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HomeMy WebLinkAboutMiscellaneous - 45 WHITE BIRCH LANE 4/30/2018A CT m W n x Date ..... 1j. 14, K A 6.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that�� ......................... .. ............................................................... has permission for gas in Iation .... . ......................................... in the buildings of .................................... at.3Q�.WC- Fee,'..6. .... j ...... Lic. Not.(/Ye ........ Check # �10 0 .00572 ........................................................................ I North Andover, Mass. . ......... GA*IN'SPE*Cmq'7 .......................... •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 4 r .1' V F MA DATE I PERMIT # L�GC4 JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIA CLEARLY NEW: [_� RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NOD APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER_J _ - _ J �— _ _ _ _ I -- I ! � COOK STOVE _ DIRECT VENT HEATER _.. ICY -_ ,.._ _ . �1 . _ . _ L- _ I - -- -... _ _ �7_ ..- -_--_- DRYER FIREPLACE I 1- FRYOLATOR —_ �! FURNACE GENERATOR GRILLE( INFRARED HEATER LABORATORY COCKS�_J ! Lam..-- MAKEUP AIR UNIT OVEN �. _ �.._ _- _ POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT + TEST UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER OTHER --- -- -- -- ._!_ r- JIL INSURANCE COVERAGE have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j NO [] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IQ OTHER TYPE INDEMNITY ® BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE # 3 SIGNATURE MP 0 MGF El JP 19 JGFj LPGI © CORPORATION ©# PARTNERSHIP# LLC [3# COMPANY NAME: &.3_ �_- )Uw%�� .I^ JADDRESS Tof a c aWa r _ CITY fa e� i' _ � STATE ZIP ]TEL FAX CELL_! EMAIL H O z z H U W a w a z Oz �❑ W >- W LU O CL U W *� z w F-� a W COa o > w � w � a d o a a a U J F, a a ' < �. S2 w X w LL H O z 0 H U W a c7 O 0 M 'sa The Commonwealth ofMassachusetts DepaiftintofIndustriqlAccidints 600 Washington i i ,� sia ata s� Boston., 02111 a� / a / / Name (Business/Organ-zation&, ividual): 1 D Pt H .Address: P City/State/Zip: t) rot Phone if: 9'7e— g9 - F ?, q -2 Are your an employer? Check the appropriate box: Type of project (required): 1. ❑ I a7n a employer with 4. ❑ I am a general contractor and I 6. ❑ New cOnstruction employees (full and/or part-time,).* have hired the sub -contractors 241I am a sole proprietor or partner listed on the attached sheet.1 7. ❑ Remodeling ship and'have no employees These sub -contractors have S. [( Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. F1 Electrical repairs or additions required.] officers have exercised.their 3. ❑ I am a homeowner doing all work right of exemption per MGL 111gPlumbing repairs or additions myself EEO workers' comp. c. 152, §1(4), and wehaveno 12.❑ Roofrepairs insurancere firedemployees. [No workers' �. a � 13.n Other comp, insurance required.] *Any applicant that checks box#1 mustalso fill dutthe section below showingtheir workers' compensationpolicy information. i -Homeowners who submit this affidavit iadicatingthey do'doing allwork and then hire outside contractors must submit anew affidavit indicating such. tcontractors that checkthis box must attached an gdditional sheet showing the, name ofthe sub -contractors and their workers' comp. policy information. -Taman einployar that is providing workers' competasation insurance, f oYmy employees Bellow is thepoliey and lob site information. insurance Company Name:. Policy # or Sol£ -ins. Lic. #; Expiration. Date: Job Site Address: City/State/Zip: Attach a copy oldie workers' comp ensation.polley declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a flue 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. B e advised that a copy of this statement may b e forwarded to the Office of. Investigations of the DIA. for insurance coverage verification. X do Izereby c 'ti under flee pains aid penalties ofper, f ury Mat the information provided above is trlae and correct. 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 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 ofhire,- express or implied, oral ox written.,, An employer is defined as "an individual, partnership, association, corporation or other legal entity, ox anyiw0 oxmore of the Foregoing engaged in a joint enterprise, and including the legalrepresentatives of a•deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. Aowever the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant oft1jo 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 employers." 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, MaL 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-contractox(s) name(s), address(es) andphonenumber(s) alongwithiheir certificates) o£ insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLp) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. if an LL C or LLP does have employees, a policy is required. B e 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' compensationpoliey, 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 Towns Officials Please be sure that the affidavit is complete andprinted 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 thatmust submit multiple permit/license applications in any given year, need only submit one affidavit indicating curtent policy information (if necessary) and under "Job Site Address" the applicant should write ,all locations in (city or towiz)" A copy of the affidavit that has been officially stamped or marked by Fb e city or town may be provided to the applicant as proo£that a valid affidavit -ii on file for future hermits or licenses..A. new affidavit must be fillgd 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 orpermit 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 faxnumber: Tho GomrAonwealthofWossachvsP a Depaxi ent o£laftWal .A,ccidonts Me ofTntVestzga-iong 600 Wash*on 8l7reet Boslo% MA 021.11. ` QJ. # 617.7.2' 400 ext 406 or 1:-877-AIASSAFF, Revised 5-26-05 Fax 617-727-7749 www.ntaagov/dia Datea.12glq........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. ..( l lL:........ C � ..................................................................................... has permission to perform ..... . .............. , P.2- .....:........................................... plumbin in the buildin , of ......... !�.-?. ................................................. at .. �........... U` `.� `.... �.......... �,QC ..�, �I !,.........., North Andover, Mass. Fee ..3v."...... Lic. No. ���.. ... !v �'�`'............................................................ PLUMBING INSPECTOR Check # 2-1W7 M. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C�� MA DATE I PERMIT # lWi15 CITY JOBSITE ADDRESS �� OWNER'S NAME kW-4,+Sk,� lei. P OWNER ADDRESS TEL ?$-a31— FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIALN PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:.0 PLANS SUBMITTED: YES ❑ NO❑ FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES EIGC WATER PIPING OTHER 4 € INSURANCE COVERAGE: I have a current liabiliV nsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO ❑ IF YOU CHECKED YES, PLEASE iNDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK -ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. eLW, ` V S CIA.yl `I �— PLUMBER'S NAME Eric Schuberth LICENSE # 12625 SIGNATURE MPO JP❑ CORPORATION O# 2313 PARTNERSHIP❑#LLC❑# COMPANY NAME I Main Stream Mechanical ADDRESS 1110 Haverhill Road, Suite 330 CITYCAmesburySTATE MA ZIP 01913 —� TEL 978-834-0849 FAX 603-895-6283 CELL I EMAIL I eschube0h@mainstreammechanical.com M. The CommonweaM of.Massachasetts , - Department of lncius%rnl Accidents Office of lnvestigatIons 600 Washington Street .Boston, .ZtlA 02111 www.Mass govId a Workeo' CompengationInsuranceAffiidadt: Buffdera/Cont°acfors/BlectrxcianslPIer$ ,Ap 'team Mormation Please Prhit Legl . Name (Businesslorgani'zation/%aWduat): Address: I l O TT V. V K t.0 I NZA— C2 ue �c 9ncJ City/Sime/2i , 006- 13 Phone #: Are you an. employer? Check the appropriate box: Type of project (required): A. [] I am a general contractor and I f / a exaployex with. _�___� 6. �] New cbnsiruciion employees (full and/or paxt time).* have nedthe sub -contractors 2. [i I am a sola proprietor or Partner -listed on the attached sheet. � 7• E] Remodeling ship and`haveno•employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. g, El Building addition [No workers' comp. insurance 5. ❑ We are a corpora#on and its 1.0.❑ Electricalrepairs or additions required.] officers have exercised.theix ri ht of exemption or MGL ll.[[ Plumbingrepairs or additions 3. [] I am a homeowner doing all work c j 52 xe anal w have L myself. [.No workers comp. a § ()a 12.N] Roofxepairs insuranceragw-ed.I i" employees. [No workers' 13.� comp. insurance required.] Any applicantthat checks box#I must also Moutthe section bel6w shovwingtheirWorkers' compensationpolicy information. Homeowners who sabmitihis affidavit indlcatiugthey tie doing all.worlc and then hire outside contractors must submit a new affidavit indicating such. TContractors that cheAthis box must attached m addifiond sheet showingthe name of the sub. -contractors and their workers' comp. policy information. lam are employer that is pr ovidirzg workers' compensation insuraneo fo,-My employees Berow as the policy and job site information. Insurance CompanyN'ame% 1-76Nj:!�(Dad :5,'nS policy # or Se%ins. iL' ic. #: —71. A ��Q n 10 � �"' ExpixationDate: T'ob Site Address:- YJ �— Cityatep: U H35' Attach a copy of t.I:te workers' compensation -policy declaration page (showing the policy number and expixatiolz crate). Failure to secure coverage as requiredunder Section 25A ofMGL o. 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 WORSE ORDER and a fine ofup to $250.0 0 a day against the violator. Be, advised that a copy of this statement maybe forwarded to the Office of investigations of the DSA for insurance coverage verification. X do liereby ceptt� under triepains and penalties of per' that the information provided above is ue and correct. - Q-ircn aiiTYP• 4'%-%-, —l > � Date. —1-1 -% - t Official rose ortly, vo not write in Mis area, to he completed by city or town official. City or Town: Permit/License # Iss-aing.Authority (circle one): 1. Board o�FL%aIth ?. SuildingDepa�rtment 3. City/Town Clerk 4. Electrical fuspector 5. Plumblugfuspector f. Other Information and Instructions.* Massachusetts General Laws chapter 152 requires alt employers to provide workers' compensation for their employees. Pursuant to ibis statute, an employee is delved as "...every person iii 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 ox more Of the Foregoing engaged in a joiut enterprise, and iucluding the legal representatives of a•deceased em to ex o .the receiver outrusfee of an individual . artnershi association or other legal entity,em to in em to ee . However the �p p� g employing pY owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction, orrepair work on such dwelling house or onthe grounds orbuilding appurtenant thereto shallnot because of such employmentbe deemedto be an employer,, MGL chapter 152, §25C(6) also states chat "every state or local ZWensmg agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth fox' 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedta the contracting authority." Applicants Please fill out the workers' compensailon affidavit completely, by checking the boxes that apply to your situation, and, if necessary, supply sub-contxactor(s) name(s), addresses) and phone numb er(s) along with theix cergificafe(s) of insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than, the members or partners, are notrequired to carry workers' compensation. insurance. If an LLC orLLp does have employees,apolicyisxequired. Be advised ihatthisafldavitmaybesubmitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit: The affidavit should be retumed to the city or town fbat the application fox the pormit 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' compensationpolicy, please call the Department at the comber listed below. Self-insured companies should enter their self insurance license number on the appropriate lino. City or Town Officials Please be sure thatthe affidavit is complete andpxiated legibly.. The Department has provided a space at the bottom of the affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fdl iii the pe,n itllicense number whichwill be used as a xefereuce number, In addition, ai Fold, Then Detach Along All Perforations o COMMONWEALTH OF MASSACHUSETTS PLOMBERSW FISFITTERS `ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER ERIC V SCHUBERTH 110 HAVER1i l LL RD STE 330 AMESBURY MA 01913-2124 12625 .'05/01/16 223838 Fold, Then Detach Along All Perforations v COMMONWEALTH OF MASSACHUSETTS PLUMBER SF I TTERS ISSUES THE FOLLOWING LICENSE LICENSE.O AS A JOURNEYMAN PLUMBER ERICV SCHUBERT14 110 HAVER ILL RD STE 330 8 AMESBURY MA 01913-2124 20205 05/01/16 223839 Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS • • ••• • PLUMBER : .. SF I TTERS ISSUES THE FOLLOWING. -LI -CENSE REGISTERED AS A PLUMBING CORP t I C V SCHUBERTH IIN STREAM MECHANICAL INC M1262 0 HAVERHILL RD 'E 330 '8 :ESBURY MA 01913-2124 2313 05/01/16 223840 Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current H se 3) Insurance Binde not on fil or expired 4) No Workers' Compensation Insurance Affadavit Form V Please call with any questions 978-688-9545. Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Date...%-. (i/17 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'Low— NZ! �Hus�4— . This certifies that ... / ... ��../� /7 (�. ... ..... .................. has permission to perform.:..-,e-k� — plumbing in the buildings of—j2 .......... ..................... at ....... ......... North Andover, Mass. Fee ... Lic. No. 7 .............. .. PLUM'BIN'G INSPECTOR Check # 7429 Date.....�.�1J1..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... .........� .... ........... has permission for gas insulation . tom.... ...:.. ...... in the buildings of ........... ..................... at .. - �-'©©! �-�'` ..'l . 4l` ,North Andover, Mass. Lic. No.rc967 ` �/ �- f .......... !! � `GAS INSP,ECT.OR Check 6047 r 1 . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING , (Prim or Type) -- I� ,, S I- .Mass. Dale ----- -Owner's �_ Permit �J' Building Location _'1�P +Q(s %L1i'�w Owner's Name iiI ✓ 1190J�SIr� t T AQ yy yp o ccupancy t' New ❑ Renovation p Replacement/N] Plans Submitted: Yes❑ No ❑ Installing Company Name AYOTTE PLUMBING - HEATING Address Alm C0NDLj1tr*MtN13r_ NORTH CHELMSFORD, MA 01863 Business Telephone heck one: ly Corporation ❑ Parinershlp ❑ Flrm/Co. CertKlcate # 'lame of Licensed Plumber or Gas Filter �IyuOArt`at INSURANCE COVERAGE: I nave a current bllfty Insurance policy or Ks substantial equtvalent which meets the requirements of MGL Ch. 142. Yes No 0 f you have checked yes, please Indicate the type coverage by checking the appropriate box. I - A I abllrly Insurance policy Q' Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit appllcallon waNes this requirement. Check one: gnalure of Owner or Owner s Agent Owner❑ Agent ❑ 1 nereoy ceniry that all of the details and Information I have submitted (or entered) In above appllcallon are true and accurate to the best or my rnowleogs and that all plumbing work and Installations Perlormad under the per t Issued (or this ap catlo will, be In compliance with all eri Hent Provisions of the Massachusetts State Gas Code and Chapter 142 o1 l eneral laws. T " of Ucense: Phrmbor ign u o ce i or r as liter hslittor town astor Ucenso Number .; i i rm f5 T?5il'zfiRr-bTTrg-- Journeyman No NONE IN N mom 0 0 No moon mom 0 0 4TK FLOOR No on NOON 0 mom Installing Company Name AYOTTE PLUMBING - HEATING Address Alm C0NDLj1tr*MtN13r_ NORTH CHELMSFORD, MA 01863 Business Telephone heck one: ly Corporation ❑ Parinershlp ❑ Flrm/Co. CertKlcate # 'lame of Licensed Plumber or Gas Filter �IyuOArt`at INSURANCE COVERAGE: I nave a current bllfty Insurance policy or Ks substantial equtvalent which meets the requirements of MGL Ch. 142. Yes No 0 f you have checked yes, please Indicate the type coverage by checking the appropriate box. I - A I abllrly Insurance policy Q' Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit appllcallon waNes this requirement. Check one: gnalure of Owner or Owner s Agent Owner❑ Agent ❑ 1 nereoy ceniry that all of the details and Information I have submitted (or entered) In above appllcallon are true and accurate to the best or my rnowleogs and that all plumbing work and Installations Perlormad under the per t Issued (or this ap catlo will, be In compliance with all eri Hent Provisions of the Massachusetts State Gas Code and Chapter 142 o1 l eneral laws. T " of Ucense: Phrmbor ign u o ce i or r as liter hslittor town astor Ucenso Number .; i i rm f5 T?5il'zfiRr-bTTrg-- Journeyman �11 >r v j 6. \' MASSACHUSETTS UNIFORM APPLICATION FOR PFRMIT TO pQ PLu'�e?r!G 1 (? nan1( or I 4. rr.. Mas:. Datc Pcr(�f1+� 6 u h d I n Q ll>.�t t o n_ t `J IJcJ� 11 I Q� Y1 nGi Nf J i.VI J I �Tr( -3 M4 TYAi 0 " V1 _ Ncw 0 FcnonHon [] Acplac;mcnI PIIn; $upmm;j; Yc;rr_ �� C .Wren fames AYOIEL21.11 M RING • HEATING & AIR CONDITIONI 4; �1cck Q �fF�ri�vn _ r�A :NORTH rHFI MqF RD MA 01863 (� P;rtnGr�nla __...:�t Tcicpoonc_�7g-��%' Innn �' Fif7T1�GQ - Uccn$ca PlumD•cr or Ges Fi;,er - S.;R:-nCE COvFr�.Gc:------- c : c rrcn; oc.y insurzncc p.:(Icy or its su0zmlw cquNalcnl WniGh m4 Sl; InG f;gwl(;m;r.ls Tc s NJ D ra,c cncctca VC1, pcc;sc i lc tnc rypc coycr-igc Dy chccklnv UlG iFpfgpr4j; pq�, c.,ar ;n,�nncc pollcy O(ncr lypc 0( IndcmnrQ Y Q v nQ Q C rr,Ep. S frnSURANCE W<.IVErR: I am awzrc Itul Inc Ilccnscc docs ncrf ilavo Ir,G IniurinGi Gatic7gc (�, ; 1;2 or Inc I.lass Gcncral hw5, and IN( my;igrulufc on Ihi} PG(7pjj jpalqIiQ mN,4 t :: ,r C'( C-- s.c l OIYfICrq FQin; Q �r :. �...r'•'f'. rll c; l,'c Cr'J::: an: Inl:rr.-7lir.� I�.l+� Ic:-.iar'. fci ln:f•I;'i:, , . . - , : ; < ,. �.n U: pf�ncin; ,.c�i anC insU4auo,u p�rtcrmsc ur,:r: v',t L+ir,.n ur• ' ar, p,c•„ on, of lht >:isacr.�san: Slab Gr, Codr snd G1+olar I42 0l Int 1� rrr T,- c� Uar.". �r Sr4tv,l01 u r ` n•Ilu -s : u r X h z Z X < V1 r N V1 O Z F h J V1 •• N V1 F• U X •( O VI LL z n x F 0 - W O D V1 C C N C I W N} G < N z (• 0 C < < w C C LL = Z 0 p ? z u f u < 3 r { v1 < Q n It Y J O V1 F o p Su0-9 S n,T, I - S E ., e n T S T F L O O R 2 11 0 F L O O R )A0 fL00R �. Tn FLOOR —T-- Sin FLOOR I - b Ti, FLOOR 1Tr+ FLOOR I - a"r. FLOOR �� C .Wren fames AYOIEL21.11 M RING • HEATING & AIR CONDITIONI 4; �1cck Q �fF�ri�vn _ r�A :NORTH rHFI MqF RD MA 01863 (� P;rtnGr�nla __...:�t Tcicpoonc_�7g-��%' Innn �' Fif7T1�GQ - Uccn$ca PlumD•cr or Ges Fi;,er - S.;R:-nCE COvFr�.Gc:------- c : c rrcn; oc.y insurzncc p.:(Icy or its su0zmlw cquNalcnl WniGh m4 Sl; InG f;gwl(;m;r.ls Tc s NJ D ra,c cncctca VC1, pcc;sc i lc tnc rypc coycr-igc Dy chccklnv UlG iFpfgpr4j; pq�, c.,ar ;n,�nncc pollcy O(ncr lypc 0( IndcmnrQ Y Q v nQ Q C rr,Ep. S frnSURANCE W<.IVErR: I am awzrc Itul Inc Ilccnscc docs ncrf ilavo Ir,G IniurinGi Gatic7gc (�, ; 1;2 or Inc I.lass Gcncral hw5, and IN( my;igrulufc on Ihi} PG(7pjj jpalqIiQ mN,4 t :: ,r C'( C-- s.c l OIYfICrq FQin; Q �r :. �...r'•'f'. rll c; l,'c Cr'J::: an: Inl:rr.-7lir.� I�.l+� Ic:-.iar'. fci ln:f•I;'i:, , . . - , : ; < ,. �.n U: pf�ncin; ,.c�i anC insU4auo,u p�rtcrmsc ur,:r: v',t L+ir,.n ur• ' ar, p,c•„ on, of lht >:isacr.�san: Slab Gr, Codr snd G1+olar I42 0l Int 1� rrr T,- c� Uar.". �r Sr4tv,l01 u r ` n•Ilu -s : u r Location At-* 3-+ l j l' i T>r i 2 c' /f No. 1 %'77/ Date 7 l3 NORTH TOWN OF NORTH ANDOVER o�.�•o :.�tio p Certificate of Occupancy $ Building/Frame Permit Fee $ = b'•reap CHuSE� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL` $ t/ ./� Building Inspector 7 188.50 PAID 3 Div. Public Works 'Location t ��U,�1�� �j ' No. ZO Y—C Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ - �- FoundatiorrP' rmit Fee $ -- Other Permit Fee $ U Sewer Connection Fee $ Water Connection Fee $ } TOTAL $ O ///v Building Inspector 74aA/94 K.10 X5.00 AILI Div. Public Works Location No. 1 U Y Dates NORTH TOWN OF NORTH ANDOVER ♦.. OL A Certificate of Occupancy $""a- Building/Frame - Building/Frame Permit Fee $ .S 0 E��' Foundation Permit Fee $ � n s�cMus Other Permit Fee $ Sewer Connection Fee $ '—,/J Water Connection Fee $ �- K �f TOTAL j$$ �% •®�� Building Inspector 94 816.5U PAID 720? Div. Public Works Location`s l 'No. Date TOWN OF NORTH ANDOVER p Certificate of Occupancy $ + i Building/Frame Permit Fee $ � s�cHus t Foundation Permit Fee $ ZZ12, l CJ Other Permit Fee $ ------, ' Sewer Connection Fee $ ----------- -------Water WaterConnection Fee $ TOTAL $ _ �y�/J•/C//% Q4/15/94 tQ:58 Building pector M-0RAID ^��� 7141 Div. Public Works L-617 3 Locatio %:f f,� < 7tz ;6 YG 12 No. Date dig 03W Water Connection Fee $ TOTAL $ l 4 -' 694-3 Buil Inspe 4 r 4/41 l Div. Public Works a i TOWN OF, NORTH ANDOVER, Certificate of Occupancy Ell Building/Frame Permit Fee $ Foundation Permit Fee $ '• Other Permit Fee $ Sewer Connection Fee $ ,n 03W Water Connection Fee $ TOTAL $ l 4 -' 694-3 Buil Inspe 4 r 4/41 l Div. Public Works LL Z 0 U Q I j I � I W I IL 1 Q 1 U. 1 O 1 0 (C 0 m S L 0 O g I 0 it F0 W tL m Z 0 Z_ 0 J m s W i W ' 0 W 0 CK IL N 0 a A Z O 0 � J k 3 0 # tb 1 °w 4 lK F x V F e F i a 0 = m w C Z LU ZZ 1 it F0 W tL m Z 0 Z_ 0 J m s W i W ' 0 W 0 CK IL N 0 a A Z O 0 � J k 3 0 # tb 1 °w 4 lK F x V F F i a 0 = m w C Z Nnn O N cl J_ m p zm A i p n Z O CD 0 >0 N M N z M, >z IP z Cut M Lei x X -A 3DN Nva °mx AZ> IN9 Nzv MN3 T �Om nwa to r 00 0-4 Oar b�n0 z�i zo o� zn Mm N .4 �m D0 3 cam Q z vv M n 0 m 0 2 n z �0 z D,z OD C r0 D poz z a.n T <D n mT Z m°C >0 N M N z M, >z IP z Cut M Lei x X -A 3DN Nva °mx AZ> IN9 Nzv MN3 T �Om nwa to r 00 0-4 Oar b�n0 z�i zo o� zn Mm N .4 �m D0 3 cam Q z vv M n 0 m 0 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: S'C 0 -7L7 -Y77 04 ✓ ) -,L/7 C _ Phone •77y 0 0.? c/ LOCATION: Assessor's Map Number Subdivision Parcel Lots) -4F'3 Street ) t -Q �e)^( 4 / }�-Z . St. Number s ************************Official Use Only************************ REC MMENDAT ONS OF TOWN AGENTS: 1 Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department I Mf `- Received by Building Inspector Date Approved Date Rejected Date Approved Date Rejected If Date Approved Date Rejected Date Approved Date Rejected icr 61994 Date r,, / ' S h u/ -- __•��� a g � O 0 0 C. 40 cr CC —oh =s« -io, gz� � a o o QR ii Is Q 1 Or J Q CL _ h u/ b \°4 o � O 0 0 C. 40 cr CC —oh =s« -io, gz� � a o o ou--' I ✓lir \ � ' ° b // \ I I \ �, � _ , u/ \`0 \°4 °0 111 �l-. \11/ 60 I \ on 60 CC —oh =s« -io, I 4 QR ii Is Q 1 16 —04 3 g t --nn J I s -°a S¢ ou--' I ✓lir \ � ' ° b // \ I I \ �, � _ , u/ \`0 -I-�111 1111 °0 111 �l-. \11/ 60 I \ on 60 CC -io, 4 Is Aft 10 4'. "t vl! Ti '1- 71 N am )EPARTMENT OF PUBLIC SAFETY IOSTON, MA 02108 )NE ASHBORTON PLACE pUPLI CA CAUTION W11! I P. !:;tjl)r Pv I F1013 FOR PROTECTION AGAINST TFECTIVE DATE LIC -NO. THEFT, PUT RIGHT THUMB PRINT IN APPROPRIATE 4 '� + gII BOX ON LICENSE .*.','r jrril:rli J BLASTING OPERATORS, NF.TI!f_-_PW0(1D Ci[) MUST INCLUDE PHOTOt t,111 030(17 Not VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY ,'tn,§I, STAMPED - OR - SIGNATURE OF THIE COMMISSIONER"k Ni hA.VAWAWAIuMUNE: �, rg�j w rl ROV_ __n U T I I., A, F M 1.41 lo j, I It qJ f LOT 4 P WHITE BIRCH LANE FO UNDA TION L 0 CA TION PLAN CLIENT. • SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION. NORTH ANDOVERNA. SCALE.1 "=40' DATE.5/2/94 CHRIS TlA NSEN ,SERGI POLAND u�ORS E 160 SUMMER ST. HAVERHILL.MA. 01630 TEL 5019-J73-0310 © 1994 BY CHRISTIANSEN k SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTSWETLANDS,EASEMENTw ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN d SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHISITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 25OD98 0005C DATE. 6/2/93 r ' MAY ` 5 1994 .r. DWG. NO.: 93067016 BUILDING (:ONti;:1tVATION I Il :ill :1'I 1 1'I.i\NNIN(; 1r\ t'I.IVAIN 1)UVL'lt I MIND IN 4 IF 1'1,�1NN1N(;. Ltc (;t)fl1f1IlIN!'I'1' I)I;��1:I,Ul'l1II:N'1' 1::11 ;1:t.' I I.I'..NI :1.tic V. I !11 tl :t :1 c 11 i CHIMNEY APDL I CA f I ON ANO 1'[:1311 I' ATE )CATION UNER'S NMIE: 1ILDER'S NAME: SON'S NAME: iSON' S ADDRESS: I i �. - 7%/4�P ✓�� +.SON'S TELEPHONE: 6(y 1•.I$11114140\1••�: r hl:�`:�:li Fig�•,e rl•: 1ti•! ; .Ilii il�ili!i•!i rti :- 1'Lltl•11'1'. JERIAL OF CHIMNEY: iFERIOR CHIMNEY: EX1 LRIOR CHIMNLY: L� IMBER AND SIZE OF FLUES: - Af d- ' Xla lI CKNESS OF HEARTH: :,z Chilllney o/. ()iAepcaee ean(anul to VIC Actiu.iltelnell.t:3 ur .thc CO(ILMid llttve Alf[C.s cul(( ,gLLzatiou been nea-becl: -- -- TE: / -;L/- GNATURE OF h1ASON: -MIT GRANTED: �f a/`r / FEL 'BERT NICETTA ILOING INSPECTOR SPECTEU: -- :,�1A;`KS SULIU (CLUCK 11E'UUIItl:1) THIS PERMIT MUSF GE UISPLAYLU 014 111E 1'IZUll L', /C) 15 ti CERTIFICATE OF USE & OCCUPANCY lh And,�v Building Permit Number 104 Date AUGUST 24 aA� THIS CERTIFIES THAT THE BUILDING LOCATED ON 45 White Birch Road -Lot #3 MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR GARAGE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO J.D.P. Dev Corp 12 Rogers Rd. ADDRESS Haverhill, MA Building Inspector CA 'v � z CD O o- r O O O � .,a O CDv CL cr 0 n CD O 0 Z m = co < av M p �=. Cl) z < CA m CD 7� Cl) � o v v CO) L! O C) CD O CD CD 3. 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