eo ILL) N O O WAD a � IA Z c � o a ` C = m • o � o to O F- ,.. W C* CO �w'flt_ N • .cm n 0 S eNe a`=� E— z sa0m E ir MoN N CDm Co C m O CD ��C 1`1 m Z O Z O 0 v O �A E Z C. O CO) Q C I Ccm O•— y Q O •E m m � Z r Z O.a �3 'O O Q L m O CL. cmQ CA c ev C. O co Z ,�) C: CD C.y O C C • C c CO2 C W W W 19 W NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordanc w' 4 the ovision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a pr6perly licensed solid waste disposal facility as defined by MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: (Location of Fa Fire Department Sign off. Dumpster Permit Signature 4 Permit Applicant m / 31 a� Date Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check the appropriate I 1. ❑ 1 am a employer with 4. employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance 5. ❑ required.] 3. ❑ I ain a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: 7 / 2 3 7J� am a general contractor and have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 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): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.E(Roof repairs 13.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my emplo s. Below 's the policy and job site information. "I— /' 4 /J /4 /% _ f�1 Insurance Company Name: V" Policy # or Self -ins. Lic. #: Expiration DaX42 � UY Job Site Address: �D City/State/Zip: Attach a copy of the workers' compensation poli4 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 tine 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 eirtify ui+r the p(Up"nYpenalties of perjuiy that the information provided MM Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # b&/ is true and correct. 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 #: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street . ,l;l� 11 ,,s Boston, MA 02111 i' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDlicant Information Please Print I,eaihh Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check the appropriate I 1. ❑ 1 am a employer with 4. employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance 5. ❑ required.] 3. ❑ I ain a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: 7 / 2 3 7J� am a general contractor and have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 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): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.E(Roof repairs 13.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my emplo s. Below 's the policy and job site information. "I— /' 4 /J /4 /% _ f�1 Insurance Company Name: V" Policy # or Self -ins. Lic. #: Expiration DaX42 � UY Job Site Address: �D City/State/Zip: Attach a copy of the workers' compensation poli4 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 tine 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 eirtify ui+r the p(Up"nYpenalties of perjuiy that the information provided MM Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # b&/ is true and correct. 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia z 0 D z 0 0 ca (9 Z 0 if 0 0 3 � �z � j .. z k.-0 z 0 D z 0 0 ca (9 Z 0 if 0 0 com CERTIFICATE 4F LIABILITY INSURANCERR ASCOC-1 DATE(M""DD""�I 1 03110/05 PRODUCER Popolizio Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 175 Littleton Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Weatford MA 01,886 Phone: 978^692-8f67 Faa : S78-692- 8588 INSURERS AFFORDING COVERAGE NAIC 4 , INSURED _ I INSURER A: PREFORPED MUTUAL INS P. INSURER e: ASCO CONSTAUCTION JOSEPH GYS 51 LONGMEADOR DRIVS LOWELL MA 01852 MED EXP (Any one person) ! s s , 0 O O INSURER D: INSURER I- COVERAGES =0 ..,- THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE RXICY PERIOD INDICATED. NOTWITHSTANDING I-1 CD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS GERTIF=TE MAYBE ISSUED OR L;, I ri MAY PERTAIN, W INSURANCE AFFORDED SYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH (f! POLICIES. AGGREGATE LIMITS SHOWN WAY NAVE BEEN REDUCED BY PAID CLAMS. LTR INSR TYPE OF INSURANCE POLICY NUMBER i DATE (Mwoo"DATE MMJDD LIMITS GENERAL LIABI.ITY EACH OCCURRENCE t 500 , 000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE I +OCCUR CPP 0130 56 13 82 i 04{26105 D4/26/06'PREMISESIEsoclurellce} j s5D,000 MED EXP (Any one person) ! s s , 0 O O _ _ I PERSONAL&ADV INJURY ( 3 5U0,000 GENERAL AGGREGATE S 1, D O D O O O GEN'L AGGREGATE LIMIT APPLIES PER; POLICY n jE { LOC PRODUCTS - COMPIOP AW 91,000,000 I AUTOMOBILE LIABILITY I) ANY AUTO I COM13INED SINGLE LIMT (Ee eadclum) I s i ALL OWNED AUTOS SCHEDULED AUTOS i ! II BODILYINJURY I IPtrt prr�o t} I HIRED AUTDS NON-OWNEDAUTOE I ! I f BODILY INJURY E (P?resdoenl) S PROPERTY DAMAGE (Ptr aeeltl! np GARAGE Lamm I I AUTO ONLY - EA ACCIDENT I S ANY AUTO OTHIERTHAN EA ACC S AUTO ONLY: AGO 3 E%CESSIUM9RELLALIAHILITY OCCUR CLAIMS MADE ( EACH OCCURRENCE S AWREGATE T S DEDUCTIBLE S RETENTION S I S '— WORKERS COMPENSATION AND EMPLOYERS•LIABILITY OT TORY LIMITS Eft E.L. EACH ACCIDENT S ANY PROPRIFTTOPJPARTNERXXECUTIVE OFFICERIMEMBER EXCLUDED? If Ye:!, AeeoNbe Under SPECIAL PROVISIONS below OTHER E L DISEASE • EA EMPLOY S _ E.L. DISEASE. POLICY LIMIT DMCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES t EXCLUSIONS ADDED BT ENDORSEMENT I SPECIAL PROVISIONS CARPENTRY - WORKERS COMPENSATION CERTIFICATE TO COM AIiSCTLY FROM THE INSURANCE COMPANY CFRTIRIaATF Hnl nF ....nvrrw� war CLOWELL SHOULD ANY OF THE ABOVE DESCRIBED pDUCM9ITE CANCEL LIM BEFORE THE EXPIRATIOI GATE THERIZdF, THE 199UIN0 IN9URER WU ENDEAVDR TO MAIL. 10 DAYS wRlrrgR NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, HUT FAILURE TO 00 90 SHALL IMPOSE NO OBLIGATION OR LIABRJTY OF ANY KIND UPON THE INSURER, RS AGENTS OR REPRESENTATIVES. Richard J. Po oiisrio I ' zs (2001108)®ACORD C 'RPO ATI 7988 UR bAtt(mm\6 Y-) . ..... .... ..... .... ............. . 05 ....... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION' PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE POPOLIZIO INS AGENCY 175 LITTLETON ROAD HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. COMPANIES AFFORDING COVERAGE WESTFORD MA 01886 COMPANY. 29H5J A HARTFORD UNDERWRITERS INSURANCE COMPANY INSURED COMPANY GYS, JOSEPH DBA a COMPANY ABCD CONSTRUCTION 51 LONGMEADOW DRIVE LOWELL MA 01852 C COMPANY D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MIADD.YY) POLICY EXPIRATION DATE(MWOD\YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ -PRODUCTS-COMP/OF AGG. S COMMERCIAL GENERAL LIABILITY —7 CLAIMS F70CCUR. ADV. M PERSONAL & URY S EACH OCCURRENCE . $ OWNERS & CONTRACTOR'S PROT. RRE DAMAGE (Any one fire) S MED. EXPENSE (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per Person) BODILY INJURY (Per Accident) HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY ANY AUTO EACH ACCIDENT AGGREGATE EXCESS LIABILITY EACH OCCURRENCE AGGREGATE : UMBRELLA FORM ]OTHER THAN UMBRELLA FORM A(UB-746X684 WORKER'S COMPENSATION AND EMPLOYERS LIABILITY THE PROPRIETOR/ PARTNERS/EXECUTIVEINCL RX 1-05) 05-01-05 05-01-06 STATUTORY LIMITS ; .. 44444;� EACH ACCIDENT 00,000 I DISEASE-POLICY LIMIT $ 500,000 DISEASE—EACH EMPLOYEE $ 100,000 OFFICERS ARE: EXCL OTHER DESCRIPTION OF OPERATIONSiLOCATIONSIVEHICLESIRESTRIC'nONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. IFICATMOUL ...... CERT DEW CANCELLATION: ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY [ONO UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE *A No. r of ABCO ROOFING & CONSTRUCTION CO. PROPOSAL AND ACCEPTANCE LOWELL, MA 01852 978-937-5840 or 978-957-8212 r f PROPOSAL SUBMITTED TO (` PHONE DATE STREET _ JOB NAME ' r CITY, STATE AND IIP CODE ' j JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ff J 1 t 'f✓ ' r 1 ,r (i 7 i n I i t % 7 % /1 We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars (E ). Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workman- like manner according to standard practices. Any alteration or deviation from above Authorized specifications involving extra costs will be executed only upon written orders, and Signature will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: This proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com - withdrawn by us if not accepted days. pensation Insurance. within Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance Signature Page No. of Pages le— • ABCO ROOFING & CONSTRUCTION CO. PROPOSAL AND ACCEPTANCE LOWELL, MA 01852 978-937-5840 or 978-957-8212 PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY, STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ! l " J We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: civ dollars. ($ Payment to be made os/follows: _ ✓�� � �' i .:r',� j () � , � i r' `.t ii.i^�/ � � iE ' T i 'r /. /.�.l�.i F�+ �{ !� All material is guaranteed to be as specified. All work to be completed. in a workman- like manner according to standard practices. Any alteration or deviation from above Authorized i' f specifications involving extra costs will be executed only upon written orders, and Signature 1 1, will become an extra charge over and above the estimate. All agreements contingent — upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: This proposal may be f and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted days. pensation Insurance. within Acceptance of Proposal -The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature i Date of Acceptance Signature 12/ 7 A 11 Lodation �� No. Date „ORTIy TOWN OF NORTH ANDOVER Certificate of Occupancy $ • : Building/Frame Permit Fee $ 'yes'„•°' E��' s/1CMU5 Foundation Permit Fee $ Other Permit Fee $ -WIV Sewer Connection Fee $ `— $�ZS� � 19(3-7Water Connection Fee $ TOTAL $ B &—�a� Ins r Div.Public Works L.,,,o -r- 1 tea% GEQ,T"l�'IE� �OVUc7J..1 A1J S � o--r--t- l� . G � L.c.S C..L. • S . ►...t o2.-rF-t A � fl o•r E.� , c�'t a sS. EzL-L,G / r M 4=7� v 1,02,17 S.F l� U 6-11 S G�.iFTll=y THAT' T'HEr c�FSrCTS SKaw�..1 c�►P�y \t/ rr l.{ --r- Sy Sy L. c%\4 -j S o F vi"c--- " f!�> u % L--T- -% .T -% Si4cs.A6.1 L j ' r"4F— l.�SE. rG. IE5 Q t V l A!q;:-, Z V 'SPE�tbR S c -j . t VSE tic—, CHET �1Z t-.� t w.A AT t c fir.{ c=:, F' Gr Pel tZ" `!' otZ. /..L d L-A e—' /moi FO CP- P1- E. k -A Ga UW, VG.Tle:o=. C.., n-rr co $4t:gr N W \ � W $A W � Z �� ? w W IV 9696 WC W '�'� C Z u t YJ ' W , W 0 C tAzz, � VE W°io vm .V• � a c � �c4 E (_V: � v i� � C W Lai O. \ � 1z ■ U n' c v Lai O. () W J ZD M c .Q n' c v H ' O u C U C . a rvjt• .V• a 'a (_V: �• O40 C C `Y *10 a=r +r c a� O O a. E c 1% y O V CkC c 3 CA C z •- c 0 ks a 4 CD m V 0 �• �' h y O O 00 . - M '`� G' X c e c W b. w ° y +' w LO' r O C 1�1 .-0 =JD a a E•y s ° a m > () W J ZD M .Q H .�' E C . a a 'a a� ccr C `Y *10 c a� O O a. E c 1% CkC c 3 � 0 C z •- c 0 c O m V 0 OOJ ER •'r\ � C \01 KYY/ V t� y g W � � A U W MW W w W a Q C1 U W D E d � 3 � c � � VF1 H � H W a w 3 aCC. Lr Q > H d w U d y a a o 00 N O � a z H cn O y V1 E V a � � 0 O O � A O a IL OOJ ER •'r\ � C \01 KYY/ '01=1 It ;la OF. l;L III .I )IN(s c:ONtilit(VATION I Il :i\1.'I'I I i'I.i1NN1N( �7'E ICATI ON NER'S ILOER'. SON'S SON'S ADDRESS: ovviIt UI F%ANNING & (;O(1I[►Il!NI"1'1' Ul;�'l:l.O1'I11l N"I' i:A ;I:N 11.1'. NI :I .ti()N. I )II tl :(: I OI t CIIIAINLY APPLICATION ANO 1'03111" I:��it�I.iii�.`.Fti i•I )'ON'S TELEPHONE:_ I"ERIAL OF CHIMNEY: `ERIOR CHIMNEY: LXILRIOR CI11hINEY: _.Qez 113ER AND SIZE OF FLUES: CKNESS OF HEARTIN chilliney on. Oiaepeace con6oam to .tete. a cqu,uteme)I•t:3 u( the carie and have -tul'e.3 alld utat i.ow been uce.Zved: �y "E: TURE OF WON:L WIT GRANTED: '�I,.OUb i Il FEE 30.w ERT NICETTA LDING INSPECTOR _ PECTEO: LARKS: SOLID BLOCK Hll;Qulltll) THIS PERMIT i' USF GE OISPLAYLO 014 111E PIMAI SES I.0 2 w. fA to R - V) W J ZD N L a c O z x = 0 0 0 � O VV c y �. .V v Uv W W c 0 O � = C O LA.Z o Z Z w GCL w 0 (�►� �C y C O y u � O • Z D Z �� �1: Z y u Qy oWe a X E WY � y O Lc 'w O C O: C E ��• ¢u ii 0 oC ii � co ii ¢ U. N V) W J ZD N L a c O z � c y • .V v Uv do a c � = C O o �: (�►� �C y C O y z � O • O: �� �1: aOur y Qy a X y ° 'w O: • ��• V a c o 0 Q 00 N .r o c. C ►�..i i h GI y 6� O U 'E _v F■ E" � t aCr d air ii V) W J ZD N L a c O z a COMMONWEALTH OF MASSACHUSETTS EXPIRATION DATE 06/30/1993 III DEPARTMENT OF PUBUC SAFETY 1010 COMMONWEALTH AVE. 4 BOSTON, MASS. 02215 LICENSE CONSTR. SUPERVISOR 6 EFFECTIVE DATE LIC -NO. RESTRICTIONS NONE =06/30/1991 016511 AALVIN J MAILLET 3 WESCOTT`ROAD SS 4 024-30-3375 ANDOVER MA 01810 FEE:: PHOTO (BLASTING OPR ONLY( �_�.'ti,•.a.. (� ({ (� 1 0 0. 0 0 ''`'"•'�. `A; '�'�'w'??t'Y' :» =mac •:,4 \',.. HEIGHT: NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY STAMPED - OR -SIGNATURE OF THE COMMISSIONER DOB. 05/15/1937 DO _ f` /NAT�UR THIS DOCUMENT MUST BE $I OF LIC ENSEE it I OTHER ,RIGr� THUMB PRINT CARRIED ON THE PERSON OF THE HOLDER WHEN ENGAG- ED IN THIS OCCUPATION. COMMISSIONER -200M,2-87.81429'-, -; i r PERMIT NQ. ASQ APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �� j�J �' ✓ PAGE 1 �10 • INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED AAGNATURC62fP OWNER OR AUTHORIZED AGENT MAP KBO. I66NE I UOT N0-- SUB DIV. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK PAGE: �C T' LOCATION a PURPOSE OF BUILDING w .2 OWNER'S NAME ' S NO. OF STORIES SIZE W -Gel C OWNER'S ADDRES //� O O!!t BASEMENT OR SLAB J�3� ARCHITECT'S NAME �,, G, / �C LI �G SIZE OF FLOOR TIMBERS IST L0 2ND 3RD BUILDER'S NAME' SPAN `Lf DIMENSIONS OF SILLS c . DISTANCE TO NEAREST BUILDING Q / DISTANCE FROM STREET Q D POSTS --♦- DISTANCE FROM LOT LINES - SIDES REAR �6G GIRDERS L AREA OF LOTI ^„-' FRONTAGE HEIGHT OF FOUNDATION THICKNESSlov IS BUILDING NEW SIZE OF FOOTING X I a IS BUILDING ADDITION 4V MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEn IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE FEE�C> n� PERMIT GRANTED - uk> a5 19 OWNER TEL. #=- CaRTf�T�- rot !TQ I J^ M 3 PROPERTY INFORMATION LAND COST EST. BLDG. COS J & / t:1iC 00 EST. BLDG. COST PER Si. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH r PLANNING BOARD BOARD OF SELECTMEN e4-t,z`t� BUILDING INSPECTOR 1. t 'NV1d 10"ld S3OV1d3tl SIHl 'a3SOdWlH3dnS '013 'S39VU 'V9 'S3H:)H0d H11M 'SaNia-un8 d0 SNOISN3WIa lOVX3 aNV S3N11 101 W02ld 3ONV1Sla aNV 101dOSNOISN3Wla 1OVX3 MOHS1SnW N01133S SIHl ZL I AONVdn000 L a8©D38 JNia11n9 VNIIV3H ON Pic "1 �1a1D313 _ P"L 1.W.9 110 SWOON 40 'ON L SVO Sa31V3H IINn J.I.H 1NVIOVa E)NINOI110NOJ 81V aOdVA 80 8.1.M IOH S831dV8 DOOM SIOD R 'SW9 1331S WV31S 'slO:) 8 'SW9 bawl! 'Nand NIV IOH 03JaOd 3JVNand SS313d1d 1SIof DOOM 0NIIV3H l L I DNIWVNd 9 OOVO 3111 aO013 3111 _ S3an1Xl'd N8300'W ONIdOOa 1108 83MOHS 11VIS ON19Wnld ON I3AVdQ 8 8V1 31V1S ANIS N3HDIDI S30NIHS DOOM A801VAV1 3310NIHS 1IVHdS7V 13SOID 831VM 03HS 1Vld I'Xld ZI W8131101 OaVSNVW 13a9WV�J _ 'X13 EI H1V9 dIH I 319VO ONiownld 0 L dood 5 3b01803d good I I S ONINIM 3WV8d NO 3NO1S UNOSVW NO 3NOIS X19 b30NID 80 '3NO:) _I 80013 8 'ss1S DMV 3WVad NO XD189 kdNOSVW NO NDI89 —� E jjj ��� _ _ 8 3111 'HdSV N7NlWO:) 3WVad NO omnis ABNOSVW NO O:):)n1S ONIOIS '183A ONIOIS SO1S39SV 0,M(MVH ONMIS 1IVHdSV H1aV3 S3I0NIHS DOOM 3138�N0� SOaVl09dVID SNO011 6 II S71VM y WO—MHDIDIMRIOW WOOS OV3H MVld 3ald 1.W 9 ON VRV D111V 'Nld % -t1-,—,7 V3aV .IM.9 'Nld llnd V38V 1NMISVS E E Z t 4 NIJNn 11VM Aa0 a31SV1d _ S831d O.M08VH 3NO1S 80 X0189 3Nld 'X.19 313SDN0:) 313a:)NO:) HSINId NOMMI 8 NOI1VONnOd Z N0IlOnH1SN0O s1N3wlavdv S3DIIIO —_ A11WVd 111nw _ i 53180!S kIIWVA 3I6NIS ZL I AONVdn000 L a8©D38 JNia11n9 SUBDIVISION FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM ASSESSORS MAP SUBDIVISION LOT(S) PER NENT A�D RnESS (AS IGNED BY D.P.W. STREET "�(,,� gU6C(� , APPLICANT PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD LA!�'t= -DATE APPROVED TOWN PLANNER 9 T DATE REJECTED CONSERVATION COMMISSION LA -CONSERVATION ADMIN. BOARD OF HEALTH HEALTH SANITARIAN DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT tom.-t�f c�c SEWER/WATER CONNECTIONS FIRE DEPT.LlhTit,�'r,<r� DATE APPROVED O DATE REJECTED DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. Icz see I -S