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Home My WebLink AboutMiscellaneous - 40 EDGELAWN AVENUE 4/30/2018 L'o A/ MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Onlv(800)392.6108, FAX(800)851-8424 9/18/2012 Form of Notice of Casualty Loss to Building Under Mass. Gen,Laws,Ch.139,Sec.3B NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: MARY LACORTE Property Address: 80 EDGELAWN AVENUE,UNIT 6,NORTH ANDOVER, MA 01845 Policy Number: 0376668 Type Loss: Water Damage:Plumbing Systems Date of Loss: 09/17/2012 Claim Number: 304546 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. MPIUA Claims Division CMA00021 Date. ��. . . AO°T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSANUS� This certifies that . . . C. . . . . . . . . . . . . . . . . has permission to perform . . . .�/. ..� . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . .A /.>. . . . . . . . . . . . . . . . . . at. . . tr . . . . �5 f . . . .. .`.`�. .. .. . . . . . . . .. North Andover, Mass. r � � y q,.. :. . . . . Fee. .3.v. . . .Lic. No..� F. . . U . . . . . . PLUMBING INSPECTOR Check # 8530 Ilk .� R• '�' ice. i •1/• • 1.1 - • H• it •� I�f • • ! • • • .. ir�rr�rr�rrr��rr�rr� irr� �rr r� irr�rrrrrrr irrrr�rrrw"Imr�rrrrmmomo�:ii iirrrrrrrrirr�rrrirrr�rrr�m��r�r r�r�r�rrr�rir�rrr�r�rrrrr�riiirrasirr�r��r rrr��rrrrrrrrrrrrNow a� �y iivr�rrr�rrrrr�rri�rr�iiirmrrrr r��ririrr��rrrrrirrrrrrr�rr ' .. �rr�rmom riririirrrrrirONSON NOrrrrirrr�ririrrr�rrir� ,t. •11.:1, 11 _ � • 11 .U r w� �. t11 , :111- . r. Iii♦:.1 � � 1 :♦ 1 ' it: 1 :{1 h" .'• :111 .•':.. t1 1 :1 /- • 1� •• , 1 1 111 � 1 1 1.•� ' i:t ■ t r 1 i 1 t : • / .. • {'1' :1t Ii ••I/ •111 /: 1 • 11 • 1� s i� 9 { •. . l .� Il • \•1 •- ,�J.111 • 11 1� �•t• 1// I . 11111/ • ',. 1 1 /i. • /1 .11•. :.•�- : I♦ Il t _1 •i ' rll/1 1 `1� �;�' • / 1 sl : "1 •111• 1♦'" / .� 1/-/ .•• •t. • _ ��'�' JI { 1 • 4�,1 • is 1 111.1. • �1 licity/T r - ... ♦ 1 1- li:1 y, III r t•/-� .• 1 APPROVM (OFFICEUSE MASSACHUSETTS UNIFORM APP11CATON FOR PERMIT TO DO GAS FITTIN (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations Permit# .►— Amount$ Owner's Name ��: —� �- New❑ Renovation ❑ Replacement Plans Submitted ❑ x w � rA U a w a x o x z w z F G �, a C7 w d x w N v� a C4 > d w i z Q w x w c4 w A H x W > Q E. w O > W F U „� F W e �" Gq z O . Z c m o x w 3 c a ° a y a ° c SUB -BASEM ENT BASEMENT IST. FLOOR- - 2 N D . LOOR2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR -8-T H . •FL0 0 R (Print or type) ` Check one: Certificate Installing Company Name uz �' - 1 / Corp. Address ® . 6 U g Partner. Ai �.6 usrness I a ep one Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance poli c or it's substantial equivalent. Yes ❑ No If you have checked yes,pleasethe type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 1 hereby certify that all of the details and information I have submitted(or entered)in above application are an accurate to the best of my knowledge and that all plumbing work andVlla'on s performed er it Issued for this a Iic on willbe in compliance with all pertinent provisions of the Massas to Gas Code d e, ter 42 e G a1 ws. By: Signature of Licensed ber Or Gas Fitter Title Plumber City/Town Gas Fitter License Number MLMaster APPROVED(OFFICE USE ONLY) Journeyman I �.. ..,.,_, r r � �. �� '� -1 r + Of PORT"1 o: ".��.•"°O� TOWN OF NORTH ANDOVER '° PERMIT FOR WIRING �1SSACMUS� This certifies that �' ........._ -r� � ....................................................... r has permission to perform .... .....,,�:-f.�..-'' wiring in the building of..... ......`.... .......�.;.� .................................... s �^ � „�.t at....�..:............... .-�'........:�-,�....::�c::...'�..........�,North Andover,Mass. r Fee..-- ........:"1.... ic.No..<.......... . .... ........................... ,..:. ELECTRICAL INSPECTOR Check # A 9 5n Commonwealth of Massachusetts Official Use only Permit No. Department of Fire Services Occupancy and Fee Checked S a 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 Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of h0 or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant i G ,v Telephone No. Owner's Address U E:V- llqc- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building -e ,,,.,a I,/ k,--4-tom f 0! ,P4 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 ollowin table may be waived by the Inspector of Wires. ' No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA F No.of Luminaires Swimming Pool Above ❑ In- 1-1 o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers 1 Heat Pump I Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of 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 c OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: My &1-p, /)-0)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 andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: 5-&, F Ce, 0? Signature LIC.NO.: (If applicable, enter "exempt"in the icense number line.) Bus.Tel. No.c97��7n7Y-YYro Address: Alt.Tel. No.:Wk-VZ.? 23a, *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my ignat a below,I hereby waive this requirement. I am the(check one) ❑ owner ❑ owner's agent. Owner/Age n Com. PERMIT FEE: - ✓° Signature Yi'Telephone No. S�' i PM Xtg Ov � 'Orb, r a A r t�-?^ NORTH TOWN/NORTIH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that ...a .. . .� <��/. . ? . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .— plumbing in the buildings of . .r?!� - - —��! 1 . . . . . . . . . . . at . . . . . . .�. . . . . ... ... . . . . . . . , North Andover, Mass. Fee. av Lic. No.. !.✓7r . . . . . . . . s PLUM I _ INSPECTOR Check # . 7325 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ��.,, Date .3 ' aa_ o Building Location go C e-L1� o Q M Owners Name 1�6 Ihe— M cc,let- L/w Permit# ,s' Amount Type of Occupancy Co A) New Renovation rl Replacement [0 Plans Submitted Yes No C] FIXTURES aw a H a w w w rz a . w a x H d F� SLRESNE WDW MFUM t MFLOOR 4M FLOOR s>�>� 61HROOt 71H ROOR su3ROOR (Print or type) ` (� n Check one: Certificate Installing Company Name �Q L �.�1Li` ['� �J (� � [I Corp. � I Address 6(?x o Partner. q—'\— q k Business Telephone (9 S-313-3 Firm/Co. Name of Licensed Plumber. �' ,J Ox C,-,W Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy tu Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance 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 Dertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus to lu mg Code and Chapter 142 of the General Laws. v BYNign o kens er Type of Plumbing License Title [Z 4 !z q fl City/Town icense INUMBer Master Journeyman ❑ r- APPROVED(OFFICE USE ONLY �� Date.. . ,SORT" pf „ao �°,�O o� �' ° TOWN OF ORTH ANDOVER ' PERMIT FOR GAS INSTALLATION �9SSACHUSE� This certifies that v . . . . . ? . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation .?-* . . . . . . . . . . . . . . . in the buildings of . . . R-. . . . . . . . . . . . . . . . . . . at . �. . . .r . . . . . . . . . . . . . . . , North Andover, Mass. Fee. Lic. NoJ. . . . . . . . . . . . . . GAS I�VECTOR Check# 99 5937 MASSACHUSETTS UNIFORM APPUCATON FOR PERNUF TO DO GAS FITTING (Type or print) Date 3 _)-,) —d NORTH ANDOVER, MASSACHUSETTS Building Locations qD e,( "hj DA- V Permit# Cb Acol t A)sL."n0Amount$ Owner's Name ht OCC fff(�-��✓ New❑ Renovation ❑ Replacement Plans Submitted ❑ z `—' a H � o � H O � cG w Q w a C w W w e x a a w a ° > w C7 E~ z Er z E, w w c7 p > w w v x x d w > w x .. m z ° z w O uFi x cc x ° x 3 c a a > A °a H 0 SU B-BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type) n Che k one: Certificate Installing Company Name_. � � /f � �'I i�.0 t Corp. Address — b ❑ Partner. 0,7 /1'! Business a ep one eh,5 ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No ❑ If you have checked es,please indicate the type coverage by checking the appropriate box. 13Liability insurance policy M Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 Stat Gas ode,and Chapter 142 of the General Laws. By; ignature of Licensed Plumber Or Gas Fitter Title ❑ Plumber tj( oq City/Town ❑ Gas Fitter License Nurn6er ® Master APPROVED(OFFICE USE ONLY) ❑ Journeyman i Date... .. `.. l.......... t NORTOI r 3�;•`�``°-.'�"�o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,S3�tCNUSEt This certifies that ...................... ......... 9 1 "�^�'i ....:e;....... has permission to perform ''"Z` <-� .. ........ ...... ...................... wiringin the building of................................................................................... r at U , ...,North Andover,Mass. Fee............... .�... Lic.No.4 ..................t '!- '� ... .... ELECTRICAL INSPECTOR ` Check # 7302 1 ti Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked -� BOARD OF FIRE PREVENTION REGULATIONS (Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work,to be performed in accordance with the Massachusetts Electrical Code(MEgx� (PLEASE PRINT IN INK OR TYPE,ALL INFO ATION) Date: City or Town of: N�2, /�iv/JUt/CiL To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electricalw rk/described beloo Location(Street&Number)—VU e,1 w A(,-, /rv,T 211, (. /1� Owner or Tenant A Telephone No.I 5' =aD /77, 9C� 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 ;gU Amps C?c)l 2AfUVolts 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: /�ovL t//er XglG Completion o the ollowin table m be waived b the Inspector of Wires. iNo. of Total No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting �.No.of Lighting Fixtures Swimming Pool rnd ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiatin Devices No.of Ranges Tons No.of Air Cond. Total No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices S ace/Area Heating KW Local ❑ Municipal ❑ Other No. of Dishwashers p g Connection Heating Appliances KW Security Systems: No.of Dryers No.of Devices or Equivalent No.of WaterK�, No.of No.of Data Wiring: Heaters Surfs Ballasts No.of Devices or E uivalent Telecommunications Wiring: e No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,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 suchcove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 7 BO1,P ❑ OTHER ❑ (Specify) / e) (Expiration D Date) Estimated Value of E ctrl al Work: (When required by municipal policy.) Work to Start: 4 /� tJ Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under t epi s a d penalties of perjury,that the information on this application is true and complete. 7/r' FIRM NAIN : '�✓ fA2 LiT!N IrLIC.NO.: Licensee:�tJ�C�o`� �i�y��Z t o Signature LIC.NO.: (Ifapplicable.applicable,enter "exempt"in the license number line.) Bus.Tel.No.: Address: /{W�S w� / 74 Alt.Tel.No.: OWNER'S ik,4SURANCE WAIVER: I am awa that the is see does not have the liability insurance coverage normally required bylaw. By my signature below,[hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ `' Signature Telephone No. Recetipt # ---- 3 M i N Location e No. O`er Date �Z NoorM ,� TOWN OF NORTH ANDOVER 0 o , Certificate of Occupancy $ Building/Frame Permit Fee $ '/ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # AN_ 1556 3 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: SIGNATURE: Budding Commissioner/I or oiBuildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number. C)?I 13 n , ,� . ) Map Number Parcel Number 1.3 Zoning Information: "S l�/�JV 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side.Yatd. :. Rear Yard R Provide Provided Provided . a 1.7 water SupplyMGLC.40. 34) 13. Flood Zone Iafomntion: 1:8 Sawerase Disposal System Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal. ❑ On Sita DisoO'sal system,a SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record 0ec-, Gcoery Co - os s`; , hi. _. t "r Name(Prit4 Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 3ignature r Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Liomsed:Construction Supervisor. Not Applicable ❑ J� -icensed C6ns#uction Supervisor. (g 61c, { ` License Number . b�e hcc.� 6 i`3 address 7W 04_3m Expiration Date lignature Telephone r .2 Registered Home Improvement Contractor Not Applicable :ompany Name Registration Number Adress Expiration Date i6nature Telephone SECTION 4-WORKERS COMPENSATION(MG.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 Pro osed Work check a!1 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work:.( s4 rf �e-roo'� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed.by permit applicant L Building (a) Building Permit Fee .2CM , Multi here.. �- 2 Electrical (b):� stimated`Total Cost of 3 Plumbing Building Permit'fee(a)x(b) 4 Mechanical AC Y' 5 Fire Protection 6 Total .(1+2t3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT,OR CONTRACTOR APPLIES FOR BUILDING PERMIT L as Owner/Authorized, gent of subject property Hereby authorize to act On' My behalf,in all matters relative to work authorized by this building permit application. rSEC�TION7b ue of Owner Date OWNER/AUTHORIZED A(GENTDECLARATION WC �11t 1�Oc .e �ices l. etas Owner/Authorized Amt of subject t Hereby declare that the statements and information on the foregoing application are true and accurate;to the best of my knowledge and belief Prin am Ae s2 0 Sim of A en Date` NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TBMERS i ST 2 ND 3 RD SPAN _ DIMENSIONS OF SILLS DIMENSIONS OF POSTS D`UIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERLAI.OF CHIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL OAS LINE NvR � h . ToqqVM . 0 E Andover -1 G . * - P C% Va' C„� W,0 , dover, Mass., sr x.9Is, RATED.PP BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System +��''� ^� BUILDING INSPECTOR v� o A Ss C, THIS CERTIFIES THAT.. ...... . .........................................................`...................... . has 5•.�.R r !! j 9) .. .... '��.. Foundation permission to erect. ... ......... buildings an.. � Rough s ,� to be occupied as ��N �Q ..�... .....�•h 0................... Chimney provided that the person accepting this permit shall in every respect conform to erms of thea lication on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspe ion, Alteration and Construction of Final Buildings in the Town of North Andover. Q 3 Y"D " �� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUXNT�ASTS ELECTRICAL INSPECTOR Rough ...... Service BUILDING INSPECTOR Final OCCupancy .Permit Required t0 Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT ' Burner Street No. SEE REVERSE SIDE Smoke Det. i I *.a � foie "i��vnr�z�ueYir�o�'✓��ra,�ctc/tuae�4 4 !i s � - r BOAA0 t7F. UIIOtNG REGI�LATION.� } ' LiCbns6; ONS?ROci N�Stf ISOR k' Numtler gCS 075259 �t Wtk,,11.1-'l ; ares12/�4j q02 Ti.no: 7$259 �sRestncfelTo: 00 3�RADLEY J SOrNTZ � 'is PINE E�ILLr��lAb $WAMPS�QTT, MA OiS07 'Admulistratar k 4i The Commonwealth of Massachusetts 1 A Department of Industrial Accidents Office of Investigations i t Boston, l�/l ass 02 777 W 'ers'Compensation Insurance Affidavit Please Print Name: Location: qty Phone am a homeowner performing all work myself. 01 am a.sole proprietor and have no on6 working in any capacity am an employer providingworkers'compensation(� for my employees working on this job. Alddress � v �`S�,(� f-F�)P�KtJP Cft_ (l 1AR oIS�Z (tone* M. -9300- In'sutance Co. PORMA �samr�arrv-panne: . - . Address , City Phone#- lnsuranriegg CNS Pow Ir?99 5 6 t!1 Pai1dre to secura cotrerage as n fired underSection 26A or MGI.152 can loaf!tathei�:d cri�►al Pena ft ora ftne and/or one years•imprisonment as Wen as dvo penalties in the form of a STOP WOW and afire of 310Q u lns X1;500.00 understand that a copy of this a'tatr ent may be forwarded to U*Office of hwesog.-ft s of the IDA fix l a m. againsE me. 1 verrlRc�ion: I do herby certify under the p ns efies ofperfwy&W the Wwmaum provkbd above is bue and.Correa Signature Pr,s Bate 5 a o Print name ��e. . �n 2 - Phone#_O! S� '-Q� . 1 Official use only do not write in this-area to be completed by city or town official* Q Build/11g Dept ' QGheak irlmmediate response is required Building Dept p Licefrsing Board Q S°/eotr»an's Officio Contact person: Panne#-_ Health De art Q p meat Q Oftrer WORKMAN'S qj('S CoM RI��HIIi ?SrPENStt/IVpi Y North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility, U(lax I stx-,Eces, Inc, S ature of-Akmit Applicant Z o? Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector