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Miscellaneous - 39 HIGH STREET 4/30/2018 (3)
A Date.b Oo. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that. . .......... has permission to perform plumbing in the buildir�gs of.. ............. a1c) (� ............ at .................. U-*****--- .... North Andover, Mass. Fee P�4q'�O— Lic. No. Z .. . M.0 DI "RADIKIel Me= 11 1 Ur-% Check # '��6 0 P 16�- 1 ta'-� — I --t) V"— ,-,I � -4 � 13 4 KI I CHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL I I= WASHING MACHINE CONNECTION F_ M___ FM 111 VVATEPTHEKT- ER —ALL TYPES. I WKWOOK WON 11 - 110-0 W_ WN - M__ 111 W 11 - W-1 - FOW F"_ FW_ 140 W_ FM_ WN I P 0 \WA—TERPIPING � li�_ F�— li�— lim- � F �-- 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND DI 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNEREJI AGENT 10 �S n 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 'Z< and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME F 110 'LICENSE # Dl SIGNATURE MPM JP FJ CORPORATION R] #=PARTNERSHIP 0# LLC Ek COMPANY NAME M 1�� ADDRESS L CITY -:]STATE TEL �4]Ctj ZIP FAX CELL EMAIL A vNIJ % -I oni MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY L MA DATE --1PERMIT#1A6i& _"e JOBSITE ADDRESS Q OWNER'S NAMEE��J6 P OWNER ADDRESS —J TEL[ ________jjFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL DI RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: El REPLACEMENT: MJ PLANS SUBMITTED: YES NOOP FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _&EDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM L - -- ---- L J F__ __j DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ...... j =___j L-A FOOD DISPOSER FLOOR /AREA DRAIN f -------- Dj INTERCEPTOR (INTERIOR) LLL__ I KI I CHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL I I= WASHING MACHINE CONNECTION F_ M___ FM 111 VVATEPTHEKT- ER —ALL TYPES. I WKWOOK WON 11 - 110-0 W_ WN - M__ 111 W 11 - W-1 - FOW F"_ FW_ 140 W_ FM_ WN I P 0 \WA—TERPIPING � li�_ F�— li�— lim- � F �-- 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND DI 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNEREJI AGENT 10 �S n 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 'Z< and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME F 110 'LICENSE # Dl SIGNATURE MPM JP FJ CORPORATION R] #=PARTNERSHIP 0# LLC Ek COMPANY NAME M 1�� ADDRESS L CITY -:]STATE TEL �4]Ctj ZIP FAX CELL EMAIL A vNIJ % -I oni 0 �--q u 0 z r U) LLI a_ 4b LLI X I-- 00 0 < LLJ U) IL LLA co z P -d 0 EE LLI F - Of) w The Commonwealth of Massachusetts Department of IndustrialAccidiiits Office of Investigations 600 Washington Street Boston, MA 02111 IF www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansfplumbers Applicant Information Please Print Legib Name (Business/Organization/Individual): me Address: A4 I P%IR 03029 Phone#: 921(— '�'�3-769'1 City/State/Zip: 41e Are you an employer? Check the appropriate box: LEI I am a employer with 4. El I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2.X 1 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. 0 We are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL myself. LNo workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. [J New con.struction 7. EJ Remodeling 8. E]Demolition 9. E] Building addition 10.FJ Electrical repairs or additions 11. 0 Plumbing repairs or additions 12.n Roof repairs 13F1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers, compensation insurancefor my employees. Below is thepolicy andjoh, site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date; Job Site Address: -,City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a 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 cert! der the pains andpenalfies ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/Llcense # 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 b" V i a Information and Instructiolis 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 employerIs defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint 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." i Additionally, MGL chapter 15 2*, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is ' required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmationof 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. Pleas ' e 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 now 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 p* ermit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of M-assachusefts Department of Industrial Accidents Office of Investigations 6 00 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext. 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 __WwW.mass,gov/dia f ) V - V 10185 f Date 5.J�M 1,3 ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies ................ has permission to perform.. plumbing in the buildings of. ................. at . . .......... < .......... North Andover, Mass. Fee Lie. No. M!D ................... ... 4 PLUMBING INSPECTOR Check # 4�4� --!s i 'i L�) 9 -4N- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY CITY JAJ 0 AJ 12 MA DATE 41 � PERMIT # 101S15 9cl JOBSITE ADDRESS 9 ZZ, 619 3t OWNER'S NAME C OWNER ADDRESS -3 2 XVOP'26 Dbe-ler?/' 0 TEL FAX OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL (:1 NEW: 00 RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES D NO [29 FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIIJSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) .9, -4� KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECT \IYATER HEATER ALL TYPES I 'WATER PIPING b Q'THER F::F INSURANCE COVERAGE: I have a current liabili!j insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY kj OTHER TYPE OF INDEMNITY 0 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 Ej SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 77 PLUMBER'S NAME VZ LICENSE# 1571-61 SIGNATURE MP JP CORPORATION [:1 # PARTNERSHIP [] # LLC [:1 # COMPANY NAME 71A-A)e.5 ADDRESS eR I'De 5-1' CITY STATE zip 307'� TEL FAX CELL 9 73 51a 3 -7-( 2.'V EMAIL '/ - �rv\v The Commonwealth ofMassachusefis Department ofIndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govIdla Workers' Compensation lusurance Affidavit: Buflders/Contractors/ElectriciansfPlumbers Applicant Information Please Print Legibly NaMe (Business/Organizationffndividual): A Me -5 covnje Ad&ess: 7'1 /,� I', citylstatelzip._��Iqm Phone Are you an employer? Check the appropriate box: - Type of project (required): LM I am a employer with 4. F1 I am a general contractor and 1 6. El Now construction employees (fall and/or part-time).* 2. El I am a sole, proprietor or partner- have hired the sub -contractors listed on the attached shoot. 1 7. FJ Remodeling ship and'have no employees working for we in any capacity. These sub -contractors have workers' comp. insurance. 8. 0 Demolition I 9. E]Building addition [No workers' comp. insurance 5. We are a corporation and its officers have exercised their 10.FJ Electrical repairs or additions required.] 3. El I am a homeowner doing all work right of exemption per MGL 11. E] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.Q RoofrepAirs insuran 'cc required.] t employees. [No workers' 13.[J Other comp. insurancerequired.] 'Any applicant that checks box#f mustalsofill out the section below showing their workers' compensation policy ifforniation. I Homeowners who submit this affidavit indicating they alre doing all work and then hire outside contractors must submit a now affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers , comp. policy information. I am an employer that isproviding workers'compensation insurancefor my employees. Below is ikepolley andjob site information. Insurance Company Name:. Ve Ile 12- 5 Policy # or 8 elf -ins. Lic. �'!S — (9'— 3_ Expiration Date: 9ZI !Y__ Job Site Address -.,39 Citvlstate/zip: VE Atiach a copy of theworkers' compensation -policy declaration page (showingthe 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�ycar 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 maybe forwardedto the Office of investigations of t1a DIA for insurance coverage verification. Ido h'ereby certlounder thepains andpenaftles ofperjuiy that the information provided above is true andcorrect. Date: 9/,3e9zz,3 Official use only. Do not write in this area, to he 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 Ph nn 1-- 9. Information and Instructio HS - 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 ofhire, express or implied, oral or written.,, An employe�js defined as "an individual, partnership, association, corporation or other legal entity� or any two or more Of the f0rego1g engaged in ajoint 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 dwelfing house having not more than three, apartments and who resides therein, or t 0 cup nt of dw he c a the elling house Of another Who employs persons to do maintenance, construction or repair work on such dwelling house or on the groutids 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 constiruct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of co pliance with the insurance coverage required.,, Additionally, MGL chapter 152, §25C(7) statGs'Weither the cmommonwealth nor anY of its political subdvLions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Please fill out the workers, compensation affidavit completely, by checking the boxes that apply to �our situation and, if necessary, Supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cany workers' compensation insurance. If anLT—C orLLP does have employees, a policy is required. 13a advised that this affidavit maybe submitted to the Department of Industrial Accidents for c0nfirma:tionof insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should be, xetumed to the city or town that th'a 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-iusured companies should enter their SeW-insurance license number on the appropriate Eno. City or Town Officials Please be sure that the affidavit is complete and printed'Jogibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigati has to co ta t your gard caat. ill in the perinit/lice'use number which will be used as a reference number. In addition, an applicant Please be sure to f Ons n 0 e ing the appli thatmUst submitmultiple permit/license applications "in any given year, need onlysubmit one, affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in—(city or town)." A copy of the affidavit that has been officially stamp dormark dby h ci ortow maybe ded t applicant as proof that a valid affidavit ii on file for fhtare pe a e f 0 tY R Provi o the imits or ic s . A w a da t must b do t a ,iise or permit not related to any business or commercial venture year. 'Where a homeowner or citizen is obtaining a Ece 1 en es nB ffi vi 0 filleL u e ch (i.e. a doglicense orpermitio bumleaves etc.) said person is NOT required to completethis affidavit.' The Office of Investigations . would like to thank you in advancefor your cooperation and shQuId you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Comr. moawalth of M-assochvSt.-tts Depafteat offaduMal Accidents Office off"Ostigatim. 600 Washingtoa StKQ(,,t BostonMA02111 Teel,# 617-72,.7-4900 oxt.406 -1-877,7MASS.AFF, or Revised 5-26-05 Fax # 617-727-7749 Town of North Andover Your permit has eee"n sent back t too�you for the following reasons: 1) Check amount incorrect U l/�Y Q�'` 2) No copy of current license 3) Insurance Binder not on file or expired I Ce, d� 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. This certifies that .... . ............... has permission to perform . . . . . ......... plumbing in the buildings of .... at ... .41 North Andover, Mass, Fee IA9... Lic. No. . PLUMBING INSPECTOR Check # -.X-5 F- 7 A COMMON A (-,,-A 1 M56 SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES M NO �]l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE OF INDEMNITY D 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 0 AGENT 10i SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L,,�--1 M G A)jgf --LICENSE # j `J SIGNATURE MP [ JP Q CORPORATION Q# #= PARTNERSHIP # LLC ,_...`:' IS j COMPANY NAME! _rC,p ADDI CITY STATE ® ZIP FAX CELL .-2?'EMAIL Iz MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOR CITY _ MA DATE _ _/ �( PERMIT # JOBSITE ADDRESS OWNER'S NAME C _ POWNER ADDRESS TEL FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ( REPLACEMENT: 0 PLANS SUBMITTED: YES ® NO op FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE m M i - _ . __I ! _ !I I 1 DEDICATED SPECIAL WASTE SYSTEM __. ____._� ......_.._.__- --�_--• _..�_ _..-___) __,..__.l . DEDICATED GAS/OIL/SAND SYSTEM _ f _.___._.) f ___._-,►. ____.�f ., _ I _ (__,__,.__ __-, __...- ._J f f DEDICATED GREASE SYSTEM ____{ .___._1 _ _. _{ DEDICATED GRAY WATER SYSTEM i f DEDICATED WATER RECYCLE SYSTEM I ______...1 .._._....__6 ..___.(._.___J ___..i i _..__._._► ____.._1 DISHWASHER ..---..__I ___-.__l ___._I _......i _ _I ___1 DRINKING FOUNTAIN -j L___.__I FOOD DISPOSER FLOOR /AREA DRAIN .._---( ----i _ 1 _--__-.P J 1 ..._.._.._.1 INTERCEPTOR INTERIOR E .--...__._1 __771 i _---..._i KITCHEN SINK —f _ _-._.1 __..---._..4 _....-.___:f LAVATORY _ ._� ..__ _. I 4 ..._.__1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES M NO �]l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE OF INDEMNITY D 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 0 AGENT 10i SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L,,�--1 M G A)jgf --LICENSE # j `J SIGNATURE MP [ JP Q CORPORATION Q# #= PARTNERSHIP # LLC ,_...`:' IS j COMPANY NAME! _rC,p ADDI CITY STATE ® ZIP FAX CELL .-2?'EMAIL Iz on z W CL w w v The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatioon/Individual):A Address: -?,y,y &I C ua� e City/State/Zip: „ rP NI � D9 03029 Phone #: 72- ��3-% 4 4 P/-/ Are you an employer? Check the appropriate box: 1. [0I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship'and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 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.] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ace 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 thepolicy and job site information. Insurance Company Name:. 0 1 C 0 N l✓ g( l Z Ai S, Policy # or Self -ins. Lic. #: CSD U 9'S',�, % % Expiration Date: 7Z91 !Z Job Site Address: 32 //, � h S-/- , City/State/Zip: 5.4)e 1-7 , V /1 0 3U 7� 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 certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA. 02111 Tei, # 617-727-4900 ext 406 or 1-877rMASSABB Revised 5-26-05 Fax # 617-727-7749 www.mass.govldia f.s LTH,OF MASSACHUSETTS �:; PL JIVISERS'ANU GASF�ITfi°FR5 i CjIb-,1=NSED:AS AJAASTER PLUMBL. r ISSUES THE ABOVE LICENSE TO: ` f`AH,;: 'N GREENE 74 tRTDGE ST -SAL��M NH 03079-3273 115'_ 05!01114 187559 Date.. ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING -I;- �"U- This certifies that ... .................. has permission to perform ............... ............ S��.e . ........... wiring in the building of 1� C- C-3— ..................................................................................................... at .................................. ...... .......... North Andover, Mass. Fee.R..H,q..6,� .... Lic. No. Check # 11599 °d � Commonwealth of Massachusetts Department of Fire Services QM BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked' [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 CMR 12.00 (PLEASE PRINT IN MK OR TYPE ALL .INFORMATION) Date: V—/, 7/-1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrica7,661or—, escribed below. Location (Street & Number) 5of //W Owner or Tenant Owner's Address No. Is this permit in conjunction /with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ( /%4040e— 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: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Total Trsformers KVA Trans No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o Emergency ig tIng Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches T No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW S P g Local ❑ Municipal [_1 Other Connection No. of Dryers Heating Appliances KW SecN . o Systems:* or E uivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the inspector of rr+res. 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 office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains a d nalfles o per ry, t theZinfAation��ation is true and complete. FIRMNAME: eLIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "ex p " ' e 'ens er 1' Bus. Tel. No.: Address: 1V Z Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security Vork requires Department of lic Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, ti, e permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible notification of completion of the work as required in M.G.L. c. 143, § 3L. for the Permits shallbelimited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. [E01 Rule8 — Permit/Date Closed: ***Note: Reapply for new permiPermit Extension Act — Permit/Date Closed: Wrench Inspection Pass 0 Inspectors Comments: Failed Re- Inspection Required ($.) ❑ Inspectors Signature: SERVICE INSPECTION: Date: Pass M Inspectors Comments: . Failed 0 Re -Inspection Required ($.) ❑ Inspectors Signature: PARTIAL ROUGH INSPECTION: Date: Pass M Inspectors Comments: Failed Re -Inspection Required ($.) ❑ Inspectors Signature: ROUGH INSPECTION: Date: c Pass F71 Inspectors C me s: Failed Re- Inspection Required ($.) ❑ I 3� Inspectors Signature: FINAL INSPECTION: Date: Pass 0 nspectors Comments: Failed Re- Inspection Required ($.) ❑ Inspectors Signature: Date: :B WEINHO .' The Commonwealth of Massachusetts Department of Industri�cl Accidents Office of Investigations 600 Washington Street Boston, HA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician [Pl m ers A licant Information Please Print Name (Businessiorganization/Individual): Address: City/State/Zip:y����'�U! Phone #: a✓_� ����D� Are you an employer? Check t� appropriate box: 4. ❑ I am a general contractor and I 1.( I am a employer with employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. 2. ElI am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ 1 am a homeowner doing all work right of exemption per MGL c. 152, § 1(4), and we have no myself. [No workers' comp: insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. g^RemOdeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomiation. I Homeowners who submit this affidavit indicating they ai�e 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 7j Insurance Company Name:. l� Expiration Date: Policy # or Self -ins. Lic. #: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under tlt azns and penalties of perjury that the information provided above s true and correct. Znstw 4Z/' 11�) 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 #• k COMMONWEALTH OF MASSACHUSETTS ;:DIVISION OF PROFESSIONAL LICENSURE -BOARD OF; AS A REG JOURNEYMAN ELECTRICIAN ISSUES THE ABOVt �U'CPN8E TO: '- YOUNG & SON ELECTRIC CO MIRP;SLAVe -MLADY: .6.2-- NORFOLK*ISTREET' CA14BRII-DGE MIA '021397-26.22' ' X2426 E 07/3Iv/13 ,S r 833830 LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS, tc-JAN kgGISttRED,MA5,T9Rr ELECTR... yESqTHE.ABQV.E LICENSE YbUN'G SON ELF,.OT'RIG- CO Et. 0 21,.' 13047- A 9. A Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ....... ....... .................................. has permission to perform .......... / ........... ............ ... ( ........ /.� ................... wMng in the building of ... ...... ........................................................ . . . ...... -,North AndoveriMass. at ............... ... ........................... o'4 — t ........... Lic.N "I LEcTRICAL INSPECTOR Check # 16 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Comrno►twaa[!h o l�ad9acltud¢t'� For Office Use Only (Rev. 11/99) D / %� Permit Number: / (� 1J¢ParEn>,arsE o�J`ira �arvica.! BOARD OF FIRE PREVENTION REGULATIONS Occupancy &Fee APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:0/0) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: City or Town of: IV. ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location: (Street & Number) 9 I SJ Jam_ Owner or Tenant: f —{ U M V- 1!4, Owner's e_ ( Is this permit in conjunction with a Building Permit? YesNo ❑ (Check Appropriate Box) Purpose of Building: Utility Authorization #: Existing Service: Amps / Volts Overhead p Underground.❑ # of Meters New Service: Amps / Volts Overhead ❑ Underground.❑ # of Meters: dF Number of Feeders and Ampacity: Locriion and Nature of Proposed Electrical Work: No. of Recessed Fixtures No. of Cell.-Susp. (Paddle) Fans No. of Transformers Total KVA No. Of Lighting outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground ❑ In Ground ❑ # of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of Zones # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained Detection/Sounding Devices Local ❑ Municipal Connection ❑ Other ❑ No. of Switches No. of Gas Burners tt. of Ranges t� g No. of Air Conditioners TOTAL TONS: No. of Waste Disposals Heat Pump Totals: Number: TONS: KW: Security Systems: No. of Devices or Equivalent No. of Dishwashers Space /Area Heating: KW Data Wiring, 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 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 ❑ Please specify: 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. l certify, under the pains and penalties of perjury, that the information on this application is true and complete. Firm Name: L( [`t LIC. # Licensee:_��e� l — L4-)yoi- Gly Signature: LIG. # !1 tE rl �(if applicable, enter "exempt" in the license number line) Address: Z �Ya4r1� i�L LI -e ( )e.S 1 ,IT>`c1 &LLQ ,,,. T_ 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 ❑ OR Agent ❑ Signature of Owner/Agent: Telephone # PERMIT FEE: S b TAJ. o0 Qe >e -4 Date... �� ,PI1 -6 7 ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... . . I- ........................................................ . .............................. has permission to perform ..� ...... .. ............... .............................. wiring in the building of ....... ............... --. ............. ..... . ........ .... ... .............. at ..... �-3.7 ....... " ...................... . North Andover, Mass. 7' Fee/7Z...'—.... Lic. NoFg:�.�t;?-� .............................................. ELEcrRICAL INSPEcrOR Check # 7662 V rtJ Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] 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: City or Town of: P • 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) -5 T Owner or Tenant V.:�A V I ,(` © S -A Owner's Address 4' i...� Telephone No. Is this permit in conjunction with � as build' ag permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building s L-6th4', „C.•� Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Utility Authorization No. s*# -'k X1.1 �._il 4-`A G R^ t L .d.� % No. of Meters No. of Meters Completion ofthe foillowine table may be waived by the Insoector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. ofTotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Abov❑ In- e ❑ nd. nd. o. o Emergency Lighting Battery Units ' r No. of Receptacle Outlets 3 ''1 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners N-o—.of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers eat Pump u...er ........ ..................... ons ................... o. of e - ontaine Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [-]municipal El other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. ofater, o. of o. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Te ecommunications iring• 1 No. of Devices or Equivalent OTHER: 04 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1 O O (When required by municipal policy.) Work to Start: _ .G Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE!: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation” coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and p naldes of perjury, that the information on this application is true and complete. FIRM NAME: rn'Q i >`-� q- co rp LIC. NO.: A JS6 E Licensee: Si Si re LIC. NO.: E 3 (If applicable, enter "exem t" in the lice number line.) uJ %%(w Bus. Tel. No. ��8Z Address: t Z 4tj ct.Q ar �,.z.1.�. 2\G A Alt. Tel. No.: --I 79 - 6 14-W 97 *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent PERMIT FEE. $— Signature Telephone No. I j Date. 11—'26' . . ..... ................. .. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .......... ... . ............ .................... ....... has permission to perform ............................... wiring in the building of --> ........................................ ....................... at:��.z ...... ....... & .............. i.i .............. . North Andover, Mass. /';L5 6-1 Fee;� ................... Lic. NXxgr�l.....-� Check # 7063 I Commonwealth of Massachusetts official WY Perinit No. o r Department of Fire Services Y Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS FRev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordancc with the Massachusem Electrical Code (*MEC% 527 CMR 12.00 (PLEASE PRINT IN INK OR TYP ALL NFOTdON) Date: City or Town of; tn To the Inspector of Wires: By this application the undersigned wives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9 / i,a h C5f,v P_ f Owner or Tenant (Owner's Address Telephone No. Is this permit in conjunction with Auilding permit? Yes ® No ❑ (Check Appropriate Boa) Purpose of Budding Utifity Authorization No. Existing Service Amps ! volts New Service Amps ! volts Number of Feeders and Ampaeity Location and Nature of Proposed Electrical Work: +Overhead ❑ Undgr+d ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completiint of the followmR table may be waived by the hmrctor of ff'ires M No. of Recessed F t rr%tr res No. of Cell-Susp. (Paddle) Fans NO. of Tota Transformers KVA , No. of Lighting (Outlets (gyp No. of Hot Tubs Generators K -VA No. of Luing Fixtures Cp Swimming Pool AbovIn- d.e ❑ d. ❑ PRgea Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 2, No. of Gas Burners o. o _ n an brit Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Defaces No. of Waste Disposers eat nunp Totals: I NumberonsKW ' No. o Detection/Atertin Devices Na, of DishwashersAlunial , SpacelAr+ea Renting ICY Local ❑ Conne�e !❑ Other No. of Dryers Heating Appliances KW Securlh' No. o -roes or Equivalent No. o aterKW Heaters o. o o. o S• s Ballasts Data W. . No. o;Xvices or Equivalent No. Hydramaswige Bathtubs No. ofMotors Total IIP innsirutg: No. of Devices or Equivalent OTHER: ' Attack additional detail if destred, 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 91 BOND ❑ OTHER ❑ (Specify) (_.��� (^ C) Estimated Value of Electrical Work (Expiration Date) SGY�C> (When required by municipal policy.) Work to Start:�2�/Z-6 ( Inspections to be requested in accordance with MEC Rule 10, and upon ootnpietion 1fy, under thtepairts a>l petuthrks 4o r, jury, that the infj abort on this appfication is true and conjpkA . FIRM NAME: t LIC. NO.: -4916 E% Licensee:Xf3 hp Y-4 _ Signature LIC. NO.: (ffapplicable, a er "exempt"in ehoeme ngolber lute) Bus. Tel. No.• Address: /� baa/ Ob im e_,f t' 07/0 Alt. Tel No.: OWNER'S INSURANCE WAIVER.• I am aware dist the Li stmt ham the liability insurance coverage normally required by lain. By my signature below. I hereby waive this requirement_ I am the (check one) ❑ owner 0 owner's a nt_ OwnerfAgent Signature Telephone No. PERMIT FEE. $ Paul Dovies - September 28, 2007 Mr. Gerald Brown, Inspector of Building North Andover Building Dept 400 Osgood Street North Andover, MA 01979 Re: Report - Rough Partial Tenant Fit Up Aurora Imaging Technology, Inc. 39 High Street North Andover, MA In accordance with Section 116.4 of the Massachusetts State Building Code, I hereby submit my report for the rough framing of the partial tenant fit up. Inspection of this took place on September 28, 2007 and the following was observed; All metal stud walls have been installed, and generally in accordance with the approved plans submitted by this office. truly yours Ve V" Paul L Davies, AIA Mass Reg. #3280 ' i 1-• 4 C � WESTFO,iD c a 44 ria ..... •* �����i_s� 635 Rogers St. Unit 4 Lowell, MA 01852 978-459-2154 N2 ,AORTot ;0 0 449L A JS This certifies that //' �i - Date.Z�L—r-" TOWN OF NORTH ANDOVER PERMIT FOR WIRING ............................................................................................. has permission to perform . .............. ................... wiring in the building ........... ....... 000!�� . ........ �/ .................... at ......... . ....... z ............ .. North Andover, Mass. ....................... Fee/� .................. Lic. No . ............. ............................. ; ........................ ELEemicAL INSPECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Official Use Onnii! Permit No.(O�rJ rrie�ianteueat o� �u�lie Sci�etry BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checkedl� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 5217 CMR 12:00 (Please Print in ink or type all information) Date l0 " GG To the Inspector of Wires: Torr, of North Andover The undersigned applies for a permit to t'o perform the electrical work described below. Location (Street & Number / 1�a i Cj j--, S+ Owner or Tenantt��P (� , Owner's Address_ Is this permit in conjunction with a building permit Yes ❑ No (Check Appropriate Box) Purpose of Building_ i `� ia�� ``� Utility Authorization No. Existing Service Amps Voits Overho ad ❑ Undgrnd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity 1 Location and Nature of Proposed Electrical Work tv't �t —7-� No. of Lighting Outlets No. of Hot fuse i orai No. of Transformers KVA No. of Lighting Fixtures No. of Receptacles Outlets. Swimming Pool No. of Oil Burners Above ❑ In ❑ grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting Batte Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Ranges No. 5f Di osal No of Air Cond No. Total Tons Heat Total Pum s . To Total KW No. of Detection and Initiating Devices No. of Sounding Devices No. :?f Dishwashers Space/Area HeatingNo./ KW of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW ❑ Municipal ❑ Other Local Connection No. of Water Heaters KW No. of Signs No. of Bailases Low Voltage Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equi lent YES = NO = have submitted valid proof of same to the Office YES = NO = If/you have checked YES please indicate t e e of coverage by checking the appropriate box. INSURANCE = BOND = OTHE (Please Specify) Estimated Value offillectricalWorkV A,,0 ®1 (Expiration Date) Work to Start Inspection Date Resquested t.0�� Rough Fu Signed under the Penalties of perjury: i FIRM NAME I i 'I F % L'C �—f� �� LIC. NO. A Lr"qensee_2,n hn f'Signature LIC. NO. E r' Address_Jp.GO r. �C> J d r� �� „ �L� t Tel. No. s. Tel No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Oj Telephone No. PERMITTEE / C N2 .. �.0117Z . -6N 9 Date..... z ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... �'i .................................................................................. has permission to perform ....................................... 4 .................... J A wiring in the building of P� ......... .............. .......... .... .......... ........... .......... ................................ j ...................... . North Andover, Mass. .. .............................. Fee/ '7� ..... Lic. No!E�(�.�(- ....... , '/ Check # ";-4142 - — ELEcrRICAL INSPEcrOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer '�'•�•� IIm L1UYY1LY1CJ1Yffr-1%C.111 Up 113 umce use oruy/ p DEPARTAf&WOFPUBLJC&4FM Permit No. CF 7 BOARD OFFMEPREVEVHONRE M77ONS527Cti 1R 12.00 ' Occupancy &Fees Checked APPLICATION FOR PEP-Aff TO PEJ?FORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date�,'10/00 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street b Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building �.�-�vJ�tt�Utility Authorization No. Existing Service Amps/ ,Volts Overhead Underground No. of Meters New Service a5 Amps ;V/1ALP, Volts Overhead ® Underground No. of Meters Number of Feeders and Ampacity >„ocatton ana Mature of rroposeu rstectncat worts 4Z Ly c w_ FlJ•}-1� 'C 1 0--- Flt^ h- No. of Lighting Outlets ID No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total is Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW ? No. of Self Contained Detection/Sounding Devices Local® Municipal Other No. of Dryers Heating Devices KW Connections ® No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER h reCa�aage Rim" tDthem4wen>aitso(NL%mdxsdlsGenera1Laws I ha,,ea=atLiabkhePthcymdjiugCmpide CmeaWcrksablataleWrivWat YESNO ,4Ihawsutxrtittedvandptoofofsarwbfhe0(II. YES 0 NO® lf}cuhavechedcedYES, pleaseinditthetypeof byd=ldrgthe q4xL QNiSURANC BOND ® OTHER, VlmseSleffy)— i ETxi�lficnD& Estim&i Vans dElertrical Wok WodctoStat I spetionD*-ReWesWd Ro# `� (° Ftrial Signed trderTfir; Rambles ofpajtay. \ � � � �'� C� � '-7 FIRM Is�eNn— 1 Lioaisee C•ra-N�`P'r\sem Sig a - Li eNo ' f �Y,� zj Brsates aNa OWNER'S INSURANCE WAIVER, IamawareflAdeL = riot trmm= A�TeINa al I oa�ssle�trivala�asrecgr¢adbYMmmtaBemGmaalIaws anda�mysisec�Ithapan�appl�ionwai�this regttiranag. (Please check one) Owner Agent � ,) Telephone No. PERMIT FEE o Date .... �A/� ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that J.. ...................... . ...................... has permission to perform .. �/� �;;- ..... ..... ...... ....... wiring in the bdildl]70f.,7�,*/,/J.A..)z.a—....,k,9-.-///.,�,.,.*,-",/ at ...... .................................. . North Andover, Mass. M 1,Ae Fee �2M� ......... Lic. No.A? .... . 4 ... *** m- ............. - I ........... ......... ELEcrPdcAL INsPEcToR Check # J�4�7 5513 /iilf����oz7 /2--3c--0C/' The Commonwealth of Massachusetts Department of Public Safety / BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12:1 Permit Na. Occupancy 4 Iter Checked 3/90 (kava blank) APPLICATION FOR PERMIT TOP ��f RM ELECTRICAL"1NORK All work to be performed In accordance with the Ma Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INR OR E ALL INFORHATIO ) Datee�,� City or Town of To the Inspector of Wi s:• The undersigned applies for a permit to perform Che electrical work described below: Location (Street h Number) -3f 1-1161-6 S71' Geer or Ienanc Owner's Address 0 J D c S 0 LL Is this permit in conjunction with a building permit: Yes ❑ No 10 (Check Appropriate Box) ?urpose of Building_ I,) =16r ' Utility Authorization NO. =xisting Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Few Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Naber of Feeders and Aapacity Location and Nature of Proposed Electrical Work p� Ttnl Q /00 /a IZ64eij OTHER: INSURANCE .COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current ability Insurance Policy including Completed Operations Coverage or its substantial ea�.4valenc. YES W NO C] I have submitted valid proof of same to this office. YES ❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE CK BOND ❑ OTHER ❑ (Please Specify)-, xpiracion Date Estimated Value of Electrical Work S Work to Start f Z -(3 — (0(, Inspection Date Requested: Rough Signed under the penalties of perjury:' FIRM NAME Licensee Address Ca Final / Z -'��s'�y LIC. NA -1962,6 0 LIC. NO. E/ 01 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stancial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent No. of Lighting Outlets No. of Hot IubsNo. of Transformers Total INA No. of Lighting Fixtures Swimming Pool Above ❑ ❑ lGeneracors grnd. KVA No. of Receptacle Outlets No. of Oil Burners (No. of Emergency Lighting Matte Units No. of Switch Outlets No. of Gas Burners (FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of'Air Cond. Total tons Initiating Devices No. of Sounding Devices No. of Self Contained No. of Disposals.Eai, I No. of Heat Total Total Pumos Tons KW No. of Dishwashers Space/Area Beating KW Detection/Sounding Devices Local El Municipal ❑ Other No. of Dryers(Heating Devices KW Connection No. of Water Heaters No of No..or Siens Ballasts r Low Voltage trine No. Hydro Massage Tubs INo. of Motors' Total HP �I1 OTHER: INSURANCE .COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current ability Insurance Policy including Completed Operations Coverage or its substantial ea�.4valenc. YES W NO C] I have submitted valid proof of same to this office. YES ❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE CK BOND ❑ OTHER ❑ (Please Specify)-, xpiracion Date Estimated Value of Electrical Work S Work to Start f Z -(3 — (0(, Inspection Date Requested: Rough Signed under the penalties of perjury:' FIRM NAME Licensee Address Ca Final / Z -'��s'�y LIC. NA -1962,6 0 LIC. NO. E/ 01 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stancial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent Locatior No. Date 0.1 14ORTIJ TOWN OF NORTH ANDOVER AL Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspe,-Yor TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING s , y i s �.p c'This Section for Official Use Only *..?�� - ` aT �� s.y 3 J <' Dr k C r, �-%K . t �..'-77 BUILDING PERMIT NUMBER: � aar 0 DATE ISSUED: *7 4 SIGNATURE: A • Building Commissioner/I or of Buildings Date SE 1. I PropertygAddress _--S 1 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zonin g District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BT DING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required I Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ 2.1 Owner of Record V111'. PRoPec���s � 4wk 82d Na�Print) Address for Service 5?78- �1�bk- S70 Signature Telephone 2.2 Authorized Agent 2ePvbClc, �, «w ��►�� ST Name Pnn Address for Service: 7 - %S-0 -00,? Sig a e Telephone `5Et i`I+Clt+f3�•a£ 3.1 Licensed Construction Su rvisor IZAJS Not Applicable ❑ Address License Number Expira ontt�Date Licensed Co struction S sor: 6e .s4at/. Telephone 3.2 Yegistered Home Improvement Contractor ) Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone t!z SECTION 4 - WORKERS COMPENSATION 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. Siened affidavit Attached Yea ....... No ....... 11 SECTION 5 - PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR $UILDWGS AND STRUCTURES SUBJECT,.TO CONSTRUCTION CONTROL PURSUANT TO ?SO CMR I.I.6 (CONTAINING MORE TfTAND. 35,b00.CF. OF ENCLOSED SPACE) 5.1 Registered Architect: Name:ttr)�,a- Address <- 9-?(?)- (17V- 6t-lol Signature Telephone 5.2 Registered Professional Eagineet(s). Area of Responsibility. Registration Number Expiration Date Name: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Not Applicable 0 Company Name: Responsible in Charge of Construction I,f�""e5 l.>✓t��►� (�d1�Lie �(_Jfi/ /+'tai �L�t%i9�, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name n i 7 of Owner/Agent Item Estimated Cost (Dollars) to be uS$ -OI+1j, Completed by pernut applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction from (6) 3 Plumbing Building Permit fee (>> X (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) L Check Number /So • oc� NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr 2 0 3 PD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE le `% f � S$CTI0N-.4.DnGWTI0N. OF PROPOSED WORK (check ail .l7.bL--1 New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) Addition Accessory Bldg. ❑ Demolition ❑ Other Specify Brief Description of Proposed Work: SAD P� )4 ie/y O uP2 CONSTRUCTION TYPE A Assembly ussy:uns , - von�.wlwX:Rl!W I. VPfJllcUF:liVPf.`.2;Y�L�;' :: USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-] 0 A4 ❑ A-2 ❑ A-3 A-5 0 ❑ IA 1 B ❑ 0 B Business 0 2A 2B 2C ❑ 0 ❑ C Educational ❑ F Factory 0 F-1 ❑ F-2 ❑ H High Hazard 0 3A 313 ❑ ❑ IInstitutional 0 I-] ❑ I-2 0 I-3 0 M Mercantile ❑ 4 0 R residential 0 R-1 0 R-2 0 R-3 0 5A 5B ❑ 0 S Storage ❑ S-1 ❑ S-2 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height (ft) Independent Structural Engineering Structural Peer Review Required Yes 0 No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date The Commonwealth of Massachusetts ^� �(_: Department of Industrial Accidents Otflcso!/nyest/gallans 600 Washington Street Boston, Mass. 03111 Workers' Compensation Insurance Affidavit I am., a homecwner.percrmmnz all work myself. I am a seie propr=e:or and have no one workinc in an,/ capacirt I am an emcicyer pprrovicLna w(Orkers' compensation fort my employees worxm2 on this job. c2mQ rJ r1T,2: 1`Q��ih�lC J1 Utm C) ...0 nOa= S/ C." r-- hgiwea-s me on( -s 29- 70-a)99 u W I = a sole procre:cr, Dene r=1 con[rac:ar, or homeowner (c:rc:e one; and have hir.d the ccae-ac:ars lis -,ed below,, a"ve t.e followins workers' ccmcensation ;:clic:!-I: Fa,iurc :o scour; co-crage as requ,rca unucr �r_aon _�A of .tiIG:. l5' can iced to the imoosr[ton of cnm,n�l pcaait:c of a fine uo to S1_'t70.!}0 >tae,'ar ooe year_' imcrsonmcar a �c:1 as cvii rcnaiucs in the furm of a STOP WORK ORDER and a fine oi51100.00 i day 2g2insr me- ( underund :Car 3 coo- of ;Iia sta:emca[ ma- 'ac :o the OfFicc of Invcsug puns of rhe DIA for cover=;^ Ycr:5c3dcn. ! do he: -COV per a Jra'er:he?ai.ns and c i 2:...--• - of pe^urs that the inJarmadon provided above is trn•e and carne O ofTic:at use an,y do not -roc in :his arcu to be compic:cu by c:r+ or ;own utTicisi cirt or :own: permia!iccnsc c..^.e:x if immC�i ltG rG`7Un5e :I re�Ulf'Q cont -c: pc: -:on: phone.:: r'Buddiag Dcpar,:acst Licensing 3o2ra ORcs Hc]I[h Dc32rmc3t —O[ncr Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street + North Andover. Massachusetts OIS" 5 WILLIAM I. SCO -17 Director (973)638-9=:1 Fax (973) 68S -Q;.; 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 MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE.- Demolition permit from the Town of North Andover must be obtained for this proiec: thrcu.c-h the Office of the Building Inspector W 9 21_1LDI`G 6 5 4 f CONSE:,VAT'ON P r !\. 3 -- June 23, 2000 Mr. Michael McGuire Building Inspector Town of North Andover 27 Charles Street North Andover, MA 01845 Dear Mr. McGuire, This letter will serve as my approval as the representative of Yale Properties, Building Engineer for North Andover Mills, that the attached documents as specified on Exhibit 1 for the erection of stud and sheetrock partition over an existing steel roll -up door (rendering the door inoperable) to be approved as noted. Please note the location of this work (Building No.34) as indicated on the attached Locust Plan. Attached please find (3) stamped/signed copies of these documents along with affidavits marked Exhibit 1 for your review. If you should have any questions, please do not hesitate to call me at (978) 682-9494. Many thanks for your time and assistance in this matter. Sincerely, Arthur Boujoukos Building Engineer North Andover Mills One High Street, North Andover, Massachusetts 01845 Tel.: (978) 682-8708 Fax: (978) 682-8713 AFFIDAVIT FOR ARCHITECT AND ENGINEER THE COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS SS: COUNTY OF ESSEX On this 22nd day of June, A.D. 2000, before me, the undersigned notary public, personally appeared Linda S. Smiley, who, being duly sworn, deposes and says that she will review the preparation of Interspeed tenant fit -out work on the first floor of Building 34 at North Andover Mills in North Andover, Massachusetts; and that she will review and/or provide for the proper checking of all the working drawings and shop drawings for construction; and all modifications to the existing structures will be designed for construction in accordance with applicable provisions of Chapter 1, Section 116, Massachusetts State Building Code, and that such plans conform to all the applicable provisions of the Massachusetts State Building Code, and that all the materials used in the construction will be selected by specification by her or her registered professional Designee in accordance with the Controlled Materials Procedure therein defined. Z�&d� - Linda . Smiley Sub ri ed and sworn to before me thiel day of A.D<� - 0_05 / I - / "A�,��/� WoCary Publi,1 My commission expires on \Wdv_file\projects\Projects\Affidavits, Bldg. Insp. Letters\INTERSPEED BLDG.34 AFFIDAVIT.DOC N®tsry Pubk ®� ®nwowth of Msssech'U— �y 00MM11010n Ex pires Juno 9, 2008 WATER STREET TT TT TT TTTTT TTTTTTTTITTTTT7Tg17fTT7T7T7777TTTT ...... .. ... ....... I I I I I. .... . T T T 7 I I I I I I I I I I. I 7 47 (d (o-23-O,a NOT TO SCALE -dj - LY I --------- ------ -SEE -r-- SEESK -2 FOR ENLARGED PLAN ------- _AND AND DETAILS OF THIS AREA. ----L.-- - --} ---0 -;+;- - W 5LDG, 34 v v7 T T T T T ii ii Iii i i• i i i I I i i i` = I �t-�--i it I l l i i i i i i i i i l i i i i i I I I I I _i FTI i -i-i- TM, T, ; l �� /�FO�► @tea I � �$ MASS. 1 OF N1`'S' INTER5PEED INS, BLDG. 34 Burt ��� ��� � DrawingDrawing �o. 39 HIGH STREET � 300 wicks¢®ne Square SK -I NORTH ANDOVER, MA. 01845 Andover, Imo! 0Il8Il0 Date 978474-640 5 lCt�.9g8-�4'��° ®Il (d (o-23-O,a NOT TO SCALE i i i -------- ------- --------------------- - - {}-- ---------------------------------------------- ----- i i i i i I ---------------------------------------------- -i- -} - --------- --- - - - - - - - - - - - - - - - - - - - SCOPE OF WORK r•-•-•-•-.1. .i i !NEW WALL - 3 5/8" MTL. i. STUD a 16" O.C. WITH RIcJ INSULATION AND POLY FILM i ON DOOR SIDE SURFACE. 5/8!' i GWB ON ROOM SIDE SURFACE WITH PAINT (NO BASE). SECUREE}<ISTING OVERHEAD DOOR TO, JAMB TO RENDER DOOR NdN - OPERABLE. i _ ------------------- - ------- ---'---- ---- - --- ------------------------------------- #---- - _ --i--- 1 ------Y------------- L-.-.-.-.-. .-.-a '/k FAFT I T I ON FLAN SCALE 1/8" = I'-0" L RETURN NEW PARTITION TO EXTERIOR WALL. SECURE NEW PARTITION TO EXISTING BRICK SURFACE AS REQUIRED: SECTION THfRU NEW FART I T I ON SCALE 1/4" =` I INTER5PEED, INC. 5LDG.34 BuftHMKow Riaehnam Awdatm 1Dming No. 39 HIGH STREET 300 Brickst®mar 8gwaae 5K-2 NORTH ANDOVER, MA. 01845 Andover, MA 01810 978-4705 m Date Scale AS NOTED FAX: 978-474--6401 06-23-00 T 7� O 1 0 RS 0� w ° x d v u �, o w2 a cn o z z Q 5 o •° v °" v w x w z �¢ z A w P-4 w v c o z V) o cn a� c A!c� Q co y-� % cc o r Qv LEL Cc Cc �CO Com: •� �Q o ►- h �a� ♦.':oar oo-- CM y m c ' m m L oc N : COm 3 L w-. c C CIO WitO N ca O .mE cc o 0 CLC_cm N 0 c �. 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