HomeMy WebLinkAboutMiscellaneous - 41 MILLPOND 4/30/2018 41 MILLPOND
210/095._q 0041��0
n
Date.s:,"... y,
.........................
40RT"
TOWN OF NORTH ANDOVER
0
0 PERMIT FOR WIRING
C14US
This certifies . .........................................
has permission to perform ...
................ .... .......
wiring in the building of............... ........................... ........................................
...... . .......�o .......:ea:...............................North Andover,Mass.
Fee,--.,.4):............. Lic.No3"6-1kri1$r...............i�..................................
ELECTRICALINSPECTOR
Check # 76 90
802.1
Commonwealth oO&aachuseft ,:.. Official Uses
Department of Fire Services Permit No.
•ccupamcy and Fee c'�tecicoa,.
BOARD OF FIRE PREVENTION REGULATIONS pwv.9/05]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in am rdance with die Massachnset#s Elsaricxl Code(MEC),527 CMR 12.00
(PLEAMPRINTININKOR TPP ALL NI' I Iyom Dane:
City or Town of: To the kipector of Jruw:
By this application ftundersigued gives notice of his or her ibo perform She elecerical wo&described below.
Location(Street&Number)
Owner or Tenant Telephone No.
a3
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boa)
Purpose of Banding Utility Authorization No.
Existing Service Amp- / Volts Overhead❑ Undgrd[] No.of Meters
New Service Amps i Volts Overhead❑ >Lndgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
F h
ca
fbe rab�e be waived by rke of Witps
al
No.of Recessed Lumblai res No.of Ca'4.Snsp.(Paddle)Fans i KV
ecA
No.of Landualre Outlets No.of Hot Tabs Generators KVA
1 mrgencyLipm
No.of LuminairesPoN ❑ Q ve In- o.ftauunits
5
No.of Receptacle Outlets No of Oil Burners FM ALARMS NL of Zones
No.of Switches No.of Gas °' Detection an
Devices
No.of Ranger No:of Air Coad. Tom o.of Akrft D vices
NJKW
a of Waste Disposers ed
Totals= offi a Devices
No.of Dishwashers SpacdArea Head KW ❑ .❑ Other
Cwtneetian
No.of Dryers Applianees KW �, t
aHof eaters of
a - - Data Wirt
Iftllasts
KW
BaN&of Devices.or
Na Rydromassalre Bathtd o No.ofMotors Total NP
tt OTRM-
1, Aurack ed*d and demgjf dt bv4 oras mpbe d by the rmpedorojW nw
Estimated value of Ebmuied Workr: J Wbm required by policY) '
WO*to Starts hVectioust to be requeded in dance with MEC Rile 10,and upou,completion.
INSURANCE COVERAGE: Unless waived by the owner.no pemrit frw the perflo of electtical wo&may issue unless
the ficensee Provides proof of liabMy hourence including`aw*htted operators"rouge or its substaontial equivalent. The
undersigned certifies that suchis in fne and has exhibited proof of same to the permit issuing office.
CHWX ONE DMM ANCE 9 ND ❑ 07 ❑ i fy) e.., , T•,v�l«r 6/00Icoiffy,
ander the and of - filar iWa madbu ah:this is tray mrd am
FIRM NALicense= ME: LIG NO»
rpt -sin� atm LIC.
Addr�fl Pill CL�► s Mars, 1 d f 9 Bus.Teel.N � D •
No»
*Soaaity System Contract Lioause ruched for this wank;if clue lime number lane:
OWNF,R'S INSURANCE WAIVER: I am aware that the Li�see does mthavoc tike
habr7ity insurance coverage normally
required by law. By my signature below,I hereby waive this requuemen I am the(check oue)[3 owner owner's agent.
s"rgna�trr,re `t Telephone Ne. P
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TOWN ORTH ANDOVER
♦ . PERMIT FOR GAS INSTALLATION =
,SSACMUSEt
-... L�` u�_ ,tel . . . . . . . . . . .. .
This certifies that . . . . . . . . . . . . . �:��. .���1..-rt.-�-�. . . . . . . .
has permission for gas installation_..taf.-ya.,.- -. . . . . . . . . . . . . . .
in the buildings of . . . .!� ��-� -�.�,�✓ . . . . . . . . . . . . . . . . . . . .
at . . �. . ��'?a-S �� - ... . . . . . . . . ., North Andover, Mass.
Fee. Lic. No. . . . . . . . . . . . .
GASINSPECTOR
a:
Check#
6Z87
i
MASSACHUSETTS N ORM APPLICATION FO PERMIT TO DO GASFITTING
ter,Mass. Date 1 a C 20 U7 Permit#
Building Location 1 Owner's Name a rj
Type of Occupancy
New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No❑
lid
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rn
a z 94° wF— w0 � o6a <Cn
vHza 0 CA
rLOcj:4� ]C � 3At¢7a. Uate ' a AO
SUB-BASEMENT
BASEMENT
FIRST(I ST)FLOOR
SECOND(2ND)FLOOR
THIRD 3RD)FLOOR
FOURTH(4TH)FLOOR
FIFTH(5TH)FLOOR
SIXTH(6TH)FLOOR
SEVENTH 7TH FLOOR
EIGHTH 8TH)FLOOR
Installing Company Name l
Address heck one: Certificate
XA4Q Corporation
R Business Telepho a `?— Partnership
Name of Licensed Plumber or Gasfitter U eazz4c ❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liabiliry insurance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes No❑
If you have check pleas irate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE RIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the MGL,and that my signature on this permit application waives this requirement.
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 the
permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State
Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title ❑ PlumberMaster Sign�ure of Licensed Plumber/Gasfitter
City/Town E] crasfitter tourneyman License Number P
APPROVED OFFICE USE ONLY
f. ..
�,
Date.
".O R7:�4, TOWN OF NORIA OVER
tr ° PERMIT FOR PLUMBING
" v ,SSACMU51
This certifies that . . . . . . . . . . . . . . ..�t . . �fr. r. . . . . . . . . . . . .
has permission to perform V, �-r - .�„4�. . . . . . . . . .
plumbing in the buildings of . - --. . .. . . . . . . . . . . . . . . .
at . . .. . . . . . . . North'Andover, Mass.
1
Fee-42-5 . . . . .Lic. No.. � d . !,� a�,�. .. . . . . . . . . . . . .
" PLUN INSPECTOR
n /
Check
c
7619
'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO X -0 PL yM_%ING
(Print or Type)
ti 1)r n O&t) 'C ( , Mass. Date t9 Permit# ��
Building Location -41 lel rt f l i or J Owner's Name
Type of Occupanry �Se2
New ❑ Renovation O Replacement Plans Submitted: Yes 0. No O
I
FIXTURES
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44 66 a
sus—dSMT.
BASEMEOT
1ST FLOOR' i
2H0 FLOOR
3RD FLOOR
4TH FLOOR
..
5TH FLOOR. .
I 6TH FLOOR •• ° ':' r' ' •
ti TTHFLOOR
ti 8TH FLOOR
Ins IIng Company Name n Check one:. Certificate
Addressration. _.
❑ Partnership
Business Telephone Z O Firrn/Co.
Name of Licensed Plumber a� �
INSURANCE CO RAGE:
I have a curren litty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No O
if you have eked y,. pi-as
ica a indicate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity O 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
Owner O I Agent.O
gnature of Owner or Owner'sent•
I hereby certify that all of the details and'information I•have subs ttW-toi entered)-in above application'are true and.i6�iate to the best}o}tiny
knowledge and that all plumbing work and installations performed under the permit i=ued for this application.vAll.be,in compliance wiM all,.._
pertinent provisions•of the Massachusetts State Plumbing Cod !�
d t f t2 ofC.e feral
Sy
Title Signature o sed um r
Type of license:Master Journeyman❑
f E
(O NL (cense Number �. i
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,
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT WA RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-:" �. i��e say. •.:1 ....,.. .....- - .. '^�.ks'�Sy �t��, ,.. + r^ ��'vfi r
.,,, s :,... m ... ..., .. � w.• - .., c svgs�, •§,; tom:`;.
BUILDING PERMIT NUMBER: - . DATE ISSUED. '� r O
41 �r X
SIGNATURE:
Building Commissioner/I r of Buildings Date •Q z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
61A/ TT y 15'tA
PMap Number Parcel Number
CIAl
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I Lot Area Fronts ft
1.6 BUILDING SETBACKS fit
Front Yard Side Yard Rear Yard
RegWred Provide ReqWred Provided ReqWred Provided
1.7 Water Supply ACLL.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside blood Zone 0 Municipal ❑ On Site Disposal System ❑ J
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No rn
2.1 Own r of Record
V 401)
e( rint) Address for Service
q77 F6-
Signature Telephone t
2.2 Owner of Record:
Name Print Address for Service:
z
rn
Signature Tele hone
SECTION 3-CONSTRUCTION SERVICES
3`1 Licensed Construction Supervisor: Not Applicable ❑
T,-ire I�+r'�t'—���--��
LicenkConstructton Supervtsor.
�`1)IT� License Number
aan
�
Expi ra6on Date
Sign Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name f " M
rn
Registration Number
r
Address
Expiration-Date /1
Signature Telephone Y�
, y
i
SECTION 4-WORKERS COMPENSATION(NLG.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.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Constructionve @ Existing Building ❑ Repair(s) Alterdfions(s•) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Propo-pdfftrks" a
'
!!!!!! SECTION 6-ESTIMATED CONSTRUCTION COSTS
�6 E3F)H' Clij USE(}
Item Estimated Cost(Dollar)to be
Completed b permit a licant .
F �
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)X (b)
4 Mechanical(HVAC) -7 �0 CT
5 Fire Protection )- � /
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
eHereby authorize to act on
My behalf,in all matters relative to work authorized by this building permit application.
e
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, f [ C7 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
c-
ame '
'--1 -
/ !✓
Si atur f Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 ST2NID3RD
SPAN
DEvIENSIONS OF SILLS
DEV ENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION- THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.g ov/dia,
f .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): O"FO 3e^ r�
Address: ��� � r/-,),_) (Z�
City/State/Zip: ( (,t „ ,,ft Phone #: 603 (P?�E3G �'7
Are you an employer?Check the appropriate box: Type of project(required):
1.[:1 1 am a employer with 4. ❑ I am a general contractor and
New 6. ❑ e construction
employees(full and/or part-time).* have hired the sub-contractors
+
2.❑ l am a sole proprietor or partner- listed on the attached sheet. + 7. E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for the in any capacity. workers' comp. insurance. q. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbi epairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12. oof repairs
insurance required.] employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant Ihat checks box A I must also till out the section below showing their workers compensation policy intimnation.
+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: /_t
Policy #or Self-ins. Lic. #: tdl G Expiration Date:
Job Site Address: 3 .5-" n4 t 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
tine 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 tine
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 her certify antler the pains cud penalties of perjury that the information provided above is true and correct.
Si nature: --- Date:
Phone 4: Z
Q11ficial 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):
I. 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 apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in ___(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
BOARD OF BUILDING REGULATIONS 1
License: CONSTRUCTION SUPERVISOR -
Number: CS 071037
- Birthdate: 06/18/1950
Expires: 0611812007 Tr.no: 11773
Restricted:;00
THOMAS A DEFUSCO
23 DUTTON ROAD` G'
PELHAM, NH 03076 Commissioner
____ _., ,_�--"`J� �amnzaruue� a�✓��a�scu,'�euaell�
-� Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
_ Registration: 117756
Expiration: 11/15/2006
Type: DBA
TOM DEFUSCO GENERAL CONT
Ta6'IA9 DEFUSC0
23 DUTTON RD �� "` Y
Adm
PELHAM,NH 03076
Page Na,
• ` 1 Pages
a _
Tom DcFusco
23 Dutton Road
Home Improvement.Reg.# 117756 Pelham, NH 03076
Constr.lic.#071037
fROPOSA�SUBM(TTEO To Tel 603-635-3017
Fax 603-635-3751
s cT' L Pt{6NE
E''� OATE
AN' �= aos rva>ae � G
CRY,STATE D P CODE ' I ,
;ru
4
JOa LOCATION �''• 1.
.d
ARCtt
DATE OF PtAN3 A/
Joh���L � S �,• 3/
We hereby submit Specifications .tee PHONE
and estimates for:
_3j t z r c 3 or 1
�s
i uiy p
-atePaR_-___--
cipitii t
2 t r ,r,
_ Pt
e fropr5r, hereby to furnish material abo
nd labor—
`�–� complete in accordance with the ave specifications, for the sum of:
PaymeM to be made as follows: t/ �-- d l
— ollars oej
All material is guaranteed to be as Spec;tFed. All work to be w le
manner according to standard y tr m above
ve Authorized
Practices. An alteration ar orders,
n from ahave Sngnature
epeciflcatiorrs involving extra cone will be exeeuted_pnty upon written orders,and will become
an extra charge over and above the estimate. Ag agreements contingent upon strikes,
accidents or delays beyond our corilml. Owner to carry tire,tontade and othes neceasaay Note:This proposal may be insurance. Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us it not accept
qhs $ r days.
Cxrryitttt" ja` rlypVSal—The above prices,specifications
and conditions are satisfactory and hereby accepted..-You are authorized to do the Sign
work as specified. Payment wolf(e made as outlined above.
Date of Acceptance:
Signah-
^I AC4$i, CERTIFICATE OF IABILITY INSURANCE U811771200s
PRODUCER (978)459-7744 fAX (978)459- 88 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wilson Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,E)I TEND OR
6 Courthouse Lane Suite 14 ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
Chelmsford MA 01824
INSURERS AFFORDING COVERAGE NAIC 4
INSURED Toro De usco dba Tom DeFu5CO wneral INSURER Ac Scottsdale Insurance
Contracting INSURER B: Liberty Mutual Insurance
7 Austin Street INSURER C:
Methuen MA 01844 INSURER I
INSURER E:
CO
THE POUCIES OF INSURANCE LISTED 13ELOW HAVE BEEN ISS ED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED-NOTWITHSTANDING
ANY REQUIREMENT,TERM ORCONDITION OF ANY CONTRAC OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY POLICIES. THEAGGREGATE INSURANCE S OWN ED BY THE
BEEN RED CEO RI ED HEREIN
SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POUC
INSR D TYPE OF INSURANCE POLICY NU BER POLICY EFFECTIAIE POLICY EXPIRAnDN LIMITS
GENERAL UABRftY CS 1153932 08/03/2005 08/03/2006 EACH OCCURRENCE f 1,000.000
X COMAERCIALOENERALLIABILITY PRFMISa,SCEED f S0,00
-._,D _
CLAIMS MADE a OCCUR EXPIA�Y aIre Perbont
S 1,
A PERSONAL a ADV INJURY f 1.000,00
GENERAL AGGREGATE f 2,000,00
GENL AGGREGATE LIMIT APPLIES PER-
-XI POLICY M z7 LOC
COMBINED SMG
LIMIT
. AUTOMOBILE LIABILITY (Ee>a�dMH) S
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
(Perperaon)
SCHEDULED AUTOS
HIRED ALTOS BODILY INJURY f
(P-wdd-d)
NON-OWNED AUTOS
PROPERTY DAMAGE S
(Par ecddent)
GARAGE LIAR AUTO ONLY-EA ACCIDENT f
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE 3
OCCUR CLAIMS MADE AGGREGATE S
S
S
—UICTIBLE
S
RETENTION f
WORKERS COMPENSATION AND
NtCl-318 38466-014 10/18/2004 10/18/2005 we STATU DTH
EMPLOYERS LIABILITY EL EACH ACCIDENT $ 100,00
B ANY PROPRIETORWARTNEWEXECUTNE E.L.DISEASE- f 100.00
OFFICERMENBER EXCLUDED?
Byee de ibeunder EL DISEASE-POLICY LBM S S00,00(
SPECIAL PROVISIONS bebr
OTHER
DESCRIPTION OF OPERATIONS I LOCATXM I VEHICLES I EXCLUSIONS ADI IED BY ENDORSEMENT SPECIAL PROVISIONS
For information purposes for proof of insurance.
C C
SHOULD ANY OF THE ABM DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPTRAMON DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CEKnIRCATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MALL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY IDND UPON THE INSURER ITS AGENTS OR REPRESENTATNES.
For Infamation Purposes AUTWWOEDREPRESENTA]WE
Clark N. Lindley
ACORD 25(2001108F @ACORD CORPORATION/988
L4vt TOTAL
Check #
Building Inspector
\� EXPLANATION AMOUNT
`N TOM DE FUSCO 061
GENERAL CONTRACTING
23 DUTTON RD.
PELHAM,NH 03076 _ 5-7515-11,
PAY
AMOUNT
OF l/ c DOLLARS CHECI
DATE TO THE ORDER OF DESCRIPTION CHECK AMOUR
NUMBER
u
Sovereign Bank
sovereignbank.com
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No.
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=== A o dover, Mass., -0 is•0.'S
COCMICKEWICK y�.
.1 ADRATED PP�� �y
`s BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
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BUILDING INSPECTOR
THIS CERTIFIES THAT.... ll.. 06.. ........Rome.. .... 4% ............................................ Foundation
has permission to erect........................................ buildings on .Af.1........M1..1
1.?.&Jd.......................................... Rough
to be occupied as...... r.1t. &....... . .. ..1�1�.00 . ............................................................................... Chimney
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provided that the person accepit,. 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. % A/41 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS C®NSTRUCTIO STARTS
Rough
.... ....... �.. ........ Service
UIL G 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 BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
- ,
Street No.
SEE REVERSE SIDE Smoke Det.
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NO .ANDOVER , MA Mass. Date �`� ig G�� Permit ;!f
a Building LocationMIMILLPOND Owner's Name
NO . ANDOVER, MA Type of Occupancy RES
New ® Renovation ❑ Replacement ❑ Plans Submttted: Yes❑ No I]
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SUB—BSMT, I I I I I I I I I I
BASEMENT I I I I I
1ST FLOOR I I I I I I I I I I I I
ZND FLOOR I I I ( I I
ORD FLOOR
ATH FLOOR I I I L I I I I I I I
57H FLOOR I I I I I I
16TH FLOOR I I I I I I I I
7TH FLOOR I I I I I I I I I I I I
aTH FLOOR
Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certmcate
Address_ 91 BELMONT STRFET ❑ Corporation
NO . ANDOVER , MA . 01845 ❑ Partnership
Business Telephone 508-689-9233 ❑ Firm/Co.
Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142
Yes �] No ❑
jIf you have checked Yes, please Indicate the type coverage by checking the appropriate box-
A Itabtltty Insurance policy 2 Other type of Indemnity O Bond O
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:
owner-0 Agent ❑
Signature of Owner or Owners Agent
I hereby cartiry that all of the details and information I have submitted (or enlerec'r :n ove appfica(lon are Uue and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the rermit sued for this app11 U will b In pflance with all
pertinent provisions of the Massachusetts Slate Gas Code and C•tiapler 142 of the neral Law
ey T e of License: / A`
Plumber Snatur o c nse(rKum e or Gas Ater
T tieasfil
aster r
Ucense Number M– 3 4 4 0
City/Tovm Journeyman
M r'f x-)%T-( C5�5�T` 0
2118 Date.v? /3�1. .
„ORTH TOWN OF NORTH AN-DOVER -
Of.�`tD 4
PERMIT FOR GAS INSTALLATION H
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�9SSACHUSEt�y
3;
This certifies that . �-f. ' C Lgl9G z
has permission for gas installation . . . f'
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . .A
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at . . �/. . f.l�l.'v.�. . . . . . . . . ., Andover, Maw, s
Fee. ?. . . . . Lic. No.. �� �l,.U. . f . . . }'. . ..
�GASINSPECTOR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer. GOLD: File
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' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
\� .Y (Type or print)
NORTH ANDOVER,MASSACHUSETTS Date "1'3
Building Locations f /44 d2 0,.,/ _ Permit # 36 VR
Amount /
Owner's Name U `s 0
New Renovation Replacement ® Plans Submitted
FIXTURES
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.(Print or type) Check
Check one: Certificate F
Installing Company �Ui7i?�C is � �L�/�/� � Corp.
l^
Address � Partner.
Business Telephone p Finn/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 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
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have su itted(or entered)in above application a
yCjrue and accurate to the
best of my knowledge and that all plumbing work and instal ' s erformed uoder Permit Issuedfor will be in
compliance with all pertinent provisions of the Massach tts t Plumbing Code Ch ter I f e General ws.
By: rfaare o kens um er
{ Type of Plumbing License
Title 4
City/Town License T-um er Master Journeyman n
APPROVED(OFFICE USE ONLY F� �/
1r�r��� n.e�..• Y l 4.... ... ,— -.' as —.. a M• _• w..��.s.•P... r _� - _. �_/�-_
�r
Date..« . . . . . . .
NP 3673
ECEIVED PAYMENN
�j�a�`•_°.;•��ooL ,, F ,. ...TOWN OF NORTH ANDOVER
} PERMIT FOR PLUMBING
SSACHUS�
This certifies that. . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . . . . . . . . . . . .
plumbing in the buildings ofd....!-- -'. . . . . . . . . . . . . . . . . . . . . . 3
North Andover, Mass.
Fee.e. . . . . .Lic. NO.. . . . . . . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
i
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
V919919 MASSACHUSETTS UNIFORM APPUCATON FOR PERMT TO DO GAFITTINGe or print) Date ��, L 19 91
NORTH ANDOVER, MASSACHUSETTS j
Building Locations �J' ,�/ L Q Permit#
Amount$ o0
�/r/�(J✓L�2 Owner's Namey S X
New❑ Renovation ❑ Replacement Plans Submitted ❑
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SUB-BASEM ENT
B A S E M E N T
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH . FLOOR
5TH . FLOOR
6 T H . F L O O R
7TH . F L 0 0 R
8T H . F L O O R
(Print or type) � ��C !� � ���/�Z/ � Check one: Certificate Installing Company
��
Name �+ El Corp.
Address i� L b/ c�A4,k� V7 ❑ Partner.
Business Telephone ^ ❑ 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 lia No❑
If you have checked yes,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 installat' ns performed under Permit Issued for thi applicati n will be in
compliance with all pertinent provisions of the Massachus Ado er 142 of the nera aws.
By:
Signature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber a c/o R-P—
City/Town ❑ Gas Fitter License Number
❑ Master
APPROVED(OFFICE USE ONLY) M%? Journeyman
24837 Date.q. .. f.......
RECErm ROMP _A
HotxrM TOWN OF NORTH ANDOVER
NORTNMd=NM- GAS INSTALLATION
h
'y9SSAC MUSEtl
� t
This certifies that ..!. . . . . . .- . . . . . . . . . . . . . . . . . .
has permission for gas installation
in the buildings of J ?: .: / . . . . . . . . . . . . . . . . . . . . .
� � ?
at . . . . .�.:. . . ,. . . . . . . . . ., North Andover, Mass.
Fee. '.� . . . . Lic. No.. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GAS INSPECTOR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer