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Miscellaneous - 365 JOHNSON STREET 4/30/2018
to W=r-o rm Phone: 978-632-2660 JAMES A. TRUDEAU Adjustment Service Inc. P. O. Box 7 Fax: 978-632-2662 Gardner, MA 01440 claims(0trudeaua4i.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B February 21, 2015 ilding Inspector 120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Susan Bournival Loss Location: 365 Johnson Street, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100753200 Date of Loss: February 7, 2015 File Number: 15-12859 Claim Number: 15104547 Type of Loss: Ice Dam Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000-00 or cause "Mass. Gen. Laws Chapter 143, Section 6" to be applicable. If any notice under "Mass. Gen Laws Chapter 139, Section 313" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Joshua M. Trudeau Claims Adjuster w *f ,r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 242-1159 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the Joseph Pelich computer, use Name only the tab key to move 231 Sutton Street, Suite 2-E your cursor - Mailing Address do not use the North Andover MA 01845 return key. City/Town State Zip Code rQ 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: William Barrett Homes Name August 20, 2002 242- 1159 Dated DEP File Number 3. The project site is located at: 365 Johnson Street North Andover Street Address City/Town Map 98A Parcel 113 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner (if different) Essex North 7973 53 County Book Page Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 8/28/07 Date B. Certification Check all that apply: ® Complete Certification: It is hereby certified that the work regulated by the above -referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: It is hereby certified that only the following portions of work regulated by the above -referenced Order of Conditions have been satisfactorily completed. The project areas or work subject to this partial certification that have been completed and are released from this Order are: wpaform 8b.doc • rev. 7/13/04 Page 1 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 242-1159 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above -referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: 50 C. Authorization Issued by: North Andover Conservation Commission 943L,07 Date of Issu nce This Certificate must be signed by a majority of the Conservation Commission and a copy sent to the applicant and appropriate DEP Regional Office (See Attachment). Sigl wpaform 8b.doc•rev. 7/13/04 Page 2 of 4 LI)Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. Authorization (cont.) Notary Acknowledgement Commonwealth of Massachusetts County of 'r' � 1 '1 On this Day Essex North DEP File Number: 242-1159 Provided by DEP Of s -'. b, -7 MonI Year before me, the undersigned Notary Public, personally appeared Name of Document Signer proved to me through satisfactory evidence of identification, which was/were Massachusetts License Description of evidence of identification to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of DONNA M. WEDGE NOTARY FU; ' fS I, cn,..; 'V:.ALTHCP JS North Andover City/Town Place notary seal and/or any stamp above Conservation Commission /& t/4" 12, Signature of Notary Public j/)�00'0 �7f �; lre- Printed Name of Notary Public � �00q My Commissio E-x7.p�ires (Date) rQ-wv� /'2 L✓2 SZ� Signature of Notary Public wpaform 8b.doc • rev. 7/13/04 Page 3 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance Ll Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 24Provided vb by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. --------------------------------------------------------------------------------------------------------------------------- To: North Andover Conservation Commission Please be advised that the Certificate of Compliance for the project at: 365 Johnson Street 242-1159 Project Location DEP File Number Has been recorded at the Registry of Deeds of: County for: Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant wpaform 8b.doc • rev. 7/13/04 Page 4 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments, payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 Acton Charlton Hopkinton DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Suite 402 Alford Cummington Hatfield Monterey Richmond Ware Springfield, MA 01103 Amherst Dalton Ashfield Deerfield Hawley Heath Montgomery Monson Rowe Warwick Phone: 413-784-1100 Becket Easthampton Hinsdale Mount Washington Russell Sandisfield Washington Wendell Fax: 413-784-1149 Belchertown East Longmeadow Holland New Ashford Savoy Westfield Sterling Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Oxford Blandford Erving Huntington New Salem Shelburne West Springfield Lunenburg Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Groton Buckland Gill Lee Northampton Southampton Whately Bolton Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Weymouth Chester Granville Leyden Otis Springfield Williamstown Tyngsborough Chesterfield Great Barrington Longmeadow Palmer Stockbridge Windsor Royalston Chicopee Greenfield Ludlow Pelham Sunderland Worthington Freetown Clarksburg Hadley Middlefield Peru Tolland Acushnet DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashburnham Clinton Hubbardston Millville Shirley Warren Worcester, MA 01608 Ashby Douglas Hudson New Braintree Shrewsbury Webster Phone: 508-792-7650 Athol Auburn Dudley Dunstable Holliston Lancaster Northborough Northbridge Southborough Southbridge Westborough Fax: 508-792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Boylston West Brookfield TDD: 508-767-2788 Barre Fitchburg Leominster Oakham Sterling Westford TDD: 617-574-6868 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Westwood Boxborough Hardwick Medway Phillipslon Townsend Weymouth Boylston Holden Mendon Princeton Tyngsborough Wilmington Brookfield Hopedale Milford Royalston Upton Winchester DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Lakeville, MA 02347 Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Avon Duxbury Halifax New Bedford Rochester Wellfleet Phone: 508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax: 508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport TDD: 508-946-2795 Bourne Easton Harwich Norwell Scituate West Tisbury Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plympton Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 1 Winter Street Andover Chelsea Holbrook Methuen Randolph Walpole Boston, MA 02108 Arlington Cohasset Hull Middleton Reading Waltham Ashland Concord Ipswich Millis Revere Watertown Phone: 617-654-6500 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 617-556-1049 Belmont Dedham Lexington Nahant Rowley Wellesley TDD: 617-574-6868 Beverly Dover Lincoln Natick Salem Wenham Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherborn Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester -By -The -Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose Peabody Topsfeld wpaform8b.doc • DEP Addresses • rev. 8/29/07 Page 1 of 1 L9 IF } X ESSE SURVEY SERVICE OSBORN PALMER BRADFORD 8 WEED PLOT* PLAN OF LAND LOCATED IN /Y!JlZD�I i��i0vb�i1 , MASS. ngmeers - 1958 - 1986 1911 - 1970 1885 - 1972 1'5 5412ic - JGNNSGN S7IZEc'�" I hereby certify to the A(i�' Building.Inspector that I have " examined the premises.and the SCALE: / `�G buildings are located on the DATE; ground as shown, and buildings shown conformed to the dimensional zoning laws of ga�,N/x�!!L72, MA REFERENCE: BK 'PG when constructed. This Plan has been prepared for Building , CHRISTOPHER M'7 r permitting purposes only for the above party, and is not to be used for boundary measurements, HELLO land conveyancing or mortgage loan inspections or ,� ►�o. 31317 �o plot plans. Christopher R. Mell -f :yrµ 104 LOWELL STREET PEABODY, MASS. 01960 (978)531.8121 FAX: (978) 531-5920 NORTH TOWN OF NORTH ANDOVER F 1 ot.4", 'a OFFICE OF BUILDING DEPARTMENT a * 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER ;�A,�� �o�4�iJ�9L 9� qy T 3/5— 97 8- 6 /A/ '76419- Name 76419-Name Home Phone Work Phone PRESENT MAILING ADDRESS QGS c/a`,�,ysv.� SjnyFrr A o knz Aw d / eyT5 City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. / HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:!"=20' DATE. 7/21/98 Scott L. Giles R. P. L. S. Frank. S. Giles 50 Deer Meadow Road North Andover, Mass. THE ZONING DIST. IS R4. AN S w e!z/f I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BYLAWS OF NORTH ANDOVER WHEN BUILT OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. MP 911 707, 5'00/ � APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit # ADDRESS/LOCATION OF PROPERTY: 3G5 �Oht�So� 1�, A Parcel SUBDIVISION /VDV (Z - Lot Number DATE REQUESTED FILED/READY FOR INSPECTION J(_ C CLOSING DATE ON PROPERTY:,. AOe 1 C2 JOOG FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED CONSERVATION PLANNING0 DPW - WATER METER SEWER/WATER CONNECTION NOTE ROUTING Epu w/ /ate DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST Signature File: OC form revised 2006 O N a 0� N c - m Ln A c 3 c o w O m u Fu u a C E � a ` m 0 0 L - IM m �° c 'D c m E N ti aj C2 r Ln m O L Z O c o U g 0� O L in In H m W cl LU U) ce W LU 19 W 0 H � a �o Q Ilk �z �o w� a O N a 0� N c - m Ln A c 3 c o w O m u Fu u a C E � a ` m 0 0 L - IM m �° c 'D c m E N ti aj C2 r Ln m O L Z O c o U g 0� O L in In H m W cl LU U) ce W LU 19 W 0 Location2� 4 No. Date TOWN OF NORTH ANDOVER o F 9 Certificate of Occupancy $ E<� Building/Frame Permit Fee $ s�cMus � Foundation Permit Fee $ ��hs Other Permit Fee $ TOTAL $ Check # 12 7Y 75,G 9 q �} Building Inspector (/ L Eo ori9 APPLICATION TO CONST AUCT REPAIR. RF�TOVAT OR.. DEMOLISH A ONE ORTWO FAMILY.DWEI LING .00 'rf d, v, EMUm BUILDING PERMIT NUMBER: DATE ISSUED: 'SIGNATURE: CCS Buildin :Commissioner bfBWIdihgs Date z SETION - (� CTION 1- &ITB INFORLAii 1 I Property Address: 3b Johnson Street SECTION 2 -PROPERTY OWNERSY01AUTHORIM AGENT 1.2 Assessors Map acid Parcel (166 MP N=ba' Number=, j Paroel Number North AIIt3pvar 2.1 Owner of Record 1.3 ZaninglufonnaGm: Ri nnl A 'Fermi Zoriin District (ke 1 v ` IA. ProperttyDhnenslons: IatArm Frnnta fl 1.6 BIUDING SETBACICS ft Front Yard RWfired Provide Regi&ad, Side:Yard Provided Reu Yard Provided G . Signature Telephone I.S. Flood 7.omo lafa=ft: 1.g` 1.7Wswr SunlyM.GS.C.40. ser) zoo oubwhoodzoo ❑ muoicipat Public ❑ P&zli ❑ S--geDivoul Systecr. l OnSioD4 ml Syctom ❑ SECTION 2 -PROPERTY OWNERSY01AUTHORIM AGENT 2.1 Owner of Record 333 Johnson Street R.T./Eddngton Place R.T.' 231 Sutton S . Namo (Print) Address for Service: 978-683-3200 N -Andover Ma. G . Signature Telephone 2.2 Owner of Record:' Q Name Print Address for Service: 'Z m r Si Lure Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Consrrirctien Supervisor: Not Applicable 0 ' Stephen Maiuri CS 073482 0 i Licensed Construction Supervisor. 12 Meadowlark Farm Rd. Middleton, M 978-681-3200 Signature Telephone .n pop r 1:iceaseNumber . 3-2-06 Expiration Date 0 G 3.2 Registered home Improvement Contractor Not Applicable 0 m r r CompmyName Registration Number mdress z Expiration Date A OFF 3' Workers Compensation Insurance affidavit must be completed and subnntted w;tliis;applicstioa.: Failure to provide this affidavit will result iri the denial of tho issuance of thobWldin permit SignodaffidavitAttachoi Yes :..:: No ....... 0 SECTIONS Desai "tion of Pru sed walk efiecican able New Construction' IX X ' Existing Builn Repau(s) 0 Alterations(s) '0Addition -0 AccessoryBldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work:. ci_n T1 A fami 1V hpme to he hili 1 t SECTION 6 - ESTIMATED CONSTRUCTION COSTS •. Item Estimated Cost (D6W)to be " Completed pemt oplicant 1. Building (a) BuildingPeimitFee Multiplier 2 Electrical (b) Estimated Total Cost of ;Construction 3 Plumbing Building Permit fee (a)x.(6) S� 4. Mechanical AC 5 Fire Protection 6 Total 1+2+3+4 ZY 00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT. i, Joseph P e 1 i c h , as Owner/Authorized Agent of subject property Hereby.authorize Stephen Maiuri , to act on ' My behalf, in ail matters relative to work authorized by this building permit application. 1_2—A—n4 Si htreof.owner Date. SECTION 7b OWNERIAUTHORIZEDAGENI DECLARATION I, o s e p h Pelich as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate tothe best of my knowledge and belief Print N .. 12-9-04 Si pmatune 0 Own ent Date 140. OF STORIES 2 SIZE 63x54 BASEMENT ORSI AB Rastnrnpni- SIZE OF FLOOR TIMBERS. l 2' 3 SPAN D34ENSIONS OF -SUB . DWENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION 8r THICKNESS rr SIZE OF FOOTING 'r X MATERIAL, OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND Sond 15 RT M.T)TNG CONNECTED TO NATURAL GAS LINE x7-- — _- r FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** 3 n JoANSVPJ SAfexfi L -V - APPLICANT Stephen Joseph & Associates,LLC PHONE 978-683-3200 LOCATION: Assessor's Map Number / /� PARCEL SUBDIVISION STREET Johnson Street LOT (S) 4 ST. NUMBERe�� ************************************OFFICIAL USE ONLY*********************************** OF TOWIN A GENTS: COU ERVATION A MINISTRATOR DATE APPROVED DATE REJECTED ft COMMENTS X J \ L��Q11���`�hAt(U T-� OWN COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ /UBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT XRE DEPARTMENTN/ Pe✓ m jiX fed RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm FROM.: Fastern Land Survey FAX NO. 9785315920 Mar. 29 2004 03:06PM P2 LIJ L!j tail(i Surwyorf, fi Civil Fnqimeetsl, issf x F;o8vEY SERVICE 1958- 1986 '),.-;Q()HN PALMER 1911 - 1970 8 Wi 11) 1885 - 1972 11IB"i OF UYJd'E ATE?) IN, ZONE; J3 LOT .EA: m Z FRONT YARD: SIDE YARD: SCALE: DATE: REFERENCE: BK PG LOT FRONTAGE: REAR YARD: I hereby certify to the IY,- Buildin& L%spector that the pro - Posed construction shown conforms to the dimensional zoning of Mass. C-11rigtopher R. Me PLS 31317 104 I.OWELL. SI KL ET PEA500Y, MASS. 01960 I .6121 :L North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: 11) dation of Facility) ao dM M Si nature of Permit Applicant 12-9-04 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector /ce v� omvnw�uaea a�✓�iaasaciu�vei tir . BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 073482 Birthdate: 03102/1967 Expires: 03/02/2006 Tr. no: 24056 Restricted: 00 STEPHEN M MAIURI 12 MEADOWLARK FARM LN �j" MIDDLETON, MA 01949 Commissioner UtU-107e tl I, I mu) 10. d r mm\ rUVVLth INN. krhA) d (t5 C iM%-1 TLJ. L;LK i INUAL i t ur LIAbILI i Y M-UKANCE PRODUCER A c K Fowler Insurance Agency 200 Park Street North Reading, MA 01864 INSURED Edlington Place Realty Trust 383 Johnson Street Realty Trus P.O. Sox 583 N. Andover, MA 01845 COVERAGES YAIL Irn n,W l.Ir, rr r, 12/9/04 THIS CERTIFICATE IS ISSUEDASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THECERTIFICATE HOLD91. THIS CORTIFICATEDOES NOT AM END, EXTEND OR ALTER THE COVERAGE AFFORDW BY THE FOLI CIE BLOW. INSURERS AFFORDING COVERAGE NATO # _ INSURERk Western World insurance Co. INSURER B. ASM Mutual Insurance Conpany _ INSJRCR C: INSURER O: INSURER C•• THE POLICIES OF INSURANCE LISTL'O OCLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVC FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANC C AFFORDED BY THE POLICIES DESCRIBED HEREIN IS Slj"-CT TO ALL THE TERMS, E)CLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN81(%DO'Lr LTR NSR0 P POUCYNUMBER POrUCYEC:6ChV6 WAUNTINNnAm IRATON — ---'LIMITS — GENERAL UABILRY EACH OCCURRENCE S 1 D0_, O00 A x COMMERCIALC4NERALUANUTY NPP890039 6/23/04 6/23/05 — , �PRaAI'., S((Caamweenoe S 50 000 MED W (Anyone wow) _ S CLANAS MPD E 7 OCCUR PERSONAL L, ADV INJURY S 1.0001000 GCNCRALAGGRMATC S 2.000.000 GT -WL AGGREGATEUMITAPPUaPER: PRODUCTS •COMPIOPAGG S QQ POLICY I JF --1 LOC AUTOMOBILELIABILITY COMBINGDSWAEUMIT ANY AUTO = (Fa 2mm" Q BODILY INJURY ALI OVWFD AUTOS SCHEDULED AUTos (R' permr) = HIRED AUTOS BODILY INJURY S NON•OANED AUTOS (Per W'ddeaQ PROPERTY DAMAGE S —.... „_ (Per aluddeaq GARAOE LABILITY AUTO ONLY - F,AACCIDENT S E & ACC S OTHER THAN _ ANY AUTO AUTO ONLY: AGG $ EAICE397UMBRELLAUABLITY EACH OCCURRENCE Is AGGREGATE S OCCUR CLAMS MADE S _ s DECIUCTIBLE S RETENTION S WORK Bt S COMPENSAT ION ANO T A lu.ORY I WITS SR B EMROYERs'LIABILm ANY AWC7009355012004 7/23/04 7/23/05 ELEACHACCIDENT s 10_0,000 PROFRiETORIPARTNCRG(CC1ThG OFFICERI EMEIM IDE OC17? EL DISEASE- 154% EMPLOYEE I s 1001000 Ite�rrr deeallnalyder . -i- 9 51'EQALPROVISONSbebw ELDI9EASE•POUCYLIMIT S 500 000 OTHER O E$CRIPTIO N Of OPERATIONS# LOCATIONS I VDI CLOS f EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS Insurance verification CERTIFICATE HOLOM CANCELLATION SHOULD ANY OF THEABOVE D ESCRIWO POLICIESBE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE TNEREOF, THE ISKIINOINSURER WILL ENDEAVOR TOMAIL 10 _ DAISWRITTFN North Andover, Ma 01845 NOTIOMTHE CERTIFICATEHOLDERNAMED TOTHE LEFT, BUT FALURETODOSOSMALL I MPOSENO OBLOATION OR LIABILITY OF ANY KIND UPON THE INSURER ITSAGENTS OR Rm RAVES. I ACORD25 j20D1/08) - - L - -- -VACORD CORPORATION 19U Alec -OG 04 03:50p NORTH ANDOVER 9786889542 p.2 The Commonwealth of Massachusetts Department of Industrial Accidents 0lirce of lnvesfigadons Boston, Mass. 02111 Workers' Cwnpensakw Insurance Affidavit Name . Please Print Name: Location: City, Phone � I am a homeowner perforating all work myself. 0 I am a sole proprietor and have no one wworldng In any capaaty I am an employer providing worked cornpertsation for my employees working on this job. Address Q.� I �u�a� e Sic Ccs ,('u„ I l� Citv:_ to r -Oy �e R Phone *1 � � �O �?J 3 a OD . S S 01 a 004 Insurance Co. PoNcar 8 FdWre to mm overage as required under Section 2M or MOL 152 cm teed to"kMOSEon of aWnei penalft d.e Mve up to 51,5110 oo arrdror one years' hWinarv, -n wam-cmAmcamajol mftmsl, STOP.Wl3RKDRDER=dA.floa d.($IIIOAM aj yr aQaloetma. I understand thet a copy of this statement may be forwarded to the Office. of Invedgeff ne of the DIA for coverage veriNcatlon. otrlcial use only do not write In this area b be completed by city or town snider 3 x C)0 City or Town PermltlL�ensirxr ❑ Buft ting Dept C]Chedr X onmk Yoft reWme to rapkid 0 Ltenst Board p Seledman's Olfice Canted person: Phone M• O Health Department ❑ Other > > nnn De.,:ooA A t11 JM TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Telephone (978) 685-0950 Fax (978) 688-9573 DRIVEWAY PERMIT (Please Print) DATE: _aZ - ¢' STREET & NUMBER: ,-31, r CONTRACTOR: �' �4o r--,> ADDRESS: LOT NUMBER: 4 TEL: FAX: OWNER: TEL: ADDRESS: PROPOSED PLAN OF DRIVEWAY ATTACHED: PROPOSED SITE DISTANCE: DIG SAFE NUMBER: SITE INSPECTION IS REQUIRED BEFORE FINAL SURFACE IS INSTALLED AND A FINAL INSPECTION WILL BE MADE WITHIN 48 HOURS OF NOTIFICATION OF COMPLETION. INITIAL INSPECTION DATE: BY: FINAL INSPECTION DATE: BY: FAILURE TO COMPLY WITH THESE CONDITIONS OR TO OBTAINREQUIRED INSPECTIONS AND APPROVALS VOIDS THIS PERMIT. APPROVAL OF THIS PERMIT DOES NOT RELIEVE THE APPLICANT FROM MEETING ALL OF THE REQUIREMENTS FOR SAFETYAND DRAINAGE. A SEPARATE STREET OPENING PERMIT IS REQUIRED FOR WORK PERFORMED WITHIN THE STREET PAVEMENT. Attachments made a part of this permit: Form U & Driveway Application Requirements Sketch "A" Proposed Driveway Plan, dated 06-01-99 Sketch "B" Typical Dri y Detail, dat 06-01-99 ((JJ APPLICANT SIGNATURE: � DATE: �Z•1'61�, DIVISION OF PUBLIC WO SIGNATURE: DATE: 1'Z 141-04 l4Orm U h Driveway Applications Rev 6-7-01 TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845-2909 J. WILLIAM HMURCIAK, DIRECTOR, P.E. Timothy J. Willett t µORTq , Telephone (978) 685-0950 Water Superintendent 3?•�`���. °o� Fax (978) 688-9573 40 AUTOMATIC LAWN IRRIGATION SYSTEM PERMIT �a DATE — 4— (;)4 RECEIPT NO. I 2,_'& HOMEOWNER LOCATION ,--77 INSTALLER i L PHONE PHONE Note: The Installer shall verify that there is sufficient water pressure for the new irrigation system prior to the start of any work. General Requirements — I. Bypass Meter Set-up - A plumber shall set up a horizontal space for the bypass meter. The bypass meter shall be located before the house meter. Deduct meters are not allowed except for those homes with water booster pumps. Ball valves should be installed on both sides of the meter. II. Rain Sensor — A Rain Sensor shall be installed on all new irrigation systems. III. Backflow Preventor — The proper backflow preventor shall be installed. The backflow preventor shall be tested annually by the DPW, and the homeowner shall be billed for the test. Fill out the attached Design Data Sheet and submit to Dennis Bedrosian at the Water Treatment Plant, 420 Great Pond Road, for approval. IV. Sprinkler Head Location — All sprinkler heads and piping must be installed entirely on the homeowner's property. Sprinkler heads will not be allowed in the Town's Right -of -Way (R.O.W.), which is typically ten to fourteen feet back from the edge of roadway pavement. V. Bypass Meter Installation and Town Inspection After all work has been completed, call the DPW for bypass meter installation. The meter installer will use this Permit to inspect for proper meter set-up, rain sensor, backflow preventor, and sprinkler head location. This Permit must be present at the location for the bypass meter when the Town's meter installer arrives at the property. Bypass Meter Rain Sensor Backflow Preventor Sprinkler Heads Date Initials 1995 APPLICATION FOR SEWER SERVICE CONNECTION Q -c )3% North Andover, Mass. L Application by the undersigned is hereby made to connect with the town sewer main in Street, subject to the rules and regulations of the Division of Public Works. �--7 The premises are known as No. _ or subdivision lot no. � J Owner Contractor Street � r �V So Address Addres '>("' 0"I"i . � . Appi i7l, s Sig ture PERMIT TO CONNECT WITH The Division of Public Works hereby grants permission to ��- to make a connection with the sewer main at subject to the rules and regulations of the Division of Public Works.. Inspected by Date R MAIN Street Division of P' lic rks By L4� See back for rules and regulations 11361 APPLICATION FOR WATER SERVICE CONNECTION �G L �6y North Andover, Mass. Application by the undersigned is hereby made to connect with the town water main in l � Street, subject to the rules and regulations of the Division of Public Works. � � \ � � K ���'�� The premises are known as No. Street or subdivision lot Owner Contractor (---1 0 - r � '2C%.- I i " �' r "�'5 : Address --'J W1 Vi PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main at �1f';* Street subject to the rules and regulations of the Division of Public Works. Inspected by Date Boar of Public Works By See back for rules and regulations kt-vka 1�CS11/xlG JoaSolv S7YlE�r SCALE: DATE: (;'C REFERENCE: BK 'PG This Plan has been prepared for Building permitting purposes only for the above party, and is not to be used for boundary measurements, land conveyancing or mortgage loan inspections or plot plans. 104 LOWELL STREET PEABODY, MASS. 01960 (978)531.8121 FAX: (978) 531-5920 I hereby certify to the 16.6h` Building Inspector that I have examined the premises. and the buildings are located on the ground as shown, and buildings shown conformed to the dimensional zoning laws of 9-o101X&bt!L-V , MA when constructed..,; CHRISTOPHER i1s�a R. -' MELL0 Wo. 31317 n j I .' Pr07 ofes'slonal Land Surveyors £t Civil Engineers ESSEX SURVEY SERVICE 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD & WEED 1885 - 1972 PLOT'PLAN OF LAND LOCATED IN , MASS. IYD96 l'ka& kt-vka 1�CS11/xlG JoaSolv S7YlE�r SCALE: DATE: (;'C REFERENCE: BK 'PG This Plan has been prepared for Building permitting purposes only for the above party, and is not to be used for boundary measurements, land conveyancing or mortgage loan inspections or plot plans. 104 LOWELL STREET PEABODY, MASS. 01960 (978)531.8121 FAX: (978) 531-5920 I hereby certify to the 16.6h` Building Inspector that I have examined the premises. and the buildings are located on the ground as shown, and buildings shown conformed to the dimensional zoning laws of 9-o101X&bt!L-V , MA when constructed..,; CHRISTOPHER i1s�a R. -' MELL0 Wo. 31317 n MAscheck COMPLIANCE RBPORT Maseachuaetts Energy Codd Permit # MAScheck Software Version 2.01 Checked by/Date CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 11-19-2003 DATE OF PLANS: 10-31-03 TITLE: The Eddington PROJECT INFORMATION: Lot 4 Johnson Street North Andover Ma COMPANY INFORMATION: Cyrus Construction Co. COMPLIANCE: PASSES Required UA ■ 600 Your Homo - 525 Area or Cavity Cont. Glazing/Door Perimeter R -Value R -Value U-Valuo UA ------------------------------------^ CEILINGS 1775 30.0 0.0 63 wALLs: Wood Frame, 16" O.C. 2878 15.0 0.0 221 GLAZING; Windows or Doors 294 0.340 1.06 GLAZING: Windows or Doors 31 0.320 10 GLAZING: windows or Doors 46 0.300 14 GLAZING: Windows or Doors 40 0.360 14 37 0.280 10 DOORS FLOORS: Over tinconditioned Space 1950 19.0 0.0 93 HVAC EQUIPMENT: Furnace, 85.0 AFUE ---- -------- ---- ---•--- --- - --^ COMPLIANCE STATEMENT: The proposed building design described here is coneistent with the building plans, specifications, grid other calculations eulitdl-,tea with the Th^ pYopo"d bui.ldinq has been designed to meet the requirements of the Naasac2husett8 Energy Cede - The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than the load as specified in Sections 780CMR 1310 and 6/ 4 Builder/Designer Date L .01 MAScheck INSPECTION CpfEcnisT Massachusetts Energy Code MAScbeck,Software version 2.01 The P.ddingtcn DATE! 1119-2003 Bldg. Dept. Use CEILINGS: 1. R-30 Comments/Loc0iQ11 WALLS: 1. woad Frame, 16" Q.C., R-15 Cocmente/Location wINDMS AND GIA -59 DOORS: 1. U -value: 0.34 For windows without labeled U -valuta, describe feature6: # Panes Frame Type_ Thermal Break? (1 Yes Comments/Location 2. U -value: 0.32 For windows without labeled U -values, describe features: # Panes_ Frame Type_____!_.. Thermal Break? ( 3 Yes { ] No Comments/Location 3. U -value: 0.3 For windows without labeled ii -values, describe features: # Panes,.,__ Frame Type Thermal Break? [ I Yes [ ] No Coanttents/Location 4. U -value: 0.36 For windows without labeled U -values, describe features: Yes No #Panes Frame Type,._ Thermal Break? I Comments/Location XORS: 1• U -value: 0.28 Comments/Location FLOORS: 1. Over Unconditioned Space, R-19 Comments/Location XVAC EQUIPMENTS 1. Furnace, SS.o AFUE or higher Make and Model Number AIR LRAKAGE: Joints, penetrations, and all other such openings in the building envelope that arc sources of air leakage must be sealed. when installed in the building envelope, recessed lighting fiXtUre9 shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recesaed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned apace. I 2, Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfm (0.944 L/s) air movement frac the the conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 pA or 1.57 lbs/ft2 preeaure difference and shall be labeled. VAPOR RETARDER: Required on the warm -in -winter side of all nos -vented framed ceilings, walls, and floors. MATERIALS IDENTIFICATION: Materials and equipment must be identified so that romPliance can be determined. Manufacturer manuals for all installed heating be and cooling equipment and service water beating equipment provided. Insulation R -values, glazing U -values, and beating equipment efficiency must be clearly marked on the building plans or specifications. DUCT INSULATION : Ducts shall be insulated per Table J4.4.1.1. DU= COCtSTRUCTION: All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavitite/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. The HVAC system must provide a means for balancing air and water systems. TEMPMATURE CONTROLS: T'hermostate are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING; Rated output capacity of the heating/cooling system is not greater than 1253 of the design load as specified in Sections 780CMR 1310 and J4.4. J swiloaliG POOLS, j All heated swimming pools must have an on/off heater switch and require a carver unless over 20$ of the heating energy is from non-depletable sources, pool pumps require a time clock. [ ] j HVAC PIPING INSULATION: HVAC piping conveying fluids above 120 F or Chilled fluids below 5S r must be insulated to the following levels (fa.)-' PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-441 Low pressure/temp. 201-250 1.0 l.S 1.$ 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 I Steam condensate any 1.0 1.0 1.5 2.0 COOLING SYSTEMS: 40-55 0.5 0.5 0.75 1.0 Chilled water or refrigerant below 40 1.5 [ j CIRCULATING NOT NATER SYSTEMS t levels hot to the following Lin.): jamiate circulating water pipe® PIPE SIZES (in-) NON-CIRCULATING CIRCULATING MAINS & RUNOUTS MTED MATER TEMP (F): RUNOUTS 0-1" 0-1.25° 1.S-2.0" 170-280 0.5 1.0 1.5 2.0+° 140-160 0.5 0.5 100-130 0.5 ` 0.5 ----NOTES TO FIELD (Building Department Use Only) ------------------------- I'7 TOTAL P.05 O o m C ,L O a a C.i a V O LZ y O O 0coo .M z cn cn .,�. r io r m C ,L O C.i V O LZ y O O .M = m= O L C � o C m o oc CIS E C po is 19 OF ELI ca E Go=go h: • 4_m4 L ��' R -0 y Amo . CLU m cm : ? C4 a '� 1r1 a L Go- v .1-:2 Z O M O O i a Of = O � IDL ��o o COD LJJ o� O L_ •y O 14 W dL C r .y �E n Z O v m, c a � Cl H� Q N m z 0 w a U) P -A �I i 0 ts a) O. CO2 C O CM C O C M� �M�y� W W Location No. Date TOWN OF NORTH ANDOVER f • 0 9 t Certificate of Occupancy $ _ Building/Frame Permit Fee $ Id Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 7/1: Check # 10739 L" Building Inspector nl W am 0 v o. Cm Q m c o ca CO CD MN �• � c O o m 0 0 fti cmc E N R ` Ajj*4jjb oago� 4D.3 : m �: A �40 N c g w 2cm 1: = a0� pC o c cm a cc 40; �v •N Z O t5 ar- x m m o noii CL— ~ 8 N oS~ z COD W co �w+•bt .. c *- � •N dZ A C Z V •m V O •c 0 C* as o� 0v CD CL 90 N _kI y O h E O L O C O V ev o. CIO 0 0 'o. y C V cl N ul ce W LLI V9 W N a� \ U) " x � 0 G w° 0 v U Cd w x a�' w x � pG w a a�' coC w M ° � cn o cn W am 0 v o. Cm Q m c o ca CO CD MN �• � c O o m 0 0 fti cmc E N R ` Ajj*4jjb oago� 4D.3 : m �: A �40 N c g w 2cm 1: = a0� pC o c cm a cc 40; �v •N Z O t5 ar- x m m o noii CL— ~ 8 N oS~ z COD W co �w+•bt .. c *- � •N dZ A C Z V •m V O •c 0 C* as o� 0v CD CL 90 N _kI y O h E O L O C O V ev o. CIO 0 0 'o. y C V cl N ul ce W LLI V9 W N ss,uMM CERTIFICATE OF US OCY TOWN OF NORTH ANDOVER Building Permit Number 416 (12/15/2006) Date: June 15, 2006 THIS CERTIFIES THAT THE BUILDING LOCATED ON 365 Johnson Street MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: 383 Johnson Street RealtTrust P.O. 583 North Andover Ma 01845 /�51� - , q,.n, Building nspector 6 rs W to OE� O VJ 0 0 f) sc Cc a C=j 1=0 OC 6 40 U u w" cx'ca iii 110 w0 V) V) — O VJ 0 0 sc Cc a C=j 1=0 OC CL *Ali E 16. 3 c 00 0 ts cm -fti .mm_c 0Ma CC ca (r 00 M 4.0 * : - M. fA .gym o CDCD CLCO3 .6: A =ID 15: 3::S "o 0 CD zr ca ca 0 00 to cp S C" .0- 0 SCL— Go COO LAJ =0 =0 =20 -e • fS&= !.s ZO u M 00 (A cm CS L3 COD ca 006 44 M 0 A Q CL..- Cc O Date. TM T - OPNORTH ANDOVER • � • PERMIT FOR GAS INSTALLATION s This certifies that ../17 #'1. ... R .l1ti.* .S........ • • • • • . . has permission for gas installation ... . (,:k:. t'& ... • . in the buildings of ... S -f. t ................... at 3 .... %I r :: A ............. . North Andover, Mass. Fee h ? -' .. Lic. No.2..�- 1 "GAS INSPECTOR Check # L/ t 537_. MASSACHUSMS UNIFORM APPUCATON FOR PERMIT TO DO GAS FPMNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS , 1 Building Locations 3 "' /';ZI'IV , Permit # 4 s, Amount $ -) Owner's Name�v„v S New Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) ,� / C one: Certificate Installing Company Name kd o e cv I ` -t e-3 C7 Corp. Address .L t� t 2 S —Drtr' u (� ( e- N.� �❑ Partner Business Tel 777- —77-7— �( Firm Co. Name of Licensed Plumber or Gas Fitter lease Indic a type coverage by checking the appropriate box. ,,.you have c ec a Y_, p 1:1Liability insurance policy INSURANCE COVERAGE • Check one: I have a current liability Insurance policy or it' ubstantial equivalent. Yes ❑ No❑ h k d es Other type of indemnity 1:3 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t hereby certify that all of the aetaus ana mrormanon ► nave suvuuucu ku► cuwicu� III avvvc aFFIMCIuvu aw { best of my knowledge and that all plumbing work and installations Pe#brmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St/ a Codn Chapter 142 of the General Laws. gnature of Licensed Plumber Or Gas Fitter Plumber T3 7C tie ty/Town ❑ Gas Fitter (cense Numb7 Master PPROVED (OFFICE USE ONLY) � Journeyman MEN IN �SEENNE ■■■■i■■ ■��i■■�■■■■■�■�i��ii■■moi■■■■■�i■�i■■ .. ' (Print or type) ,� / C one: Certificate Installing Company Name kd o e cv I ` -t e-3 C7 Corp. Address .L t� t 2 S —Drtr' u (� ( e- N.� �❑ Partner Business Tel 777- —77-7— �( Firm Co. Name of Licensed Plumber or Gas Fitter lease Indic a type coverage by checking the appropriate box. ,,.you have c ec a Y_, p 1:1Liability insurance policy INSURANCE COVERAGE • Check one: I have a current liability Insurance policy or it' ubstantial equivalent. Yes ❑ No❑ h k d es Other type of indemnity 1:3 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t hereby certify that all of the aetaus ana mrormanon ► nave suvuuucu ku► cuwicu� III avvvc aFFIMCIuvu aw { best of my knowledge and that all plumbing work and installations Pe#brmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St/ a Codn Chapter 142 of the General Laws. gnature of Licensed Plumber Or Gas Fitter Plumber T3 7C tie ty/Town ❑ Gas Fitter (cense Numb7 Master PPROVED (OFFICE USE ONLY) � Journeyman Date .� f• •' TOWN OF NORTH ANDOVER ° : A PERMIT FOR PLUMBING 'Ss4cmus This certifies that ... . ! �. . ?. • • ......................... • • • has permission to perform ... �` t. `' .. ?. �." ./ / • • • • ...... • • • • • plumbing inthe buildings of ....CJc.Y^':.•4•�•••••••••••• .�..'. V^ ................ . North Andover, Mass. r' Fee A. 7 V Lic. No........L ........ 'PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location, Owners Name t� S.Sd Permit Amount Type of Occupancy New Renovation Replacement 1:1 Plans Submitted Yes ❑ No ❑ (Print or type) G / / Check one: Certificate Installing Company Name_141\1 71 (' Py'r'es 1� (7 ❑ Corp. Address 2 4 -p( M'C .� f �(Nv� (C. /��ii, E� .3 �� �� ❑ Partner. Business Telephone Name of Licensed Plumber: Insurance Coverage: Indicate the type of ' smattce coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent 13 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 Dakmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett ; Wa�-Pl �r�d C han+Pt i d� „+ rha — ranneral Laws. / T Title 7ype of Plumbing License City/Town icense um er Master0— Journeyman ❑ APPROVED (OFFICE USE ONLY 1' • J .J i il ....................WMMWWWNMMNMMMMMMMMMMMMW . -... #s' E.NM..M ................... '., �;., miiiiiiiiiiiaiiii MMMMMMM WMMMM®WMNMWM■MMMWiiiiiiii W11 1100 -11's MMMMMMMMWWMWWMMMMMMMMMMM� . i 11_' MOMMMMMMMOOMMMMMMMMMMMMMM Wil-11IFT-11's MMMWMMMMMM0MNNMMMMMMMMMMM W.11 -1181 -1 -ca MWMMWWMMMWMNWWWMMMWMMMMMM (Print or type) G / / Check one: Certificate Installing Company Name_141\1 71 (' Py'r'es 1� (7 ❑ Corp. Address 2 4 -p( M'C .� f �(Nv� (C. /��ii, E� .3 �� �� ❑ Partner. Business Telephone Name of Licensed Plumber: Insurance Coverage: Indicate the type of ' smattce coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent 13 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 Dakmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett ; Wa�-Pl �r�d C han+Pt i d� „+ rha — ranneral Laws. / T Title 7ype of Plumbing License City/Town icense um er Master0— Journeyman ❑ APPROVED (OFFICE USE ONLY 191 qq Date....c ............................ p NORTH °f,"`° '•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that S/;I.lt 6........� has permission to perform �El�J 1't'�.f>.1.�K� ............................. ................. .......... wiring in the building of ....!!..�✓ S ��/ / • at ........34 7.... .............. . North Andover, Mass. F, ee+? ?3r Lic. No. .1QQI MW .......� R �`���J�... ...,. ............ ELECTRICAL I ._ ECCO Check #��D f i� ..1.1sPar>faesatl a� � ,�ieedea3 Permit ltnnrbrrs; • BOARD OF FIRE PREVENTION REGULATIONS Occupancy b w. APPICA O t�FOR PERM TO PERFORM ELECT CAL WORK (ALL WORK'rr:) IM FUMMM WrM TIM MASSACBUSECTS IISMUCAL CODE M Cie 12.00) PLEASE PRINT IN INK OR TYPE ALL INFORMATION DaLe: 2 - % - l% & !y City or Town of: _ °,, ��d a /? 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)__ 6 5 L�h Owner or Owner's vJ Is this permit in conjunction with a Building Permit? Yes No o (Check Appropriate Box) �T 4 .- 00— Purpose of Building: i?TZ No. of Gil.-Suap. (Paddle) Fens Utility Authorization # 26/ - 3 3 No. of Hot Tubs Generators KVA No. of LVhting Fortures Existing Service: Amps / volts Overhead 0 Underground. C. # of Meters New Service: ZGU Amps / Z i y Volta Overhead D Undergmund.o---' # of Meters: Number of f=eeders and Ampacity: Location and Nature of Proposed Electrical Waris: ?'✓' /f/� 1,4, c, -_r -e No. of Recessed Fixtunas No. of Gil.-Suap. (Paddle) Fens No, of Transformers Total KVA No. Of Lighting Owdets No. of Hot Tubs Generators KVA No. of LVhting Fortures Swimming Pod: Above ground a In Ground o # of Emergency U'gW&V Battery Units No. of RsceotacW Outlets No. of OII Burners Fire Alarms # of Zones # of Detection & Infti MV Devices # of Sourcing Devices: # of Self Contained Detamonf5ourtdMtg Devirxs Local a Municipal Connection o Omer a No, of Switches No. of Gas Burners No. of Ranges No. of Air Conditioners TOTAL TONS: No. of wase Disposals Heat Pump Totals: Mmber: 'TONS: KW: NpDevicas or Eouivataht No, of Dishwashers Space /Area Heating: KW Data Winng, No. of Devices or Equivalent; No. of Dry" R . Heeling Appliances KW Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW No. of Signs-.____-* of Balissts: OTHER; # of Hydro Massage Tubs No. of Mftm Total HP 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 'compWadopwation' coverage or its subatwidai egrtivelen tris'undersigned car9fea 00 such coverage is in force, and has exhibited prod of same to the Perm issuing office. CHECK ONE INSURANCE � O OTHER >a Pimme specify: Estimated Value of Eledricai Work S (Wien required by municipal policy) Work to Start 2 — ,,-y tm Inspections to be requested in accordance with MEC Rule 10, and upon corroletior. I certify, under the pains and panalit" of perjury, that the information on fh/a application is We and complKa q Firm Narne: A 4 'zLIC./ 33 Licensee: a�-. �s r s /' Signature LIC. #. /-Y,- / % 3 3, Tel- # (fl 4 7 Tel. # OWNSWI1 INauRANGE WAIVIR, I em aware that the Waanm* dove not have Re MWIhy inUffice coverage normally required by taw. By my signature netow, i mieoq weave thN roouifemen6 I am fbe (trach ono) owner a oR Agent a til nnttrrrr of OwneN # Agent Telephone A !!'RiKIT *6E: S _, t'�r(Rev. t tJ89} spar>Jwtnf a� „7`ira �ervica! tttittttnber: pancy & Fee BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (AU WORK To aE IrIMMOM WCIH THE MASSACHLRO TS II ECfRICAL CODE =7 cl at 12.-M PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: 2 _ % - C2 L — City or Town of;/—�, �,,/IOv , , 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) > Owner or Tenant'. ' r v' 1 °v rt i Owners Address: y ✓� l% Jr /Sr'.Y /f/• ����/� Is this permit in conjunction with a Building Permit? Yes No o (Check Appropriate Box) Purpose of Building: S / j �� s 1 =i ✓�" Utility Authorization C4 — —� Emsting Service: Amps / Volts Overhead 0 Underground. M # of Meters New Service: Zy!/ Amps/ 2 / ? t- Volts Overhead 0 Underground.4/� # of Meters Imber of Feeders and Ampacity: "cation and Nature of Proposed Electrical Work:- 4o. ork:_ 4o. of Recessed Fixtures No. of G8.-Susp. (Paddle) Fans No, of Transformers Total )CIA No. Of Ughting Outleta No. of Hot Tubs Generators KVA I No. of Ugnting Fixtures Swimming Pool: Above ground 0 in Ground a # of Emergency U9htlin9 Battery Units o. of Receptacle Outlets No. of OD Burners Fire Alarms # of Zones # of Detection & initiating Davie" # of Sounding Devices: # of salt Contained Deteawsounding Devices Local 0 Municipal Connection a Cine, c fNo. of Switches No. of Gas Burners I No. of Ranges No. of Air Conditioners TOTAL TONS: tit No. of Waste Dismanis Haat Pomp Totals: Ntmnber TONS: Kw: _ Security Systems: No. of Devices or Equivalent No. of Dishwashers Space /Area Heating: KW Data Wrong, No. of Devices or Equivalent No. of Dryers Heating Appliances KW Telecommunications Wiring: No of Devices or Equivalent No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydro Massage Tubs No. of Motors Total HP INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insuance including 'completed operation' coverage or Its substantW aquiver ifie -undersigned certKiaa ttW such coverage is in force, and has exhibited proof of same :o rte pem: msumg office. CHECK ONE INSURANCE fig BOND t7 OTHER ❑ Please spetxty: I Estimated Value of Electrical Work S (When required by municipal policy) Wo'k `o Start: V 7 Inspections to be requested in accoroance with MEC Rule 50, and upon corrc:ebor / certify, under the pains and penalties of perjury, that the information on this application is true and compists. Firm Nam�. �-r R r �, / LIC..1 /4 Name: 3 Ucensee:_�= �i. r + L % Signature �' ,v/ (ff applicable, an r "axe f" !n ti» rice e n m r line) UC. # /� S ( //' " (, Address:�J' / l j i iL L Bda. Tel �� Tet. Al QYa1`16R'S INBURANGE WAIViR: I am aware that the leaner dmw not have the liability wawa thea feoulrement, I am the (cheek one) owner o OR Agent 0 Signature of Owner/Agent: Toisahone 0 ooverape normally recurred by taw. By my signature Deiow, i nerecy r,.p Dk 3 — /6 —'en 4. P/-� 6 A� Phone: 978-342-2660 JAMES A. TRUDEAU Adjustment Service Inc. P. O. Box 942 Fitchburg, MA 01420 Fax: 978-342-2699 James A. Trudeau Thomas Murphy Joshua M. Trudeau Fitchburg, Mass. Greenfield, Mass. Templeton, Mass. Notice of Casualty Loss of Buildinp- Under Massachusetts General Laws, Chapter 139, Section 3B September 20, 2006 Building Inspector 400 Osgood Street North Andover, NIA 01845 Board of Health 400 Osgood Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Susan Bournival and Lawrence Buote Loss Location: 365 Johnson St., North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100753200 Date of Loss: September 17, 2006 File Number: 06-05225 Claim Number: 06013625 Type of Loss: Water Damage 2006 r: 3 Flt Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1.000.00 or cause "Mass Gen Laws Cha -ter 143, Section 6" to be applicable. If any notice under "Mass Gen Laws Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, YYlC,3 /u UA,� FP) homas Murphy Claims Adjuster Phone: 978-342-2660 Fax: 978-342-2699 JAMES A. TRUDEAU Adjustment Service Inc. SEP 2 1 2006 P. O. Box 942 Fitchburg, MA 01420 rl CF H�HL7N DEPF�RT7�EN � James A. Trudeau . Thomas Murphy , Joshua M..Trudeau . Fitchburg, Mass. 'Greenneld, Mass. Templeton, Mass. Notice of Casual Loss.of Building g Under Massachusetts General Laws 'Chapter 1-39 Section 3B P September 20, 2006 Building Inspector 400 Osgood Street North Andover, MA 01.845 Board of Health 400 Osgood Street North Andover, MA 01845 Fire Department Dept. of Records 1.2-4 MainStreet North- Andover, MA 01845 Insured: Susan Bournival and Lawrence. Buote Loss Location: 365 Johnson St., North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co.. Policy No.: PHOO100753200 Date of Loss: September 17, 2006 !File Number: 06-05225 Claim Number: 06013625 Type ofLoss: "Water Damage: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause. "Mass:. Gena Laws, Chafer 143, Section 6" to be applicable. .If..any notice under "Mass. Gen. Laws,.Chapter 139, Section. 3B" is appropriate; please direct it to the writer and include a reference to the captioned insured,, location, policy�number, date of loss; and file or claim number. On this date, I cause copies of this notice'to be sent. to the person(s). named above at the address indicated by first class" mail. S'ncerely, M I��'n.c S � i homas Murphy Claims Adjuster Date.... 7.? /�................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that/�Z`-! /gE(b..............��..1.IC has permission for gas installation-7�- .......................... in the buildings of ......... �U./1.�c,................................................. � st se /,P4/ ......................... at ........&.1.. . V..5 .....^..,5 .. ........................................ North Andover, Mass. Fee.,-.v�O.'v..... Lic. No./3514....... .................................................................. GAS INSPECTOR Check # /off - rt: �0 I .1 ��r S. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (� CITY ido, A1)dw-e MA DATE 4S 7 PERMIT# "I JOBSITE ADDRESS �i i'�n 36� �* OWNER'S NAME GOWNER ADDRESS sAAl TE3 ZIP1, FAX J TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: [Q RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER T:::i -:j _ [1 E:Ewz( 1. L::j _ ._ BOOSTER CONVERSION BURNER , _. _zl _ s-1 _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS i MAKEUP AIR UNIT OVEN( - POOL HEATER _( ROOM / SPACE HEATER ROOF TOP UNIT _ I TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - .. .._.............. .. ..NJ 11 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES4�NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Ej AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com liapcpAvith I Pe ' lent pr vision of the Massachusetts State Plumbing Code Chapter 142 the General Laws. and of PLUMBER-GASFITTER NAME LICENSE # 3SY� SIGNATURE MP ®.I MGF 0 JP 0 JGF Q LPGI E1 CORPORATION ©# PARTNERSHIP 0#= _- p LLC F# COMPANY NAME: ADDRESS CITY _ _ _ ( STATE ZIP FAX I - al CELL EMAIL U1 N S o rl z N ❑ H W a ui w LL The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 UT www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print UAW NaT110 (Business/Organization/lndividual):/�1,✓'% 45 �.4e Address: % �/D 104 OP City/State/Zip: ee4 j' 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- r_Vship listed on the attached sheet. 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 3111 am a homeowner doing all work right of exemption per MGL mvePlf Mn wnrkarc' rmmn c. 152, § 1(4), and we have no insurance required.] f comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 13.❑ Other. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Phone #: that the information provided rug andcorrect. n.gte. / f7/ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint. enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) 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' censation insuranra Tf an T T f' nr T T p .a.,gs aav@ employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confmriation 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 he. 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 omxonwealth oassachvsetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 Tel, # 617-727-4900 oxt 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 vvwWanass,govaa .4� kvl.,::%OvlvlmvlmVVr-ALI rl Vl- MA SAE HUSF_TTS BOARD OF PLUMBERS ANb GA S FJTT-t*�A:§i��! ISSUES THE FOLLOWING "LICENSE, .-.i-t,T-..CENSEO AS V:::MASTER �P L UL MBE GLENN M m c CARE I POOR :ARM ROAD .".:DERRY: NH 03038 3 rl rl a A