HomeMy WebLinkAboutMiscellaneous - 350 GREENE STREET 4/30/2018-L 5�� - 91 b
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Date..... ........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... ............
has permission to perform ...... ....... .......
Ci
wiring in the building of ....................................................
at—:3�5 ........ North Andover,Mass.
....... . .......................................
Fde,�.! . . ....... Lic. N/3.Z2!.-,6 ..............
EC�'UCAL INS iE
Check # 121Y
9366
August 15, 2016
Michael Winston Associates, LLC
Innovative Risk Specialists
POB 287
Salem, NH 03079
Tel: 603-494-2366 - Fax: 888-306-8106 - E-mail: michaelwinston@comcast.net
Building Commissioner/Building Inspector
Board of Selectman/Board of Health
1600 Osgood St. Suite 2043
North Andover, MA 01845
RE: Angelina Decaro
350 Green Street ##'210
North Andover, MA 01845
Type of Loss: Soot
Date of Loss: August 1, 2016 J
Policy: HO12301710
Claim number: HC221851
Our File. #: MW 16-210 Location of Loss: Same
To whom it may concern:
The above captioned claim has been made involving damages or destruction of property which may exceed
$1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice
under Massachusetts General Laws, Chapter 139B is appropriate, please direct it to the attention of the
undersigned and include a reference to the captioned insured, location, policy number, date of loss, cause of
loss and claim or file number.
On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated
above via first class mail.
Sincerely,
Michael Winston
Adjuster
Commonwealth of Massachusetts
Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked— = .
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL'AI
All work to be performed in accordance with the Massachusetts Electrica41nsctor
Q), S27 C R12.00
YY O RK
(PLEASE PRWflV . NK OR TYPE ALL INFORMATION) Date:Z lZf
City or Town of: NORTH ANDOVER
By this application the undersigned To .the t�Wires:
gn gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 139%�t9 5L
Owner or Tenant r\ -1 I e r•/ r— 7
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps _ / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes ❑ No/,,-" (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Hydromassage Bathtubs
OTHER:
Fol
table may be waived by the
jL ransiormers KVA
Generators KVA
ALARMS INN of Zones
Of Alerting Devices
❑iviumcipat
Conneetinn ❑ Other
o. of Dei
Wiring:
o. of Dei
of Motors Total HP Telecommunicatii
No of Devices
Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start:(When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify.)
I certify, under the pa' s nd penaltie o er' p ��)
fpep 1wq at the information on this application is true and complete.
FIRM NAME: Cr ems'
Licensee:Signature LIC. NO.: ,b-0
�
(If applicable, enter "exempt " in the license numbe line.) LIC- NO.:
Address: Bus. Tel. No,:
*Per M.G.L c. 147, s. 57-61, security work requires D Is,, AIL Tel. NO.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ehave the liability Lic. No.
required by law. B m signature ty insurance coverage normally
By y gnature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature �/ _ Telephone No.G(3 —�& 78— 5 ERMjT FEE. $
V
Com letion of the
No. of Recessed Luminaires
No. of Ceil.-Sus p. (Paddle) Fans
No. of Luminaire Outlets
No. of Hot Tubs
No. of Luminaires
Swimming Pool Above—r-, �_
d.grE
'--., No, of Receptacle Outlets
No. of Oil Burners
No. of Switches
No. of Gas Burners
No. of Ranges
No. of Air Cond. otal
No. of Waste Disposers
Tons
eat Pump Number To ]
Totals:
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances KW
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Hydromassage Bathtubs
OTHER:
Fol
table may be waived by the
jL ransiormers KVA
Generators KVA
ALARMS INN of Zones
Of Alerting Devices
❑iviumcipat
Conneetinn ❑ Other
o. of Dei
Wiring:
o. of Dei
of Motors Total HP Telecommunicatii
No of Devices
Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start:(When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify.)
I certify, under the pa' s nd penaltie o er' p ��)
fpep 1wq at the information on this application is true and complete.
FIRM NAME: Cr ems'
Licensee:Signature LIC. NO.: ,b-0
�
(If applicable, enter "exempt " in the license numbe line.) LIC- NO.:
Address: Bus. Tel. No,:
*Per M.G.L c. 147, s. 57-61, security work requires D Is,, AIL Tel. NO.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ehave the liability Lic. No.
required by law. B m signature ty insurance coverage normally
By y gnature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature �/ _ Telephone No.G(3 —�& 78— 5 ERMjT FEE. $
V
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, 11114 02111
www muss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip:ffu T
Phone #:_ LJQ --� C57 — 1) .
Are you an employer? Check the appropriate box:
1..g -t -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. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
`Any applicant that checks box #1 must also fill out the
sector below sl,-" r a' -
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
•--e -nZU Wu.—.= compensation polscy 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
information insurance for my employees Below is the policy and job 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un er-the pais and penaltiesof�7 that the information provided above is true and correc>"
Phone #:
F
cial use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Issuing Authority (circle one):
Permit/License #
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 19,ca1 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 mturned to the city or town tha`R the application for the pernait or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current.
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
vvww.mass.govidia
6.1
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .....
has permission to perform r4.�'�Fo ........ . ........................
wiring in the building of ....................................................................................
at ..... .... .... ............ ........ ,North Andover, Mass.
Fee A� ...... Lic. No.
Check #
.:-664-3
04
Commonwealth of Massachusetts
Department of Fire Services
~BOARD OF FIRE PREVENTION REGULATIONS
Offici I Ude Only
Permit No. (6 q,�
Occupancy and Fee Checked
[Rev. 9/05] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: �,. 11►►w`ul.krz To the Inspector o Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) X� G,,Le tee_ SA2ee.�z
Owner or Tenant
Telephone No.
Owner's Address Z5AN.e
Is this permit in conjunction with a building permit? Yes ❑ No R (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps <do / .2a. -t Volts Overhead ❑ Undgrd Eg— No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Bee0NWccf :/CCfaitAI seav,u fo
�� 1-\auk►rJ �,
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- 1:1
rnd. rnd.
o. o Emergency Lighting
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
g
No. of Waste Disposers
Heat Pump
Number
Tons
'"
KWNo.
of Self- ontamed
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
HeatingAppliances KN'
pp
Security Systems:
No. of Devices or Equivalent
No. of Water KW
No. o 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 Equivalent
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 Covera e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: TQ LIC. NO.:
Licensee: � L� �`� Signature LIC. NO.: 80 �3a
(Ifapplicable, enter"exempt" in the license number line.) Bus. Tel. No.: c71<=[6.i' ii4o
Address: 170;;3(-,y ';Z7C3k Akcuva� f)AA ok%sak Alt. Tel. No.:
"Security System Contractor License required for this work; if applicable, enter the license number here:
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.
O�
lZl",�c � /t .. 4161-06
P.
il
Date. -I.-.
O',•`•� -.'� TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that f9!...,� .....�..... .
has permission to perform .... �! C `... �. ...... ....1.
plumbing in the buildings of ... P P r ........
at... ..........
. ,North Andover, Mass.
Fee,). Lic. No.% "" .�... .......
PLUMBING INSPECTOR
Check ff / 2 i r,
5858
00,p,? lee75 7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
94,gev YY
New Renovation
/ Owners Name/
/Ype of Occupancy C
Replacement
FIXTURES
tv D o S
Date " C�
Permit #
Amount a c,?h
Plans Submitted Yes ® No
(Print'or type)/j, Check one:
Installing Company Name / i�S s � f f `Z aCorp.
Address cl-JAIX</G'£ ��� �s Partner
Business Telephone ® Firm/Co.
Name of Licensed Plumber: l C/ :TCf 7e
4
Insurance Coverage: Indicatethe a of insurance ebverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Certificate
E-�IR 7
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 E]
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 Sta g Code and Chapter 142 of the General Laws.
By: i i er
Type of Plumbing License
Title .
City/Town kens um r Master Journeyman El
APPROVED (OFFICE USE ONLY j'�
,
•
(Print'or type)/j, Check one:
Installing Company Name / i�S s � f f `Z aCorp.
Address cl-JAIX</G'£ ��� �s Partner
Business Telephone ® Firm/Co.
Name of Licensed Plumber: l C/ :TCf 7e
4
Insurance Coverage: Indicatethe a of insurance ebverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Certificate
E-�IR 7
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 E]
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 Sta g Code and Chapter 142 of the General Laws.
By: i i er
Type of Plumbing License
Title .
City/Town kens um r Master Journeyman El
APPROVED (OFFICE USE ONLY j'�
Date.).
F
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that S.... .. `............ .
has permission to perform ..... ..`........................... .
plumbing in the buildings of ....4 ?.r ` L c
...... ..................
at .. 3.j . (-,. .6 nc` r` .. C-
............................... . North Andover, Mass.
Fee J. %� . " . Lic. No. .-)... ......
PLUMBING INSPECTOR
Check # / y )-
6Ou"9
,� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
e�� 44 .. luau. Date ' -/I - ( Permit t� O
}
Lo.
BWding Locatlon *3S6
6 �2
es Nam-4L5—'e
of Occupancy Q "rro ms`s
NOW
NOW ❑ Renovation O Reptaceff'wt' ❑ Plans Submitted: Yes ❑ No ❑
Instalgnt Company
Business
Name d licensed Plumber
<� > .Y/0 ?-
Check one:.
e�orporation
❑ Partnership
❑ Rm✓Co.
INSURANCE COVERAGE
I have acurrent WAlty hsurance pocky or Its substantial equivalent which meets the requirements d MGL Ch. 142.
Yes^ No ❑
It you have checked M, please indicate the type coverage by checkbW the appropriate box.
A liability Insurance pdkq Other type d IndemMty ❑ 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:
of Owner or Owner's Aaant Owner ❑ Agent [I
1 Hereby CKW tial aft of the details and iMmrnatkm I have wbrnitted br entered) in above Wfiatim are true and aawrate to the best of my
krawfadge and Wall pirmrbinp work and instalaliam perfarmad under the pem* =Ad for this appGation w01 be n affo"with AN
pertinent provisions of the Massadmetts State PkmdW4 OK% WKI the General taws
BY,---
Type
YType of license: Master��"` imsi eyman ❑
tieense Number---2Zf2
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Date ... ...... . 3...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that t t .. ..�`'
.............................................5............... ...........
has permission to perform ..... c o N do t N r kt i C o M -&A V t'c l (ON
.........t..........................................................
wiring in the building of ....' �.l.u.t. ...!?. -,P .1. a.Q....... t.. p SS. t.. .... .`I......
at ......
S ...... r -C.. .........
N-3 S �............ . North Andover, Mass.
............... ...............
Fee ... .r� Lic. No. �O . �, v c v ..............
..............................................i�SPECTOR
......
ELECTRICAL
Check # g oZ 6
4828
•A
_ r..-.............._.�. � ..d..,F,NwNa7rsai�—•..-.... va.; Vala�t
1'etmil tyo.
Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev, i 1199] leave blame)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfontted in acceeadance with the Massachusetts Electrical Code (lrt • , 5;7 MIR 1200
(PLE4SE PPJNT IN INK OR TYPE ALL IiYl•OReI 4TIO19 late: / ,)3
City or Town of: _ /I✓ A,,) Je z To t1ie Iltspec or of Wires:
By this application the undersigned gives notice orhis or her intention to perform the electrical work described below.
Location (Street R Number) V ;U f
Owner or Tenant 14&eW00j CVU11Yjr41,&L1Telephone No.
Owner's Address U, , 4 I X&2J � Lx l a 044.9
Is this penult in conjunction vrith a building permit? lyes IT No (Check Appropriate Box)
Purpose of Building Utflity Authorization No.
Existing Service Amps / Volts Overhead 0 Undgrd ❑ No. of illeters .
New Service_,614b Amps /a a 12 tly Vohs Overhead ® Undgrd No. of Meters:
Number of Feeders and Ampacity �•
Location -nd Nature of Proposed Electrical Work !Z3 `nddy,ji is w/-/( 19 4/,,L)/,
-
r mml ri: %n nfdK- &&Int bin table mnv he •rotsmd by dre Insnertor of Ivires.
No. of Recessed Fixtures -
No. of Cc% -Scup. (Paddle) Fans -
ofsformers KVA
No, of Lighting Outlets
No. of Hot Tubs
erators N'B'A
F
No. of Lighting Fixtures
A In_o
swimming pool d ® rnd❑
mergency ig ting
Units
No. of Receptacle Outlets
No. of Oil Burners
---
E ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
Me. of and
Initintin .Devices '
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat ooip iVu r'irons I KNY
Totals:
No. o - ontain
MDevices
DetRq!2MLAlerf
No: of Dishix_ashers
5 ee/Area Heats ICY
pa
�l ❑ Munictp. ❑Other y
Connection
No. of Dryers
Heating Appliances KNY
Security System:
No. of Devices ter E uisratent
No. or Water
Heaters X%V
No. o No. o
psis Ballasts
Data -wining: .
No. of Devices or E trivalent
No. Hydromassage Bathtubs
No. orblotors Total HP
'e eco nn t ng:
i No. of Devices or E trivalent
OTHER:
._� _ter:--..a.is...:isr.��,",r,,.-..Q..,....tvAh,.r!■ntnseectarafWires.
INSURANCE COVERAGE. Unless waived by 'be owner, no permit for the performance of electrical work may issub unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such c*veFd&e is in fame, and has exhibited proof of same to the permit issuing office.
CHECK ONE: I`SURANCE U BOND ® OTHER a (Speci�i Oration Oate,
Estimated Value of Electrical Work: (fin re"ired by numicipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule I O,eVd upon completion.
I ce,; fy, under the pains and penalties oJpsn 107, tleert the f Oermattioss on this arpprreation a and ea7mpteta
FIRM NAME: ��\� s - _ LIC -NO.: iSa35
Licensee: `�� z� �crw "F Signature LIC. NO:
'
Bus. TeL No ---,L ` ` � J
flf aPPlicaMc esarar esrmpt " in flee ceaas_e a _ AIt. Tet.1Ra:
Address: L cx '
O�YNER' INSUitAi�iCE 1YAiYER: I am aware that the Licensee does oat have the liability itssuraiece cot'arage normally
required by Iay. i3y my signature belov�, litereby s+raive hies requireirtent. I aux the (chccb: once owner ❑ onhtcr's a t
Owner/Agent Telephone No. I'.i:RAlI?' .EEE: �
Signature 1
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Date..
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
?.! S'
This certifies that .......... rt!i.. .... ........... jf
c has permission for gas instal atilSn .. r"!5!.*.' . ........ � .
i
in the buildings of . f�� t`�'J z```'?, ................ ...... .
at ....!�.... �. , North Andover, Mass.
Fee. �.. `r Lic. No.`.� 4'?
GAS INSP CT`0A
Check # %/lfo
4651
s MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
t�• (Print or Type)
,Mass. Date 200 Permit #loR
Building Location -S7, ',Owner's Name
TelephoneType of Occupancy CoAJ A6�
New Renovation Replacement ® Plans Submitted: Yes No�
O
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 500 Myles Standish Blvd. X❑ Corporation
a
+.' Tauton, MA 02780 El Partnership
mousiness Telephone (800) 822-1300 X8051 M Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson
INSURANCE COVERAGE: EnergyUSA Propane, Inc.
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes X❑ No F1
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
IA liability insurance policy X❑ Other type of indemnity ® Bond F1
4ER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
pter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner El Agent El
of Owner or Owner's 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 the permit
issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
Signature of Licensed Plumber or Gasfitter
Licensed Plumber or Gasfitter
License Number 3707 /[O �_.
Type of License:
By
F-1 Plumber
Title
X❑ Gasfitter
City/Town
X❑ Master
APPROVED (OFFICE USE ONLY)
Journeyman
Signature of Licensed Plumber or Gasfitter
Licensed Plumber or Gasfitter
License Number 3707 /[O �_.
Date.. ....`!
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..l xf.r. .<... 1. .........
has permission to perform ....) --. � . .4-F. el A^ ................
plumbing in the buildings of ....a 5 ................
at ... ............ North Andover, Mass.
Fee ? ; �.. Lic. No.. �! f.... ��'P-L*UMBING
INSPECTOR
Check !t } t
5906
B
Pd G� 25 MASSACHUSETTS UNIFORM APPLICATION
0
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
PERMIT TO DO PLUMBING
Building Location Oso a&g'!5'v "q Owners Name
A vi't "5-1rV9
of Occupancy �dv'od
New 0 Renovation ® Replacement
FIXTURES
Date �
Permit #
Amount
Plans Submitted Yes ❑ No
(Print or type)/ Check Qne:
Installing Company Nam e,C �j,�%G1 AE�CII . [corp.
Address -717 &'LQ 1/ 11 Partner
le X�2 i9
Certificate
Business phone �7F- �'��_ �/a Z ® Firm/Co.
�I
Name of Licensed Plumber:�ti�y
Insurance Coverage: Indicate the type of insuranceboverage by checking the appropriate box:
Liability insurance policy ® Other type of indemnity 0 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 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 Sta m Code and Chapter 142 of the General Laws.
By: Signa e o
Type of Plumbing License
Title .
City/Town License umDer Master Er Journeyman El
APPROVED (OFFICE USE ONLY w
Date ............. ........6.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..�Q'/6"-`
Lp-�
.......................................
permission to perform .......... ..................
f.
T*
.wring in the building of ...... ...........
at .....
.......... . North Andover, Mass.
Fee ..&. .......... Lic. No.... . �: :: - ........................
INSPECTOR
Check #
4456
THE COMM0ATUTALTHOFMASS4CHUSE77S Office Use only
DEPARTA1EATOFPUB11CS4F=�`y, 7/(L5S7?
Permit No.
I BOAMOFMREPREVEMONRBGM77ONSR7OMl2OID -
Occupancy &Fees Checked
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL 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 JJV1113
Town of North Andover/To the Inspec r of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) LSU cye,'I e S�-'it?- V
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes u No " (Check Appropriate Box)
Purpose of Building Z�y�� Utility Authorization No.
Existing Service Amps / Volts Overhead M Underground
New Service Uo Amps llo / �y� Volts Overhead Underground
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work /6-2p ,S'�Z"vice u: J�5 \ rrnAe2 to ,.1 CGvJC T(i t klwj
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA_
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ound
round
No. e�Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. o anges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating 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
U
OTLI)Ic•
kM1aI=COVe[age. PI1LAlaT)C[Ot11el0gtllZelTlenlSOfMaSS Il19etiSCi d1L3WS
Ibawaameritlia i ylr>st r&=PblicyinckdWCompkv, CoNaageoritsalwaalegtumbI YES F1 NO E3
IhaNembnritmdvafidptudofsametDdrOffim YES j' If}auba,&drekedYES,plemmdk= tietypeofcc)Na Eby
INSURANCE BOND ® MIER
( SPeffy)
ExpuafimDale
Estima VahleofDecftxalWodc$
FIRMNAME L k0 --(V IiomseNo. S D 3 S '1
Li=, e t� �ce Sigoatiuel lioawNo
� nn Bus�Tel.No. CM- 3 Cj W O
Addreec �U 3oT �. ie �l cF (� Q�1 U i 1 At Tel No.
O"A E SINSURANCEWAVER;IamawarethattheLi wdoesnothavethem canoeoDwWoritsatbst<n]tialetltrimletttasmW[edbyMass dmseasGena'alLaws
andthatmysigimmonthis pennitappficalionwaiversthisteat iffeni trt
(Please check one) Owner Agent�d-j
Telephone No. PERMIT FEE $
Signature ot Uwner or Agent
The Commonwealth of Massachusetts
1
Buildings Dept
d Department of Industrial Accidents
Licensing Board
Office of Investigations
f
F�
Boston, Mass. 02111
Health Department
Sy. Workers' Compensation Insurance Afdavit
Other
Name Please Print
I
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:.
Address
City: Phone #:
as
Insurance. Co. Policv #
Company name:
Address
City: Phone #.
Insurance Co. Policy #
Failure to secure coverage as requiredunder 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' imprisomientasweU_as_civil.penaltiesmlbeiorm- A-STQP]NORK ORDFRand_a.fine.af-(,$1DA.OD)-aliayAgainstnip- I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
r
! do hereby certify under the pains and penalties of perjury that the information provided above a true and correct.
7
Signature Date
✓
Print name Pbone.#
Official use only do not write in this area to be completed by city or town dficial'
City or Town PermitA icensing.
Buildings Dept
pCheck d immediate response is required 0
Licensing Board
p
Selectman's Office
Contact person. Phone #. E]
Health Department
Ei
Other
vk w'�''q`H:rs'dY�•f'�'y�('` �.�X, . , . `-- _...� v t - -.'.� -. �, •w� •, ro----�.�'.� r-. ...._: �__. _. y y M �y.; y,,.+r-��v� y � .....- .. _ .. ark,.„�
R I1.
R Town of
NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: PROJECT: U'�Qkj` INSPECTION DATE: � 1j
zt'fev
UNIT NO.: FLOG StedC4 �n 4> TIN A16 -BUILDING NO.:
Excavation - depth and.soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:;
Date: - -Cof 0#
Inspector
Inspector
Inspector
Form #995 Action Press, 685-7000
- -40 V" n' n n >.�+S7rt✓
a
wog rN ,
Town of
NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
t,PERMIT NO.:
A 1PROJECT:
'��l�
��Nk
�Oc ►� �-
INSPECTION DATE:
Inspector
Inspector
Inspector
UNIT NO.:
Insulation -
FLOOR: 4 -MA
Date:
WING:
BUILDING NO.:
REMARKS:
t
` k
1
Excavation - depth and soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: -Cof 0#
Inspector
Inspector
Inspector
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it ..._.o
o
Town of
•`��_,���_�' NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
VAr PERMIT NO.: PROJECT:—L7 (rR E'4t Pt3hJ f INSPECTION DATE:
UNIT NO.: FLOOR: WING: BUILDING NO.:
A
(v v e/1 0.1 6,1
ticA at) Jrl V-0 14-t/2- NAll .If 0106A,iq
Excavation = depth and soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
)ire,Dept -
il burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: —Cof 0#
Inspector
Inspector
Inspector
form 8`J`Jb Action Press, bl5b-/UUU
�r
- 200aknetrl d Jim semice4 i'ctaltit No.
rte -occupancy and Fee Checked
BOARD OF FIRE PREVEiVTION
REGULATIONS Rev. 11/991
(leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be pedforassed in accordance with the Masswhusctts Etcetricat Codc t&113S 7 alit 12.00
(PLEAS,C PRINT 11V INK OR MY ALL INF'ORAUTTON) Date. / ,)3
City or Town of: /_y' JC 2 To the Inspec or- of Wires.-
By
ires.By this application the undersigned gives notice orhis or her intention to perforin the electrical work described below.
Location (Street & Number) So f
Owner or Tenant o 00 l "_ t '- ✓ Telephone No
Owner's Address .....
Is this permit in conjunction with a building permit? Yes[� No _ (Ghcc_1c-Appropriate Bos)
Purpose of Buildinn tftility.lutharixatlon_bto. r
Existing Service Anhps ! Volts Overltead 0 undgrd Q No. of viictors .
New Sem ice to Anhps /1 a1�t_I) volts �'erbcad ❑ tludgrd � No. of idleters
Number of Feeders and Ampacits
Location and Future of Proposed Electrical!WOrla !,/ (01vJJ i,1J4
Cdraufetian ofthe (oltowFtate teA61e Wrap be sraimd by tltc lttsiPcctor of Jt'irrs.
PlNo.
Recessed FsYtures i+lo. of
Ce,-Stssp• (Paddle) Fans Transformers KVA
Lighting Outlets
No. of Hot Tubs Generators K'VA
dye in_ o. o Emergency hb ting
Lighting Fixtures Sn�tmmmg Pool roti_ ® rid. Batt Units
Receptacle OutletsNo. of Od Bhn-ners FLRE AI,AkIS iYo. of Zones
_- ^ ftr no4swilan an
of Snitches oho• of Gas Burners
No. of Air Com3-
of Ranges _ -. _ _�
iso. ofNVaste Disposers Totals:
No: of Dishwashers Space/Area cleating jC%V
Heating Agprsasices. K%v
Date ... /(.. ..3.�..... ... 3...
° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING WIR INLG
`
.................................................
..-
.... ..This certifies that ....: j F�,
has permission to perform ..... e�::
wiring in the building of ....! i. .."...!'J.. ".
at ......... ....... ......._................................................... , North Andover, Mass.
Fee ... f-jf.. `.'.~:'.. Lic. No..:'. `.:.......: ?.:... ; �' ,r,...........................
ELECTRICAL INSPECTOR
Check #
of Alerting Devices
n'fu`ncW!u ❑ Other +
!`n»nartinn
;rd, or trs required by the lnspectar of ►runs
ante of electrical work may issue unless
rage or its substantial equivalent. -rhe
the permit issuing office.
(E.-piration Date)
tl policy.)
Rule I 0,�qd upon conVletion-
aztidrtt a and complete.
LIC_ NO.:
Vic No. .3
Bus. TeL 1`Io
Alt. Tel. No-
e liability insmznce co�-crag Y
iscck onc) I] owner ❑ 0%%I cr s assent.
p
Town of
•`��=;���zt'' NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: PROJECT: 2 4/2,1-1a 5 INSPECTION DATE:
UNIT NO.: FLOOR: WING: BUILDING NO.:
REMARKS: �'` / �,
�,��'�fry'• f...•/' �;f v� !•-,� �.,fr.�_,�°'-9..��"'
Excavation - depth and soil conditions
Framing -
Other: .
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical- g W
}
Plumbing and/or gas - rough -
Other:
Date:7_C7 t
Date:
Date:
Inspector
f
Inspector � �
Inspector.
Electrical -final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector`
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: C of O #
Inspector
Inspector
Inspector
r-orm fft= Acuon rress, use-iuuu
HONTH
Town of
NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: 4N4 PROJECT:�J �y�INSPECTION DATE:
UNIT NO.: FLOOR: WING: BUILDING NO.:
REMARKS:
=Xc)0
V
/ems 7�?,,
Form 99% Action Press, 685-7000 7.
Excavation - depth and soil conditions
Framing -
Other:
Date:
Date:
Date: C%< -L
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electric rou -
Plumbing and/or gas - rough -
Other:
`w
% d
Date: ,
Date:
Date:
Inspector `
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: -Cof 0#
Inspector
Inspector
Inspector
Form 99% Action Press, 685-7000 7.
�.'"�.".r......r.}r�w;f,tyy -.,' w.p 5.a:3-�,•�tiwd,.7�'" -s• `�"yr �a""'+'y�y''-+ti',,.,•SF`�wt
.: Town of
._ NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: PROJECT: ����� W'/ INSPECTION DATE:
UNIT NO.: FLOOR: WING: BUILDING NO.:
REMARKS: Q�(/! f� IdOK- l.�l.(n.�`� S d%
A e Ns2e'
All
Excavation - depth and soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: -Cof 0#
Inspector
Inspector.
Inspector
corm Mb Action Press, bUb-NUO
Town of
NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: PROJECT:- INSPECTION DATE: "2
UNIT NO.: FLOOR:--L_� WING: BUILDING NO.:
REMARKS: � a-tAL � L •,`. UA,1 f U �?
Excavation - depth and soil. conditions
Framing -
Other:
Date:
Date:
Date: `
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector -
Inspector ----
Electrical- final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: -Cof 0#
Inspector
Inspector.
Inspector
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I
I-
"3!�b
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ORN
Town of
NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
PERMIT NO.: PROJECT: 6W I `"' INSPECTION DATE:
UNIT NO.: FLOOR: J�"'°"""" WING: BUILDING NO.:
g
REMARKS: rriA LAX- , '"` to tg,r
corm fftlUb Action cress, otlo-/uuu
Excavation - depth and soil conditions
Framing - r,
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings, and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas -rough -
Other -
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: C of O #
Inspector
Inspector
Inspector
corm fftlUb Action cress, otlo-/uuu
�+ Town of
�'• NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
3��
PERMIT NO.: PROJECT: dL5 5� hJ�f' INSPECTION DATE: 3 a4
UNIT NO.: FLOOR; WING: R1 III DING NO.:
REMARKS: f UD1LS 1 L,vt S
L'Z (= \I Fay
Excavation -depth and soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector.
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final; inspection
Certificate of Use and Occupancy
Date:
Date:
Date: -Cof 0#
Inspector
Inspector.
Inspector
Norm BYdb AC11on Press, bUb-NUV
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............
has permission for gas installation -f tA .. F ......
in the buildings of B ..........................
at . .3J-- . .............. . North Andover' Mass.
O Lic. No.Vii.?...
Fe
... �- .
,�) 1-1111:z"I ......
GAS INSPECTOR
Check#
4766
9-1
MASSACHUSETTS UNIFORM APPLICATION FO
(Print or Type)
Mass. Date
Building Location
G
New Renovation ❑
�-s `-
PERMIT TO DO GASFITTING
Permit # 1-17d4'"
Owner's Name 7r__ , C07751,
Type of Occupancy fff/CI 06
ent ❑ Plans Submitted: YesA No ❑
Installing Company Name c
Address %3
&/ Z& dery A-2 /v -
Business Telephone 97g-7, 5-3 / O id 2—
Name of Licensed Plumber or Gas Fitter
Check one:
❑ Corporation
❑ Partnership
Firm/Co.
L4 ef /C
Certificate
INSURANCE COVERAGE:
insurznce pNicy or its Substantial ecuivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond C3
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I 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 the permit issued for this applicabon will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
By T of License:
Plumber Signature of Licensed Plumber or Gas Fitter
Titleasfitter
aster License Number � �� .
Qty/Town Journeyman
APPROVED (OF ICE USE ONLY)
1
•
•
•
•
•
1ST FLOOR
00,
• •
.■■.■N■■■■■M■ME5TK
���
FLOOR
00-
son
MEMEMEN
Installing Company Name c
Address %3
&/ Z& dery A-2 /v -
Business Telephone 97g-7, 5-3 / O id 2—
Name of Licensed Plumber or Gas Fitter
Check one:
❑ Corporation
❑ Partnership
Firm/Co.
L4 ef /C
Certificate
INSURANCE COVERAGE:
insurznce pNicy or its Substantial ecuivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond C3
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I 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 the permit issued for this applicabon will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
By T of License:
Plumber Signature of Licensed Plumber or Gas Fitter
Titleasfitter
aster License Number � �� .
Qty/Town Journeyman
APPROVED (OF ICE USE ONLY)
Robert Brunelle
Sent By: S. R. Stafford Enci.neering, Inc; 978.582.0890;
P.O. Box 1310, Pepperell, VA 0 t 463-3310
868-599-9302 of 976-582-0641
978-582-0890 FAX
To: Brunelle Brothers Inc.
978-663-9165
Sep -15-04 16:25;
From, Ralph Hutsiander
P.
PAge 'i2
Fax: (978) 663-9165 Pages: 1
Phone: (978) 663-9864 Date: 9115104
Re: fiver Bend Crossing Condo. CC:. n/a
North Aridover, Ma
0 Urgent X For Review O Please Comment L3 Please Reply 0 Please Recycle
COMMENTS:
We are pleased to submit our progress inspection report for the subject project.
At your request, we performed our Final Electrical inspection of the River Bend Crossing condo
project, We performed the Inspection on 9115/04.
COMPLETION ESTIMATE: 100%
OBSERVATIONS:
in general, the electrical contractor is providing an electrical installation Haat appears to be .of a
high quality. We find the installation satisfactory. We walked through the building checking that
all the receptacles, switches and related plates were installed. We checked the unit electrical
panels for required schedules as well as the main electrical room panels. We did a generator
start up. We tested the Fire Alarm Panel with random testing of smoke detectors and pull
stations. We checked for exhaust fan slam up during our inspection. At this tuna, we did not
observe any unusual situations. From this visual review, it appears tt4at the project has been
installed according to the plans and specifications developed by this office.
I reviewed and retained a copy of the Fire Alarm test report that was done with Mammoth Fire
Alarms on 8!25104. City Fire Department to conduct a complete test and inspection within the
next few days.
The pages of this facsimile ttansirissior. Contain confidential information trortr S. R. SUffurd Engineering, Inc. This information is
intended solely far use by the individual addressee named above, if you are not tre naked redplerrt. be aware that any disaiasurc,
coping, distribution or a:s a of me 0ontents of the facsimile s proMblied. If yuu Have revelved this facsimile in error, please notify us by
tatephone at (978) 582 •0341 su that we axon retrieve this transmission et no cost to you
RECEIVED
SEP 2 8 2004
BUILDING DEPT.
A Rab -rt: Brunelle 978-663-9155 p.2
Sent By: S. R. Stafford Engwneeriig, Inc; 978-582-0890; Sep -15.04 1E:26; page 212
S. R. STAFFORD
ENGINEERING. INC.
P. 0. BOX 1310
PEPPERELL, Mil 01463.3310
9T8) 433 - 9302 or (888) 599 - 9302
(878) 582 — 0890 FAX
In accordance with Chapter 1, Section 116.0 of the Massachusetts State
Building Code, 1, Steven R. Stafford, being a Registered Professional Engineer, certify
that I have perfumed the necessary professional services and have been present on
the construction site on a regular and periodic basis to determine that the work
proceeded in accordance with the documents approved for the building permit, and
have perforrnad for the following as specified in Section 116.2.2,
Review of shop drawings, samples and other, submittals of the contractor
,as required by the construction contract documents submitted for the
building permit, and approval for the conformance to the design concept.
2. Review and approval of the quality control procedures for ail code -
required controlled materials.
3, Spec;al architectural or engineering professional inspection of the critical
c,oristr!rctior, components requiring controlled material or construction
specified in the accepted engineering practice standards listed in
Appendix B.
After the c , nplativn of construction. I have performed a final inspection to verify
the satisfactory ( )i ipletion and compliance with the pians, specifications and Rules and
Regulations of t:,e :tassachusetts State Building Code of the intended use and
occupancy.
PROJECT _.t !TLE,
RIVERBEND CROSSING
(Stamped)
PROJECT LOC; TION: Greene Street North Andover, r4a
NAME OF Bt=`€`_fJINIG: RIVERSEND CROSSING
NATURE Or F ROJECT: Electrical and Fire.Rtprm System:
L
Office of the Conservation Department �a
0
Community Development and Services Division
27 Charles Street`s��c►�u �`
978
North Andover, Massachusetts 01845 Telephone Alison McKay p ( ) 688-930
Interim Conservation Administrator Fax (978) 688-9542
March 8, 2004
North Andover Residential Property, LLC
C/o Paul Slavik, Rosewood Construction r-e-� no e (--;7-
259 Turnpike Road, Suite 100
Southborough, MA 01772
VIA Certified Mail # 7003 1010 0001 0781 7365
RE: Enforcement Order- DEP File # 242-1025, 350 Green Street, North Andover, MA
Violation of the MA Wetlands Protection Act (M.G.L c.131, s.40) and the North
Andover Wetlands Protection Bylaw (c. 178 of the Code of North Andover).
Dear Mr. Slavik:
On January 31, 2004, this Department performed a site inspection of the above referenced property
and found several violations of the Order of Conditions. Upon review of the file at the time of
inspection, it was noted that the Order of Conditions expired on October 18, 2003. An Extension
Permit was never requested, therefore never granted, and exterior work on the property within the
North Andover Conservation Commission's jurisdiction must stop immediately with the exception
of the following, of which shall be completed by no later than Friday March 19, 2004:
I. There is a port -a -potty located in close approximation to wetland flags AI -A3 and B1 -B3.
There are also tanks being stored in this location. The port -a -potty and all tanks must be
moved to a non jurisdictional area.
2. The erosion control throughout the whole site is in need of repair. Please repair and replace
all erosion control measures, where necessary (condition #43).
3. There are two large soil stockpile areas either right up against or topping over the erosion
control barrier. The soil on the wetland side of the erosion control needs to be removed, by
hand. The soil stockpile area located right up against the erosion control needs to be moved
back so there is no overtopping threat to the resource area.
4. Extra haybales were not noted on site at the time of inspection. Per the Order of Conditions
(condition #44), you are required to keep 50 extra haybales in the event of an emergency.
Please obtain 50 haybales and cover them with a tarp for protection.
S. A trash pickup is necessary on site. Trash was noted in headwall #1 and #2 at the time of
inspection, as well as other jurisdictional areas. Please pick up and properly dispose of all
loose trash within jurisdictional areas.
6. Per condition #62 of the Order of Conditions, please submit a foundation As Built showing
distances from the foundation to jurisdictional resource areas.
BOARD OF APPEALS 688-9541 B117ILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLAINNING 688-9535
M
7. Per condition #63 of the Order of Conditions, please submit a monthly progress report to
update the construction sequence and to outline what work has been conducted in or around
jurisdictional areas.
8. Per condition #53 of the Order of Conditions, please submit a revised plan depicting plant
locations and species to be planted throughout the site.
9. Per condition #56 of the Order of Conditions, please submit a revised plan depicting a
fieldstone wall for review and approval of the North Andover Conservation Commission.
10. Per condition #51 of the Order of Conditions, please submit a snow stockpiling plan with
written authorization from the North Andover Department of Public Works.
11. Lastly, the restoration areas have not been completed. It is not reflected in the construction
sequence when this will take place. Please indicate, in writing, the construction sequence for
restoration work.
Please refer to the attached Enforcement Order requiring you to cease and desist all activities
within NACC jurisdiction with the exception of completing the above by no later than Friday,
March 19, 2004. The Enforcement Order also mandates the submittal of a new Notice of
Intent to complete the remainder of the jurisdictional work by no later than Friday, April 16,
2004 by noon.
Also, please find a Violation Notice in the amount of $300. Please be aware that the NACC
reserves the right to impose additional fines at any time in accordance with M.G.L. c. 40, s.21 and
the Town of North Andover's Wetlands Protection Bylaw, Section 178.10. Also, be aware that
each day or portion thereof during which a violation continues shall constitute a separate offense; if
more than one, each condition violated shall constitute a separate offense.
Failure to comply with this Order and the deadlines referenced herein will result in the issuance of
additional penalties. This Enforcement Order shall become effective upon receipt.
I suggest you work closely with your Environmental Monitor, Leah Basbanes, to address all of these
outstanding issues.
Your anticipated cooperation is appreciated.
Sinc rely,
Alison McKay
Interim Conservatio Administrator
Cc: NACC
Leah Basbanes, Basbanes Associates
Heidi Griffin, Director, Community Development and Services
Robert Nicetta, Building Commissioner
Michael McGuire, Building Inspector
DEP-Northeast Region
File
It
Massachusetts Department of Environmental Protection
DEP File Number.
Bureau of Resource Protection - Wetlands
WPA Form 9A - Enforcement Order 242-1025
` Massachusetts Wetlands Protection Act M.G. L. c. 131, §40 Provided by DEP
B. Findings
The Issuing Authority has determined that the activity described above is in violation of the Wetlands
Protection Act (M.G.L. c. 131, § 40) and its Regulations (310 CMR 10.00), because:
® the activity has been/is being conducted without a valid Order of Conditions.
® the activity has been/is being conducted in violation of the Order of Conditions issued to:
Richmond Realty Trust 10/18/2000
Name Dated
242-1025 43,44,62,63,53,56,51
File Number Condition number(s)
wpaform9a.doc • rev. 12/15/00 Page 1 of 3
A. Violation Information
Important:
When filling out
This Enforcement Order is issued by:
forms on the
North Andover
3/8/2004
computer, use
Conservation Commission (Issuing Authority)
Date
only the tab
key to move
To:
your cursor -
do not use the
North Andover Residential Property LLC, c/o Paul Slazik, Rosewood Construction
return key.
Name of Violator
259 Turnpike Street, Southborough, MA 01772
ffi
Address
1. Location of Violation:
SAME
Property Owner (if different)
350 Green Street
Street Address
North Andover, MA
01845
Cityrrown
Zip Code
11
60
Assessors Map/Plat Number
Parcel/Lot Number
2. Extent and Type of Activity:
See attached correspondence dated March 8. 2004.
B. Findings
The Issuing Authority has determined that the activity described above is in violation of the Wetlands
Protection Act (M.G.L. c. 131, § 40) and its Regulations (310 CMR 10.00), because:
® the activity has been/is being conducted without a valid Order of Conditions.
® the activity has been/is being conducted in violation of the Order of Conditions issued to:
Richmond Realty Trust 10/18/2000
Name Dated
242-1025 43,44,62,63,53,56,51
File Number Condition number(s)
wpaform9a.doc • rev. 12/15/00 Page 1 of 3
Massachusetts Departm6nt of Environmental Protection
DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form 9A — Enforcement Order 242-1025
Massachusetts Wetlands Protection Act M.G. L. c. 131, §40 Provided by DEP
B. Findings (cont.)
® Other (specify):
See attached correspondence dated March 8, 2004 .
C. Order
The issuing authority hereby orders the following (check all that apply):
® The property owner, his agents, permittees, and all others shall immediately cease and desist
from the further activity affecting the Buffer Zone and/or wetland resource areas on this property.
❑ Wetland alterations resulting from said activity should be corrected and the site returned to its
original condition.
® Complete the attached Notice of Intent. The completed application and plans for all proposed
work as required by the Act and Regulations shall be filed with the Issuing Authority on or before
Friday, April 16, 2004 by noon
Date
No further work shall be performed until a public hearing has been held and an Order of Conditions
has been issued to regulate said work.
® The property owner shall take the following action to prevent further violations of the Act:
remove soil stockpiles (refer to attached letter for locations and methods), repair any inadequate
erosion control measures, relocate port -a -potty and tanks to non -jurisdictional area, obtain 50 extra
haybales and cover with a tarp, perform trash sweep, submit foundation As -Built, submit monthly
progress report, submit revised planting plan, submit revised plan depicting fieldstone wall, submit
snow stockpile plan, address when restoration areas will be.complete. Refer to attached
correspondence dated March 8, 2004 for all of the above.
Failure to comply with this Order may constitute grounds for additional legal action. Massachusetts
General Laws Chapter 131, Section 40 provides: "Whoever violates any provision of this section (a)
shall be punished by a fine of not more than twenty-five thousand dollars or by imprisonment for not
more than two years, or both, such fine and imprisonment; or (b) shall be subject to a civil penalty not
to exceed twenty-five thousand dollars for each violation". Each day or portion thereof of continuing
violation shall constitute a separate offense.
wpaform9a.doc • rev. 12/15/00 Page 2 of 3
Massachusetts Department of Environmental Protection DEP File Number:
L7/ IBureau of Resource Protection - Wetlands
WPA Form 9A — Enforcement Order 242-1025
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
D. Appeals/Signatures
An Enforcement Order issued by a Conservation Commission cannot be appealed to the Department of
Environmental Protection, but may be filed in Superior Court.
Questions regarding this Enforcement Order should be directed to:
Alison McKay, Interim Conservation Administrator
Name
978.688.9530
Phone Number.
Monday through Friday, 8:30am-4:30pm
Hours/Days Available
Issued by:
North Andover
Conservation Commission
In a situation regarding immediate action, an Enforcement Omer may be signed by a single member or
agent of the Commission and ratified by majority of the members at the next scheduled meeting of the
Commission.
Signatur s:
Signature of delivery person or certified mail number
wpaform9a.doc • rev. 12/15/00 Page 3 of 3
1 I
TOWN OF NORTH ANDOVER
NOTICE OF VIOLATION OF WETLAND BYLAW
0156
DATE OF THIS NOTICE , a� dot
NAAM'E OF OFF NDER r��/ J `3�Ra & 'Ij i
ADDRESS OF OFFENDER iG2C 1
to rn L . 00
DATE OF BIRTH OF OFFENDER
MV OPERATOR LICENSE NU ER
MV/MB REGISTRATION NUMBER
OFFENSE:
WOf lii(�Tll � ctr+l_'d
dtc� CCG
(�4t�.as Wp('c+ a, J,; -(I C tie
Sb i 6 J& ex ire Order 'i' — l49.2.5;
TIME AND DATE OF VIOLATION
(A.M.) (P.M.) ON �dtJ1 L.tLft' 20
LOCATION OF VIOLATION f 1
AT .50 Gmen 54r�.t. 0. veh]r 61915
SIG RE OF ENFORCWG PE J�N_FORCIN DEPARTMENT
I HEREBY ACKNOWLEDGE EIPT OF THE FOREGOING CITATION
X
G/ -Unable to obtain signature of offender. Date Mailed
Citation mailed to offender
THE FINE FOR THIS NON -CRIMINAL OFFENSE IS $ 300"
YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO
DISPOSITION OF THIS MATTER.
(1) You may elect to pay the above fine, either by appearing in person
between 8:30 A.M. and 4:30 P.M., Monday through Friday, legal holidays
excepted, before: The Conservation Office. 27 Charles Street, North
Andover, MA 01845 OR by mailing a check, money order or postal note to
the Conservation Office WITHIN TWENTY-ONE (21) DAYS OF THE DATE
OF THIS NOTICE. This will operate as a final disposition of the matter, with
no resulting criminal record.
(2) If you desire to contest this matter in a non -criminal proceeding, you
may do so by making a written request, and enclosing a copy of this citation
WITHIN TWENTY-ONE (21) DAYS OF THE DATE OF THIS NOTICE TO:
The Clerk -Magistrate, Lawrence District Court
380 Common St., Lawrence, MA 01840
ATTN: 21 D non -criminal
(3) If you fail to pay the above fine or to appear as specified, a criminal
complaint may be issued against you.
O A. I HEREBY ELECT the first option above, confess to the offense
charged, and enclose payment in the amount of $
❑ B. I HEREBY REQUEST a non -criminal hearing on this matter.
Signature
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Location iso -�;: 4
No. / �--71?ArIEb2 l Date 11-3-2003
TOWN OF NORTH ANDOVER
s
Certificate of Occupancy $
"° Ate Building/Frame Permit Fee $
s,�wust
Foundation Permit Fee $ "
Other Permit Fee i r $ ° % O D
TOTAL $ r /00
Check # i Q
x6280 P_AAI.�---
Building Inspector
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
�r
-'a .�"rti'^�i=.� r•,?i. "i'. �'3`�w.-.s, r-'...�. �-.?rs ur- .ilLL3 °7ectYon for Oficial Use Onl 3r �'�aF .a r ,_;� �.xi„�,t• � � nz, 4i;� 7 =� E O
BUILDING PERMIT NUMBER: I DATE ISSUED:
SIGNATURE:
Buildings or of Buildin to
1.1 Property Address:
/6-7 9" °
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide. Required
Provided
ReqWred
Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal On Site Disposal System ❑
2.1 Owner of Record
W 0 . /s1--nJG�� 1 \��:� l t l l /4� ��t `i��T �j 1...LC
Name (Print) i Address for Service:
Sign re Telephone
2.2 Authorized Agentr ��
b PPO
Nam Address for Service:
Signature Telephone
3.1 Licensed Construction Supervisor
Not Applicable .
Address
License Number
Licensed Construction Supervisor:
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
0
TM
N
Z
0
Z
M
i
;s>�czlto>v alttscr�+.
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 Yea .......❑ No ....... 0
5.1 Registered Architect:
Address
Signature Telephone -
.'y' � /tel •:,,,-. .,,..,-y .,, �,�,�'
Resisted )i��YlB�SSi4iat `
Z ..
Name:
dress:
J
y
Expiration Date
Not applicable ❑
Registration Number .
f
Expiration Date
- , f � . c'u+ �+.1 j�it1•c x. tit;:.; `->>"}
Area of Responsibility''
Registration Number
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Area of Responsibility
Registration Number
K
Name:
Address
Signature
Name
Address
Signature
Name
Total
Telephone
Telephone
Address
.t
ti
Signature gam, - Telephone
(( E
Conn nv Name:
Responsible in Charge of Construction
Not Applicable ❑
1:I
`,«'�&�"! . , ,�,�!�'+!T1.� , .•� ?�1! :�# •.t'�Ic all•sunl�G,able� ':;
New Construction ❑
Existing Building 0
Repair(s) ❑
TAlterations(s) ❑
Addition 0
Accessory Bldg. ❑
Demolition ❑
Other j< Specify t -A,
k--' t
Brief Description of Proposed Work:
mac%
`
to r'4
L
A-2 ❑ A-3
A-5 ❑
0
lA
1B-
r ��N 7 ��� ,G•`i�� � C��'s����
USE GROUP Check as applicable)
CONSTRUCTION
TYPE
A Assembly ❑ A-1 ❑
A4- 0
A-2 ❑ A-3
A-5 ❑
0
lA
1B-
❑
❑
B Business ❑
2A
2B
2C
0
0
❑
C Educational ❑
F Factory ❑ F-1 ❑ F-2 ❑
H High Hazard 0
3A
3B
❑
❑
I histitutior dl ❑ - I-1 ❑ 1-2 ❑ 1-3 ❑
M Mercantile " ' ❑
4
0
R residential ❑ R-1 0
R-2 0 R-3
❑
5A
5B
❑
❑
S Storage ❑ S-1 ❑ S-2 ❑
U Utility 0
M Mixed Use ❑
S Special Use 0
Specify:
Specify:
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
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BUILDING AREA r
�5
2♦
EXISTING if applicable)
PROPOSED
Number of Floors or Stories Include
Basement levels
_
Floor Area per Floors
"ZZ
F
Total Areas
"ZZ y
Total Height ft
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Independent Structural Engineering Structural Peer Review Required Yes ❑ No
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, LJ� z c ooh /r as Owner of the subject property
Hereby authorize OLa. °2 r K
My behalf, in all matters relative two work authorized by this building permit application
Signature o Owner Date
to act on
9
as Owner/Authorized
Agent
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief
Signed under the pains and penalties of perjury.yam.
t_,461.2
Print Name
Signature of Owner/Agent 1 Date
-Item
EMS -
Item
Estimated Cost (Dollars) to be
Completed by permit applicantxx
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction from (6)
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
r.
Check Number
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NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS l ST 2ND 3RD
SPAN
DEMENSIONS OF SILLS
DEMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CBRviNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured: Helen Donahue
Property Address: 350 -Greene Street, Unit 1011
Policy Number: HP2432615
Date/Cause of Loss: 5/8/2012, Mold Damage to Shed
File or Claim Number: 26248-J
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Jim Taylor
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail. ;
-/;/- ) ,)—
Sign*ure and
ANDERSON ADJUSTMENT`GO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053