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Miscellaneous - 412 SALEM STREET 4/30/2018 (2)
412 SALEM STREET r 210/037.B_0051.Op00.0 v 7�e, ��71 Form $I, P - 1. (+1962) North .Andover Planning Board SUBMISSION TO PLANNING BOARD �OF PLAN`BrLIEVED NOT TO REQUIRE.,.-APPROVAL UNDER THE , SUBDIVISION CONTROL LAVj Name,and-Address of Applicant: Date of Submission of .Plan: - AM North ,Andover Planning Board Town office`'Building North Andover;` Massachusetts � A Gentlemen: ` Pursuant to the provisions of G:L. c. 41, 81 P; theoriginal of the p.l'an' described below, together with two copies thereof, is herewith submitted to YOU for a determination. that \your approval of the same is-not required by the subdov is iron 'c'6htra:I ° "I aw. _ ~Exact t i't I e ofI Pian. p o : L l +brth`.Pir�do NSa�s f m er oyd O' Se'4, A. I3eEus.c:o h 68t of Plan: J AyL 1963, 'Eng i neer c ` Brassr3ur: Assoctss IIame and Address of Record Owner of Land: JQSeph. A. Deftsero 412 . S:alem�. St.. No, Andover, Mass:. Ti l le Reference: forth :rd - Deeds' Book ,�72 ,, Page : or 771 Certificate o'f-Tiile-No: Z. Regis atio.n-Book ,Parc<> ` ;or Other. . "Description of Land "sufficient for identificationl': , • , L,ots;:#XS. and; . ,` 6- on Assessors 17 a 3'T5 \. - ... /2-Mc At`torneY, for `Apq`I icant: , 1'T is beli eved ` ,Iiat' such. a determ inat iron shou.l d be made for. .the reas*ns . given upon the reverse hereof. APPLICANT'S REASONS FOR BELIEVING THAT APPROVAL OF THE PLAN SUBMITTED HEREWITH , IS NOT REQUIRED BY THE SUBDIVISION CONTROL tAW: Plan does not show a subdivision as:defined below:. Very, truly yours, Applicant N.B. The subdivision control law requires the Planning Board to make the requested determination "unless such plan shows a subdivision." G.L. c. 41,, § 81 P, Accordingly,' the foregiong 'statement of "reasons" must clearly indicate that the subject plan "does not "show a subdivision", which is defined -,by G.L. c. 41, § 81- L as follows: "Subdivision" shail;mean the division of a- tract of land into; two or' more lots and shall include resL1bdivisibn, and when appropriate to the context, - -hall relate to, the ,p�rocess of subdivision or the Iand,. or territiry _subdivided; p,;- ,ided,, howeverj `that the division of a tract of land into two or more lots shall :zt be deemed to constitute a sub-divi.sion within the meaning of the ,subdivision control law if, at the time when it is made, every lot within the tract so divided fibs frontage on (a) a public way, or (b,) a way shown on a plan theretofore approved in accordance with the subdivision control law, or tic) a way in existence when the subdivi.sion control I.aw became effective in the city or town in which the land lies, havin,g, in the opinion of the planning"board, sufficient width, suitable grades and adequate construction to provide for the needs of vehicular traffic in relation to the proposed use of the -land abutting thereon or served thereby, and for .the installation of municipal. services to serve such land and the buildings erected or to be erected thereon. Such frontage shall be of-.at least such distance as is then required by zoning or other ordinance or by-law, if any, of said city or town for erection of a building on such lot, and if no distance is so required, such frontage shall be-,of at least twenty feet. Conveyances or other instruments adding to, taking away from, or changing the size and shape of, lots in such a manner as not to leave any loft so affected without 4 the frontage above set forth, or the division of a tract of land on which two or more 'buildings were standing when the subdiivision 'control, law went into effect in the city or town in which the land I-ies' into separate lots on each of which one of such buildings remains standing, shall not constitute . 9 a subdivision. North Andover MIMAP March 7, 2016 .:r p, mw : .-. w a , II j "•f - xe ' � -al• -• :' PpQ ell 1q. a � �Vz- g,a ., •" Stu ,�' ..• : tT � ��� �'• s: \\0 .,a MVPC Bo [3 Municipal Boundary Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, - Rail Line Meters Data Sources:The data for this map was produced by Merrimack Interstates - - NORTH Valley Planning Commission(MVPC)using data provided by the Town of -I �f;TLS o q� North Andover.Additional data provided by the Executive Office of -SR ,Z a �s�Q Environmental Affairs/MassGIS.The information depicted on this map is - Roads - - - F --, 9 for planning purposes only.it may not be adequate for legal boundary - definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 47;Easements MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels • # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ♦ i # OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT - Trails - #o • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF - - 0 Hydrographic Features �o4.t�o�¢Staj THIS INFORMATION -Streams SS�ICNUSp - Wetlands - Q Exempt Lands 1".=382 ft i I ! I BOOK `k COMMONWEALTH OF MASSACHUSETTS. 8 72 1958PACE Essex as. May 5, 271 Then personally appeared the above-named Richard Rodda John and acknowledged the foregoing instrument by him. subscribed to be his free act and deed. Before me, 9 /yLo Notary Fu lie. 1 'My commission expires:6 f Essex,ss. Recorded/May 5, 1958 at 45m past 2P.M. #97 Benjamin H. Miller, of Newmarket, County of.Rockingham and;State of New Hampshire, Executor under the Will of Carl D. Miller, late of Newmarket, County of Rockingham, State of New Hampshire, deceased, by power conferred by license of the Probate Court for the.County of Essex on the 30 day of April 1958, and every other power, for Three Thousand and No/100 ($3,000) Dollars paid, grant to Joseph A. DeFusco and Pauline M. DeFusco, both of North Andover, in the County of Essex and Commonwealth of Massachusetts, husband I and wife, as tenants by the entireties, to them, their assigns and the survivor I of them, his or her heirs or assigns forever, A certain tract or parcel on the Easterly side of Salem Street:in the Town of North Andover, County of Essex and Commonwealth of Massachusetts, more iparticularly bounded and described as follows: Beginning at a point on the Easterly side of Salem Street, marked by a drill hole in the stone wall and being the Sbutherly comer of la nd of Arthur J. Keating et ux; thence turning and running Easterly by said Keating land a fI distance of 210.4 feet to a drill hole in a stone wall; thence turning and running In a Southeasterly direction by the wall and bounded by Lot#14, a distance of 329.6 feet to a drill hole in said stone wall; thence turning and running Southerly and bounded by land of the estate of Carl D. Miller a distance of 160 feet to an i Lr° iron pin; thence turning and running Westerly by Lot#17 a distance of 405:4 feet a' f to an iron pipe in the stone wall on the Easterly side of Salem Street; thence - 1111 ; turning and running in a Northerly direction by said wall along Salem Street a distance of 362 feet to the point of beginning. Said tract contains 2.935 acres, more or less. ! +• = � Meaning and intending to convey Lots #15 and #16 as shown on Plan of ze, P-6• Lots Estate of Carl D. Miller, prepared by,Ralph D. Bresseur, C.E, Haverhill >'- u ,,;:;;< Massachusetts and said plan being dated March 10, 1958. WITNESS my hand and seal this day of JQ U 1958. Wltness: i ' j Date..�/7/�/................ RT#, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies thaw.-..-0 a - .................. has permission to perform 1zP,"e-,U *"*'**'**"P,*................................ *************'**'**'*...**'*"****.....**....../..................................... wiTing in the building at. ...... I.......................I "S� North Andover,Mass. ......................................................... . Fee &..'T............Lic.NA�g ,,4....... hL4EC'TR*I*C*AL' SPECTOR Check# 5Zfl 12730 V P Commonwealth of Massachusetts Official Use Only .Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of res: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) L!IQ 5-A LIA Owner or Tenant Q i V— 01r-=� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes " No ❑ (Check Appropriate Box) Purpose of Building 57j fV 6 0 fAM 14 Utility Authorization No. Existing Service /0-0 Amps7-- lts Overhead R-;"—Undgrd 1:1No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �,�'° � 1 J 'G �/ 4. Completion of the following 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 Above In- o.o Emergency Lighting fJ No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones L No.of Switches No.of Gas Burgers No.of Detection and _— Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump 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 E uivalent O'T'HER: 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: 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 cWfBOND is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:) I certify,atnder the pains and penalties fperjury,that flee information on this application is true and complete. FIRM NAME: _ v ' /,d' LIC.NO.: Licensee: e / �' NO.-,, � SignaturLIC. � r�l— (If applicable,enter ,exempt"in the license number 1' e.) r - Bus.Tel.No. Address: L)—IT- 9' /M, A-0 eA) = 'Alt.Tel.No.: Oc *Per M.G.L c. 147,s.51-61,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 by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ (QdCYU Signature Telephone No. 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 I 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 of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses 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 "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Datc Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Y Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: r Inspectors Signature: Date: ROUGH INSPECTION: J Pass❑? Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comme �,�•�%S Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): liM /,ff :7 5- 2)zko �tx Address:_ 0 L A City/State/Zip: L,t1�/j Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ iarn,a employer with 4. El am a general contractor and I ` * have hired the sub-contractors 6. ❑New onsiruction ployees(full and/or part-time). 2. I am a sole proprietor or partner- listed on the attached sheet.1 7• emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 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' ' comp.insurance required.] 13.[J Other *Any&plicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i-Homeowners who submit this affidavit indicating they 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. lam 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attaclf a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failurpi to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiq under thepain and e aLY' of perjury that the information provided above is7ue and correct. Jc Signature % Date: 14M . V( 1/1,V 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#: ' J 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 ofhire,• 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-contractors)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 4r 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 COMIMORWealth of Massachusetts Department of Industrial.Accidents Office ofInvestigations 600 WasWngton Street Boston?MA.0211.1 TO.#617-7274900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax#617-727.7749 wwwxnass,govfdza 9/9/2014 Division of Professional Licensure:License Search The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) ' Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home> Division of Professional Licensure> ONLINE SERVICES ........................................................................................................................................................................................................................................................................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name: THOMAS P. DOHERTY REFERENCES& WOBURN, MA RELATED INFO NEW SEARCH I Disclaimer Regarding **This Licensee has additional Licenses click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: ELECTRICIANS JOURNEYMAN ELECTRICIAN More... License Type: TYPE CLASS: E License Number: 28908 i Status: CURRENT Expiration Date: 7/31/2016 i Issue Date: 5/28/1985 Exam Date: 3/30/1985 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server or,Tuesday,September 09, 2014 at 1:44:48 PM. O 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type_class=_E&license_number=000028908&color-blue&Ib=EL 1/1 Date.. . .......... 10690 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 8`QACMUS� This certifies that.�:�?vY'��2....P has permission to f perform.K-A Y'e'yNV ..��.....-..2.. ` .. plum ;ng in the buildings of...... ................ . .�.........^ :c....... ... at........... .�a. .................. L?'I.... , North Andover, Mass. AFee" .....Lic. No. (0EM P PLUMBING INSPECTOR Check* MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 14-Auq-14 PERMIT# JOBSITE ADDRESS 429 Salem St. OWNER'S NAME Belford Construction POWNER ADDRESS 130 Marbleridge Rd, N.Andover MA 01845 TEL 508-509-9430 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES❑ NO FIXTURES 7 FLOOR-" BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM c j DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) to KITCHEN SINK 1 LAVATORY 1 2 ROOF DRAIN N SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER i INSURANCE COVERAGE: I have a current!4Minsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES191 NO ❑ dP IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a ac ate he t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i plia ce i' ro ' 'o of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert J. Frazier LICENSE#13425 SIGNATURE 7 MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-8958 _ FAX CELL EMAIL Bob@BomarPH.com 1 t�JG�rI� _ II r 1 • °1 r i S L4 . t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street - J Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bomar Plumbing & Heating Address: PO Box 694 City/State/Zip: Derry, NH 03038 Phone #: 603-325-8958 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. E]New construction 2. X❑ 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 me in any capacity. employees and have workers' comp. insurance.I 9• E] Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑X Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Fire Insurance Company Policy#or Self-ins.Lic. #: WC2-31 S366059-022 Expiration Date: 22-Apr-15 Job Site Address: 6#2 A26 Salem St. City/State/Zip: N Andover MA 01845 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. Ido hereby certify un th ' s and penal es of perjury that the information provided above is true and correct Si ature: Date: 14-Aug-14 Phone#: 603-325-895 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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#: OMMONVV9Ml 0 MaSS1srCHUSETTS EHWRD PLUMSER"S `AND GA FITT RS: ISSUES THE F:OLLQ41iNG L4CEN5£ ` L CNSED AS—& �QUR[ �(MAN .,PLUMt3R R3tuRT J FRAZ I 19R fa PO: BOX 6 �+ ORRY SIH 03038 0694 ` an�ac� n COMMON E�ILTH:OF MhISS}tt0IfiUSETTS �', PLUMBERS A10 GASFtTERS r 159UtrS T-HE FOLLOWNC LICENSE � 1»aCt $Efl 0 .A #tltS` ERj,PLUMBER RpBERT J FRAZIER j PO BOX "94 OE,Rky 03038-06g4 '. JAIi4l°Jq Chl�\IQ7111:1.TC =�1�17I`i` � Date... .�.. ..... ..t..................... OF NORTH�� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION g8ACHU`3� This certifies that ........ . ........" ...:......... .!: ..... It has permission for gas installation . .� Q.�!..�...0 ec.. .1......est' in the buildings of... ....................................................` �`�, ' North Andover, Mass. at...."f' ...... �^^..... - .......... , Fee....6.(.).. Lic. No.�-�5.... .............:.........:................. ...... ,.� GAS INSPECTOR 4. . Check# `�' 4 963 , -11Z � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS F!TTING WORK CITY North Andover MA DATE 12-Nov-14 PERMIT#_ JOBSITE ADDRESS 412 Salem St. OWNER'S NAME Belford Constrttction GOWNER ADDRESS 130 Marbleridge Rd, N.Andover MA 01845 TEL 508-509-9430 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ❑ RESIDENTIALPRINT ® �' CLEARLY NEW: ® RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO 91 APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE - 1 DIRECT VENT HEATER DRYER FIREPLACE �r FRYOLATOR FURNACE N GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j OTHER INSURANCE COVERAGE r, _ I have a current liabilft nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ c� I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE 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: OWNER M AGENT ❑ SIGNATURE OF OWNER OR AGENT ( I hereby certify that all of the details and information I have submitted or entered regarding this application are true and aaCurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com Iia wi all Pi t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Robert J. Frazier LICENSE#13425 SI ATURE MP® MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑ LLC❑# COMPANY NAME Bomar Plumbing& Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-8958 FAX CELL EMAIL Bob@BomarPH.com h � _ c .. �, ,, �. . .` .. , . ,. _ R � , , . �1 _ 1 1 _ _ _ _ _ ' ' _ t R _ I r _ .� ,- . , .. �' ,r , . ;.. . _� _ . . � r - �s.. � � r x. � � x .. _ ... P i . ._ . y,� , _ '� � ,3. . e 4 � . .. I I - .. - —- �' --- -- -- t I i .,. ., _. _ __ -- - i COMMONWEALTH OF MASSACHUSETTS NMI o •e ® :e •a e PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUP ISSUES THE ABOVE LICENSE TO: � s e. ROBERT J FRAZIER ?m per\ PO BOX 694 DERRY NH 03038-0694(�; �. suagnaa;aa,{Iit+FivalH Ua'it!uU_ `aye:; COMIMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS f LICENSED AS A MASTER PLUMBER.. ISSUES THE ABOVE LICENSE TO: ROBERT J FRAZIER POBOX 694 DERRY NH 03038-0694 13425 05/01/14 240124 " . r„ ti?" a f. e, a ®. •. a COMM011YI11E=J'4 3'Tt�'COF NIAS�AC:Ii�SE'tTS. _ PLUMS�RS (1f1D `GASF t'fi"f1=RS �.. ,��. , " FOLLOVJI#dG L10EN5� ' L r I; MSEV AS A� OU# t+1 OMAN PLUMB.F�R J FRAZIIrR e j` {.. � #tt�BBRT , X03038 0694 OOMMONWEALT#i OFzMASkOIUSETfS: ",o o • • e o PLUMBERS 'AfifD GASF I >ERS , I,SSIlI~S SHE>FOLLOWG LICENSE t 1~fEIS�D AS A �4ASTER.•PLUM1BE�t ` K� LpBf±T J FRAZI ER #' PO BOX 112'Y H 030,38 06:9.4 f �z niz:>nt - i i l I I I - i t i ,10059 277 Date . . . . . . . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . has permission to perform . C?�r plumbing in the buildings of . . . , , ,North Andover, Mass. Fee . f7 � . '. .r . . . . . PLUMBING INSPECTOR Check# 1607 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY v �c9 c�A2- ✓ly 1 MA DATE __L z 3 11 PERMIT# JOBSITE ADDRESS OWNER'S NAME Lai- OWNER ADDRESSP OWNERADDRESS _ _ TEL FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL i' EDUCATIONAL Q RESIDENTIALPRINT 0� CLEARLY NEW: FJ1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES N01]I FIXTURES 1 FLOOR- BSM 1 2 3 1 4 5 6 _ -_7 _.8_._..._.. .._9 1_..._...0._ 11__r.. 12 1.�3 ..14 BTHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i DISHWASHER 7 _ _ I _ __(II!i DRINKING FOUNTAIN i ...._..-.....{[-- FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) i .._ I I -.- i __-__1 —_I .--.___J J __.__-I KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION ( _i _.__._ 1 _._� __' _ _ _.-. -_ _.J i � 't ! WATER HEATER ALL TYPES WATER PIPING - _i __i . . .I OTHER F .,..__._.....�-__,.._ _.__.. ._._._.__� � _•.._.-� _-- i ______I _._.___ � ..._..._.__i � _..__I __ __-_� ._ . .._i _...___._� __i .._...__t __.._._i _... i _._i y INSURANCE COVERAGE: 0 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[�NO �I DF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND ]II 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. Z CHECK ONE ONLY: OWNER 0 AGENT R SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicatio rue and accurate to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b in co I a with a ertine rovisi of the Massachusetts State Plumbing Code and Chapter 142 of the Genera!Laws. PLUMBER'S NAME V- LICENSE# 3_ _` SIGNATURE MPO JP Q CORPORATION E3 (( PARTNERSHIP D# LLC COMPANY NAME �ADDRESS 3e S 9 � STATE 1V --? TEL ZIP 0 1 -/ 1 _ �i?_ _ a.. . . FAX CE91- ��� �,; EMAIL _ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No /,Z�e THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts - Department oflndustritrlAccidents Office o fInvestigations 600 Washington Street Boston,MA.02111 www.massgov/ilia Workers' Compensation Insurance Affidavit:JBuilders/ContractorsfFIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationgndividual):� Address: City/State/Zip:_ D . �u Lit k/LPhone Are you an employer?Check the appropriate box: Type of project(required): L RI m a employer withy 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have nod the sub-contractors 2,111 am a sole proprietor orpartner- listed on the attached sheet.x 7. B- emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.J]Electrical repairs or additions 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.] employees.[No workers' comp.insurance required 1 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submitthis affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. -1am an employer•that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name:-'_�0 Policy#or S elf-ins.Lic.P Expiration Date: Job Site Address: City/State/Zip: Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 flhe form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. 13e,advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xdo hereby ce a u er the pains rdpenaltre Ofper'ury tl2at ilte information provided above is true and correct. - sinafore: Date: '7 L Phone#: cj /� ze 0 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Date . TOWN OF NORTH ANDOVER a PERMIT FOR GAS INSTALLATION This certifies that . . AIP, �V� .. . . �.� -VA. . . . . . . . . . . . . has permission for gas installation . .e�!? �,2., . . . . . . in the buildings of. . . . . . . . . . . . . . . . . . . . at . . . . . � ! .'. �' , - . , , North Andover, Mass. Fee . . aLic. No. �� �H i. . . . . . . . . . . . . . . . . . . . . . . . . "' GAS INSPECTOR Check# !r 8-79.2 S , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY t' d� dy �' MA DATE PERMIT# JOBSITE ADDRESS y iOWNER'S NAME -j OWNER --� G OWNER ADDRESS _ TELT---- JFAX -R TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL DI RESIDENTIAL j.--j� PRINT / CLEARLY NEW:E1 RENOVATION:F REPLACEMENT:4�-,� PLANS SUBMITTED: YES F-11 NOE] APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER n-.-- —j Jam. . -..I[:::j BOOSTER _. CONVERSION BURNER _ . . - �__._ 1 ._:- l _�1 -1 - ti, COOK STOVE DIRECT VENT HEATER DRYER - -FIREPLACE v FRYOLATOR FURNACE GENERATOR -�.-r_. _I I I_ f I �(I-_f - �I _ _ GRILLE ---J[^1 .,.__.,(.(-- ---[ ___-__ _T-.L_._:_ f= 1---- INFRARED -__INFRARED HEATER LABORATORY COCKS i MAKEUP AIR UNIT OVEN = - POOL]HEATER !I— - L - 1l _I - -1 r I _. -- - I - - ROOM/SPACE HEATER __.._ I _ __ --- ,r- C -- l-_ - - TROOFJOP UNIT [-���-�-1( UNIT HEATER :_ 11 _ __--_ _ ___. -._-. - UNVENTED ROOM HEATER __ L. I I 1-��-J -= I -I - EE WATER HEATER - OTHER 1 1 I t �^ I INSURANCE COVERAGE � 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1� E 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BONDE] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ID AGENT Q SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are tru d accurate to t e best of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com ' ce wi II Pert' ent provon of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a PLUM BER-GASFITTER NAME� r�,. -e_ LICENSE# 3 � GNAT�URE l MP�I MGF C JP JGF LPGI ( CORPORATION 3 J_-f/1 PARTNERSHIP[._ (#�__-__..__II LLC[II# COMPANY NAME: --!1 S ` f _.----I ADDRESS CITY YI- --/}N� U v-C n, e_1m^�_.._ _ . f STATE µt�iL�ZIPe���TEL FAX CE 7 SZ!EMAIL _ - --- -�-- - - - - - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 'V 1 r i i The Commonwealth of ll'Iassachusetis - Department of Industried Accidents Office of Investigations 600 Washington Street Boston,MA 02111 1Lvww.rnass.gov1d1a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): .-`r r S f� �/7 4 Address: City/State/Zip: ">-I 6 . �cJ Ut UUL-Phone#: % 2 6-F Z" Are you an employer?Check the appropriate box: Type of project(required): 1.L Iv 1 am a employer withy 4. ❑ I am a general contractor and I 6. []New construction employees(full and/or part time).* have hired the sub-contractors ,�,` , 2.❑ I am a sole proprietor orpartner- listed on the attached sheet,z 7• emodehng ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. []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 I LD Plumbing repairs or additions myself.[No workers' comp. C.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they die doing allwork and then hire outside contractors must submit anew 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. -ram an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. (��2/► �1�r/ �✓ .P Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: f Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL e.152 can lead to the imposition of criminal penalties of a f no up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Ofice of Investigations of the DIA for insurance coverage verification. Ido liereby ce ! u er tlaepains dpenalti ofpeY'uYy that the informationprovided above is true and correct. - SigLiature: Date: "7 Z Phone#: Cj /� �' 0 ®fflcial 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 Iffealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Date./.-.,?. 7 TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING 41 r s o� �,�• a SSACMUS� This certifies that has permission to perform . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . ' 1�. -. - :.,./. . . . . . . . . . . . . . . at. . .��' >. . . . Sr!`, ' :r r. . . . . . . . . .�. North Andover, Mass. Fee. 3:'. .Lic. No..(--./. . . . . . . . . PLUMBING INSPECTOR Check # 5503 7 A3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO P (JY/ r� -3 (Niln�t/or Type) PLUMBING Mass. Datd�J�,, / c;(v?11oj� Permit # . Building Location 6-/02 �Ci� — Owners Na 61,,4 v/ d Type of Occupancy E N rl �-- L_ New ❑ Renovation ❑ Replacement OR"' Plans Submitted: Yes ❑ No ❑ FIXTURES z m fA zY � p. y N O Z }• } y ' w � y > <? < y = to w GZ y < Q < r. Z ooCC .. ¢ z a U, y 1- Z y r U W y Y d as z 6 r V _ ¢ m y W r to z D < c7 .C d a@c 0 0 s < N x �. w Z r r w 3 o ,a y cc j rld IL < Y g m aAL U. ~ < < x y In < < O z o p N w F- O V y < A J < Q: < y < O < H m y a a J 3 z r 03IW6 V Cf < ¢ m o SUB—BS MT. BASEMENT 1ST FLOOR 2Nd FLOOR v 3RO FLOOR 4TH FLOOR 5TH FLOOR 8TH FLOOR TTM FLOOR STH FLOOR Installing.Company Name �T Q• �,4m►�n�7A,�c7. Check one: Certificate Address 30— 004 4MAt i,n__J ❑ Corporation J?'1 E r N4 a FA 1� 41,4 •U 1rf cls I ❑ Partnership Business Telephone T 1-59'7 1 e-K'�/Co. Name of Licensed Plumber __ r4f!r'�,=,L'T __f� SA�vrryl�q TfC1r N - i SURANCE COVERAGE: I have a current mobility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Er No ❑ IF If you have checked YSI. Pies /Indicate the type coverage by checking the appropriate box. A liability Insurance polity fid' 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: • nature of Owner or Owner's ent Owner El Agent❑ 1 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 pe0ormed under the permit issu for this application will be,in compliance with all pertinent provisions of the Massachusetts State Plum and er of the rai taws. By L o n um er Time City/Town Type of License: Master JourneMikh ❑ - ;3 APP{i[7NF L 1 irwn*A wtmhnr f BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS FINAL INSPECTIONS SKETCHES FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING - PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR r i I Y y/f Location i No. �� Date 02 0.1 NORTH TOWN OF NORTH ANDOVER 40 � 9 ' Certificate of Occupancy $ b''••°''tom GMBuilding/Frame Permit Fee $ ,SSAUSt Foundation Permit Fee $ Other Permit Fee $ TOTAL $ S Check # 16577 ' Building Inspe� r ' TOWN OF NORTH ANDOVER f BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 2 BUILDING PERMIT NUMBER DATE ISSUED. fj xd F ° SIGNATURE: Building Commissioner/Ins for of Buildings Date z,51- Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 03 2 6,0,5-) AV O&7-9 A • 9 0 0'!9 F p Map Number Parcel Number 1.3 Zoning Information: V f� 1.4 Property Dimensions: t . Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R aired Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ .Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O -• License Number Address onD Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v I V(17 CAS7 9) Ca19,- R00PIV& SID/A)(5--ZNC- �� SC Company Name M �S' (&T-TD A) S / .q— S'a/�, �„Z Registration Number r s r E iration.lla�!��G Si nature Telephone xp Y) SECTION 4-WORKERS COMPENSATION(M.G.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.......❑ No.......0 SECTION 5 Description of Proposed Work check applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item (Dollar))to Estimated Cost be ©Fk ICIAI,IU0,4.,NLY Completed by permit a licant Ell 1. Building Q (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tat x (b) . 4 Mechanical HVAC 5 Fire Protection Vl . 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 - I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTIOON 7b OWNER/AUTHORIZED AGENT DECLARATION I, Al D CA 9 T d /V)E ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are tnne and accurate,to the best of my knowledge and belief UID CAS 7-A COA � Print am Z SZ SJillei a ntre o Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS —DIMENSIONS OF GIRDERS HE-IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1 ORT4l Town of North Andover o`l �4Eo ,64, Building Department o 27 Charles Street * ,� North Andover, Massachusetts 01845 978) 688-9545 Fax (978) 688-9542 / 9 A�RgTED hP¢,y'�y RSSRCHus�� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a. The debris will be disposed of in/at: r Facility location n Signature of Applicant �/3do E Date NOTE: A demolition permit from the Town of North Andover must be obtained for this m o project through the Office of the Building Inspector. 07 � t`* - fie 'Coanvnzaouuecacuz o�✓��!u[6e�6'l''_-- �-\ Board of Building Regulations and Standards,. License or registration valid for individal use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:` 104569 One Ashburton Place Rm 1301 lug Expiration: 7/14/2004 Boston,Ma.02108 Type; Private Corporation i DAVID CASTRICONE ROOFING;S `' + �aY0d tastricone 7 Hillside RoadBoxford,MA 01921Administrator Not valid without signature DATE (q lDD�YY) CERTIFICATE OF LIABILITY INSURANCE 01/2202 FRDDUC94 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORIMATIQN' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I INTYRNST xx9U3kJWI E A=IgCY HOLDER,THI8 CERTIFICATE DOES NOT AMEND,EXTEND QR S22 CKTCXX=NG ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BEL W. NORTH AXDaaR, MA 01845 INSURER$AFFORDING CCVERAGic INSURED INSVRERA! ARSELLA thV'ID CABTRICONE INSURER E; ARRELLA BROTECTION RAOSIN3 AND SIDING INC. 200 BUTTON STREST, 6UITE1 226 INBURERc; ROYAL SUN a1iIrLIALiC>>< NORTH ANDOVER NA 01848- INSURER 0! INSURER E; COVE CpES. THE POLICIES OF INSURANCE LISTED BELOW HAVE BECN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHST DINO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIOH THIS CERTIFICATE MAY BE ISSUED 0 MAY P9RTAIN,THE INBURANDE AFFORDED BY THE POLICIES DESCRIBED HEREIN 03UBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF UCH POLICIES,AGGREGATE UMIT$$MOWN MAY MAVa BEEN REDUCED BY PAID CLAIMS, I TYPE OF ENDURANCE POLIOY NUMBER POLICY EPFEO VE POLI LIgIT N 'B GENERAL LIABILITY EACH OCCURRENCE 1 00 000 A CONINIMCIAL GENERAL LIABILITY 0500012710 106/06/2003 06/06/2004 fIREDAMAGE n oneflrel i 50 040 CLAIMS MADEOCCUR MED BXP AnE ons parson) ® I 5,000 PERSCNAL&ADVINJURY Is 1000,000 GENERALAGGRECAT13 14 1 000 000 011nAGGRE6ATaUMITA"LIEBPER: PRODUCTS-COMP/OP AGO II 1 000 000 El POLICY PRO- LCO 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ' ANY AUTO (Ba ewldent) Sli B ALL OWNED AUTOS 44506400001 09/01/2002 ,08/01/2003 i0D1LYINJURY SCHEDULED AUTOS (Per prion). D 250,000 �.HIM AUTOB BODILY INJURY NON•OWNEDAUTOS (Peraooldald) � 1500,000 t PdtOPERTYDAMA13FPOD. i i 100,000 ( arcld acaN) GARAGE LIABILITY AUTO ONLY•K5A ACCIDENT { ` ANY AUTO© EIA ACC S OTHER THAN . AUTO ONLY: AGO I EXCESS uAmILITY , ~;CLAIMSMAOI EACHG URR6NCE g 00OUR FAGGREGATE i DEDUCTIBLE S I RETENTION S WORKERS COMPENSATION AND OTH. EMPLOYERS'LIABILITY Ell C 791X97BA01 03/23/2002 09/23/2003 E,LEACHACCIDENT 100,000 ELIPOEMS-CAEMPLOYE 4 i S00r000 OTHER F.L.DISEASE.P Y 61MIT f 100,000 I OEDCRIPTION OFOPCRATONUCCA'r!QNBNIHIOLEBIEXOWBWNS ACDED BY GNDORSKIMINTIEPEGAL PRMIONG ( I CERTIFICATE LDER ADDITIONAL INSUREbiINSURERL CANCELLATION SHOULD AMY OF THE ARMS DESCRIBED POLICIES BE CANCBLI.ED BEFORE IS EXPIRATION DATE THEREOF,THE I4OUING INSURER WILL ENDEAVOR TO MAIL 010 4ye WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAIHEO TO THE LEFT,BUT FAILURE TO{�O SO SHALL IMPOSE NOOBLIBATION OR LIABILITY OFANIY KIND UPON THE INSURER,ITDA�KNTS OR REPRESENTATIVES. AUTHORIZED REPRI10NYAMVE ACORD 254.(7197) ®ACORDCMI114POUT1,10IN 9988 ! I own of Aindover No. -77 0 roc LA E 'C dover, Mass., c� 0RATED IF, C, BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D THIS CERTIFIES THAT....204010�................................................................ ...................... ....................................... BUILDING INSPECTOR ............. . ......... Foundation ...... . ................... A has permission to erect........................................ buildings on . ........... ...... .............................. ..................... Rough .... .................... tobe occupied as ... .............. ......*...... ...... ...... ................................................................................ . .... Chimney i an accept' l provided that the person g this permit shall in every r pest conform to the terms of the application on file in Final 0 this office, and to the provision 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 S Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE _ Smoke Det.