The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 395 CHESTNUT STREET 4/30/2018 395CHESTNUTSTREET 210/098.0.0080-0000.0 MAPO Box 55098 Boston,MA-02205=5093 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER,MA 01845 NORTH ANDOVER,MA 01845 RE: Insured: RICHARD A PINEAU and CHRISTINE M PNEAU Property Address: 395 CHESTNUT ST,NORTH ANDOVER,MA Policy Number: HMA 0016138 Claim Number: BOS00060322 Date of Loss: 3/17/2015 Company: Safety Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy'number,date of loss and claim number. Daniel Magee Claim Examiner 5/1/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston,MA 02205-5098 Phone: (617)951-0600 EXT 3551 Fax: (617) 531-2758 Email; DanielMagee@Safetylnsurance.com PO Box 55098 Boston,MA 02205-5098 617-951-0600 _ :r r Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER,MA 01845 RE: Insured: RICHARD A PINEAU and CHRISTINE M PINEAU Property Address: 395 CHESTNUT ST,NORTH ANDOVER,MA Policy Number: HMA 0016138 Claim Number: BOS00056251 Date of Loss: 3/17/2015 Company: Safety Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate,please direct it to the.attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Joshua Terenzoni Claim Examiner 3/18/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston,MA 02205-5098 Phone: (617)951-0600 EXT 3287 Fax: (617) 531-6648 Email: JoshuaTerenzoni@Safetylnsurance.com ' Date..(.. ......rPl ; f Not+rM 1 o:;•,� ":' "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� a �aR�,This certifies that ............... Az ......... T4N- ......... ........................ . has permission to perform y s wiring in the building of.............. ......................................... at......... 7..5 ! ` !r!�/l.....ST .............North Andover,Mass. k Fee.1 Lic.No.....1 k-'17' 7 ..... •E CTRICALNSPECrtl 4 Check N —w l i F 10417 Common-wealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee,Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Dectr'ca Code, (PLEASEPRflff NNK OR YYPEALL EVFORMATIOA9 Date. T 0 S P City or Town of: NORTH ANDOVER the 41n By this application the undersigned gives notice of his 0r her i cation to perfotm the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building -_Utility Authorization No. Eidsfing Service Amps Volts Overhead F-1 UhdgrdEJ No.of Meters New Service Amps volts OverheadF] UndgrdF1 No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: jej Completion of the following table may he waived by the Inspector of Wires. No.of Recessed Lumian-n;]7e-s No.of Ceill.-Susp,(Paddle Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [I Jh- -E] N-O.-Of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlet's No.of Oil Blowners F-MX.A.LAMMS INo.of Zones No..of Detection and No.of Switches N• o.of Gas Burners Initiating Devices No.of Ranges No.of Air Concl. Total Tons No.of Alerting Devices Heat Number I Tons f Self-Contained No.of Waste Disposers lumber................ No.o Totals- .......... Detection/Alerting Devices -1 municipal No.of Dishwashers Space/Area Heating KW Local El Connection r_1 Other No.of Dryers 'Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: . Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: c Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of ElectriSWork: (When required by municipal policy.) Work to Start: PS 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 coyerage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND El OTHERTI (Specify:) I certify,under the pains and penalties ofperjury that the information on this application is true and comple4 FIRM NAM:C SU c— LIC.NO.:/''-q 7 Licensee: Ce2&(jC\L/ SignatureLIC.NO.:!�� ffopplicable,enter"exeTRt"in the license number line. Bus.Tel.No.: &6-5 Address: 0-30? Alt.Tel.No.: 9:7e q2-5 *Per M.G.L c.147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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)[I owner ❑owner's agent i4e Commonwealth of Massachusetts /� ( Dep4wment ofIndustriad Accidents M Office of Investigatiom t iiii r° 600 Alarhington Street Boston,MA 02111 wW .VWSggov/dia . 'Vllo . rkers'Campensation Insitaranee Affidavit:Builders/Contr�ctors/Eleetricians/Plumbers Apt>rlicant Information Please Print Legiblo Name(Business/Organi-tion/Individual): Address: City/.State/Zip: Phone#:. F2. nEn] re you an employer?Cbeck-the appropriate.box: ' I'aI am a genera[contractor and Im-a employer With 4, Type of prgjeet(required):❑eployees(full and/or parttime), have hired the sub-contractors 6• ❑Newconstruction I m.a.sole proprietor.or partner- listed on the attached sheet.t 7• ❑Remodeling y ship and.have no employees These su&contractors have 8. ❑Demolition, working for in any capacity, workers' comp,insurance. 9 [No workers comp,insurance 5. ❑ We are a corporation and its ❑Building addition required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ I ain a homeowner doing all work right of exeinption per MGL 11.❑Plumbing repairs or additions myself,[No-workers'camp. -c. 1.52,§1(4),'and we have no insurance-required.]t •employees,[No workers' 12•❑Roofre'pairs camp.insurancerequired.] 13❑Outer °Any applicant that checks bo$#I mast also fiif ou HameovmErs who submit this a davit t the section below showing theirworkere compensation policy information, t lndicating they 210 doing all work and then hire outside conaactors must submit a new- idavit indicating such. �Coatzactots that check this box mastettached an additional shyct shawl the nye afihe sub conhactor and th€i .-aromp.Fo1i :; ;erro I ain an Employer that is pryuidbig: e®MpeR.se dOR insurancefor a Inyees:informadonfed®u is the oldc andJ®b sie Insurance Company Name:' Policy#or Self-ins.Lie,#: Expiration Date: ra Job Site Address: r City/State/Zip: Attach a copy of the workers',compensmtion 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 tc•$1,300.00 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 fy under the pains ai:dpenalties of perjury that ti:e information proveded above is true and correct Sittrtature: - Date; Phone#; L[6.0th6r only. Do not w.rxe 6�s,��is a:ea,to bz cn.;,p' �d by eu`,✓or tvw:t official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/T•own-Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#: Location --:3 �� C��s L)� j No. Date Cy f MORT1y 3:O • TOWN OF NORTH ANDOVER f ��f,•o .M�0 • ; Certificate of Occupancy $ Buildin (Frame Permit Fee $ g s�cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 17 ' Check # if 164 € 9 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER DATE ISSUED. _ M SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: , Oct. Map Number Parcel Number O �nGfOr`A' . 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot ATea(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided v 1.7 Water SupplyM.G.L.C.Q.. 54) 1.5. Flood Zone Information: 1.6 Sewerage Disposal System: n Public 0 Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District:Yes No III 2.10 of Record Name(Print) Address for Service: 91 i Signature Telephone W 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 3.1 Li6nsed Construction Supervisor: Not Applicable ❑ 9t-%erJ ctn�rl;.4r-3 Licensed Construction Su rvisor: �S �3 O License Number Address a 9 7 0 Expiration Date O� ic tgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑C-�"- v A Company Name f CS 9(,►S m (� �4 GSI Registration Number r ` � Address 7�1 7 7F YS-1, Expiration Date nature Telephone SECTION 4-WORKERS COMPENSATION(XG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check allapplicable) New Construction ❑ Existing Building X Repair(s) Alterations(s) JQ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: `'1 -0'Jc - kJc4,, , C"4.3� 9,+&'C24d/ c;#,u/rAQj �st�,rf' tie� S��.l•ti. �o� o K�,�.,,. cat�o�. � SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Q C (JSE:pNLY Completed by permit applicant _ 1. �. Building a Building Permit Fee . Multiplier 2 Electrical (b) Estimated Total Cost of — Construction v 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total, I+2+3+q+5 1% •�y+ -• .i l++• Check Number 97 C7 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT 1>�� (]-e r-a as Owner/Authorized Agent of subject property I lereby authorize to act on My behalf,in a;1 matters elative to work au rued by this building permit application. - , a6-p-)-03 SiSi n�f Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, (z nn t?o.-! as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 7 / I 4 ti Print Naive - -2'7 —6-2 SignaturFof Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS i DiMENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE P.� Glenn Gary General Contractors 60 Island Street Builders Lic.# 058238&065519 Lawrence, MA 01840 Home Improvement Lic.#105965&122124 Telephone 978-557-5981 978-469-0055 Lawrence Haverhill Fax 978-557-5439 Glenn Gary Buddy Latham CONTRACT PROPOSAL FORM Prepared Rich&Chris Pineau-= For: Date: "-04fI5T2003 = Telephone: 97.$)683-1569 Location 395 Chestnpt Street 14o th'Andover Ma*tW General Description of Project: Bathroom Addition, Kitchen Renovation, and In- law Conversion Kitchen Remodel , • Demolish kitchen cabinets to included wall cabinets, base cabinets, and island cabinets with counter tops • Demolish tile floor and dispose of waste 4 • Demolish kitchen ceiling and dispose of waste p • Remove existing kitchen window and dispose 2 • Reframe opening to accept new Anderson#C33 • Purchase and install new Anderson#C33 0 • Sheetrock kitchen ceiling and exterior wall and tape three coats 0 • Purchase and install Brookhaven 2 Edgemont Full overly maple as specified per 7 design by Chris Ann Sullivan 02/28/2003 o • Purchase and install Black Galaxy granite counter top as specified per design by q Chris Ann Sullivan 02/28/2003(basic edge) (� • Purchase and install tile back splash 4"x 4" Pagliarino(no decos or borders included) J • Install one of each of the following appliances supplied by owner(model numbers included) : 1. Kitchen-Aid 42" Refrigerator KSSC42FKS 2. Kitchen-Aid 30" Double Oven KEBC208KSS 3. Kitchen-Aid 24" Dishwasher KUDS01FLSS 4. Amana 36" Electric cook top AKT3650SS 5. Broan 36" Downdraft 273603 6. Sharp 2 Micro R530ES 7. Sharp Trim Kit RK51 S-30 8. Delivery of the 42"Refrigerator Great Room • Remove sheetrock from entire cathedral ceiling and gable end wall.to expose existing framing • Remove existing great room counter top and dispose of • Reconfigure existing cabinets to accept new appliances (please note the layout was not measured by a kitchen designer and if the appliances do not fit the home owner accepts full responsibility) • Install one of each of the following appliances supplied by owner(model numbers included 1. Marvel 15"Wine Captain 30WC-B-S 2. Marvel 24" Icemaker/Refrigerator 6RFI-B-S 3. Marvel 24" Kegarator 61 HK-BS • Purchase and install new Black star Caesar stone counter top with back splash(basic edge) • Demolish existing bedroom walls and dispose of waste • Install new 2"x8"collar ties 16"on center and strap ceiling • Reframe gable wall to accept 6 new Anderson windows • Purchase and Install Anderson#C25(one), #A41(one),#C15 (two),#A21 (two) • Sheetrock new great room ceiling and gable wall and tape three coats • Reframe door opening to accept a new 6'-0"x6'-8" French door • Install new 6'-0"x6'-8" French door Living Room • Remove existing wainscoting and dispose of • Remove trim around existing beams and dispose of • Trim existing beams with pine and install crown molding around entire room Electrical • Supply and install new Panasonic fan for first floor bathroom • Install three separate circuits to bar area(kegerator, mini refrigerator, and wine cooler) • Purchase and install eleven (11)recessed lights with white trim (kitchen) • Purchase and install eleven (10)recessed lights with white trim (great room) • Install wiring for two(2)ceiling fans(fans supplied by owner) • Wire for two pendant fixtures over island switched separately(fixtures supplied by owner) • Wire for hanging light over kitchen table switched separately(fixtures supplied by owner) • Purchase and install two(2)four inch recessed over sink area switched separately • Purchase and install three(3)under cabinet lights • Install outlet on new island in kitchen • Install two new circuits for lighting in hutch and glass door cabinets • Demolish existing 12 circuit sub panel and install new 24 circuit sub panel Plumbing • Install owner supplied kitchen sink and faucet • Install owner supplied bar sink and faucet • Install water supplies for two ice makers • Purchase and install two (2)toe kick heaters Painting (colors picked by owner) • Prime and paint great room ceiling and walls • Remove family room wallpaper, prep, prime, and paint walls,trim, and ceiling • Remove kitchen wallpaper, prep, prime, and paint walls, trim and ceiling • Remove dinning room wallpaper, prep, prime, and paint walls, trim, and ceiling • Remove foyer wallpaper Prep, prime and paint walls, trim, and ceiling • Prep, prime and paint new master bathroom walls, trim, and ceiling • Prep, prime and paint new walk-in closet walls, trim, and ceiling • Prep, prime and paint new cedar clapboards to match existing as close as possible Miscellaneous • Remove existing carpet, pad, and tack strip and dispose of waste • Purchase and install 3 '/4" natural maple pre-finished hardwood flooring in the great room, family room, kitchen, and master bedroom walk-in closet • Remove ceiling in deep bay of garage to provide access to plumbing and electrical • Sheetrock ceiling in deep bay of garage and tape three(3)coats 0 Purchase and install 2 '/"colonial casing on new doors and windows • Purchase and install 3 %"colonial baseboard to new walls • Purchase and install cedar clapboard around new windows • Install two toe kick central vac receptacles(one in the kitchen and one in the bar) • Purchase of plans • Securing of local building permits Total Cost Acceptance of Upon When great Upon Upon Estimate Proposal installation of room is dry completion Completion $80,420.00 $16,084.00 great room walled of hardwood $16,084.00 windows $16,084.00 floor $16,084.00 $16,084.00 Please note price dose not included:grills for new window,any plumbing fixtures,any eleetrial fixtures above and beyond that which is listed - 12� Please review this Proposal and if acceptable please sign both copies and retain one for your files.If there are any changes please modify this Proposal by marking the changes and providing us with the document for review and preparation of a final Prop Thi p p 1 may be withdrawn ifcepted within 30 dams. not Accepted: By: ) Date: ( tomers Signatura� 7i Francis Latham __ Date (Contractors Sigp res _�/ NQRTH Town of Andover .a - TO No. 0� -OC L� W,�� lover, Mass., ADRATE D P?p0 �C3 BOARD OF HEALTH Food/Kitchen PERMIT T.. D Septic System tt-- P(..*Aj. '4..k0 BUILDING INSPECTOR THIS CERTIFIES THAT...... .�. ...!!�.13.r` ........... ... ....................................................................... Foundation has permission to erect.... ..... buildings on .....3.0 C .N.v S Rough to be occupied as...Y%T.C. ..t.. .Cw....V�I..ty d .. ... ?. �. !p.r. .. ... himney C provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection Alteration and Construction of Buildings in the Town of North Andover. d or./ 8o goo . PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR CRough .. ....... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE smoke Det. REVERSE SIDE 1 Date. .?- ./-.C' . . ".`°T"1� TOWN OF NORTH ANDOVER . o PERMIT FOR PLUMBING ,SSACHUS� �,/, This certifies that . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . :-.f-1 7"- ` .`. . . . . . . . . . . . plumbing in the buildings of . . .PA-. lei. ! . . . . . . . . . . . . . . . . . . . at. . ._� ..s. .�.f. .. . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . .�. '-Aic. No.. .Z. 3.L. . . . . . . . . . . PLUMBING INSPECTOR Check # 5647 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) --y NORTH ANDOVER,MASSACHUSETTS l� u / 7 ? 1 } �/ Date Building Location J ��/�of4WnersName ?lC� - ,Y� /�!%),, Permit# Amount '3 7 D Type of Occupancy New Renovation ® Replacement ® Plans Submitted Yes No FIXTURES Cr Ln QW Ln a SRM R4SUVINr IST R m Z1D EfM �FIDCit 4'II3 FUM 5M RfM 6114 FIOQt 7IH 1ID�t gII31aIOQ2 (Print or type) n/� n Check one: Certificate Installing Company Name K(K Ao 13'1 hl� 1-1 Corp. Address n doz)C/" El Partner. MY! +l vP iv 42 0/911 V Business Telephone 91�,(% (�,P j—317? F'r"'�C°- Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy ® Other type of indemnity D Bond Insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate Plumbin Code an Chapter 142 of the General Laws.By: Signature orLicense =um er Type of Plumbing License Title 3�j 3 Mr iMM um er Master ® Journeyman Lr APPROVED(OFFICE USE ONLY Date.... - NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that ......1 a '" So"�t EJto ...... P has permission to perform ... n `` �......../..:....... � .U..�.......... wiring in the buildin of... .... 1 N D 9j C/t� . ... . .................NorthAndover,Mass. at...... .................................................. V] CDI,� f Fee.... fl....... Lic.No. .. ...!.. .....�- .... ............. :P.................. ..... ................ I O ELECTRICAL�SPECTOR Check # 46 '10 Official Use Only Permit No. ?�fc ed?�Z?�Ld?22ri/Cf11'�f d� SS��7LS�77S De/�nte�t ad�u8ite Sa�diy Occupancy&F C BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 C R 12:00 (Please Print in ink or type all information) Date To the Insp for f Wires: Town of North Andover The undersigned applies for a°permit to perform the electrical workdescribedbelow,. Location(Street&Number �✓� � �✓�v` > 1 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building ' \ Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters New Service Amps Volts Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity _ Location and Nature of Proposed Electrical Work t Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures 6 Swimming Pool grnd ❑ gmd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal / No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW signs Bailases Wiring i No.Hydro Massage Tuds No.of Motors Total HP OTHER: _i INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = tted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANC = BOND = OTHER = (Please Specify) 9 Q O (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under n�Ries, �f '�jG �) ��1 � 1 LIC.NO. FIRM NAME T_�� 6G1�7 `�" �C/ / I Lkensee�v�" 4 �" �y Signatu LIC.NO. Cr>�� Bu Tel Address No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Ma achusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please check one) i Telephone No. PERMITfE (Signature of Owner or Agent) The Commonwealth of Massachusetts ` d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for rry employees working on this job. Company name: Address Gity Phone#. Insurance Co. Policy# Company name: Address Cit�r Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead tathe kgxsfion of aiminal penalties of.a fine up to$1,5W.00 and/or one years' onrrient v+[elI_as_civil Qenafties�nlhelorm�fa�TS)P] FiK9RDERand_aTme�f711O DB)a�aY agai�tme I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for image verification. I do hereby certify under the pains and penallies of perjury that the information provided above a true and correct. Signature Date r Print name Phone.# t Official use only do not write in this area to be completed by city or town official' City or Tawn PetmitA icensin4 Building Dept ❑Check if immediate response is regu,red Licensing Boats/ p Selectman's Office Conte&person: Phone t E] Health Department F-i Other I 9 1 � t j Date.// .z/`�`! . . . „ORT1y TOWN OF NORTH ANDOVER OT . o ,�1ti0 PERMIT FOR PLUMBING ♦ i � I ,SSACMUS� 7-0 This certifies that . .. . . p R<)r,6wq . , . , . , , . , . . *.X,has permission to perform . . �5. plumbing in the uil Ings of .,5; Cs�n�• . .-�/. .l�/.e � Q J ' at . S �? -Sj. . . . . , North Andover, Mass. Fee. Lic. No. 2!3 . Grr�?!r. . . . . . . . . PLUMBING INSPECTOR Check # 683 �� x S b i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: CJS D MA. Date.,/2 A Permit# •11V� Building Location-2 '' r Owners Name: r �j �•hQ�/ k Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement:[ Plans Submitted: Yes❑ No FIXTURES DEDICATED z Z SYSTEMS � U h W z a z ¢ �„ u i2 w o 0 m z '� _z a a W z _a gy�m{{ a m C O m Cn w F- N } Q Cn .,,� y O 4 N Vf W14 FW- W tJ = 2 d' Q FQ � W y00 H , Wp, 0 NN U 0 vF- Q W a u a 3 Ln Ln = SUB BSMT. Q 0 BASEMENT 1sT FLOOR � 2ND FLOOR 3RD FLOOR X 4"FLOOR .' 5T"FLOOR 0 FLOOR 7'FLOOR 8T"FLOOR lnstaiiir�Lun�pany i ame: + G chsck One cmih, Gl�lrif;,y+ti � V �� q Address: d20K :�ayJ El Corporation City/Town: 'K State: j� ��8•�•� 9�� p El Partnership Business Tel: l Fax: Name of Licensed Plumber: Firmicompany INSURANCE COVERAGE: 1 have a current liabi!i Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.442 Yes❑ No❑ If you have checked Y_s,please indicate th .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 442 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only >icinature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted(or enfered)regarding this app►icafion are true and accurate Knowledge and that f t e um Massa work and fnstallatiors performed under the permit issued for this application will he in compliance with all Pertinent provision of the Pnassa husetts State Plumbing Code and Chapter 142 of the General Laws, c'a.e tc the beat o.my L Type of License: :le ❑Plumber Si atu a of Licensed Plum y/Town WMaster �7 'PROVED(OFFICE USE ONLY journeyman License Number:��oC