Loading...
HomeMy WebLinkAboutMiscellaneous - 38 FARNUM STREET 4/30/2018 (2)N O O J �Y 0 0 0 0 0 966; -- r Date../ ...... .... l/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... has permission to perform /i/ -`c C. e.s s . - wiring in the building of ....... X-9...... ................................... r 3 �' /'-4 / n 4 S ............ . North/IftIdover a` Fee,:.. e y... Lic. No .............. ,,/C ............ ..- .. :.................... ELECTRIC NSPECTOR Check # �� 921-1— 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the -provisions of M.G.L. c.143, §. 3L, the -Ikknlit application form to provide notice of installation of wiring shall be uniform throughoutthe Commonwealth, and applications shall be filed' on the prescribed form. After a permit application has been accepted by an inspector of Wires appointed pursuant to M. RL c. 166, § 32, an electrical permit shall he issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shalL.be limited as to the time of ongoing construction. activity, and maybe deemed_bythednspector_of-Wires abandoned.and.invaliddfhe—. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity sated on the, permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Se7ctions.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job;growth and Iong-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certaispermits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any pemmit or approval that was m effect or existence' during the qualifying period beginning on August 15, 2008 -and extending'tbrough August 15, 2012. 8 — Permit/Date Closed: (2 Dote: iteapply for new perm' ❑ Permit Extension Act —Permit/Date Closed: � Department of lire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) ]Date: 9—)-7 ` / 0 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersi ed gives notice of his or her intention to perform the electrical work described below. Location (Street &ber) ti►y. Owner or Tenant7cAuj Telephone No. Owner's Address Is this permit in counction with a building permit? Yes Q—No ❑ (Check Appropriate Box) Purpose of Building lb i}=� Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,, ., i � A Completion of the f owing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Sus Fans No. of Total p (Paddle) Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. of Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW Local ❑ ""'n ctio [_1 Other P g Connection No. of Dryers Heating Appliances KW Security of System : or Equivalent No. of Water No. of -No. of Data Wiring: '° Heaters KW Signs Ballasts No. of Devices or Equivalent r No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications 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 NEC 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 pains and penalties f perjur that the information on this application is true anti con:ptete`. / FIRM NAME: C� 1WA X P a LIC. NO.: la 6 Licensee: C: 11�Q_/qyt, Signature LIC. NO.: t� (If applicable, enter "exen in the license nz ber h e.) Bus. Tel. No.: 6 ` Address:lC/�l e, ,dZ - ;�� Alt. Tel. No.: *Per M.G.1�7, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE. $ Signature Telephone No. Date..I.I. ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . dP4This certifies that .... e ...... ealri-n ............................... has permission for gas installation .....&.A ........I... .. ......... ...... in the buildings of ......... S . . .......................................... atT ........... 0.14 .JDY 4 .....t.'......... 120..�k.. �.., North Andover, Mass. Fee. - ...Q.. Lic. No.......... .....2(070 ............ ...................... ............................................. i GAS INSPECTOR Check 13 LO fFyz4-f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ciJtG' MA DATEl-_ 7 -) _J1 PERMIT # JOBSITE ADDRESS A2 U Aq i� - _.OWNER'S NAME GOWNER ADDRESS^ S l"` TE TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL [_-Jj EDUCATIONAL D] RESIDENTIAL CLEARLY NEW: a RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES El NO P9 APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER- BOOSTER CONVERSION BURNER COOK STOVE _ C-,1 --�-� . T- _I _.__ _ _ z r•-J DIRECT VENT HEATER DRYER.. FIREPLACE FRYOLATOR- FURNACE GENERATOR_>:>:� GRILLE INFRARED HEATER _.- - -_ r—. �I - _J [_-=✓ ,_._.� [_' 1 -- I ._.._ _ - =1 LABORATORY COCKS MAKEUP AIR UNIT_. OVEN POOL HEATER =--=1- ,.--. _ ROOM/ SPACE HEATER - - - - _ -- .. .� ( — ROQ; TOP UNIT .. TEST �J ( .a l� --I --� - ! _ _._ = I , J —AL— UNITf-IEATER _ UNVENTED ROOM HEATER WATER HEATER.. .._..,_AJ OTHER �_ �� EV _........... ... .................... .... ...... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO [( I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E3 OTHER TYPE INDEMNITY © BOND Ell 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. - % v. �✓�� CHECK ONE ONLY: OWNEk4ZAGENT ,(,. 1 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 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 complianceith all Perti t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _�c � ?�LAN�_ _ LICENSE# F I ii z-d SIGN, TURE MP �4 MGFi JP JGF 0 LPGI © CORPORATION ©# PARTNERSHIP ©# LLC [j# COMPANY NAME: ADDRESS I_ _ -� 1�C CITY STATE ZIP TELX3- FAX CELL ! --- LJ .1 MAIL _�w�L� - -- - - - -� 13 LO fFyz4-f O z z 0 F U W a o o a z Oz �❑ W >- o °z a W On Cl)a a W a Cl) CL LU O u w U a o a a a U J a ' a � = w F- LL F O F U W a U t�7 l ry The Commonwealth of Massachusetts ` Department of 1'ndustriglAccMiks Office of Invesfigations 600 Washington Sheet Boston, NIA. 02111 www.mass gov1d1a Workers' Compensation Insurance Affidavit: Buildere/Cont°actors/Electriclans/Pliimber.s A licant Information Please Print Le 'bl Name (Business/Organizaiionfindividual): Address: City/State/Zip: Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 4. ❑ I am a general contractor and I 6. E] New construction. employees (full and/or patt time) * have lifted the sub -contractors 2.K I am a sole proprietor or partner listed on the attached sheet t 7• ❑ Remodeling ship and'have no -employees These sub -contractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised.their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. [I Plumbing repairs or additions myself. [No workers' comp. c.152, §10), and wehave no 1211 Roofrepairs insurancerequired.] i employees. [No workers' Un. Other comp. insurance required.] fAny applicant that checks box#1 must also fill out the section bel6w showingtheir workers' compensation policy information. 111omeowners who sabmit this affidavit indicatingthey t're doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. ram an employer that is providing workers' compensation insurance for my employees .Below is the policy and job site information. Insurance Company Name% Policy # or Self ins. Lia #: Expiration Date: Yob Site Address: City/State/zip: Attach a copy of the workers' comp ensationpolley declaration page (showing the policy number and expiration date). failure to secure coverage as requiredunder Section 25A ofMGL 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. Ido 12ereby cert uiior the p as antlpenalties of perjury that the information provided above is true anti correct. I-"-41; Official use aitly. 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 iii the service of another under any contract ofhire,- express or implied, oral or written." An emPloyei is defiu.ed 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 notmore 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 ou such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." 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 till. 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 theircertificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cant' workers' compensation. insurance. If au LT C or LLP does have employees, apoIicyisrequired. Beadvisedthatthisaffidavit may besubmitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 7'be affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in.the peimit/license number which will be used as a reference number. In addition, an applicant thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant shouldwrite "all locations iu (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 affidavitis on file .for future permits or licenses..A new affidavit must b e filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho OQUU- •0'aw. ealthOfmwsachwetts Depatment Ofludusftial .Aaddemts QfiRce WAVOsUga-ions 600 Waftgtw ftec,�t Boston, MA, a2X Z 1 TO, # 617-l2.' -4900 ext 406 or 1-877W ASSM Revised 5-26-05 Fax # 617-727-7749 www-mms,govid'a ` '10046 Date..Y.../f h/............ t N°RTM TOWN OF NORTH ANDOVER .- PERMIT FOR WIRING AcmU- This certifies that ..... .................� .-....,, ........ ............. has permission to perform......./V�Y1�....s:(!1.4� .............................. wiring in the building of............. at..... & ...... /15rt,r4,A.4� o e.......5 ..-...A...EcrRl* ....... . North Andover, Mass. x:.31647 Fee.. ,,,,`„� ....... Lic. No. .. .... ................ .. ... .... .. CALINSPE R � Check 4 �_�� Commonwealth of massach usefts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. l 17d Z4 6 Occupancy and Fee Checked 'ev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (PLEASEPRINTH NK ORTYPEALLINFO TION) Date: (NMC), 527 MR 12.00 City or Town of: l WA To the Inspector of Wires: By this application the undersi ed Zq ives n o f his or her intention to perform the electrical work described below. Location (Street �& Number) e Owner or Tenant 119/. /V'^� 1 ?1 , ,.► _ Owner's Address Is this permit in conjunction with a building permit? Purpose of Building�� js�YU Cr Existing New Service Amps O Number of Feeders and Ampacity Location and Nature of Proposed Overhead IJU/ Undgrd 0 Overhead ©� Undgrd ❑ Telephone No. PERMIT # No. -Z69/ i,/'< l No. of Meters No. of Meters_ 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 coverage is in force, and has exhibited proof of same to the permit issuing off ce. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certio, under thepains andpenalties o er u that the information on this application is true and complete, .fP I rJ'� FIRM NAME: 1!5-D W q ?—J2,- Licensee:A M� LIC. NO.: �- A SignatureajiZ LIC. No.: (If applicable, enter `exempt" in the license number line.) Address: 1 h, Lc�� ,� 6?�� Bus. Tel. No.•.s�' ya 1 *Per M.G.; , c 147, , 57-61, security work requir s Department of Public Safe "S" Licen A t' Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins LIC' a coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $� No. of Recessed Luminaires COTletion of the following table may be waived by the Inspector of Wires. No. of Ceil.-Susp. (Paddle) Fans No. of Total. No. of Luminaire Outlets No. of Hot Tubs Transformers KVA,Generators KVA No. of Luminaires Swimming Pool Above❑ In_ rnd. ❑ o. o mergency ig tmg No. of Receptacle Outlets rnd. No. of Oil Burners Battery Units FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. Total Initiatin Devices Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW Totals: No. of Self -Contained No. of Dishwashers Space/Area Heating KW Detection/Alertin Devices Local ❑ Municipal No. of Dryers Heating Appliances KW Connection ❑ Other Security Systems:* No. of WaterNo. Heaters KW of No. of No. of Devices or Equivalent Si s Ballasts Data Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent Telecommunications Wiring: OTHER: No. of Devices or Equivalent 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 coverage is in force, and has exhibited proof of same to the permit issuing off ce. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certio, under thepains andpenalties o er u that the information on this application is true and complete, .fP I rJ'� FIRM NAME: 1!5-D W q ?—J2,- Licensee:A M� LIC. NO.: �- A SignatureajiZ LIC. No.: (If applicable, enter `exempt" in the license number line.) Address: 1 h, Lc�� ,� 6?�� Bus. Tel. No.•.s�' ya 1 *Per M.G.; , c 147, , 57-61, security work requir s Department of Public Safe "S" Licen A t' Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins LIC' a coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $� ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL I. ROUGH 1NSFEC lION: irassea — I Failed — [ ] Re -inspection required ($50.00) - [ J Inspectors' comments: (Inspectors' Signature - no initia 2. FINAL INSPECTION: Passed J Failed — [ ] Inspectors' comments: (Inspectors' Signature - no initial Date Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Y ti The Commonwealth ofMassachusetfs UqVDepartment of Inrlustrial.Accidents Office of -Investigations 600 Washington Street Boston, MA 02111 Vww.massgov1dia Workers' Compensation Insurance Affidavit: Buiidelrs/Contractors/JElectricians/PIurnbers Applicant Information Please Print Legibly Name(B.usiness/organization/T.ndividual): 6 -bb) /94 � jU+Q aa, Address: i I/ _'�i O 6.9 . /1? L [vb City/State/Zip /�-' + 6 Phone #: Are you all employer? Check the appropriate box: 1 • ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project (required): ^ e�lployees (full and/or part-time).* have hired the sub -contractors 6. New construction. 2. (r am a sole proprietor or partner- listed on the attached sheet. z 7. ❑ RemodeIing . ship and have no employees These sub -contractors have 8. [] Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 1011 Electrical repairs or additions 3. ❑. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] _-J aykucaiit that cnecxs ooxrt.t must also rut out the section below showing their workers' compensation policy information. 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. Expiration Date: Sob 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 $250.00 a day against the violator. De advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certi undder thepains andpena Pies ofperjury that the information provided above is true andcorr ect. Si azure: of LAI�"-�% Lj/-� / �f J� U Date: Phone Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -Issuing Authority (circle one): 1. Board of$ealth 2. Building Department 3. CitylTown CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone t Date. /'_ . �. " ' . 3 . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...s. �? ! �1 � % has permission to perform ................... plumbing in the buildings of .. T). ..................... at ...:.............. . . North Andover, Mass. Fee.. . !'..� .. Lie. No.. l'. J �... ....... ...� a:� . ....... /PLUMBING INSPECTOR Check # �/ 3 5565 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location Owners Name pate (Permit Type of Occupancy P� Newri ElRenovation Replacement � Plans Submitted Yes ❑ No (Print, or type) �--� �� Check one: Certificate Installing Company Name 4 Corp. Address ✓�-,--� . r S Partner. Business Telephone -7 — —&- 3J — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the hDe of insurance coverage by checking the appropriate box: Liability insurance policyET Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I hereby certify that all of the details and infon best of my knowledge and that all plumbing w compliance with all pertinent provisions of the By: Title City/Town APPROVED (OFFICE USE ONLY Owner 11 Agent haves bmitted (or entered) in a a kation are true and accurate to the nstall 'ons perfoed �ed for this application will be in tusePfs State PlutAkWCodeAfid ObAter 142 of the General Laws. Type of Plumb in Lice Use NumDer I Master Journeyman ❑ f' ......................... MWOMOMMMMMMOOMMMOMMMMOMMM (Print, or type) �--� �� Check one: Certificate Installing Company Name 4 Corp. Address ✓�-,--� . r S Partner. Business Telephone -7 — —&- 3J — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the hDe of insurance coverage by checking the appropriate box: Liability insurance policyET Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I hereby certify that all of the details and infon best of my knowledge and that all plumbing w compliance with all pertinent provisions of the By: Title City/Town APPROVED (OFFICE USE ONLY Owner 11 Agent haves bmitted (or entered) in a a kation are true and accurate to the nstall 'ons perfoed �ed for this application will be in tusePfs State PlutAkWCodeAfid ObAter 142 of the General Laws. Type of Plumb in Lice Use NumDer I Master Journeyman ❑ Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... 5!v.,5y,.d ....... ..................... has permission to perform ..... ........ ............. wiripg in the building of ...... .......................................... at ....... 3..� . ... .......... .......... North Andover, Fee .,". M Fee..:A0. Lic. No'M.73 .......... Check # ELEMICAL IN9'PECTOR 44-25 r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. p Occupancy and Fee Checked [Rev. 11/991 (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 INFO ATION) Date: s City or Town of: d�/- �� To the Inspector of Wires: By this application the undersigned gives notice of his or &r intention to perform the electrical work described below. Location (Street & Number) 3 „P*- ,Lo�vA Ny ,-7 f f Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building ,'x ,�� Utility Authorization No. Existing Service 2 G el Amps / ZJC-1/ YIlVolts Overhead Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �. ti /, � �� C No. of Meters No. of Meters a No. of Recessed Fixtures 0 No. of Ceil: Susp. (Paddle) Fans u UC WULVGU Uy ine uis ecior ol wtres. No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o. of Emergenc—yEighting— nd. Battery Units No. of Receptacle Outlets /V No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. of Gas Burners No. of Detection and Initiatin2 Devices No. of Ranges No. of Air Cond. TonsTota No. of Alerting Devices No. of Waste Disposers Heat Pump Number .......................................................... Tons KW No. of Self' -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Water No. of No. of No. of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: /1LLUL,L{ uuuuLunal aerau y aesirea, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the 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 OND ❑ OTHER ❑ (Specify:) -�p - 3 Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: 3- 3/ ti' Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains andpenalties ofperjury, that the information on this application is trite and complete. FIRM NAME: LIC. NO.: y Licensee: y . `f Signature IC. 0.: #"7 (If applicable, e r "exem t " in the license number line. I 7 Address: f� d Bus reL No.: ,'// '®> Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li ensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this ret ement. I am the (check one) ❑ owner ❑ owner's age t. Owner/Agent Signature Telephone No. PERMIT FEE: $ Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...li.�`.r<'..�?'....� ...�i has permission to perform ...�",F!�..! �... C c �, plumbing in the buildings of�.►.!�.. ! .. ....... at...3../�/���!q:'...r.�.............. North,Andover, Mass. Fee. . 3 9. ! . Lic. No../ z L G '7 �. -'. j: ......... a PLUMBING INSPECTOR Check # L/ �~ 7369 :1 0 SSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS G j p/, Date �r _ Building Location O r /U /1 �9='Lt Owners Name �. L/.f ✓! /I i' Permit # Amount Type of Occupancy New 13 Renovation Replacement [3' Plans Submitted Yes No FIXTURES (Print or type) v /j // Check one: Certificate Installing Company Name �4 ��/ / 11-2C11 Corp. r Address sd, �D �f S f ���C� • �� Partner. a U2 Business Telephone Firm/Co. Name of Licensed Plumber. z,�//� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0-� Other type of indemnity El Bond a 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 11 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and ins ns performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas ZIM State Plumb' C an 142 of the General Laws. r By: Signatureo kens FROM Title Type of Plumbing License City/Town icense Number Master umeyman ❑ APPROVED (OFFICE USE ONLY Location No. l Datey MORTN TOWN OF NORTH ANDOVER AL 3? •. • O � A Certificate of Occupancy $ Building/Frame Permit Fee $ sAGNUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / Building Inspect6r' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: o,' 3) /� QV C � SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: a�a r(JLf M +re P r 10 4. Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: q7, Soo Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Nam (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone 9"-j � f f SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au a licable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) 0 1 Addition 0 Accessory Bldg. ❑ 1 Demolition 0 1 Other ❑ Specify Brief Description of Proposed Work: 8 'Y(-8 (!SV,PLI iA) kNe, C . I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building A 0� ` v (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction CO/v v 3 Plumbing Building Permit fee (a) X (b) C9 V e, 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf. in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFMvMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE �x FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT 0-0 f,A(21 4 y /1 N ti ti PHONE aV26 ASSESSORS MAP NUMBER l0 `� LOT NUMBER SUBDIVISION LOT NUMBER —� STREET ' U f� STREET NUMBER "39 ........................................................................... OFFICIAL USE ONLY IE......E...E................................................ ....w.� ..NEEM. RECOMMENDATIONS OF TOWN AGENTS � �� ACX LAD---V-L &il V\ DATE APPROVED d 0 CONSERVATION ADMINISTRATOR DATE REJECTED e DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOODINS, R - HEALTH DATE REJECTED DATE APPROVED TIC IN§TfCTOR - HEALTH DATE REJECTED ISE COMMENTS nom-r� S t,t �- % /-� a HZ `r .�1 •-�.�y ....� gLi� a:/�.. cC ��� IV �e- -F elf PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT 4 DATE APPROVED FIRE DEPARTMENT DATE REJECTED CON RENTS RECEIVED BY BUILDING INSPECTOR DATE MORTGAGE INSPECT/ON, PLAN AT 38 FARNUM STREET NORTH ANDOVER, MA. WESSEX REGISTRY OF DEEDS.' 8/C 2,2/8 PG. 92 CERTIFIED TO.'ANDOVER SAV/NGS BANKO 5,3/8 S�' AL E' /`-- 60' , DA TE.' SEPTEMBER 25, /995 63— � 09' � o W /90.5/ coNc. 2 STY. PAT/O FRM. OWL ENCL. PORCH I LOT /4 47, 500 S.F. -i 's N.OTES.' Y'%) DO NOT USE OFFSETS TO ESTASL /SH PROPERTY LINES OR TO ERECT ANY STRUCTURE. 2)PROPERTY LINES ARE DETERMINED FROM COMP/LED INFORMATION TO BE USED FOR MORTGAGE PURPOSES ONLY. CERT/F/CAT/ONS.' dASEO ON MY KNOWLEDGE, INFORMATION AND BEL /EF, / HEREBY CERT/FY THAT THE PERMANENT STRUCTURES INDICATED ARE LOCATED ON THE. GROUND APPROXIMATELY AS SHOWN AND ARE CONFORMING TO THE ZONING SETBACK REIX1/REMENTS OF THE MUNICIPAL /T Y NO. ANDOVER WHEN CONSTRUCTED AND THAT THE STRUCTURE SHOWN /S NOT LOCATED /N A FLOOD HAZARD ZONE AS PER FE. M. A. MAP, COMMUNITY NO. 250099 EFFECTIVE DATE.' 06- 02-93 ZONE.'X JOHN ABAG/S 8 ASSOC/AYES, PROFESSIONAL LAND SURt,-,E 137 CHANDLER ROAD, A ND0VER, MA. (508) 688- 4899 rim AfPL/CANT.' CAH/L L NO. P2,458 ....._,•—•...�.�...,....��:a+ra+._.,.._......—....,_..«... .... ..,.........,. __._,....�.. ..._. ,ti... _..., _..,,_..�,.,..c.,.._.._...,_....,,.n,cin.�L,-+:�c.;:...�a;�.nc;;at:iS':�7:i�a�r„' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECYION FORM PART C SYSTEM INFORMATION (continued) Property Address: { � Y1liV� 1�j�)c` 1 /It,, (kiJ i f . Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks Flie-alllwells within 100' (locate where public water supply comes into house) (revised 04/25/97) page 9 of 10 I 1 ¢� x w O A x o Co v aG o w° � J)asto a Cf) o w z 0 z =1o w° >1 v U w w as °�° C4 �+ w a za U U w w °a° c�° cn w x O u w a z z °�° w z w w a kr c �'' o cn v Q o cn ui ► V) CL= :cccc CD Cc Cc, r t s a cl) ♦ 013. A: w O + �m c y O 3 = C!) •. CO) R C_ m r y Cm VJ O C Z :fy 0 w � y O �'E m U � toa.� y O ; cD Of O C COD W `� V •y O • C cc Z o� r• co 0 CD cc i 0 co Z a O H � C I c CM ca Q 0 y O> �E m m CD 0 CD CL O — � CCDO L !C O CL cmQ y C o R V d O � CA C Z CD V t/* cc c c— cc CL CO) 0 C2 C., mr3 Y N S ~ Cf) LLI C N m R O t O • _ LL m A � CO) �_ 0. .y C 4 Q. O y m ' �a�m s a 3 � „► fah, r• co 0 CD cc i 0 co Z a O H � C I c CM ca Q 0 y O> �E m m CD 0 CD CL O — � CCDO L !C O CL cmQ y C o R V d O � CA C Z CD V t/* cc c c— cc CL CO) 0 Location `3 No. L13 8 Date 3 —D ! 0 140RTN TOWN OF NORTH ANDOVER 3:�. • O F w s i }° Certificate of Occupancy $ s Building/Frame Permit Fee $ s,K MU e Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #3 6t— 5 � ..,M til r Cs' -- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING °, . •' • qg# fbr 0ffM " Use Qul BUILDING PERMIT NUMBER: 4-138 DATE ISSUED: SIGNATURE: Building Commissioner/Inspector o Buildings Date SECTION 1- SITE INFORMATION Q1.1 Property operty Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infocwation: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record NPri Address for Service Signa 're Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: l Address " �,( Signature(—Telephone Not Applicable ❑ License Number Expiration ate' 3. istered Home Improve nt Contraor P� c 5 Not Applicable 0 Company Name � 'I ase S ^ � �C)�-R I�`� 11 Registration Number dress Expiration Date Si n ture Telephone Ma M X Z O IS SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2546) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a0plicable New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s ` Addition 0 Accessory Ardg. ❑ molition ❑ Other 0 Specify r fil Brief Description of Proposed Work: YA �IMA C �\rtl& k&,og SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building( a) (a) Building Permit Fee CC, Multiplier 2 Electrical (b) Estimated Total Cost of accSJ C. C' Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection , 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZAJrTON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hero -X authoto act on beh f in all matters a ativ o rk autl o ' ed by this puilding permit application. Si ire ofWer' Date SECTION 7 OWNER/AUTHORIZ ENT DECLARATION I, E l -Q l ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief KA'4A, �' AX__'k4 (�AA �' \'\ P ' ame d / 0 Si ture o wne en Date 1011 1 01511,4110 11Z' lip" NO. OF STORIES SIZE J. BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1 2 ND 3 RD SPAN DfMENSIONS OF SILLS DIN ENSIONS OF POSTS DEI IENSIONS OF GIRDERS -HE- IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE `AC4RD,. CERTIFICATE OF LIABILITY INSURANCE DATE 03/24/2003 PRODUCER NORTH ANDOVER INSURANCE AGENCY, INC 9 WAVERLY ROAD NORTH ANDOVER MA 01845-2415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED Michael Rodden 47 Prescott Street North Andover MA 01845— INSURER A: NATIONAL GRANGE MUTUAL INSURER B: TRAVELERS PROPERTY & CASUALTY INSURER C: INSURER D: INSURER E: I K e1T1 =1 •l'Tei XV THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MMfDD LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE Fx_1 OCCUR IAPP37395 02/01/2003 02/01/2004 MED EXP (Anyoneperson) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 RO- F117 POLICY JECTT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS / / / / SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS / / / / NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILI / / / / EACH OCCURRENCE $ AGGREGATE $ CUR❑CLAIMS MADE DEDUCTIBLE / / / / $ $ RETENTION $ WORKERS EMPLOYERSOMIAPBNSTY ION AND ' / / / / X TORY LIIMITS OTH- E.L. EACH ACCIDENT $ 100,000 B 849K419 01/01/2003 01/01/2004 E.L. DISEASE - EA EMPLOYEE$ 100,000 E.L. DISEASE- POLICY LIMIT Is 500,000 OTHER DESCRIPTION OF OPERATIONSfLOCATIONSIVEHICLEStEXCLUSIONS ADDED BY ENDO RSEMENTISPECIAL PROVISIONS TOWN OF NORTH ANDOVER Building Department North Andover MA 01845 - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVFS_ f © ACORD CORPORATION 1988 *T,r INS025S (9910).01 ELECTRONIC LASER FORMS, INC. - (800)327-0545 Page 1 of 2 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: p (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Name_ D D The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit k 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' Please Print S? my empi yes (cJ C (, Address . �A ,-1 �JCp C C I )K- S� 0 Company name: Address City. Phone #7 Insurance Co. Policv # 7�1)1� working on this job. Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as weU_as_civil.penattiesinsheiorm da -STOP VVDW ORDFR-and_a fine.L(...($1DO.DO)-aJdW againsime. t understand that a copy of this statement may be frded to the Office of Investigations of the DIA for coverage verification. ! do hereby certify under the pains and Haloes of perjury t d above is true and correct. Signature-Y\C 9 �L �_� Date l Print ke hae�- Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing El Building Dept ❑Check if immediate response is required 0 licensing Board E] Selectman's Office Contact person: Phone #. ❑ Health Department Ei Other a� W b O w aQi cn 0 w �° p w O w .0 U x o w a p a: C w x ° a w p w V) w" � O a rs: w z w u0. «� z cin O cn rn W • 150 •aa O ER **M s T Ell Ccm O•� � Q LA m m CD CD CL ♦.,. � O � �3 O � � � o e_9 o a CL ac ca O cc v -J . Ci 042 CO Z Q. co 0 CL V h � C C !O H C 0 U) crw w M: CO • 150 •aa c CD ad C h t C. 1 C C c l0 • , m C 2 2� oo y r d 3:Ey 5 r a c y � E m CO y Am +�•� y : �C. - m Cc .0 O ?: #AO GO) W 4ow p o .so COL y r =CD O .+ cm • O y •� aa= m V y O CL cm C Q i y O C •p "' CD CO � _ � CDW .. •� _ ... •y D c .. •CL:s O o ~ W •Ev C io w •y CD Z o C.3 o a 0 O S Vi _ 9)m o .� C M O H .r= .0 a w C=c � T Ell Ccm O•� � Q LA m m CD CD CL ♦.,. � O � �3 O � � � o e_9 o a CL ac ca O cc v -J . Ci 042 CO Z Q. co 0 CL V h � C C !O H C 0 U) crw w M: CO