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HomeMy WebLinkAboutMiscellaneous - 429 WAVERLY ROAD 4/30/2018 (2)Location No. Date TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ Mu Foundation Permit Fee $ Other Permit Fee s 6C) TOTAL $ Check # e -7 r - U 3 4-"!) Building Inspector N2 Sa .0 * -� - -1 Date �� ..... I--, �'- ;�j ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies ........................ M .... ....... / . ..................................... has permission to perform ....... t wiring in the building of ........................................... ............................ at ...... YS,."Q ....... ........ ............................... . North Andover, Masser -Z� I 'j Fee. ..... Lic. Na�'.. i.0 ............................................................. V ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Town of North Andover *t 749ey D.B.A. — Zoning Compliance Form \+� Dp ,9 �DgArED �'.P��S 978-688-9545 This form must be reviewed with the Inspector of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. Applicant Name: S4 egkm /'' Ji.o r'S Name of Business: LAW /liI?7d5 Addres's of Business: Ya R wvv{rl,/ G -d-9' Zoninjz District: Map Lot Phone: 751- 73 f - .30.5, Email �,�� �� law ty �tk,l c CGd"� Nature of Business: G "W OA- C-6, Do you own this property? Yes No If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes No X Willan ou have major deliveries? Yes No Y Y J Description of Business Activity (Must be Completed) .W_113/ Signature of Applicant For Signage Refer to North Andover Zoning Bylaw Section 6 The proposed u is owe u in this zoning district. Issued1,/late j4 2.40 Horne Occultation (1989132) z accessorSr use conducted within a dwelling by a reszden wha resides in the dwelling as bis principal address, which is clearly secondar3r io the use. of the biai7ding for lift purposes. Home occupations shall 'iiidfiido,"bur iiotlimited to the following uses; personal services such as Fant shed by an artist or instmotor, hat not occupation involved with motor vehicle repairs, beau4, parlors, animal k�.nels, ox the conduct of retail business, or tlae rnan-ufadming of goods, which impacts the residenfiial nature offire neighborhood; d. For use of a dwellvrg in atiy residential district or multi-furgy distdct for a Borne occupation, tlo following conditions shall apply. a. Not more than a :total of threq (3) people may em�loyec� �n thy, home occupation, one of whom shall bethe owier ofthebt C; oci upatioi and residing-irisaiA'&elting; b. The use is carried on s6 ictlT withinthe principal building; c. `Ihdo shalt be no exYte&r alterations, accessory buildings, or display 'which are not customW • with zesideniial buildings; . d. Not more than -twmit r fZve (25) percent of &o existing gross floor area of;ihee dwPDng unit . so used, not to exceed one thousand (1000) square feet; is devoted to'such use. In conneciion.wiih such use, there is to be kept no stod< in trade, commodities or products which occupyr space beyondthese limits; e. Thero will be no display ofgoods or wares visible from the sheer; f The briding or premises occupied shall not be rendered objectionable or detrimental to the xesidertial characiex of the neigh�boxhood due to the exterior appearance, emissioxi of odor, gas, smoke, dust, noise, drsu bance, or in any other way become objectionable or d&hmtal to any residential use within the neighborhood; g. .Avy such building shall indude no features of design. *got cu&nrary in bindings for resider +w :. . . use. signature Date Waver y ?Z&a /ReaUy 7"ru4t 281A 3ro&adway Lawrenc,� Mil 01841 978-688-8880 Fa,X1978 -688 -0110 March 27, 2017 Attention: North Andover Inspector of Buildings I am writing to inform you that I am the owner of the property located at 429 Waverly Road, No. Andover, MA, 01845. I grant permission to my tenant, Stephen Miliotis, who rents apartment # 9 at 429 Waverly Road, to apply for a business license using the above address. My understanding is that it will be a law office and no clients will be coming to the property, Si Step5,n B r Waverly Road Realty Trust i Town of North Andover D.B.A. - Zoning Compliance Form 978-688-9545 This form must be reviewed with the Inspector:of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. -4G/✓ 4Co �� ` t � 1'` � Name of Business: 64"1 d -//-.S. r Address of Business: �a 14-1.ri fZ Rcl # Zoning District: 94 Map 2IL- Lot 12-5 . Phone: 70/ - 7J I — 3OS 7 Email 141, f•`4 �' S �Gt G,i /� 5 �-ter""' Nature of Business: L--ol-w -;2j A C e Do you own this property? Yes No If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No x Will you have any employees? Yes No Will you have any major deliveries? Yes No Description of Business Activity (Must be Completed) C1-eaA]f� 1,-.713 4-�'-vsf41. eco Signature of Applicant For Signage Refer to. North Andover Zoning Bylaw Section 6 The proposeis w se ' his zoning district. Issued By ate 0 -"4 Y'v ` lorth Andover MIMAP r �• 121,_0ELUCIA'WAY/ 022:0=01.3& I 022 0=0137 26 ID:ELUCIA; WAY ;022:0=01'_35! '022 O 0131 140' 415r'WAVERL&Y'RD 022:0-0125 fDelucia' Way CID `i . t. ii 022:0=0:129 i i 022-0-0:133 0 433''W4ERLYiR6 �r Q-2-X&0130`443'',INAVERLYhRD} {022 �0;-'0132 © MVPC Bo Zoning Overlay Zoning 13 Boundary 13 Adult Entertainment Distric Busin s 1 District Municipal 0 Machine Shop Village Ove A Buslne,. s 2 District -• Rail Line 0 Watershed Protection Dist ■Busin s 3 DistrictInterstates Q Historic Mill Area ■ Busine s 4 District �1ORTM Interstate ® Medical Marijuana ■ Genera Business District 0t tS�1O.r — Major Road 0 Downtown Overlay District 0 Historic O Planne Corrid Commercial Dev Development Dist ? • - Roads District L.1 Osgood Smart Growth (40 -' C Conido Development Dist 3 O t Easements Hydrographic Features C Comdo Development Dist I` ❑ Parcels Streams Industri . Industri I 1 District t 2 District �, c Wetlands ❑ Industri it3 District r♦ o sp" :7 Exempt Lands O tndustri it S District w �1 °+err;° Reside . Reside ce1 District ce 2 District ��►�`�c US 7' "' Reside ce 3 District de ce 4 District 1" = 62 ft " .de ce6District YYY de ce 6 District 1`- 0 0 w April 19, 2017 � :0022:9'=0094 022:0e 0093 r w 0? Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Once of Environmental AffairslMassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION WawerLy RoacLReatty -'rust 281A1 8roadAvay Lawrenca, MA 01841 978-688-8880 Faw 978 -688 -0110 March 27, 2017 Attention: North Andover Inspector of Buildings I am writing to inform you that I am the owner of the property located at 429 Waverly Road, No. Andover, MA, 01845. I grant permission to my tenant, Stephen Miliotis, who rents apartment # 9 at 429 Waverly Road, to apply for a business license using the above address. My understanding is that it will be a law office and no clients will be coming to the property. Since StepFZp B e6r Waverly -Road Realty Trust Date/!�/-?� /�-.k TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that (i . ...... . has permission to perform ... /0 r: /I ................. ......... ' -/O�.'r A plumbing in the buildings of . .19f ......................... a t / .... .. I North Andover, Mass. Fee. Lic. No.h� ... ..... PLUMBING INSPE&C(R Check# '111`7 8 8 S MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,, MASSACHUSETTS Building Location (4o)- 1 (M 4., fe of Occupancy ,('•3 , New Renovation INN -1 Replacement FIXTURES (Print or type) Installing Company Name—/j�, a Address Date Permit < � Amount Plans Submitted YesNo ❑. Check one: Certificate Corp. •—��� Partner. ttusmess Telephone Firm/Co. Name of Licensed Plumbe� Insurance Coverage: Indicate the type of insur9fide coverage by cheicEng the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance �rgnature ❑ Agent I hereby certify that all of the details and formation I have sub ' ted (or tered) ' abo e p a ' n e true and accurate to the best of my knowledge and that all plumbing w Iatio e o ed un r Permit ed r s application will be in compliance with all pertinent provisions of the sachusett tate p the P. o C de d a 1 of the General Laws. By: igna ure o icens um 7er Title Type of Plumbin icense I O U '} , City/Town iZ cense umber APPROVED (oFFicE usE oNLy Master Journeyman ❑ Date 1� ......... 0 t \ \L TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLAT14 `00 .............. ........ This certifies that ......... has permission for gas installation A?. ................. Jn the buildings of .... P/9 11-�7 e?� .............................. at Lo. C ... ... I North Andover, Mass. 97 <q� Fee. Lic. No. Aq .. .... /GAS Check# A U-6 6579 MASSACHUSETTS UNIFORM APPLICATON FOR PERMMI T TO DO GASG (Type or print) Date ,F%!) 0 NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # ' Owner's Name Amount S New Renovation D Replacement D Plans Submitted rM (Print Name, Address N - ussiiness R. Name of Licensed, Plumber� or Gas Fitt�I 40 Check one: Certificate Installing Company Corp. . Partner. Firm/Co. INSURANCE COVERAGE I have a current liability Insurance,' policy or it's substantial equivalent. Yes Check on If you have checked es ' please in ate he type coverage by checking the appropriatb Liability insurance polic appropriate No 1:1 Y W Other type of indemnity 1:3 Bond 1 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. Signature of Owner or Owner's Agent Check one: ,�- -1-1 I hereby certify that all of the details and infotionI have best of my knowledge and that all plumbing work a instal compliance with all pertinent provisions of the Massachu t Title City/Town, APPROVED (OFFICE USE ONLY) 7a on are true and accurate to the or this application will be in the General Laws. 6 natur of Licens6d Plumber Or Gas Fitter Plum r Gas F tter Licebseum er Journeyman w � m o O z-' c rA a w w � w e z F w c7 0 d� o x 3 0CQ --t SUB -BASEMENT BASEM ENT 0 IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH.. FLOOR 7TH. FLOOR 8TH. FLOOR (Print Name, Address N - ussiiness R. Name of Licensed, Plumber� or Gas Fitt�I 40 Check one: Certificate Installing Company Corp. . Partner. Firm/Co. INSURANCE COVERAGE I have a current liability Insurance,' policy or it's substantial equivalent. Yes Check on If you have checked es ' please in ate he type coverage by checking the appropriatb Liability insurance polic appropriate No 1:1 Y W Other type of indemnity 1:3 Bond 1 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. Signature of Owner or Owner's Agent Check one: ,�- -1-1 I hereby certify that all of the details and infotionI have best of my knowledge and that all plumbing work a instal compliance with all pertinent provisions of the Massachu t Title City/Town, APPROVED (OFFICE USE ONLY) 7a on are true and accurate to the or this application will be in the General Laws. 6 natur of Licens6d Plumber Or Gas Fitter Plum r Gas F tter Licebseum er Journeyman Date........................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ....... ) .................................... 7 1-, has permission to perform ... ../ ................... ... . ........................................ wiring in the building of ........................................................ ,qo) lQ1_7 at ................................. ............................ N rth Andover, Mass. Fee-?.............. Lic. NoXzC4USI5) ............... �,,. -j ............ ELEcrRICAL INSPE4R Check # Ell :"" -74, 1% Commonwealth of Massachusetts - Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ti Official Use Only Permit No. S _3 - Occupancy and Fee Checked 2p Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC), 5 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE A � �FO ION) Date: X619 0 City or Town of: (CC� � � To the Inspector of Wires: By this application the undersigned gives notice of this or her intention tord orm a electrical work described below. Location (Street & Nu ler) a W `% �' Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps/ Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Amaacity\\\ n and Nature of Proposed Electrical Work: � 1 n6 ( I I r-lofinn nftho fnllnwin mhlo may ho wnivod by tho lncrrrinr nfWirn.c. No. of Recessed Fixtures No. of Ced. Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures f Swimming Pool Above ❑ In- ❑ rod. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners /® of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Disposers eat Pump Totals: umber -. ........ Tons KW - -- o. of Self -Contained Detection/Alerting Devices of Dishwashers Space/Area Heating KW MunicNo. Local ❑ Connnectinecti lon ❑Other 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 a ecommunications firing: No. of Devices or Equivalent OTHER: Attach additional detail J desired, or as required by the Inspector of Wires. INSCIRANCE 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 age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 4Z BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Workl��_d L9 (When required by municipal policy.) Work to Start: �� ' ��� (j� Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under t/fe pains and penalties of perjury, that the Information on this application is true and complete. FIRM NAME: p �7'd,T W LIC. NO.: 2/3 Licensee:L TLZ � Ad)h �l � ///jSignature t� LIC. NO.: (1f applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: a2, J2 / /qp Lam' I-/—1—gzoksl?b)?_t-1 /1/1 A Alt. Tel. No.- JJ ,g2t �`7,V8 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does of have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Sv Signature Telephone No. PERMIT FEE: $ i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 V Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiv Name (Business/Organization/Individual): c f� p 6 Lz�`r W P I&h1_e,l Address: .2_ 3 3 M p p L c S- City/State/Zip: LtJ f LS 131J12-� ��1 01 /hone #: 3 0'7,F Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.N I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No. workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised.their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' I comp, insurance required.] *Any applicant that checks box # 1 must also fill out the sect b 1 h Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10:❑ Electrical repairs or additions 11-F-1Plumbingrepairs or additions 12.0 Roof repairs 13.❑ Other in t r ion a ow s ow ng their workers compensation policy information. riomeowners Who submit this aeiidavit 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 N 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 cer under the pain and penalties �JAer ury that the information provided above is true and correct , r 1 1 1 u q^ t 1 r - i iii 1,L i 1111,1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 V Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiv Name (Business/Organization/Individual): c f� p 6 Lz�`r W P I&h1_e,l Address: .2_ 3 3 M p p L c S- City/State/Zip: LtJ f LS 131J12-� ��1 01 /hone #: 3 0'7,F Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.N I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No. workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised.their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' I comp, insurance required.] *Any applicant that checks box # 1 must also fill out the sect b 1 h Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10:❑ Electrical repairs or additions 11-F-1Plumbingrepairs or additions 12.0 Roof repairs 13.❑ Other in t r ion a ow s ow ng their workers compensation policy information. riomeowners Who submit this aeiidavit 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 N 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 cer under the pain and penalties �JAer ury that the information provided above is true and correct Information and Instructions ' 6 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability'Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' workers' compensation insurance. If an LLC .or LLP does have ._ employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents .for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass.gov/dia Ot &utmm ulth of �uaougt a w. tattl„ Petmlt No. _ Erpltranctn of Public J-nftrq r Ocwpwy isal A Fee s , 00 BOARD OF FIRE PREVENTION REGULATIONS 527 C "In 12:0 own WN* APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO , All work to be Performed In accordance with the Massacnusetts Electrical Code, S27 QAA 12. 00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)- /c, q%, or Town of NORTH ANDOVER Date 0.i l To the Inspector of Wlrea: The uderaiflned applies for a permit to perform the electrical work described below. Location (Street & Number) nn Owner or Tenant /` t C P O Ci S s Owner's Address 13 thi3 permit in conjunction with A building permit: Yes _ �1 . � No Purpose of Building 22 � c i a -J , (Check Appropriate Box) Utility Authorization No. 8'O h 7 Existing Service 12-0 Amps � aqo Volts Overhead —'---- Undgrnd — New No. Of Motors -� •' Service Amps /,116 1 R-qo Volts Overnead ' D� Unagrno No. of Meters Number of Feeders and Ampacay Location and Nature of Proposed Electrical'NorK —�QSe o2no( No. of Lignnng Outlets I No. cl gat -_ZS I , No. of ?ranalormere Tow KVA No. of Ugnttng Fixtures i Swimming P_o; Roc%,o— ;n- r Srra — Srno — Generators KVA No. of Receotacie Outlets II Na. or O I corners No. of Emergency LiQttting Banery Units ' -No. at Swuen Outlets I No. at Gds _carers FIRE ALARMS No. W Zoned No, of Ranges I No. Cl.air O1di � Gcc. No. of Oelettlon and cns . Initiating Oovicea No. of Oisoosals I No.ol Heat 2:ai -alai Pum. --s ens ;V4 No. of Sounding pevKea No. of Oianwssnera SoaceiArea qeanco Ic,v No. of Soil Contained 0oleetiordSounang Oevleee No. of Dryers I Heating Coy-cesi(yv Local ; — Munieioet ..�0 Cannecuon NO. 01 Biu Ji No. of Water Heaters KW Signs ?a iasis Low V011age Wiring No. Hydro Massage Twos I No. Of -10tcrs -alai HP OTHER. INSURANCE COVERAGE. Pursuant ;o the reouiremenis --i •.lassacnosers zeneral taws 1 neve a current Uaodily, Insurance Policy nctuaing C:r-,,-. ec Ccerauons Coverage or nave suOmttted valid proof of same to the Oltice. YES v0 — its suostantul eduivwnt. ygS t _ If you nave CneCxeO cnecking ►tie ao�a./fQ0 mate ods. – YES. p+�aae irtotcate It1e type a aoveal o ey INSURANCE aL aQNO _ OTHER = (Please Stec.-,) 9— IQ— —Estimated Estimated value at Electrical WOrk S a.5-0-0 ' ttLaOWa ouel . Wank to Sian 3 .-X 3 .Y y InsaeC:lan Jaie :.seas:ec: Rougn F u1a1 signed under the Penalurs of penury: C•' -----� FIRM NAME ``c Ucenaes S4 CC2i' UC. NO. C� d S•5 -a: re C. NO. A441062 #)Q � •S-�' LC.Ldv t;{ dt'l,� • (�( �T / Sus. Tet. No. 7?2 - 972 -023 6 All. Tel. No. OWNER's INSURANCE WAIVER: 1 am aware inat the t.:cenSee Zeee_ nnlna_e in* insurance coverage Or its WOetanbeli equlvelent ~ gtwreo cy M"saenusens Genesi Lawe. ano Inst my 3tr;nature Jn .^.is -'ermu aaPticaocin (Plea" crteox ones• waives Irba require A" ateonone No. (51111144We 01 Owner or Agenll PERMIT FEE S i 0 ' � any, N2 Date//��Zr/- ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .................... ; ........................ ............................................... P-' has permission to perform .......................... wiringin the building of ................................................................................... ...... ...................... North Andover, Mass. .... ......... Fee -'q ............... Lic. NW':ejk .. .............................. 1� ................................. ELEcrRICAL INSPEcrOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TIM M G0M10 r rr1:r4Lt 11 0Ft 14SSA(7 USEM Office Use only, DLPARTAiEVTOFPVBLICS 4FE'IY Permit No. �UCk BOAROOFF7REPREVEMONREGUTA770AS527CjWR1Z-(X) � Occupancy & Fees Checked APTUCATIONFORPLRlVIIT TOPERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date TOwn..Of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. MAP aWa PARCEL / -Location (Street & Number) Lv A Owner or Tenant Al— g as,-1t5—� rx. i-,+ � S Owner's Address 7 Is this permit in conjunction with a building permit: Yes M No JF'� -' (Check Appropriate Box) Purpose of Building(� �� 6 �, i ✓�t-� Cr— Utility Authorization No. Existing Service Amps / Volts Overhead 0 Underground No. of Meters New Service Amps / Volts Overhead [:3 Underground No. of Meters Number of Feeders and Ampacity -- Location and Nature of Proposed Electrical Work Ick 10.4 -� No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above- Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burncrs FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and NoAf Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices Ni of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal- Other No. of Dryers Heating Devices KW Conncctions No. of Water Heaters KW No. of No. of Signs Bailasis N�.Hydro Massage Tubs No. of Motors Total HP 1 6TEER- I C' � .�..- Y :. L- • - :I•I f• 11 - :. u : : II. •' .\`.. \:IIS � • - • n : au a n.� • ••e. I I al ,. •.. r::r • •:. L! . r, srs .. Is a Y.I a :. I•. m::• . L• • •.: • �� - . I - •lir ••1• � • � . • :r�:• n1•- nu•.u• I - .- •• •r :.... � • :•a .. I - .rl.u.• �.u- ..� • �nl ua•:a.•.• 1rn ':• :rr• '. A is ON�- J 011 - Lica,seNo � Zl ��� lessTeLNo. B Addtrss. tiwc0� S 1 ba,-) I �,.�� �3 kU5 AIL Tel. Na OWNER'SlNSURANCEWAIVER;IamawatellitleLicemdoes not ham drmsuadncecovaaLr,artssubtnbalepI,a as req=d by NbssadwetlsGtrfalLaws andel- tmysiemmmcndmpmn applicab'mwaiwsdhsreqmanerrt. (Please check one) Owner M Agent ® i Telephone No. PERMIT FEE $ � • Signature o wner or AgenL f:�f-'r 9691 Date..A/-:::? ......... ) ......... N2 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... 7 ...... has permission to perform �; .................................... wiring in the building of ...... ......................... . ..... I .... ................... . North Andover, Mass. L & . ..... Fee, ................... ...... ............. .................................. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE00MIt10NWE4LTH0FMAma SETTS DEPARTMENT OFPUBLICS4MY BOARD OFFIREPRE[BN110NREGUL4710AN527CMR 12:010 Office Use only Permit No. '76 9/ v` Occupancy & Fees Checked -- „�� APPUCATIONFOR PERMIT TO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 / — -3®O (PLEASE PRWf T IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 1_f. , 5 Veep " Owner or Tenant /i/yI ✓ PJ 4/ Owner's Address Is this permit in conjunction with a building permit: Yes No Purpose of Building /0 /7 AV 1331, Existing Service � Amps//�o,WoIts New Service Amps / Volts To the Inspector of Wires: 2 (Check Appropriate Box) Utility Authorization No. No. of Meters No. of Meters Overfread � Underground r7 Overhead r__1 Underground Number of Feeders and Ampacity 00 Location and Nature of Proposed Electrical Work t� 71,77 IT No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground El ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets ., No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipala Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTf�f R htstttartceC0Kra PL1RX11t1DthermpwyrttsdMassaa (xruWLim IhawaanatLiabkyhnra=Pokyhi&gCon &OpamCc, ' critsabuidegivalat YES a NO M IhmesubtrtadvalidptoofofsamelotheOffixYES n NO IfyuhmtdWWYES,pkm dc*thet)WOf CrdWby&&igthe 11`fSURANCE ® BOND OnIER � (PleaseSpedfy) EVirafm D* Est m&d VaktedEkfi cal Woiic $ Work bStart htsptxiiatD*RaWestad Rough Final 5gtredtaxierftPa1a xsofpa�tay FIRM NAME Vef /? e h, `eG/ /+Y Lio=e GCt i? C ✓ .-- . sigrmn Plrr/PP OWNER'SPNNJRANCEWAIVM-lanmmdxtlheljmwdoesrd anddratmysgvMmcnftpeant arwai,tstlusreqA'anat. (Please check one) Owner M Agent ED Lioa>,seNa � �6/� of Lioa>SeNo _ !yG/� ,/Y6d'd� Y�t,//O�t / vim/ ®3�� irtslxatneoaerageo:-Bs substantial et�rivalat as rt�tmad byMassadasdls Gataal Laws Telephone No. .PERMIT FEE � 3912 Date ..... J�. , IV TOWN OF NORTH ANDOVER 6 0 - PERMIT FOR WIRING MW Thiscertifies that .......................................................................... has permission to perform .... Zj..r� ...... Sj 6 4 WA., ................................................ wiring in the building of ...... k ...................... t�IA at ....... L)- 5.9/ ............... (��dy ............................... . North Andover Mass. Fee...,35 . .... Lic. No.o�.&611 ........ I�Dz ....... ELECMICA 1� �E� Check # utrlcial use Unly Permit No. nd V "`r °� P -,&S Occupancy & Fee Chec BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK j All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:010 (Please Print in ink or type all information) Date �� U To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number (V61, ve,i Owner or Tenant V i I � ele- J -7" ©l Y` Owner's Is this permit in conjunction withr a building permit Yes ❑ No ❑ (Check Appropriate Box) l Purpose of Building 0 U h t �- Utility Authorization No. Existing Service Amps Volts New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Overhead ❑ Undgmd ❑ No. of Meters Overhead ❑ Undgrnd ❑ No. of Meters il OTHER ). Y �'l Q -� .� ci ! �H ✓fl� / IC vi l/ S"-✓n/t C -4'o c,�� fi INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES pleas . indicate She of coverage by checking the appropriate box INSURANCE = BOND = OTHER (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the PenaltiesQ eryu�S! l FIRM NAME I l/1 !'C'.i��C/-ec A1 -1-c LIC. NO. j Lkensee �l �/� �---esfr e J Signature LIC. NO. �C? p j L Bus. Tel No. Address "~CS/�C. �!% s I11�1�..�t 'v r' Alt Tel No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not haze the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. Andthat my signature on this permit application waives this requirement. Owner Agent (Please Check one) Z� Telephone No. PERMITTEE $ (Signature of Owner or Agent) �d Os"�%-;' Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Li&ting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units f No. of Swi"k h Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Wqrs Total HP il OTHER ). Y �'l Q -� .� ci ! �H ✓fl� / IC vi l/ S"-✓n/t C -4'o c,�� fi INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES pleas . indicate She of coverage by checking the appropriate box INSURANCE = BOND = OTHER (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the PenaltiesQ eryu�S! l FIRM NAME I l/1 !'C'.i��C/-ec A1 -1-c LIC. NO. j Lkensee �l �/� �---esfr e J Signature LIC. NO. �C? p j L Bus. Tel No. Address "~CS/�C. �!% s I11�1�..�t 'v r' Alt Tel No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not haze the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. Andthat my signature on this permit application waives this requirement. Owner Agent (Please Check one) Z� Telephone No. PERMITTEE $ (Signature of Owner or Agent) �d Os"�%-;' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING � TMS Section for Official Use Onl BUILDING PERMIT NUMBER: DATE ISSUED:_ SIGNATURE: Building o n /I ngs Date — -2 1.2 Assessors Map and Parcel Number: 1.1 Property Address: y Zai � ate+ �y �Rc iq r)L`\ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Pr osed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ 2.1 Owner of Record NaFib (Print) Address for Service: Signature Telephone ��'�� i��393L! FnO.r,ca� 2.2 Authorized Agent — � e l.? tom] Name Print Address for Service: 0 �6 Signature Telephone 3.1 Licensed Construction Supervisor Not Applicable ❑ nc T e Ad ress License Number �{:,n �--7 / — Z ?'00 Licensed Construction Supervisor: i� — "'' ( 7� - ?0.2- � Expiration Date Signature— Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Cr U�-tJ`.S Company Name Registration Number 5 - 1,; — Z ®O Address )e-< 11�) „?'f 3? Z \ 0 Expiration Date Signature Telephone a v n M 0 M Z 0 Z M 90 0 ic r Cv M r Z^ Q SEC1'iON 4-�V"ORKERS COMPENSA'i�©N �G.)f� C 15Z � �S�c(� , 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 Yea .......0 No ....... 0 slEcrroN s Pxo»sstor , DESIGN nlvD Corns tt�cr�roN s»RvicEs Fo> suar rtes aNn s itu01 s s€ � CON TR11iCT ©N COAiTROL 1P 1ANT Tb 780 CMR 116 Ct3NTA +!1G MOU 7HAND 35fQOQ GF OF 1 iC ED SPACE) 5.1 Registered Architect: Name: Address Signature Telephone s.2 Reglsberer;Professon F,nitret¢s s.- Area of Responsibility Name: Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Registration Number Expiration Date Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Name Address Registration Number Expiration Date Signature Telephone >::. � i rti►1iA "v,14 h<s� �:'c: � 'Xi � �F ; i��' ; �— tj — Company Name: Not Applicable D S<ec r� Fn�rc�S Responsible in Charge of Construction 'P Ind ' ndent Structural En ' eerin Structural Peer Review R Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner i Date New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: (� USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 0 A-5 ❑ IB ❑ B Business ❑ 2A 2B 2C 0 ❑ 0 C Educational ❑ F Factory ❑ F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional 0 I-1 ❑ I-2 ❑ I-3 ❑ M Mercantile ❑ 4 0 R residential ❑ R-1 0 R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: ,sr. ,;, 5 W, RI EXISTING if applicable) PROPOSED BUILDING AREA Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Areas Total Height ft Ind ' ndent Structural En ' eerin Structural Peer Review R Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner i Date a I, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name Signature of Owner/Agent Date Item Estimated Cost (Dollars) to be '�� pp7, f V 7 < Completed by applicant, } '' ��7 r permit 1. Building (a) Building Permit Fee .)00 Multiplier 2 Electrical (b) Estimated Total Cost of Construction from (6) 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number oel o0 0 .s apt} }m j h;:,'/ C �i�.� }t�: '��,. i, {k f 1•:it itt 4.' /' .r J p �, Y �rt t rS�N� t � F % r..:.d:{i. t:,� ,i,}..J,... , >.,'+. 4k5�.E'<`.'. .,.�. hl 1F:: ✓3.� �. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2ND 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH ANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ..1_i�, 2.'.;'t-��,i�s }t• py 'Y � .. ve�. ,.� <,s`., t. _ .sk. •: R.,rk`s ., _W,;. ,� i �.-, k� +'f,-mak t'd a a ✓/tr, �am»aan,�a(� a�✓l�.�eaac/uae� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 080515 Birthdate: 07/2111965 Expires: 07/21/2005 Tr. no: 80515 Restricted: 00 KEVIN M FRANCIS 31 LAWRENCE ST — HAVERHILL, MA 01830 Administrator 1 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S.150 A. The debris will be disposed of in: TR v c e 0A y (Location of Facility)®1,c.aS�2ecy l 1�ve, Signature, of Permit Applicant _ 2' I e3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector 16 Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: ",' N -- R t- Address ry �-�- City: y -p -A 1M Phone # 9-)l 3i 2, O�T Insurance. Co. Policv # Company name: Address 1 1 k,o P S� Phone #•b— I- W C -)-3 Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,5oo.00 and/or one years' imprisonment_as_Y&H-as_civil,penalties in -the mn�aSTOP MRKOfin RDERmd_ae u!_($1 QDM)-aliayagainsi me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature } pate t -I 0 3 Print name r c %S Phone.# Official use only do not write in this area to be completed by city or town official' City or TownPermit/ Jcensi ❑ Building Dept []Check if immediate response is required 0 Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other I1VV1 tears. V�.,i\ l ■■ iVa� ■ � v. B.K. McCarthy ins. Agcy. Inc. 10 Centennial Drive Peabody , MA 01960 978 532-5445 INSURM JNR Gutters, Inc. 114 Hate Street, Suits 404 Haverhill, MA 01830 THIS CERTFICATE IS ISSUED AS A MATTEL OF NFORYATIOI OIIiY AID CONFERS NO JWKM UPON THE CERTFICATE HOLM R TIM CEiTFICATE DOES NOT AMM. EXTEND OR A1.1—TIE COVERAGE AFFORD BY THE POLICES BELOV WSURERS AFAORMS COVERAGE NAIC # mum mk The Travelers Insurance Company NS me: Liberty Mulual kmffarroe Company T16UffiRC NSURAWk WISURERE: COVERAGES THE POLICIES OF WSURANCE LWW BeLOW HAVE BEEN /SSU® TO IM INSURED NAMED ABOVE FORIM POLICY PEMOD DMATED- NOTWOTHSTANDING ANY REMAREMENT. TBMA OR COWITION OF ANY CONiRACrOR OTHER DODA93 T WITH RMPECT TO WHCH THIS CBMRCATE MAY BE MM OR MAY PERTAK THE IMMANCE AFFORDED BYTHE POUCWS DEQ MON IS MA E'T TO ALLTtE TERMS. MO LSIONS AND CXXEITIONS OF SUCH ......,ry+a� . rrrrc• c..,.,.... uav Laauc occu acru rsxl aY Pon A A LL4 .ITR TYPEOF8�INCE POUCYMUR POLICY XPR mmo-c Lam 06112103 E00fOCCURFOM x1000 000 A G'EMEMUROUDY NNKM77Y6165COF03 002102 pjjt�ITED 5300000 X MMMMULLGENOMLLNNUTY -- gRMASMATE Q OCCUR MED EXP wv cw prion) S5 000 PERsauu. a ADN NATRY $1,M0,000 GENOW ASSFaMTE 000 000 PROougm-coMP1oP Aw S2,000,000 GOft AGGREGA-M UWrAPPM PM POLICY �LOC A AUTONOBTLELTABLLITY 181086 IND02 06F21102 06121/03 )SN(><EtMT ANY AUTO ALLONIMMAUTM � S X SCF>EDULEDAUPOS X HTREa AUTOs VWa $ W#An= IxNON4Nnf Drive Other Car $ ) MROONLY-EAACCAMMr S C4UU UA8nM E Eyl1ACC S ANY AUTO RAUTO ONLY: AM S A LMf "m ISFCWISUWb7MM WMZ102 owl=$4,000,000 X OC= ❑ CLATMS MAM A EGI►TE S4,000,000, S s RnEDUCTME X TtETENTION s 9000 S YYCSTATii OTH B WORRS(X MMANO NE 15330775022 0912010209120103W EMPLOYEW UABLUY E.L. EACH AMMENT $100,000 ANY FuoEo� rmpmoag-rAsAnom s100,000 Ityes, iesaBeudElr SPECWL PROv61oNS belor OTHER ELDISERM-POLICYLWT I S500,000 DESCRIPTION OF OPERA7�0lrv! wG�►uuRs. vvw�.ar.. � a......,.�w....�.......�....-._..�.�..--.. _ ---- - Evidence of Insurance JNR Gutters, Inc. 114 bate Street, Suite 204 Haverhill, AIA 01830 GATETNEi w.TmTS6 m POLICESeEr-mKmd wBEFORETITSEMRA rL.BWEAVORTOW& _fl– DAYSWRM TOTW LEFT. BUT FABMM TO DO SO 8W IiBp UPW THE NSLWASk TTS AGENTS OR is 91 0 Z L F y W F" cc W L.3 COO c� o CD c :=o :cam : o � c ` O H V V : a'C CL C cc := O O Cc y Ea r -3 CL N L .43 $ C C da m mm O N co cm : m c Cc ca O Epoi :m0 o.8 .: 1CL4D O00R O O �-.�L _m CO) 1St O C E co.3-0Cy m We C CL cc .= O. m m a h 0 a CA C O v m >a c m o CD c 'c N CD t Q Z 0 J CD •a M. O 4S v v O O E O Z O C r.7 H O .v CLH C O u O C CL H L O v co CLy C CO ZM C co m m 0 co 3� Lft� co G O L L O CL Cm Q ..r c ev ev —i= O O Z CD CO)CL C a 0 w a a p x w z a p ' A A v d ,.a ° -°Cli C7 w a v ' U bo p p, 7 is G w m oD �G U O ° G o $ ° w° cn w° a°' w G co F y W F" cc W L.3 COO c� o CD c :=o :cam : o � c ` O H V V : a'C CL C cc := O O Cc y Ea r -3 CL N L .43 $ C C da m mm O N co cm : m c Cc ca O Epoi :m0 o.8 .: 1CL4D O00R O O �-.�L _m CO) 1St O C E co.3-0Cy m We C CL cc .= O. m m a h 0 a CA C O v m >a c m o CD c 'c N CD t Q Z 0 J CD •a M. O 4S v v O O E O Z O C r.7 H O .v CLH C O u O C CL H L O v co CLy C CO ZM C co m m 0 co 3� Lft� co G O L L O CL Cm Q ..r c ev ev —i= O O Z CD CO)CL C Location �di No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I. -- Check# 9',-/ 3 5 Building Inspector