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Date ..... �..-... �p :.. �� .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...............7.........m . P7..... &—.
has permission to perform ... ........................ /' �.
......................................
wiring in the building of ......V,47T...........................................................
at ......... CL!%? ..... L' .................... . North Andover, Mass.
Fee ... �� ".�.- Lic. No. I. A 3kAe .......
L� iCC RICAL;� A
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Commonwealth of Massachusetts Official Use Only
Department of Fire SerViceS Permit No._J
�
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRUT M Eff OR TYPEALL INFORA41 TION) Date: ;)Oki
City or Town of: To the Inspector of Vires:
By this application the undersi ed gives noo Ve—
of his or her intention to perform the ectrical work'described below.
Location (Street �i N tuber) (�j vo r
Owner or Tenant Telephone p No
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ElBLDG PERMIT #
Purpose of Building hs Utility Authorization No.
Egfstin Se A
grv}ce mps / Volts Overhead LJUndgrd ❑ No. of Meters
New Service Amps / Vohs Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
La --A
e
No. of Recessed Luminaires
mom tenon of the following table may be waived by the Inspector of Wires.
No. of Ceil: Susp. (Paddle) FansNo. of Total.
No. of Luminaire Outlets
No. of Hot Tubs
Transformers KVA
Swimming Pool Above ❑ In-
Generators KVA
o. of Emergency jughting
No. of Luminaires
No. of Receptacle Outlets a
rnd. grnd.
No. of Oil Burners
Bagn Units
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of Switches, 6p
No. of Ranges
No. of Air Cond. TotaTons l
Heat Pump Number Tons KW
......
Totals: ................. ...............
Initiatin Devices
No. of Alerting Devices
No. of Self -Contained
No. of Waste Disposers
No. of Dishwashers
Space/Area Heating KW
Detection/Alertin Devices
Local ❑Municipal ❑ Other
Connection
No. of Dryers
Heating AppliancesKW
Security Systems:
No. of Water
No. of No. of
No. of Devices or Equi valent
Heaters
Si ns Ballasts
Data Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or E uivalent
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 1115 -DO l 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 cert, under the pains and penalties of perjury, that the informado n this ap lication is true and complete:
FIRM NAME: %►�t; i/C LIC. NO.:
Licensee: jjp� b/ Signature LIC. NO.: ��6171G�
(If applicable, enter "exempt "'in the lice a numb line.)
Address: 1C> LoC.�/�/Qi% $4� ,dit` Bus. Tel. No.: 603 365- a2
Alt. Tel. No.:
*Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. 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
.3. UNDERGROUNDINSFECl'IO.N:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
4. INSPECTION —SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
5. INSPECTION - OTHER:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) 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.
%� � ��./��.
8 8 Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...%...... It
. '
�- - .`j. ``'��� ..........
has permission to perform ... �'.c ....................
plumbing in the buildings of ..... .........................
at. . ......... ....... North Andover, Mass.
Fee.(".'. Lic. No.. .. ............ .............
PLUMBING INSPECTOR
Check #
a
FIXTURES
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: /��� .� .��, MA. Date: 7 / 3hl Permit#
Building Location: %'1Ar1 La -14 I✓- Owners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes o ❑
FIXTURES
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate t e type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
signature of uwner or uwnerS Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit i sue or this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142,01 the Gen ral Laws. /
By
Title
City/Town
APPROVED (OFFICE USE ONL
Type of License:
❑ PIWber Signatur f Licensq(d Pj(Imber
aster I ,6
❑Journeyman License Number: �'D
DEDICATED
SYSTEMS
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2"D FLOOR
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3RD FLOOR
4T" FLOOR
15 T" FLOOR
6T" FLOOR
7T" FLOOR
8T" FLOOR
Check One Only Certificate #
Installing Company Name: T.4�/i%D,r!"�/�iC.t�r
El Corporation
Address: / �5l11V li 7— 7�ty/Town:7e"404—State:
❑ Partnership
Business Tel:7���—� 70s' Fax:
/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate t e type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
signature of uwner or uwnerS Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit i sue or this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142,01 the Gen ral Laws. /
By
Title
City/Town
APPROVED (OFFICE USE ONL
Type of License:
❑ PIWber Signatur f Licensq(d Pj(Imber
aster I ,6
❑Journeyman License Number: �'D
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
;- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name'(Business/Organization/Individual): JV.& 7iCOW
Address:
City/State/Zip:
A/l G/ %0 Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
e 1oyees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. emodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. E] Plumbing repairs or additions
12. E] Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractots that check this box must attached an additional sheet showing the name of the sub -contractors afid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #'or Self -ins. Lie. #:
Job Site Address:
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation policy, declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
I do hereby certify un he pains anddp enalties ofpeijury that the information provided above is true and correct
RianatnrP• � ,. - _ hate' ,/�� / //
MOM
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town'
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Permit/License #
6. Other
Contact Person: Phone #:
n
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in -any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
N
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MR
0
Date./�. /
�/
TOWN OF NO H ANDOVER
PERMI OR PLUMBING
This certifies that .. //c . -/. 0'. ! .. �f ........................ .
has permission to perform ............................
plumbing in three buildings of .../�/ ?�'./..................... .
at... . r . C.�. C. , � , ................. North Andover, Mass.
Fee .. �.... Lic. NO. 0. . �.
.........
PLUMBING INSPECTOR
Check # ( CI v
7133
r
s
�Lx
MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING
tPri�(ntt or Type)
T6
�w(/I'Date %
,)Mass. ! �t, l(� 20Permit #
Building Location 15 % L / /��i /� Owner's Name_
Type of Occupancy_
New ❑ Renovation ❑
B.P. #
Replacement ❑
SEWER It
FIXTURES
Plans Submitted: Yes D No ❑
Ccrr"11 4
Installing Company Name
Business Telephone__ `j�,�( y% N /'? /„]..
Name of Licensed Plumber or Gas Fitter
Check one: Certificate
❑ Corporation
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142.
Yes -t� No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 21� Other type of indemnityv❑ Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of
my knowledge ar.d that all plumbing work and Installations performed under/mwrmit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Plumbing Code and Cha er of the General Laws.
By
Tide Signa Licensed lumber
city/Town
APPROVED (OFFICE USE ONLY) Type of License: / ❑Master ❑Nkru'rneyman
------------
License Number (� V
•
.■�.....�...■.■....�.■
.■.-.....■..■■■....■SMM
No■
:...�:=:.�.�.■..�■�
• •
.��.�
Installing Company Name
Business Telephone__ `j�,�( y% N /'? /„]..
Name of Licensed Plumber or Gas Fitter
Check one: Certificate
❑ Corporation
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142.
Yes -t� No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 21� Other type of indemnityv❑ Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of
my knowledge ar.d that all plumbing work and Installations performed under/mwrmit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Plumbing Code and Cha er of the General Laws.
By
Tide Signa Licensed lumber
city/Town
APPROVED (OFFICE USE ONLY) Type of License: / ❑Master ❑Nkru'rneyman
------------
License Number (� V
Datel .�' . o. l
U
TOWN OF NORTH OVER
A
• PERMIT FOR GAS STALLATION
This certifies that C. !<� �l .:- -*'-**********-*-
has
. * ' . * ...... * * * . * .
.��
has permission for gas installation .. . ................. .
in the buildings of ... n Vit ..!
at 6L: North Andover, Mass.
Fee ...... Lic. No..7!!.Y t-... ...A
,6.a�S INSPECTOR
Check #
5 7 fi: 2
L K
Location
c,
No. 3 Date
,.ORTIy
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
`4L
Building/Frame Permit Fee $y�
sACMUs
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
_
5 ` C,
TOTAL $
Nz�� �zf,4-
wilding Inspector
n ! O ((
C k
09/03/98 09:49 6100 PAID
�(�70 Div. Public Works
Location
No. 7 2 Date
NORT01
TOWN OF NORTH ANDOVER
O
�?•,,`•D .•,ho
s
Certificate of Occupancy
$
CMCJ
Building/Frame Permit Fee
$
sAcHus
Foundation Permit Fee
$
Other Permit Fee
$
i
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ r_ i
LL
Building
Inspector
Div. Public Works
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A13AVS MAN 30 10NAH30
aneouverao
.�. The Commonwealth of Massachusetts
" ( Department of Industrial Accidents
_ Office 81laseSM92dons
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name
location- 14AJ� �� t
C] I am a -sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify he pains penalties a per'e In .ormation provided above is true and correct
Signature
Pri ame �Z�rJ /%�1/iC. / Phone # j 7�^ 3
official use only do not write in this area to be completed by city or town official
city or town: permit/license # r1 Building Department
C]Licensing Board
check if immediate response is required ❑Seiectmen's Office
[31-1ealth Department
contact person: phone #; r jOther
(mind 7/95 PIA)
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IVE
LTR I TYPE OF INSURANCE I POLICY NUMBER POLICY I DATE (MM/DDT/YY) I PDATE (MM/EXPIRATION
I LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY / / / / PRODUCTS - COMP/OP AGG $
CLAIMS MADE F] OCCUR PERSONAL & ADV INJURY $
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $
MED EXP (Any one person) $
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT 1 $
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE I $
I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CITY OF NORTH ANDOVER
BUILDING INSPECTOR
MAIN ST
NORTH ANDOVER MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OFUT/ANY KIND UP& THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
GARAGE
LIABILITY
ANY AUTO
/ /
/
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
/ /
/ /
EACH OCCURRENCE $
AGGREGATE $
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ ' INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
WC2-31S-311322_018
07/07/98
07/07/99
WC STATU- OTH-
TORY LIMITS I I ER
EL EACH ACCIDENT $100000
EL DISEASE - POLICY LIMIT 1 $ 5 0 0 0 0 0
EL DISEASE - EA EMPLOYEE 1 $10 0 0 0 0
OTHER
I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CITY OF NORTH ANDOVER
BUILDING INSPECTOR
MAIN ST
NORTH ANDOVER MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OFUT/ANY KIND UP& THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
............................ • • •. :C:i•: K<i:•ii:vvvvvvvv9i:vvvvvv^ilii:^is4iiiiii:v:4iiiiii: •iii:•i:•iiiiiiii: : iiiiiii............ iii:Jii:: iiiiiiiiiiiiiiiiii:v i::::: is is i::::::::::v::::::v:::::•:::::::::..iii
:.:: :;:::;:::.::<: ••;;:. ..: > >: " >' .::»>:....:::::»:.>:»»:::::>:::;»>:>:.::::::::.;;.;: DATE (MM/DD/YY) t:
CORD::`:ETI :I ��' ::.: �:::�»#�iB:�.L��T ::.:�. :�.�: :;:.:::::::::.:.::::::::: ;:;::;:::;:
2
09 0 98
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
CASSIDY ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
234 HUMPHREY ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
SWAMPSCOTT MA 01907— COMPANY
A MARYLAND CASUALTY
INSURED
COMPANY
LEVREAULT, JASON B
53 HIGHLAND RD COMPANY
C
BOXFORD MA 01921— COMPANY
(978) 1352-8235 D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
DAMAGE $
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE F] OCCUR
OWNER'S & CONTRACTOR'S PROT
PENDING
04/29/98
04/29/99
GENERAL AGGREGATE $600000
PRODUCTS - COMP/OP AGG $ 6 0 0 0 0 0
EACH ACCIDENT $
PERSONAL & ADV INJURY s 6 0 0 0 0 0
EACH OCCURRENCE $3 0 0 0 0 0
FIRE DAMAGE (Any one fire) $ 5 0 0 0 0
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
MED EXP (Any one person) $ 5 0 0 0
/ /
AUTOMOBILE LIABILITY
AGGREGATE $
$
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS (Per accident)
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CITY OF NORTH ANDOVER
BUILDING INSPECTOR
MAIN ST
NORTH ANDOVER MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
rlPROPERTY
DAMAGE $
GARAGE LIABILITY
ANY AUTO
/ /
/ /
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
/ /
/ /
EACH OCCURRENCE $
AGGREGATE $
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
WC STATU. OTH-
ITORY LIMITS ER
EL EACH ACCIDENT $
EL DISEASE - POLICY LIMIT $
EL DISEASE - EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CITY OF NORTH ANDOVER
BUILDING INSPECTOR
MAIN ST
NORTH ANDOVER MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
WILLIAM J. SCOTT
Director
In accordance with the provisions 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 1VtGL c 111, S 150A.
The debris will be disposed of in:
(Location of Facility)
U 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.
BOARD OF APPEALS 688-9541 BUUMING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
i;
Location I l YY1,C1�J�
No. A01 DateOK—
TOWN
OF NORTH ANDOVER
0! - jW
Certificate of Occupancy
$
Building/Frame Permit Fee
$
no
�SSACNUSEt Foundation Permit Fee
$
Other Permit FeeS4(�)
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ �j
Building
Inspector
e t- t` 1'2"1C/9514:17 15.00 PAID
8721
Div.
Public Works
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