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Miscellaneous - 40 SUGARCANE LANE 4/30/2018
40 SUGARCANE LANE 2101105.C-0014-0000.0 Date.... . .. } NORTI� : .•.� �o� TOWN OF NORTH ANDOVER PERMIT 'FOR WIRING 1 - *1 - �SSgCMUSE� .. This certifies that .................. ................ has permission to perform ............C '- ,,............................ wiring in the building of............ d��.�i�S ..............................:.......... at ..•1 ��✓ .!� � � rt Andover,Mas . ............... .......... ....... ................ Fee_ .�.. ...... Lic.No.!..-71.7. al�............. y . .. �........ .. EL CTRIC .L PBc_;0I { Check # ��_� 10474 - i 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the 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 for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed-by the,Inspector-of_Wires abandoned-and.invalidif_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 entitystated 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 putpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "inn effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ` &ule 8—Permit/Date Closed: ,- �� �5 ***Note:Reapply for new permiLll/ 11 Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use only Permit No. �l A Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11-11-2011 City or Town of: North 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) 40 Sugarcane Lane Owner or Tenant Lila Lagrasse Telephone No. Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building House generator Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps Volts Overhead ❑ Un'dgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: new automatic backup generator Completion of thefollowing 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 No.of Luminaires Swimming Pool Above Ei In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. 10 Tonal No.of Alerting Devices No. of Waste Disposers Heat Pump NumberTons 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:* y No.of Devices or Equivalent No.of Water Kms, 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: 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: ASAP 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 penalties of perjury,that the infoon on this application is true and complete. FIRM NAME: East Coast Electrical LIC.NO.: Licensee: Robert Walker Signature LIC.NO.: 17176A (If applicable, enter "exempt"in the license number line) Bus.Tel.No.: 978-692-3232 Address: 2 Lan Drive Westford Ma 01886 Alt.Tel.No.: *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 agent. Owner/Agent PERMIT FEE: $SS.00 Signature Telephone.No. Date. . .... .... HORTM , o? °` TOWN OF NORTH ANDOVER • t PERMIT FOR GAS INSTALLATION ° S SSACHU5ES i This certifies that . . !?QC . . . . . . . . . . . . . . . . has permission for gas installation in the /buildings of �FP4,5..el. .� rl- . . . . . . . . . . at `.� . U !' ' . . �11 a . . . . . . ., Nort n over, Mass. Fee.,,!, �:' Lic. No.)� GAS INSPECT Check# � ?895 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: AD D f 6111 dou t rz, , MA. Date: /D 0 Permit# Building Location: 7o s J�+'s42 /��,/� ! �A Owners Name: 4. 5duie Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential [� New: []' Alteration:❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES C0 tri z w W Y Ce W p w O rn = co 6 Z f- C9 >-0 C0 coqvm) O M w = Z O w W R O I— g w CO w a I. = Q w w w z to = CO �O w o = > Ce w Q w toil m > *O z 0 F' I- w ~ LU w co Z Lu Z �W �. Q. co "� � > Z 2 V O D Lu u_ 0 0 2 2 O a d' hw- > > > O a SUB BSMT. BASEMENT ` 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 6 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: sU Check One Only Certificate# 1-� _ . ❑Corporation pJCity/Town:Address: State: N{� Business Tel:fa6.3 3S - �(p Fax: 663 -S9S-39/S ❑Partnership � Firm/Company Name of Licensed Plumber/Gas Fitter: ✓ ;-" /'t 0( O A'f H FINSURAN-CE COVERAGE: e a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes�r No❑u have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner ❑ Agent By checking this box❑;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 Pe�nAt pr�ision of the Massachusetts State Plumbing C e and Chapter 142 of the General Laws. [APPROVED ✓ T�(�130 of License: `' Plumber El Fitter Sign a of Licensed Plumber/Gas Fitter EJ-Ka'ster town ❑Journeyman Li nse Number: ��7 J OFFICE USE ONLY ❑LP Installer The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigationg 60.0 Washington Street Boston,MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Address:_ City/State/tip: �n A / d 3o 29 Phone E an employer?Check the appropriate box: _ a employer with 4. Type of project(required): �_ ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached sheet. # 7. ❑Remodeling and have no employees These sub-contractors have 8. ❑Demolition ing for me in any capacity. workers'comp.insurance. workers coin .insurance 5. 9. ❑Building addition ' p ❑ We are a corporation and its ired.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions lf [No workers'comp. c. 152,§1(4),and we have noancerequired.]r employees. 12.❑Roof repairs [No workers' comp,insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my information. employees. Below is Elie policy andjob site Insurance Company Name: Policy#or Self-ins.Lie.#: ExpirationDate: Job Site Address:_ Z® .Sci rz C;,>„e 4,4 City/State/Zip: %o .4cy Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. IF do hereby certify der s andpenaldes ofperjury that the information provided above is true and correct. ii nature: /� Date: 'none#: Offrcial use only. Do not Pyrite an 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 Ins 6.Other pector 5.Plumbing Inspector Contact Person: Phone#: Info • 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 our situation and ifnecess�3,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 m uired 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/liceiise applications in any given year,need only submit one affidavit indicating policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (citycurrent 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 for any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: khe C01UMAomwealth of j)�jfassachuisetts Department of Industrial Accidents Office® Investigatiens 600 Washington Street Boston;M- 02111 Tel.#617-727-4900 ext 406 or 1-877.MASSAFE Revised 5-26-05 Fax#617•-727-7749 Www.mass.gov/dia. OAR B BOSIES AGENCY FAX NO. : 603-898-5475 Nov. 10 2011 09:51AN P1 CERTIFICATE OF INSURANCE STATE fARPA .. EiThis certifies that ® STATE FARM FIRE AND CASUALTY COMPANY, Bloomington, Illinois ❑ STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois ,«,�,. E ❑ STATE FARM FIRE AND CASUALTY COMPANY,Aurora, Ontario ❑ STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida ❑ STATE FARM LLOYDS, Dallas,Texas insures the following policyholder for the coverages indicated below: Policyholder Morin, Jean-Rock DBA Rocky'3 Plumbing Address of policyholder P O Box 2404 Salem, New Hampshire 03079 Location of operations 40 Sugarcane Ln, North Andover, NIA 01945 Description of operations The policies listed below have been issued to the policyholder for the policy periods shown, The insurance described in these policies is subject to all the terms,exclusions,and conditions of those policies.The limits of liability shown may have been reduced by any paid claims. POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE Effective Date : Expiration Date (at beginning of policy period) 94 BB D389 3 Comprehensive 08/15/13, 06/15/12 BODILY INJURY AND Business Liability----------------------------- PROPERTY DAMAGE ----------------------------- - ------------------------ This insurance includes: ® Products-Completed Operations Contractual Liability Each Occurrence $ 1000000 ® Personal injury ®Advertising Injury General Aggregate $2000000 ❑ Products-Completed $2000000 ❑ Operations AgRregate POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE EXCESS LIABILITY Effective Date ; Expiration Date (Combined Single Limit) 94-13B-A7II0 0 ® Umbrella 01/12/11 07/12/12 Each Occurrence $ 2000000 ❑ Other Aggregate $ POLICY PERIOD Part I-Workers Compensation - Statutory Effective Date ° Expiration Date Workers'Compensation Part II-Employers Liability 94 BL 2601 5> and Employers Liability 01.!07/11 01/07/12 Each Accident $ 1000000 Disease- Each Employee $ 1000000 Disease-Policy Limit $ 1000000 POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE Effective Date ; Expiration Date (at beginning of policy period) 027 9110 29 Automobile 03/3.5/91 continuous 1 Million 028 8035 29 Automobile 07/30/91 continuous 1 Million THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. Name and Address of Certificate Holder If any of the described policies are canceled before Town of North Andover their expiration date,State Farm will try to mail a Attn: Plumbing Inspector written notice to the certificate holder 30 days before 1600 Osgood 8t cancellation. If however,we fail to.ma'il.such notice, 2uilding 20, Suite 2-36 no obion or liabilityw(i imposed)br*State Farm North Andover, MA 01845 or its agents or rep¢aES'n ives.."tr ' Signature oTA*U'[h iz 4d F&presentative Agent 11/10/201.1_ Title Date Brian M. Bosies Agent Name Telephone Number 60:3 898-5220 Age Code Stamp Agent Code 2038/ 29 AFO Code F876 5513.994 a.6 Printed in U.S.A. Rev.05-09-2006 /TION pORTM pTOWN _OF NORTH ANDOPERMIT FOR GAS INSTAL. �9SSACNUSESS� This certifies that . . . . . .1'L has permission for gas installation . . .�! ./'t.. . . . . . . . . . . . . . . . . . R in the buildings of . . .1C./l, . . . . . . . . . . . . . . . . . . . . . . . . . at . . .�/`Q . . . . . .r, Norah Andover, Mass. Fee. Lic. N0. Q . . . . . . r .. . . . . . . . . . 6ASINSPECTOR Check# 6965 i t MASSACHUSETTS UNIFORM APPLICATON FOR PERNIlT TO DO GAS/FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS clBuilding LocationsyG � Permit# Amount$ ?y Owner's Name New❑ Renovation ❑ Replacement ❑/ Plans Submitted ❑ UD W r UV1 0 9rA H a W H ao w 0 a � W Q r7 w m z F z o > w GH z N Q x x w H w H x x d w ¢ `" > � W > w z o z o F U z o �, � d x d x o m w 3 A J .4 U a > SUB -BASEM ENT B A S E M ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6 T H . F L O O R 7 T H . F L O O R 8TH . -FLOOR (Print or type) f � p n 9 Check❑ Corp.Certificate Installing Company Name ,,I �( U V Address ❑ Partner. usmess Telephone — ,J ® Finn/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. 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 ❑ 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 erformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac efts St G and Chapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter By. ❑ Title Plumber /0�L 7 City/Town ❑ Gas Fitter Llc nesse Number ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. . workers'comp. insurance. 9. ❑Building addition [No workerscomp. insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t. . -employees. [No workers' 13.❑ Other comp. insurance required.] t A an licant that checks box 9l—musta.'so fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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 the policy and job 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury 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 joint enterprise,and including the legal representatives of.a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartrnents 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' conspensation 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 Washir gton Street Beoston,SIA. 0:2111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax 4 617-72.7-7749 Revised 5-26-05 -A ,.mass.govfdia r Date%.r � �i No 34 ~- 3 *. t NORTH, 410o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... 1 ..................................................................... has permission to perform.....- M:�:'-'.'�-: - t t t- --'1................................ ..�.............. wiring in the building ........................... ........ ......-�:�. ... � ' North Andover Mass. Feee .............. Lic. -ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No - l� -(� . BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 9 [[Rev.11/991 cave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wore;to be performed in ac=danee with the Mmachusetts Electrical Code(h ECS 27 C 1200 (PLEASE PRINT.IN INK ORrAAWY Date:City or Town of: TAJ To the 1 ector o Wi es: By this application the undersigned ves non of his or her intention to perfo electrical wor k described below. Location(Street&Number e. Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit' Yes ❑ No (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Senice Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ed Completion of the following table may be waived by the Insoee:or or;Nres. No. of ReCCSsed Fixtures INo.of cert-Snsp.(Paddle)Fans `No.of Total ITransformers KVA Na. of Lighting Outlets INo.of Hot Tubs Generators KVA No. of Lighting Fixtures ISwimmingPool Above ❑ In- ❑ o.of Emergency tanung rnd. ornd. Battery Units I No.of Receptacle Outlets INo.of 09 Burners FIRE ALARMS INo.of Zones No.of Switches INo.of Gas Burners No.of Detection and J Initiating Devices No.of Ranges INo.of Air Condi. Tots Tons No.of Alerting Devices No.of Waste Disposers Vicat Pump I Number Tons KW No.of Scif ontatned Totals Detection/Alertino Devices No.of Dishwashers Space/Arm Heating KW Local Municipal ❑ Connection C1 Other No.of Dryers Heating Appliances K-W ecunry ystems: No.of Devices or Eouivalent No.o ater , o.o No. of Data Wiring Heaters Signs Ballasts No.of Devices or Eauivalent No.Hydromassage Bathtubs No.of iYlotors Total HP Telecommunications Wiring: No.of Devices or Eouivalent OTHER " Attach additional detail if desired or as required by the Inspector of lFires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licenser provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such coverage is in force,and bas e:dttbited proof of same to the permit issuing off,=. CIIECK ONE: INSURANCE ❑ BOND ❑ OTE R ❑ (Specify:) (F—,q anon Date) Estimated Value of Electrical Work: S (When required by municipal policy.) Work to Start Inspections to be mWested in accordance with 1 EC Rule 10,and upon completion I certify,under the pains and penalties of perjury,lhardw information on this application is true and complete FIRM NAME: ADT Security Services ..Dr:,.••klo.l I ks. NH 03049 LIC.NO.: 1533C Licensee: John S.Bassett Sigaatu C.NO.: 1533C (If applicable,enter"exempt"in die license number line.) Bus.Tel.No..-J03594-5900 Address: Alt TeL No.:_603 594-5928 OWNER'S INSURANCE WAIVER I am aware that the Licensee does not have the abl ursurarrce coverage required by law. By my signature below,I her ry g normally hereby waive this requirement I am the(check one)C1 owner ❑.owner's agent. Owner/Agent Signature Tcicphonc No. PER1bIIT FEE: 505, k Location -No. Date iP ` . N°RTS TOWN OF`NORTH ANDOVER Certificate of Occupancy $ ® Oat Building/Frain-.fPe�mit Fee $ �ss�cMuSEs Foundation Permit Fee $ /06 Other Permit Fee $ Sewer Connection Fee $ f Water Connection Fee $ tlL g TOTAL $ F � -v Building Inspector 10-0-9 5 --- Div. Public Works Z l C Location � ��t/ /G�K2�'� /�,�'? No. J �Ly Date T� x _. .,&ORTIy. TOW I;-OF NORTH A-N'DOVER¢ � p Certifi ate of Occupancy $ i _79L ' Build! g/Frame Permit Fee $ � 'Ss�cNugEt Foundation Permit Fee $ k Y Other�Permit Fee $ o . Sewer Connection Fee Water Connection Fee $ 16 7 Z 'i a. TOTAL $ p� Building Ins or L^. y (� Div. P Kworks r`•. n &�711T NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40.��s-/► LOT NO. ' 2 RECORD OF OWNERSHIP iDATE BOOK PAGE SUB DIV. LOT NO. �-1 � � St. Qa O .oN Oa h ICI Z /) /Q�o LOCATION p/�. r. � PURPOSE OF BUILDING S f M G/.2 �C�M�f [tr 9C.0 S_ OWNER'S NAME �j '� J / .� E) NO. OF STORIES SIZE �/ [. of JatXS� OWNER'S ADDRESS BASEMENT OR SLAB �{e3 �C e,. r®'f & Ba S, ARCHITECT'S NAME jae 1l o .LSCC SIZE OF FLOOR TIMBERS 1ST �yxrQ 2ND q !Q 3RD r oC of BUILDER'S NAME e'TC ^C�QV�G / �/r► 1 �Ma rSPAN / _-- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS y 4r --_ DISTANCE FROM STREET 7l fv "' POSTS 1` bg DISTANCE FROM LOT LINES—SIDES,/',q J 13 f 0' REAR 1` L " GIRDERS AREA OF LOT 7. C7 `o FRONTAGE�JS"9PTF- l HEIGHT OF FOUNDATION 6� I L THICKNESS IS BUILDING NEW V�/���`- n7 SIZE OF FOOTING u << X IS BUILDING ADDITION -'-�- MATERIAL OF CHIMNEY 7 w IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE . IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY z IS BUILDING CONNECTED TO TOWN SEWER J7 61.Q IS BUILDING CONNECTED TO NATURAL GAS LINE fV Q- . INSTRUCTIONS '�. 3 PROPERTY INFORMATION 5-160 LAND COST SEE BOTH SIDES EST. BLDG. COST ct A n PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER 94. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED-AND APPROVED BY BUILDING INSPECTOR DATE FILED 71Z OUILDINO INSPRCTOR , SIGNATURE OF ER ORA HO Z�GE,�M� .51�r 7� F E E OWNER TEL. 4 PERMIT GRANTED 00 CONTR.TEL.# 19 �_ CONTR.LIC.# H.LC.l1 f 71996 (] i s. BUILDING RECORD ., 1 OCCUPANCY 12 SINGLE FAMILY S-ORIES - THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _ OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION ' 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ 3 t 2 I3 CONCRETE BL K. PINE !/' o _ BRICK OR STONE HARDW D PIERS PLASTER C_ _ DRY WALL _ UNFIN. Y 3 BASEMENT AREA FULL FIN. B M'T' AREA _ V, 1/2 1/1 FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HARDW D ASBESTOS SIDING COMIACN _ VERT. SIDING ASPH. TILE STUCCO ON MASONRY ' STUCCO ON FRAME BRICK:ON MASONRY ATTIC STRS. & FLOOR _ BRICCON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME - SUPERIORPOOR _ ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE HIP Irk BATH (3 FIX.) GAMBRELMANSARD TOILET RM,(2 FIX.) _ FLAT 11 SHED WATER-CLOSET _ ASPHALT SHINGLES Y' - LAVATORY ' WOOD SHINGES KITCHEN,SINK SLATE NO PLUMBING _ TAR & GRAVEL STALC'SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR ✓ TILE DADO i 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. _ TIMBER BMS. &COLS. STEAM ` w STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS �_ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd ELECTRIC lyt 13rd I NO HEATING '! 6 r� t . .� ., NpRT1y ® of VIANo.. O 'r kJ dover, Mass., -2 3 1929 O �f�._ LA E I. COCMICMEWICK 7 �ADRATED P'Pa\ '9S BOARD OF HEALTH Food/Kitchen PERMIT. T ! D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT:................................b...l..r? .G�. ,f . .A. ?. ........ -c.!.�A.��e... .................................. /l Foundation has permission to erect........(„ .P.......... buildings on ........`7..0.......... .141t C. ../......... .. . Rough to be occupied as....................:..................................... i '. - ........ f �?'f./...(.. ............................................. Chimney h' provided that the person accepting this permit shall in every respect conform to the ter sof 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION START Rough . ...........................................:..... .... ``1.................................. Service LDING INSPECTOR Final Occupancy Permit Required to Occu uilding GAS INSPECTOR gh Display in a Conspicuous Place on the Premises — Do Not Remove Fna pY l No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit(below) Address of Property for Permit(below) is vCOT �2 9'�/yQ ^r.g4ic�.-� �•.,.it Map and Parcel : Purpose of plication (check below) 2opy Y: Y of Applicant: of Family —Two Family ` I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement,restoration,or reconstruction of a dwelling in �istteence as of the effective date of this by-law,provided that no additional residential unit is created. l� The lot(s)were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals,where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents,where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section"senior"shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40%permanent reduction in density,(buildable lots), below the density,(buildable lots), permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland.The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction,dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a let which is ready for building permits,(i.e.all other permits from all other boards and commissions have been received a,rd the-project is in compliance—with those permits),-and the;Development Schedule does not acc==Uaie issuing a building permit in that Year,one—building permit will be issued per-Year per Development until such time as the Development Schedule accommodates;aat.;ng bu;ldirig pnrmi9?. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply,whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. SignatqLao1`Ownev6r Authorized Agent who signed the Attached Building Permit ate • This form must be attached to the Building Permit upon application for such permit. r JUL 0 ? 1996 I ,t ,7 LDL_P, 4 FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, �! regulations or requirements. � I ****************Applicant fills out this section***************** • i APPLICANT: 4O��fT Phone LOCATION: Assessor's Map Number Parcel /� G �•1� Subdivision � 'g� iLRCfl Lot(s) Street �yti�C:�}N� �a9-J✓L St. Number , ************************Official Use Only************************ RECOMME DATI NS OF AGENTS: 9 / 0000 - ;01 Date Approved Conservation Administrator Date Rejected Comments x� 4v �•i WW�. tc I(Rt L&U Date Approved Town Planner Date Rejected Comments f0 )no Inc AQ Date Approved Food Insspe'c�-toor`-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections -?6 - driveway permit �.1� Fire Departme�nt/ Received by Building Inspector i _N Pt� r Date 1 ' I i x JUL 1 71996 { '1 p. —7/e DEPARTHENT OF PUBLIC SAFETY :J ION 5 NS CONSTRUCT SUPERVISOR LICENSE Huber: Expires: Birthdate CS 049111 03(13/1998 03!1311960 Restricted To: 1G Lln.rw�, JOSEPH L HCCARRAN 4 RENRO WAY DERRY, NH 03038 JUL T 1996 Esc `O Plan Of Land t `r In North Andover, Mass. showing "As—Built " Foundation Location Lot 29C — Sugarcane Lane Prepared For Robert J. Jan usz Scale: 1" = 40' Date: August 21, 1996 � 309.25' Zoning Dis tric t: R— I a, (Residence 1 District)01 s ` (Previously Approved Subdivision Under R-2 Zone, July 1, 1988) Joan & Richard of \ O'Donnell `s \ / Note: Property line data token from a Definitive Subdivision Plan Of "Jerod Place — Phase I V" By Thomas E. Neve Associates, Inc., dated September 335, 165 S.F. 1, 1995 and revised to March 12, 1996. No�C 7.69 Ac. In my opinion, the existingfoundation is not in a Flood Hazard Zone as shown on the U.S.D.H.U.D. o- so, ,, 0'o���9 \ Flood Hazard Boundary Maps, Community Panel Fov�da t`� No. 250098 0009 C, revised to June 2, 1993. I hereby certify that the foundation on this property v� F0s� ;off' -� is located as shown and complies with the Top Of Foundation �''�= `� Lisa & Michael. zoning requirements of the Town of North Andover, sStaff Mossochuse t ts.pElevat7. O�01 emerde-'-- Pro i urveyor -' ra NEVE —' Na 31724 I IND Thomas E. Neve Associates, Inc. Engineers — Surveyors — Land Use Planners 447 Old Boston Road — U.S. Route 1 Topsfield, Massachusetts 01983 887-8586 1449-29C-CFP AUG 2 0 1996 r N.p R T ty ' own , of xAndover . Z -- 1 dover, Mass., 19/ O �. COC MIC ME WICK �p Aa DRATED S BOARD OF HEALTH PER MIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ........ ........b.../..fegfz..4A.A�a...... ......... ......... . ... . .. Foundation has permission to erect......... ......... buildings on ........`7......... .. Rough h / .�. � .�. Chimney to be occupied as....,. .....:......:....... ........: ..:...... ....� .. .....:........... ... .. ... l: . ....:.. ......... ......... ....... .. .. v r provided that the person accepting this permit shall in every respect conform to the ter sof 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION START Rough ................................................ ..... .. . .rel'........ ....... .f.. ..:..... ice Serv' WING INSPECTOR Final Occupancy Permit Required to Occu wilding 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. BurneFIRE DEPARTMENT_ r Street No.. Smoke Det. CERTIFICATE OP U SE & OCCUPANCY Town of North Andover Building Permit Number 348 .1996 Date_ JANUARY 1/ inn THIS CERTIFIES THAT THE BUILDING LOCATEDON 40 SUGARCANE LANE Lot #29C MAY BE OCCUPIED AS SINGLE FAMILY DWELLING WITH THE PROVISIONS OF THE MASSACHUSETTS IN ACCORDANCE SUCH OTHER REGULATIONS AS MAY AppLY. S STATE BUILDING CODE AND ' MORTN •'�o CERTIFICATE ISSUED TO Timberland Builders �o 40 Sunset Rock Road s ADDRESS 6nds�rQ CHUS r Building Inspector a fr _ S •:_� I t AAndu . N....I Yown ® No. : Z lover, IViass.,* �- - 1 9 t O LA f ;� COCHICHEW:CK - ti A_ \ 'P ADRATED� K 'y t BOARD OF HEALTH ' Food/Kitchen ;Septic System / WALR THIS CERTIFIES THAT............... b..:l.r�a a l �,�.f�h?A.. c �.1�� ING INSPECTOR has permission to erect........ .. ....... ... buildings on........... J Rough to be occupied as ..:................................ p� .... ... i ! C.. .............................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and Ry-Laws-relating to the Inspection, Alteration and Construction of gnat, Buildings in the Town of North Andover. PolLVMBING SPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ee oug IO 90 PERMIT EXPIRES IN 6 MOSS EL I AL SPECTO I TRESS CONSTRUCTION START. �(' `�l� ................................... �,'... ...... Service LDYIVG INSPECTOR A OCCUP ncy.Permit Required to Occ�c wilding GAS INSPECTOR Display in a Conspicuous Place Rough !, 9 p y p on the Premises .Do Not Remove � �� L No Lathing or Dry (Nall To Be Done Until Inspected and Approved by the Building Inspector. DEPARTMENT ty Burner Street No. .,,A Smoke Det. rt i ---- •— e%r"r'LJ%.#i i swn c%jn r rnm/i I LJ Lj%j r L-&JIvrL7uw IPrIM or Type) DI NORTH ANDOVER, r Maas. Oate Building Permit Location iy e , Owner's Name New Renovation p Replacement p Plans SubmIttYes❑ No [I FIXTURES • A F� w = Qct` M_ }} r J 0 u < M = YI r M A Z M e t i 11-� 101 0 ` .Oj ; Y M U ox w 1� d S M a. _ . i l', u = aa s M O >~ < 9 0 a a a S 1 t s H o s • s� t~ u W 1 i e=i a o 3 j s sus-11SYT. a�etcar�rrT IST FLOOR i)MO FLOON 880 FLOOR 4TH FLOOR aTH FLOOR ITH FLOOR. ITH •LOOR STHFLOOR — Check one: Certificate Installing Company Name ❑Corp. Address - o X 11 Partners hip .c/ ✓ 'i— l Y 1 ©-Firm/Co. Business Telephone .Name of Licensed Plumber j2o h INSURANCE COVERAGE: Check one I have a current liabilty Insurance policy or its substantial equivalent. Yes Cr No p If you have checked y I, please Indicate the type coverage by checking the appropriate box A liability Insurance policy 13`*'� Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the Ilcensee does not have the Insurance coverage required by Chapter 142 of the Maas. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner p Agent p Signature a et a Owner s en I hereby cerlity that all of the delalls and Information I have submitted br entmedl In above application are trueyaccuratee best o1 my knowledge and that aN plumbing wtxk and InstaNations p cxnied under the permit I for twa tion e with all pertlnen provisions of the Massachusetts Slate Plumbing Code and Chapter 112 of V Title uce of LkensW CitylTown Umse Number 3 Type of Plumbing License: Master Q'-- APFIXMD (OFFICE USE ONLY) Journeyman 0 ,.•rb`-.A..:+y....^�C."'-•-+..c-...-#a.wr�s^�",i�j•`�w,..-a-s`�.:�E.::.�_ ., �.__,... .,..__...�.,...�-,,...,;v.�-_._,,..,.,�.�.. s ,,. gw Date. . x342 Idi TOWN OF NORTH ANDOVER , o t PERMIT FOR PLUMBING P Hus This certifies that x .l has permission to perform . . . . . . . plumbing in thg buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . at . �. C /f. North Andover, Mass. (,a Feel'. . . i .. No.o& ' 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0,#40q j PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer .� rv1--A,'1aAUHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO DASFITTiNG ip (Print of Type) NORTH ANDOVER, , Mass. DatepoJ �" 10 Building Permit #, Location Owner's Name - T"1 113 0y-n 6u,(t)e'L--P, New Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ o o X C a v yr sC h ! O 7 Of Y �� O 0 O = w Q I � ~ Id a ~ tl = 0 IL J } aC X r > d IC ;2 , O O C h s o „ Is, o o a > o a< o taus—RSMT. tAGIMENT r ` 1sT FLOOR 2ND FLOOR �RDFLOOA 4TH FLOOR STH FLOOR 4TH FLOOR 7TH FLOOR 1 ; aTH FLOOR � Check one: Certificate Installing Company Nam l/"_ v (���i'' fid Dd Corp. Addrress_ ; 61y STT i C> [j Partnership 61 wm(o ❑ Firm/Co. Business Telephone '" Name of Licensed Plumber or Gas Fitter //r INSURANCE COVERAGE: Check one i have a current liability Insurance policy or its substantial equivalent. Yea ❑ No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy it 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, end that my sIgnature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best of my knowledge and that all Plumbinq work and Inslailntlons performed under the permH Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gerwal La BY Tg of License: Plumber Signakffs of LicensedPlumber or Gas Filter Title Gasnllef Master license Number /GlJ Ctty/Town ❑Journeyman Af'fT)OVED (OFFICE USE ONLY) > ® - -3�J c� Date. a l'r ,AOR*M - TOWN OF NORTH-ANDOVER. Y 10-3? •6 Lp vK PERMIT FOR GAS-INSTALLATION i � • _ <y } 9SSACMUSEt This certifies that. .{.: has permission for gas installation in the buildings of t � at � �;?. r.. :pA ��? North Andover, Mass r Fee. Lic. NoA-?//,t1. GAS INSPECTOR t3 WHITE:Applica CANATiY. rig Dept. 70.DOPINA �easurer, GOLD File= Top- office ofoffice Use Only L/2 uil he Lfutu ilwealth IIf �` sar4umi� Permit No. 7 J�]1� Y 040 'Brpzirtmzrrt IIf �P Lht(L -_56a occupant)B Fee Checked -��b��^' g/go (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 C'dR 12.00 �. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 6EPr It> \Qci QM or Town of NORTH_AN_DO TER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street 3 Number) SO�,AQCACO Owner or Tenant Owner's Address L10 . LvaSET 00r-e RQ A/U�c1F"/I /YIg Dl st/� Is this permit in conjunction with a building permit: Yes X No _ (Check Appropriate Sox) Purpose of 5uildinc ' k-L'.) Utility Authorization No. 0 Amos _J Vcits Overhead Unagrnd No. of Meters Existing Service _ New Ser./ice D0 Amps I 0 �V VC Gvernead Uncgrrta No. of Meters Numcer of Feeders ana Amcacity Location ana Nature of Preposed Electrical 1.11crx Total I No a y yys Vo. of Transformers KVA No. of Lignt+ng Quiets Abcvef— In- — No. of Licnung Fixtures i Swimm+nc Fact grna. — crnc. '_ I G2nera[crs KVA I No. of Emergency Lighting No. or Recectacie Outlets No. of Cil _urners ; 3at ery Units No. of Swrtch Outlets No. or Gas Burners I FIRE .ALARMS No. of Zones Tota+ No. at ^etection and No. of Ranges No. of Air Cone. tens in+ttaung Oav+ces Heat Total Tata+ II No. of Oiscosais No.af Pu-_s Tons KW No. at sourcing Oev+ces No. of Salt Contained i ScaceiArea r4eattr.a K`V IOeec*:anjSauncing Devices No. of Dishwashers - f i tCVV Lcca+ — Mun+c:oai —.Other No. of Oryers Heating Oev:ces — Connec:ton No. of Na. or. I Law Voltage _ No. of Water Heaters KVV i Signs Sadasts Winne No. Hvcro Massage Tubs I No. of Mctcrs Tata+ HP O HE �n�PLGTfr 4��2F OF &)UZ 90nE INSURANCE CCVERAGE: Pursuant to me reau,rements ct t.[assacnuse- general Laws ecuivaie_ NO I have a current Liaeiiity Insurance Pone'/ inclucmg�Co :etec Ccerat[t nsu-Cz eeage or Yucs,a iia -naicacenehe ye of coverage Cy nave suom+ttea valid proof of same to the Office. - rc cnegx+ng the appropriate cox. INSURANCE �, BONO = OTHER = (P!ease Scec:ty) (Exo+rat[on Oate+ Estimatea Value of E'.ec:teal Work 5 Final Wcrx :o Start Inscectton 174:2 RdGl:as:2c: Rough Signea unser the Penalties of perjury: LIC. NO. FiRM NAM UC. NO. �-� Licensee OL T"5f`V% SOA.) Signature /� Sus. Tal. No. ACCress\\ii. 4) �Q �)F Z R V A) d3 a3� Alt. Te I..NO. OWNERS INSURANCE WAIVEP: I am aware tnat ;ne !:censee aces not nave the insurance coverage or its suest. ow eaurvalerA as OWNER'S ov Massachusetts General Laws. ane that my signature an :n[s Derma aopncauon waives this reau+rement. Owner 9 (P!ease cnecx one) Te+ecnane No. PERMIT FEE S (Signature at Cwner or Agenn :.:�„�5,rad; ;a.�.PA��� ,r�e ,,,�-.. -.. .,;_�,,;Q ,�cx �: .-�-•-,�;3;�,r-.a. .-��w-a►�s-^tom'�^,.�. ��..�..� Date....•<.(�."..�.U... ... - , 438 �- 3. ! NORT1ijr 1 - 3r'°t'"`.o^: TOWN OF NORTH ANDOVER PERMIT FOR WIRING •i. i t SSACHUS� i This certifies that .......... ..... (, ...... .... ... lr! afz'1Y.r' ............ k has permission to perform ... �� � .. ........... •. , r ' } wiring in the building of // . ... t !.. .. . .. . .. . ... ............. ,North Andover,Mass. lFee.... ....... Lic.No..`3 . ............................................::............... vv"ELECTRICAL INSPECCOR !?Y' 503.00. PR 096196 1 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer