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Home My WebLink AboutMiscellaneous - 42 PENNI LANE 4/30/2018 210/107 pENNI LgNE -- --- - ---- - --- -------------- __ � ��_ _ �._� --_-- =0-0000.0 - -- J I North Andover Board of Assessors Public Access A Page 1 of 1 NORTH North Andover 'Board of Assessors OE t•�to•a,a0 `, roperty Record Card Click Seal To Return Parcel ID :210/107.D-0060-0000.0 FY:2012 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels r Search for Sales Summary I Residence Detached Structure Condo ` 42 PENNI LANE Commercial Location: 42 PENNI LANE Owner Name: SAVORY,MATHEW SAVORY,GAIL Owner Address: 42 PENNI LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7-7 Land Area: 1.04 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3328 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 563,800 498,300 Building Value: 337,900 272,400 Land Value: 225,900 225,900 Market Land Value: 225,900 Chapter Land Value: LATEST SALE Sale Price: 589,900 Sale Date: 08/31/2004 Arms Length Sale Code: Y-YES-VALID Grantor: TAGARAS,MATTHEW Cert Doc: Book: 9026 Page: 275 http://csc-ma.us/PROPAPP/display.do?linkld=1896675&town=NandoverPubAcc 5/17/2012 Residential Property Record Card PARCEL ID:210/107.D-0060-0000.0 MAP:107.13 BLOCK:0060 LOT:0000.0 PARCEL ADDRESSA2 PENNI LANE FY:2012 PARCEL INFORMATION Use-Code: 101 Sale Price: '589,900 ?Book: 9026 Road_Type_ T Inspect Date: 05/25/2011' Tax Class. T Sale Date 08/31/04 Page _ 275 Rd Condition:_ P -Meas Date 05/25/2011 Owner: TotBm Area 3328 Sale T e: P Cert/Doc: Trantran ffic: IVf EceX SAVORY, MATHEW •• Yp _- Tot Land Area 1 04 'Sale Valid: Y Water:_n_m _ _-Collect Id '�' SGC SAVORY, GAIL _ �- Grantor TAGARAS, MATTHEW Sewer Inspect Reas M Address: -. m._.=r ._o _ __ _ _ _ 4Nw w_.. �M mx�. _., . ._ 42 PENNI LANE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION St le., CL Tot Rooms: 7 Main Fn Area: 1664 Attic: N NBHD CODE: 7 NBHD CLASS: 7 ZONE: R2 _ _. -- - - ---.-__ Story Height2.00 Bedrooms: 4 Up Fn Area: 1664 Bsmt Area: 1664 _9_ Ype x Code Method' Sq-Ft . Acres; Influ Y%N. Value Class Roof: H a Full;Baths: 2�':Add Fn Area: Fn Bsmt Area 1 P 101 ' S - 43560 1.000 µ '225,640 . - __ ... O. ._ _ 2 R 101 A 0 0.040 304 Ext Wall: FB Half Baths: 1 Urifin Areae __a � � �Bsmt Grade: Al M asonry Tnm Ext Bath Fix: 0 Tot Fin Area: 3328 DETACHED STRUCTURE INFORMATION Foundation: CN Bath Qual: T � RCNLD: ' _336624- M�,...., ,„, .a: ... - - - - - A� S-1-11"u-- .1 tr Unit Msr-1 Msr-2 E YR=l31t Grade Cond %Good P/F/E/R Cost Class Kitch Qua(. T Eff Yr Bwlt 1983 Mkt Adlr - - - . a a __ _ ��.._ __ ;_ . ,._ -_. , _. SE S 8 10.00 2007 Heat Type: HW Ext„Kitch: Year Built. " 1979 Sound Value: Fuel Type: O � Grade:� GV Cost Bldg '336,600 ' VALUATION INFORMATION Fireplace: 1 Bsmt Gar Cap 2 'Condition G Att Str Val 1: Current Total: 563,800 Bldg: 337,900 Land: 225,900 MktLnd: 225,900 a - _ . Central AC��' TY'-. Bsmt Gar SF "m""PctComplefe:" Atf�$tr Att Gar SF: /oGood P/F/E/R: 7100/100%88 Prior Total: 498,300 Bldg: 272,400 Land: 225,900 MktLnd: 225,900 a _ Porch Type Porch Area Porch Grade Factor W 216 SKETCH PHOTO is 12 216 Sq.FI 12 is 44 a ` Flt/FM/B FU/FM/B i. 432 Sq.F t 1232 Sq.R y w y. 24 26 28 44 • y 4..': > .�...ry .p r'. �- :P. to.. +. � 1 n 42 PENNI LANE Parcel ID:210/107.D-0060-0000.0 as of 5/17/12 Page 1 of 1 lDate. . . . .. . . . . .. . . ... .. .. NORTH o? �` TOWN OF NORTH ANDOVER j • PERMIT FOR GAS INSTALLATION ISS ACHUSE J This certifies that . . +�5 .�`-!�° . . . .'?. p�q'``r�- has permission for gas installation . .F.�.�'�. . . ��: .� . . . . . . . . . . . . . in the buildings of . . . . T t.41 Cw4.V U( u atW�.. . �Cpl m !. . 14v i�. . . . . . ., North Andover, Mass. Fee.-' Q,.�9. . Lic. No.. t . . . . . . . . . . . . . . . GAS INSPECTOR Check# P5 6 [ 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date JULY 1, 2011 permit# Building Location 42 PENNI LANE Owner's Name MATTHEW SAVORY Owner Tel# 978-685-6948 Type of Occupancy RESIDENTIAL New 7 Renovation❑ Replacement 11 Plan Submitted: Ye[]No❑ FIXTURES a a U W h oG WW O M Z Q M h F W w 0 O O W W d x F., a a d z W W (q W Z Q x G�yC W W W A F" W.L .�7 z 1QQ- uj Z � QQ z F F OW z O z U O W W Q W > of W z d cv d d O O W i O W o! 2 O 0 = w A 3 A 0 ..l U (� > A a H O w SUB-BSMT BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR t, 8T"FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter ROBERT WHITE INSURANCE COVERAGE: I have a curM liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes ✓ I No ❑ If you have c ecked y�s,please indicate the type coverage by checking the appropriate box. A liability insurance policyF-,] 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: Owner ❑ Agent ❑ Signature of Owner or Owner's 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 ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene . a s. By Type o�License: �r h �Pfumber Signature of Licensed Plumber or Gas Fitter TitleGas tter ,3� • aster License Number/11`/0 7 City/Town •-Journeyman APPROVED(OFFICE USE ONLY) a , ; ICEIVSEtiA.MASTER PLUMM, B ql f ` -x-, ISSUES TRE 660tiLICENSE TOS pOE ,. n N 11861, MTD® -E-'ON 1 M �0194g 318, 1 10.739 7 �05/01/l / . `78477 WE L,TH Q� ' SSA Date..�/. 1x) L .,l.G.... . . MORTM 4 TOWN OF NORTH ANDOVER / O m • PERMIT FOR GAS INSTALLATION 4 fo i o 5 Sy 9SSACHU This certifies that . . . /l F t.Cl.f! ,14 has permission for,gas installation in the buildings of . ?u U !I.y . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . .Y.) . . . . . . . . . .... . . . . . , Noah-Andover, Mass. r Fee. . 3U. . . Lic. No...�A. �^-IV ��. . . . . . GAS INSPECTOR Check# / 7,303 d MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ` (Print or Type) NORTH ANDOVER ,Mass. Date JULY 15, 2010 permit# 730 , 42 PENNI LANE MATTHEW SAVORY Building Location Owners Name Owner Tel# 978-685-6978 Type of Occupancy RESIDENTIAL New F7 Renovation❑ Replacement Plan Submitted: Yet No[] FIXTURES w + v CIO x N G1. C�) U z w w w o 0 o F x x S 4 a o w614 a a z z o z w °° Q w w a °x w ¢ v j uz U) Ux L11 z Q > zrS LU W z F- z F W w o > o F U a w a sl� S z Q W Q c4 F rA Z O z O to W 2 0 0 Of 2 w 3 A 0 a OU g > A a H O w SUB-BSMT BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR f 7T"FLOOR —77+F I 8TH FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter JOHN COOMBS INSURANCE COVERAGE: ! I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. ye ✓ No ElIf you have c ecked y s,please indicate the type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent 11Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above ap ?is ion are tr d ac a est my knowledge and that all plumbing work and installations performed under the permit issued for pplica' b co I ce vVA all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Lai By Type of License: ••member Sig ure icensed Plumber or Gas Fitter Title •Gas fitter • -Master is a Number City/Town •-Journeyman APPROVED(OFFICE USE ONLY) 9424 d , =�5 /D ' Date.................................. " TOWN OF NORTH ANDOVER A PERMIT FOR WIRING ,SSACHU$ r This certifies that .......:��........ ......0 �. .F... G........ has permission to perform ... ..... ............ . /.............�?........................ wiring in the buildi�of.........5. ./�11�../............................................ /V/!J/ at........ -.... ... ................... A.1........ . ....... ,North Andov Mass. Fee ................. Lic.No. . fr' �s".. l.s...... ......... .. . .. ..... .. . .. .. ELECTRICAL I SPE R r Check # r o� ' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT T All work to be performed in accordance with the Massachusetts ERtsElectrical ORMCode EC),527 tMR ELECTRICA ELECTRICAL (PLEASE PRINTINM OR TYPE ALL INFORMATION Date: �Moo) 1p City or Town of. NORTH ANDOVER To the Ins Wires: By this application the undersigned gives notice of his or herintention to perform the electrical work described below. Location(Street&Number) L42. PC-Nt!6 Owner or Tenant H/aTT r_-,A 1 1AP V Telephone No. Owner's Address Is this permit in conjunc Yes No ' with a building permit? ti ❑ (Check Appropriate Box) Purpose of Building (,��` 14./A Utility Authorization No. Existing Service Z40 Amps 17-6/ L t(ts Volts Overhead ❑ Undgrd ✓❑� No.of Meters New Service Amps. / Volts Overhead and ❑ grd ❑ No.of Meters Number of Feeders and.Am aci ` P tY Location and Nature of Proposed Electrical Work: O LA3e, QRS GQ Com letion of thEfollou4ng table may be waived b the Inspector o Wires. PNoof Recessed Luminaires o.of r f No.of CeiL-Soap.(Paddle)Fans Total Transformers KVA ' Luminaire Outlets /b No.of Hot Tubs r Generators ICVA Luminaires Swimming Pool Above lfn- o.o mergency d• ❑ d� 0 Battery Units g No.of Receptacle Outlets i-5 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o..of Detection and Initiatin Devices . No.of Ranges No.of Air Cond. Total I Tons No.of Alerting Devices FNo. Waste Disposers eat Pump Number Tons KW No.of Self-Contained Totals: "'� - - Detection/AlertingDevices Dishwashers Space/Area Heating KW Local❑ Municipal Dryers g�� A Connection ❑ �� Heating Appliances KW Security Systems: No.of Water No.of No.of Devices or E uivalent Heaters KW No.of Data Wiring: Si,-ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: t OTHER: No.of Devices or Equivalent � ( 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 cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify;) I certify,under thains and penalties of perjury,that the information on this ap licadon is true and complete. FIRM N jG��— e LIC.NO.: /J(�36 Licensee: d()(� Signature 01 (If applicable,enter "exempt"i the license numberrlli„ne.) LIC.NO.: ' Address: /M-61 �sec j � _ I �Q/� Bus.Tel No.: $d G *Per M.G.L c. 147, ry workrequires Department of Public Safety"S"License: Alt L cl No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability required by haw. B m signature ty insurance coverage normally By y gnature below,I hereby waive this requirement I am the(check one) ❑owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE:$ 1 ............ pw i T"e C'ommonwerzith of Massachusetts Department o f£ndustrial_,accidents _ Office of jnvestigations ..6.00 Washington Street Boston, AL4 0211, _Au�licant Workers' Co mpensatioWWw.massgov/dia n Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Tinformation Please Print Legible Name(Business/Organization/Individual): C� r Address: l City/Sate/Zip:�� --------------- _1 �iS�J •� #: 3 . FAA,reyou anemployer?Check the appropriate box: i am a employer with 4. ❑ I am a o'„ Type of project(required): . tneral contractor and I ?.❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet x 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' com . 8• Xuild olition [No workers' com . P insurance' p insurance 5. ❑ We are a corporation and its 9' ing addition required] officers have exercised their 10.0 Electrical repairs or additions :� 3•❑ I am a homeowner doing all work right of ex emption per MGL 11.❑Plumb ing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no `r insurance required.] t employees_ [No workers' 12•❑Roof repairs comp.inSu ance required] 13.0 Other `enY 2PPIiCaZRt that cher.v-bei#1 must Wit+nu cut LCC Se ^^_Lto4'SBQnnja?W--;_ ort:"ers,coW..a..cae;n� t Homeowners who submit this affidavit indicating they are doing aL'work andr W---_ "Contractors that chez`', nrh— a box must attached an additional sheet showing the m rre nide con�cta:s r6ustsubmit anew affidavit indicating such. me of the sub_contractors th I am an employer that is providing workers'compensation insurance or m employees. worker coma policy information. information. J y ployees. Below is the policy and job site Insurance Company Name: I C 1 � 1 / Policy#or Self-ins.Lic.#: (�� //// Expiration Date: Job Site Address: `ry P6__Xlxli Attach a copy of the workers' compensation policy declaration nae show Cit'/stage/Zip: �ot�ee . Failure to secure coverage as required under Section 25A ofMGL page lead to policyos number and expiration date). fine up to$1,500.00 and/or one-year' imposition criminal Y rmprisonmen as penalties of a of - well as civil Penalties in n to $250.00 P P the form of a P a da STOP OP W Y S ..violator. Be advised that a co WORK ORDI✓lZl'R�a fine Investigations of the D for' urance co ge verification. PY of statement may be forwarded to the Ofnce of Ido hereby nd the p and rlurJ'that the information provided ab a is and correct Signa C Date:_.. } f Phone#: q ZZ Dffccial use only. Do not write in this area, to be completed bj,city or town ofiiciaL City or Town: Permitucense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.EiectricaI Inspector Plumbing 6. Other b inspector Contact Person: Phon",#: 1 LJR Engineering Civil Engineers and Land Surveyors 234 Park Street North Reading,MA 01864 (978)664-8141 Fax(978)664-8142 Email:Troy@ljrengineering.com May 24, 2010 North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Re: Addition Framing Inspection 42 Penni Lane,North Andover, MA Map 107D Parcel 60 To Whom It May Concern: On May 24, 20 10 1 visited the above property to inspect the installed framing for an addition currently under construction as drawn on plan entitled "42 Penni Lane, Addition for Mr. & Mrs. M.&G. Savory,No. Andover, Mass."prepared by J.Saia Jr. Architect, January 7 2010. I have found that the framing has been constructed properly according to the plan and hereby deem the frame of the addition to be structurally sound, built in accordance with design and construction standards, in many cases exceeding minimum requirements. I expect that this letter will be useful and provide the information required at this time. If there are any questions or additional information is required,please call my office. Thank you. Sincerely, SM OF o Luke J. Roy, P.E. o LUKE J.ROY U -OWL y No.47356 SS�ONAL ENG Date. 0 q A TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING- S us This certifies that . . . . J.0 C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . P.(. . . . . . . . . . . . plumbing in the buildings of .. . . . . . . . . . . . . . . . . . . . . at . .L .?. . . .TIC A! 1. . . 1. P.t% . . . . . . . . ... . . . . North Andover, Mass. Fee. 3v . . . . Lic. No..?.10—Q,; . . . . . .9— . PLUMBING INSPdC�TOR Check # 8595 r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER,MASSACHUSETTS Buil ' LL Date j` w ocation �2 inQ,n n i Permit# Owner M AAA- S Amount o i New ❑ Renovation Replacement ® Plans Submitted Yes ❑ No FIXTURE S J SWIM R4l5'N1MM ]ST)HIDt R x111,!FLOM Y f M ELCM 4IH NjCM 6��SfJi�t 7M HfM SIH)E OM (Print or type) Check one: Installing Company NameJ C —, - 12l U 4r n YS�t^ Certificate . __ Corp. Address Partner. Business Telephone b 1 S c �Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insttance policy I Other type of indemriity Bond Instiva ice Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Owner ❑ Agent F1 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 performedunder permit Issued for this application will be in compliance with all pertinent provisions of the Massaeh efts State Plumbm* de and Chapter 142 of the General Laws. By: rgna mcens um er f Plumbing License Title City/Town License Numoer Master APPROVED(oFFicE usE oNL s ❑ Journeyman 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..600 H'ashington Street Boston., MM-02111 www:oras&gov/dia -Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J eS's-(Z- ( �� Address: 3 c1 Qe �lyc) City/State/Zip: Q� Q S -� VY1 q Phone#: 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. ❑New construction 2.®I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. o workers' comp. insurance 5. corporation 9. Building addition r � p• ❑ We are a co oration 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 11.7 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairsinsurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other .An rplicant that check.box#1 must also Plo„sh, ,W,.t^ fill riot�e section�.....1. b err wort:;,,,'co:uY..::sattou policy information. a+aon. 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 cern Y under the pains and p nalties of perjury that the information provided above is true and correct Si afore: � Date.: I{ Phone#: r only. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorson: 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, 925C(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 i 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 lie returned to the cit;,,or town that the application for the pe it license is being requested,net the Departzrent.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 Invesfibations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 m ww.mass-gov/dia Date.. ,l./1. /.u. . .. . ... I T OF NORs,ti °p TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION �9SSACMUSEt This certifies that . . J. .�'.C . . . . . . :�. . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . in the buildings of .. . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .Z 1 . . . . . . ., North Andover, Mass. Fee. ./L . . . Lic. No. ^GAS INSPECTOR Check# 7205 i ^ MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date o NORTH AN D OVER,MASSACHUSETTS Building Locations + a a k Permit# Amount$ Owner's Name New❑ Renovation ❑ ReplacementElPlans Submitted ❑ U a N oU Mx a c z WCw7 xwF- w�Z x w3 a z YI .0 w xa1 U 0 W U z o z 0 a > °o w U . Wx c SUB -BASEM ENT B A S E M ENT --- 1ST. F L 0 O R 2ND . FLOOR 3RD . FLOOR 4TH . F L 0 0 R 5TH . FLOOR J 6TH . FLOOR 7TH . FLOOR 8.TH . •FLOOR (Print or type)-� "� Check one: Certificate Installing Company Name VV ❑ Corp. Address �Q Partner. `CU I usmess Ie ep one ~]kl_ 81�7 (2CIL(I ®-Firm/Co. Name of Licensed Plumber or Gas Fitter e SSL G R�l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 11No❑ 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 waves this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State as Code and Chapter 1 2 the General Laws. By. Signature of icensed Plumber Or Gas Fitter Title p Plum c —L _ �� l City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) journeyman C The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): J (? SS Q Q,r2 n Address: City/State/Zip: p 1Nt V" Phone#: -7 a I- (o- Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees (full and/or part-time)•* have hired the sub-contractors 6. E]New construction 2.2- am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers comp.insurance. [No workers coin insurance 5. 9. Building addition J p• ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.❑ 1 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 insurance required.] t 12.0 Roof repairs Q ] employees. [No workers' comp.insurance required.] 13.[1 Other , applicant that checks box.#1 must also fill'out the section below shoV,1_9 th��o;k�°compensation policy information. f Homeowners who submit this affidavit indicating they are doing allwork 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 workerscompensation insurance for my employees. Below is the police 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 nder the pains and penalties of perjury that the information provided above is true and correct Si ature: —� 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 as d 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 spar tents 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 coznpUmce 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 certificates)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 pernwtor 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 perniittlicense 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 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900.ext 406 or 1-877-MASSAAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass.-gov/dia Date " .................................. NORTN 4,6, TOWN TOWN OF NORTH ANDOVER PERMIT FOR WIRING q �SSACMus� This certifies that ......... .......i` jr. ................................. has permission to perform ....,/.ee t.".%...... f F u wiring in the building of.... . .... i�..n.rr r..:�.........X ,..... at.? ...................... . ......: ........................... ,North Mdovers'iViass. Fee.. Lic. 4........ �i� f. . 1................................ ELECTRIC AL INSPECTOR Check # 7 8182 82 vI ��ssacnus r' eLfS Official Use Only Department of Fire Services Permit /NO- BOARD OF FIRE PREVENTIQN F2EGULATIONS Occupancy and Fee Checked� �� (Rev. T'I (leave blank APPLICATION FOR PERMIT TO AD work to be performed accordance wig the M PERFORMssachuseM Electrical AD `WORK (PIF.ASEPRII��7'ININKOR 7YPE14ZL INFORM1gT10 (MEc),s27 CMR 12.00 City or Town of: NORTH ANDOVER Date: By this application the undersigned gives notice of his ar .To the I e for of Wires: Location(Street&Number) hey urtention to perform the electrical.work described below. f � Owner or Tenantj� Owner's Address Telephone No. 97p ms-:69 Is this permit in conjunction with a building permit? Parpose of Building Yes ED No (Check Appropriate Bog) ' Utility Authorization No. Existing Service Amps _Volts Overhead.❑ U New�'�°e — ``APs / Volts nd'�0 No.of Meters Num Overhead Undgrd Number of Feed a Feeders and Ampaeily ❑ No.of Meters Location and Nature of Proposed Electrical Work: L-Ln /1Cr cc-G , Co letion o the ollowin table may No.of Recessed Luminaires No.of Cert-Sus No.o be waived the lmpector o >Firw. p.(Paddle)Fans Tota! No.of Luminaire Outlets No. of Hot Tubs Transformers KVA No. of Luminaires Generators KVA Swimming Pool .Abodv+e ❑ )jn_ o, o mergency ig No. of Receptacle Outlets d' ❑ Batte Unify A - No. of Oil BuraeLS . No.of Switches FIRE ALAn No n_s No. of Gas Burners n.of etection and a No.of Ranges Initis ' Devices No.of Air Cond. otal Nn.of Waste Disposers Tons No. of Alerting Devi11 ces Y eSTom�1sP `—umber Tons o. of Self-Contain11 ed No, of Dishwashers Detection/Aie a Devices Space/Area$meg , Local❑ Municipal No.of Dryer � Co ❑Other. r3' Heaiaag A Iia Connection PP aces No,of star gOy Security Systems:- �� Heaters KW n.of No.of No.of Devices or E nivalent Si B � Data wring: No.Hydromassage Bathtubs No. No.of Devices or E aivalent of Motors Total HP Telecommunications OTITLR: No-of Devices or E ury alent Estimated Value of Electrical Work `4aa additional detail if desired, oras '(When required by municipal policy.)required by the Inspector of Wires. Work to Start'(� // Inspections to be requested in accordance �'SURANCE O GE• Unless waived by the owner no with MEC Rnle 10,and upon completion. the licensee provides proof of liability insurance incl udin «' permit for the performance of electrical work may issue unless undersigned certifies that such cov g completed operation"coverage or its substantial e is in force,and has exhibited proof of same to the gwvalent The CHECK ONE: INSURANCE [ BOND ❑ 0 Pmt issuing office., I certify,under the pains and penalties o er'u TSR ❑ (Specify-) ` FIRM NAME: fP ! ry,that the inforniadon on this aPPdcadon is true and complete, t Licensee: LIC.C.NO.: �/R� Signature �99 9 0 (If applicable, enter ezernpt of the license number line.) LIC.NO.: Address: L A Bus.TeL No.: *Per M.G1 c. 147,S.57-61,security work re �o Oquires Departzuerrt fPublic Safety"S"License: Alt.Tel.No.: OWNER'S INSURANCE ANCE WAIVER: I am aware that the Licensee does not have the liability Lic.No. requ'md by law- By my signature below,I hereby waive this re t3 insurance coverage normals Owner/Agent quire hent I am the(check one) 0 owner Y Signature ❑owner's agent Telephone No. PERMIT �; tr^, `: :. � ' 9 1 y y �, „`' M The ComosonweErtth o Mass f achusettr Department OfAdmtrial Accident, :El'�t, , Oyfe of Investigations 600 Washirtgtnn Street Basrort, M,4 02.1.11 tj Workers, C �W.n2 gov/diamensation Inr< aeeA IirmAffidavit- Elers Coacant oation tacOMMectricians/P}®bers Please Print Leib Name(B i.nesslOWiza6onYIndividual Address: Z�� 'r�-w. Agl- City/.State/Zip; �► Phone#: . .. you an eM* r?Check the appropriate boaw[Are "maemployer with Type.of project( m.plOyeesfoilandlor I sirt a general connatar and I req 'red): part-time. have 6.•;3'.I am.a ) hired the std-cantrac�o ❑New constr'uciio sole proprietor partner. n P er I lsted CQ the attached 3 shipan cheek 7. d Rem ' have no employees TbMe sub-contractors have odeimg working for me in any capacity. workers 8 Q demolition` [T1s*workers'comp. , comp.inswance. p mstu'enct; S. ❑ OUe are a corporation and ifs.. 9' ❑Bw`Iding.addition T ain.required.]ha Officetm have exercised their f 0•❑Electrical 3•D I din a homeowner doing all work right of exemption per MDL 1 I.. rcP�or additions myseIf..[No woticars'coni • ❑Plumbing repairs or additions insurance t P two. §1(4),'and we have no d. ] ._ .em I ,. I2.[]Roof a P oYees•[No workers repairs "AJY appGcomp- instmmcerequirecj 13 Q.0ther =2 that chocks boli#I mum REso fig,out the section blow dho t Homeowners who enbmit the a'ff�davit indiaeting they ars dein ell wo wrng their workers co 1Cantractors that cheak this*box mast mpensetiori poiiry infomtation 8 t1c and than hbs ouYeide contractors moat submit a new afFidavit indicgtiog such, a�ehsd an addiBoasE ahem showing the tmmt of the sub-comte�ant],��,� � � �fo��P�3'�•fhiX.irso��g:warkers'cpmp�a�a�i�srrrance or `n�•�E'�'mtonnenon. f �'��yers �,P1ow is.the.pa�,and jnb.nom 1 lnsttrance Corttpany Nance: ' �Ctt�?t T t, h. c,a i2�ir�c Policy#or Self--ins.Lic.#: Job Site Expiration Date: AA&mr,: Attach a copy of the.workers' coat City/st r-Zllp; compensation policy decl$r&tiou pap(Showing Failure to secure coverage as required ( g the policy Bomber and e i fine up to$1,500;00 and/or tm ear im Section 25A of MGL c. 152 can lead to the imp osition of zp raf�oa date}, Of up to s250.D0 a prisonment,as well as civil penalties in.the form of a criminal Penalties of a �3'against the violation. ra advised that a copy of this statmn f forwarded to ORDER�a fine Investigations of the DIA for insur�rtce coverage verification• Price of Ido hereby under the pains and pence a fPer1uj-y tlsat the informaiian provided above is Si true and correct Phone#: J1 icia use 0J* do not write is tfris are¢,to be completed bj; 1'or to affrcxa( City or Town: Issuing Authority(circle Permit/License� my( 'rde ones: I- Board ofHeattb 2. BuikiiRg Department 3.City/Town ti Other Clerk 4.EiectI Teal Inspector 5.Plumbing inspector Contact Person: Phone#: Information a lid Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empioyees. Pursuant to this statute,an employee is defined as"...every person in the swviM of another under any contract of hire, express or implied,.oral or wriftzn." An employer is defined as"an individual,partnership,i oaiation,corporation or other logal entity,or any:two ormore of the'famping engaged in&joint enterprise,and including the legal representatives of a de=amd employer,or the receiver ort ustm-of an individual;partnership, association or other legal entity,employing employees.'Howevathe owner•of a dwelling house having not more thatr three aparimenrts and who resides therein,or the occupant of the dwelling house of another who employs persons,to do ma.1ntenance,construction orn-pair 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 alt- !local geeusing 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 evidences-C compliance with the insurance coverage required." Additionally, WGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its-polit:ieal subdivisions shall enter into any contract for the perionmance of public work untt'I•acceptable evidenca of compiisnce with the insumm Tequir= rnls 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)2md phone numbers)along with their cerdficate(s)of insurance. Limited Liability Companies-(LLC)or Limited Liability Partnerships(LLP)with no.employees otherthan the members or pmtngrs,are not required to cany workers'c anpansatim insurance. If an LLC.or LLP does have empioyees,a policy is required: Be advised#i-W this affidavit may be submitted to the Department of industrial Accident 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 taw or if you-we requinrd to obtain a workers', oompenmation poliay,:please-call the Department at the nurnber.listed bolow. Self-insured companies should entertheir self i mmmae'ncansc number on fire appropriate line. r City or Town Official , I Please be sure that the affidavit is complete and printed legibly. 'Phe 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 sim•e to fill in the permitllicanse number which WiilI be used as a reference number. in addition,an appii=it that.m ust submit mul iple..permitllicense applications in any given year,need only submit one-affidavit indicating-current policy'infomsation(if necessary)and under"Job Site.Address"the appiicantshould write"all locations in (city. or town)."A copy ofibe affidavit that has been officially stamped or marked by the city or town may beprovided to the applicant as proof that a valid-affidavit is on file for fabre-permits or licenses. Anew affidavit must be fiDed out each year.Where a home owner or citizen is obtaining a license or permit not rehfted to any business or commercial venture (i.e. &dog license or permit to bum leaves otc.)said person,is NOT required to-.complete this affidavit The Office of investigmations would It - to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Depm=ent's address,telephone and fax number. The Commomrrealth of Mamachusetts DGpartm nt of 1nd.>ZstaaI Accidents Office-Of Tuvekigaflons 600 Washington Street Boston, IFMA 0211 l x TeL# 617-727-4900 ext 406 or 1-977-MASSAFE R.vised 5-X6-115 Fax#617-727-7749 wwwmam.govldia TOWN OF NORTH ANDOVER ►`T 10 o �v' SYSTEM PUMPING RECORD ,,...� SYSTEM OWNER & ADDRESS SYSTEM LOCATION 71-0 (example: left front of house) 0�? 3 P55rch i ll;�T'E OF PUMPING: �-Z,3-11Z• QUANTITY PUMPED/C%W GALLONS C 'SSPOOL: NO V YES SEPTIC TANK: NO `z'ES NATURE OF SERVICE: ROUTINE EMERGENCY U13SERV.=kTIONS: / GOOD CONDITION V FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) i PUMPED BY: � CUNIMENTS: C. 0'N'I'ENTS TRANSFERRED T0: