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Home My WebLink AboutMiscellaneous - 47 ELMCREST ROAD 4/30/2018 47 ELMCREST ROAD 210/055.0-0025-0000.0 I Libq�y Mutual. Liberty Mutual Insurance New England Region Central Property Unit INSURANCE 75 Sylvan Street Danvers,MA 01923 Tel:(800)566-0323 September 16,2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover,MA 01845 Re: Property Address:47 Elm Crest Rd,North Andover,Ma 01845 Policy Number: H3221230727802 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number: 032412571-0001 Date of Loss:1/30/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, � 313, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A &B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111,§ 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address,policy number,claim number,and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 . Date.1. 1 11r 11252 Nor+rh of ,.•° ,,�ti TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING HU <� {iY� Thiscertifies that............................................................ !` ........................................... has permission to perform Y..... 1�? ..►..t'� .......:............ plumbing in the buildings__ofii.. :.. ..!........................................................... at........... . ��v,c3�¢ T.....................................North Andover, Mass. Fee..4P .........Lic. No. 333.. ................................................................................. PLUMBING INSPECTOR Check# - `�a27 MASSACHUSETTS UNIFORM APPLICA—i ION FOR A PERMIT TO PERFORM PLUMBING WORK 11451 1. 1 1 CITY/�/ MA, DATE JO®SITE ADDRESS mC�s OWNER'S NAME r j OWNER ADDRESS TELAX r ��. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT _ CLEARLY NEW: _ RENOVATION: _ REPLACEMENT: PLANS SUBMITTED: YES i NO FIXTURES`3 FLOOR- BSiU, 9 2 a 9 S 7 8 9 10 19 12 -is7-v BATHTUB CRM CONNECTION DEVICE J ; , pECICATED SPECIAL WASTE SYSTEM 9W ICATEO GAVOIL(SAND SYSTEMNOW- DEDICATED f DEDI TED GREASE SYSTEM DEDICATED GRAY WATER SY8TEM DEDICATED WATER RECYCLE SYSTEM I DISHWASHER r DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SIN i LAVATORY ROOF DRAIN - SHOWER STALL �- SERVICE/MOP SINK To LET URINAL WASHING MACHINE CONNECTION WA R HBATER ALL TYPES WATER PIPING OTHER INSURANCE C-OVERAGE: I have a cutteM flabilloinsurance Policy or Its substantia!equivalent whit rnaets the requirements of MGL Ch.142. YES eNO _ IF YOU CHECKED YES,PLEASE INDICATE TYPE OF COVERAGE BY CNECKiNG T E AtPFROPRIA T E SOX BELOW UABILITY INSURANCE!I YCY-V_ OTHER TYPE OF INDEidnyl i`i BOND OWNEWS INSURANCE WAIVER;Tarh aware that the licensee doa,tild lnsu�mance eoverage required by Chapter 142 of the Maegactuaett General Laws,and that MY signature on this Permit ap alicatlQiiaw lues this requirement. CHECK ONE ONLY: OWNER _ AGENT _ SIGNATURE OF OWNER OR AGENT e y ceRW that all of the details and Information I have submitted or antera rewarding this applicatlon true and eccu to the best o m knowied Y ie and that all plumbing work and installations performed under the permit isswed'or this application will be lance th I ertinent provisi f the; M chys b ate PI Ing Code and Chapter 142 of the General Lg,.Ys, PLUMBER'S NAME LICENSS= NATURE MP JP CORPORATION ,PARTNERSHIP.._#�_LLC ,# 1 COMPANY �NAM— �. DOPEeS ' ALW CITY AA N STATE FAX m CELL EMAIL ± rlof& �� `��f�� Q z • `p'i'e •.• •' rrry 4444•,, • , COMMONWEALTH OF MASSACHUSETTS ' PLUMBERS 9W%*%F I TTERS I -+ ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER ROBERT A SAMMATARO 8 DUNRAV.EN RD WINDHAM NH 03087-1263 ,9333 05/01/16 226084 0 ON O C S : • ••• eC�".• r' 4 D OF r-LUMBERSBANELI D GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ROBERT A SPMMATARO ROBERT A S'AMMATARO P&H, INC 8 DUNRAVEN RD WINDHAM, NH 03087-1263 _ 337: 05/01/16 221168 ` • •i. � OF w e.• The Commonweahh of Mossachwate .w Department of IndusbialAccMM& 1.Conpw Sbeg Stfe 100 Boston,MA 02114-2017 y 4 wwKaa=pv/dna «'orlers'Compenatlon Ininrsace A!1ldavlt:I�ildaalCoaenri/EleCbiW- TO BE FILED WITH THE pzRmn=G AUTHORITY. NRR1C(kivdaa✓Orgattlzsdon/lndividual): G. AOdrCSS: YI 3' Phone#: — Aroyeo as eatAbd►e''tCbieic ebe•pproptiaa b�tkt Type otPrbleet(regalred): i 1.Qlanaaaptoyeeaid��en�ioyaasttf�uaad�orp�c�ia�e).� 7. 13 New 2.Q I am a rete peopeieeor or peetweWp a�have m employees workin3�me in Oa uwgmdw tO�'� e�sgnired.j 8• p R�ncdeling 3.Q 1 am a homeowner do4 ali work myself.(No workers,comp.tnsurm rogwred.j' 9. t7 Demolition 4.a I am a homeowrtar acrd wiq be bixin;oaatta000rs to ooaduot all work on my propeay. I wlll 10 0 8 addmon MM shat ail eoat:t esm ddw have workers'compensadon insaraace or are sole 11. Electrical pcopekeod whh no Unployaae, ❑ repairs or addition So 1 am a VMW eeanM and 1 bave hind da a�Hoed on the andwd sheet. 12.a Pht�g or addition &ISzWb000ntracM have eMbym and have workers'comp.u�turence.r 13.QRoof repairs e and a oaroeatdoa sad in of M We exereW their ri*dexem dm per MGL n 14.CIOther 15%f I ft ad wa bave no=00yw(No workers'comp.u>:vr requyd.j � Aqy appb=that aheb box#1 Mon do ml out mo ssotion below Acm—ft their wort N-ootapsneation policy intbtma on, Romeowaaa who wbmit We a9Bdavit ia0ioatbe they ase doiaD au work add=hire outside oow=oes mug Oft*Anew dfidavh Massing such. 3Lbaaaobat that dock We box moat cached as adds WM sheet showird the no of the wb rs and grog whodw or not those aatMn bave e IWMee INN saWamraoM have anpioyees,that'meet MAM their workers'=FA DOW number. . � thatlr prrovlding workers'co>alpsns�on ixtwancs joa�� Bslow�tht poly andJob alts !I Ia�moe Cannpe�Nanus Policy#or Sams.Lie.6. Expiration Dw . . Job Site City/Statemp: Attach a @W of the workers'aoaapenation policy detbradon page(showing the Polley amber and eapirntloa date). Failure 0)seonre cqv as required under MGL e. l S2,§25A is a criminal violation pimisltabie by a Bae up to$1,500.00 and/or one y. as well w civil penalties in the form of s STOP WORK ORDBR acrd a tae of up to S2S0.00 a day+ itut .�A pop} of this staument may be forwarded to the Office of Invadpd=of do DIA for iurance Iibhpmy dei► and olPal the tryornr�lon p�+ovtded is tarsmrdeorr+art MMM hd(�A AAJ 0JW the orb+. Do trot W48 IR thla keg to be cbnpletsd by elty or town offl" Cby or Town: Pormit/Llcense# iaatog Authorttj►("oke): 1.Board ofEMM 2.Buildit Department 3.city/Town Clerk I.ElecMUI Inspector Plambinglnspeetor 6� Odw Coabtet Payoa: Phone#: Date. AORT#j TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SSACmu s certifies that .Izt�z.. J. has permission forgas installation .+,�.......LAu;...1-. .................................. i p inthe buildings of...... .GA�Gx.{............................................................................ at....... .......C. !MDnp. ................................. North Andover, Mass. Feer........... Lic. NA��-��..... GASINSPECTOR Check# 1 - t 4�'� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYi A DATE ��' PERMIT# 'I WU1 Cr JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS . TEL � — TYPE OR OCCUPANCY TYPE COMMERCIALi EDUCATIONAL PRINT ! RESIDENTIAL J>�" .� CLEARLY NEW:_,,, RENOVATION: _ REPLACEMENT: � PLANS SUBMITTED: YES— NO_ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5_ 6 7 8 9 10 11 12 1 13 14 BOILER BOOSTER Memo MEN—_ CONVERSION BURNER COOK STOVE assa=!= DIRECT VENT_ HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR ie5mm , GRILLE I INFRARED HEATER mmm= Of LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATERME ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER. EATER OTHER ' INSURANCE COVERAGE _ I have a current Ila li insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Y'^ OTHER TYPE INDEMNITY — BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,afid-ftt my signature on this permit application waives this requirement. C SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are tme and accuratet e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit If P ' ent provision of he Massachusetts State Plumbing Cod and Chapter 142 o the General Laws. PLUMBER-'GASFITTER NAME ew LICENSE# SIGNATURE MP✓f MGF JP JGF_ LPGI CORPORATION 7#=PARTNERSHIP i# LLC_# COMPANY NAM KA t4,7hCADDRESS CITY (,�trn STATE ZIP TEL ; FAX` CELL EMAIL Y` ..._.. �I , 1 i �� ,�� 'w The Co w moron earth o Mossachris "�. r Deparhwnt of IndasbW Accidents -•.,., I Congress Stree4 Suite 100 Boston,MA 02114-2017 wwmmass gov/dIa Wakers'Compensation Isnfanee Affide t:BuiIderVCouUwWrsSmibhx, TO BE FILED WITH THE PERMITTDqG AUTHORITY. Name(Business/Organizidon/Individual); G. Address: hIca aty/S=ai9" Phone#; Aro you ao agfta't Chick sire approp Ute bx: l Type of prof eet(required): 1.Q I am sa Wyer with_��emtployees(titil emldlor part time).• 7. [3New mon 200 a sole pstiptWW or pumenhip and have no employees working for me in 8. Remodel' aW ate.two wiorioems'comp.insurance required.] m8 3.Q I sm a doing all work myself.No workers'comp.insurmce regwred.j• 9• Demolition 4-[31 On a homwwnat and will be biriag eoma000rs to conduct all work on meq+propety. I will 10❑Building addition eaaoe drat all aonaN=either have workers'compensation inure or are sole I L[3 E1ectzical repairs or additions proprietors wtdt no employees 1 • 2. Phnnb or additions tions SC3 I am agaaaat oatwosot and h haw hired de Pub•eor►axaors lied on the attached shm cub ante eaors have employees and have workers'comp.snsurmce.; 13.QRoof repairs 6. e aro a MPOI90 and ill OEM MY$exercised sit v right of exemption per MGL c. 14. 30thw 1A#101 and we have no amploya L(No workers'comp.uuurmce requued.] •Amy appliome diet checks box til mast also hill out the section below showmi their workers'coon policy itdbrmaebn. f Ilomeowaars who submit"affidavit i"calm dwy are doing all work ad den hire oustide oontraaors aura submit a rww al'1ldwh Wksting Pooh, torrhe000ts dee check dds box must attached an additional sheet sltowtug the name of dw sub•comtaaim and rose whedw or not those cronies have OWIIIIres. 9*8 moors have amploym they must provide their workers'comp.policy mmft. I axe an enplaye�that A providbs weaken co nsallon inset 8 � tnrreejotnt►'sn;ployses. Below is the policy ondJob site fiVo Itlsuranc a Company Name. Policy#or Self-ins.Lie.#: Expiration Date: Job She Address: City/State/Zip: Attach a oopy of the workers'compensation policy declaration page(showing the policy number and expira lon date). Fain to secure eoVIFM as required under MGL e. 152,J25A is a criminal violation punishable by a fine up to$1,S00.00 and/Cr oneyearimpns6mhaet�t,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to MOM dill+aSal>yst the vtolatol:''Al,pop]+of this statement may be forwarded to the Office of Investigations of the DIA for insurance verification. I de d'w and " at the Worntadon provided&how 6 terra deed correct Ok O Idol ase on&. Do not write in this 4M to be completed by cky or town offlcta[ City or Town: Permit/License# hmfng Authority(Check one): 1.Board otHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector !lo Other Conor ikon., Phone#: 1 � `a COMMONWEALTH OF MASSACHU8ETTS PLUMBERS °ASF ITTERS f, ISSUES THE FOLLOWING LICENSE v LICENSED AS A MASTER PLUMBER ROBERT A SAMMA.TARG 8 DUNRAVEN RD WINDHAM NH 03087-1263 y ,9333 05/01/16 226084 JSMMONWF-AladOF CQULISEWS � V BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ROBERT A SAMMATARO ROBERT A SAMMATARO P&H• INC 8 DUNRAVEN RD WINDHAM NH 03087-1263 4 3371 O;/01/16 221168 Date..q.q an............ 10662 T TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies ........&,..Je ............................................................ has permission to perform..........b-D Ae.A......................................................... ................ .... plumbing in the buildings of. :...........:....... ..................................................... at......Afl.......E.J.0.)...... ..... . ....................................... North Andover, Mass. Fee-3�-::!!n......Lic. No. ............................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I: CITY 410 MA DATEr{ PERMIT# JOBSITE ADDRESS Lkif1 «C S OWNER'S NAMt/YIk/ V CA t OWNER ADDRESS � ' � TELg?f_'/e"'!'q4t -- FAX — TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 i' BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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 `1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING z. OTHER d1.c INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ 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 may signature on this permit application waives this requirement. . zi6 _ l f' CHECK ONE ONLY: OWNER d 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. 1\ 4v� &401d, PLUMBER'S NAME LICENSE# SIGNATURE MP P-- JP❑ ,, CORPORATION❑# PARTNERSHIP❑# LLC[I# // COMPANY NAME l�"IW ADDRESS_ Y4 CITY k-e,747 a� STATE - ZIP /�A � Y TEL FAX k/14— CELL�`d w`L04'5-Cl') EMAIL /AM 60Zva44 !v I .�x The Collinionwealth of Massachusetts 57 �.�__., lDepartinent of Indrastrial.Acciden6 r4 �31h�t 2 ` Office of Investigations- _t ,—_L r-,,•a 1 600 "ashinzgton Street Tf - 4 Boston .MA 02111 Workers' Compensation Insurance Affidavit: Builde>i•s/Cono4rac>to.i•s/Eiectricians/Pivanbeu•s Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: . Phone#: Are you an employer? Cliecic the appropriate box: Type of project(required): ❑ I am a employer with 4. E] I am a general contractor and I 6. ❑ New constriction ; employees(full and/or pari-time). have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling + ship and have no employees These sub-contractors have S. F-1Demolition working for me in an capacity. employees and have workers' i • g y p ty. 1 El Building addition [No workers' comp. insurance comp. insurance. required.] 5. EJ We are a corporation and its I0.❑ Electrical repairs or additions i .❑ I am a homeowner doing all work officers have exercised their 1 LE] Plumbing c. repairs or additions myself. [No workers' comp. rig152, §1(4),and we have no ht of exemption per MGL 12.0 Roof repairs required.] i insurance re t q ] employees. [No workers' 131-1 Other comp. insurance required.] t r my applicant that checks boxill must also fill out the section below showing their workers' compensation policy information. j aomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .ontractors that check this box musi attached an additional sheet showing the name of the sub-contractors'and state whether or not those entities have iployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ' 1 l aptY air eiirpl0)Jer iliat is prot,idiito Ft,oi-icei's'corttpeiisatioiz i,isiti'altce fol•itrV eitrplovees. Below is the policp mrd job site F , formation. tsurance Company Name: Z olicy# or Self-ins. Lic. #: Expiration Date: t )b Site Address: City/State/Zip: ,ttach a copy of the workers' compensation policy declaration page(showing the policy number:nd expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WORK ORDER and a fine f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ivestigations of the DIA for insurance coverage verification. do hereby cert fii under the pains and penalties of perjury that the information provided above is true and Correct. .i nature: Date: 'hone#: i Official use only. Do not write in this area,to be completed by city or town officiaL ^ i Y• City or Town: Permit/License Issuing Aaffiority (circle one): 1.Board of I-lealth 2. Building Department 3. City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6. Other I Contact Person: Phone#: �` J Date .......................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4t `QAC 14U ....... ............... 'This certifies that ..... 0'6 permission for gas installation .....b(Dpot .). .. ........................................... intheulldingsof.. .34 ......................................................................... at..............................1 611v..U�.......................................North Andover,Mass. Fee...;4...... Lic. No. ..9%..�.... N�.................................................... GASINSPECTOR Check# 9433 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA. DATE PERMIT#4�;071 JOBSITE ADDRESS .. ...... OWNER'S NAME ............. .... ........... .............. G , - OWNER ADDRESS: TEL: .......... ...........WFAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NO D FIXLITRES I FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT DVEN DOOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT FEST JNIT HEATER INVENTED ROOM HEATER VATER HEATER INSURANCE COVERAGE hate a current RIbWinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F1 NO [I you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND El IWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the lassachusetts General Laws,and that my signature on this permit application waives this requirement. O CHECK ONE ONLY: OWNER Z,-A6E-NT R 16NTURE OF OWNER OR AGENT iereby 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 nowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'LUMBER/GASFITTER NAME: LICENSE#F-?-.!Ft.5' SIGNATURE ADDRESS: ,OMPANY NAME: "ITY: STATE: ZIP: FAXf. 'EL 71 CELLJ! EMAIL: 7FYI--5 (Ok4CA ........................ .. .............. .......... ASTER P-IJOURNEYMAN R LP INSTALLER #=PARTNERSHIP Ej#=LLC❑# CORPORATION F El ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No V THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I . File commonwealth of ffassachuselts , - - - ))epaiftent of1ndustrial Aceldents . ; Office of-In-Pesfigateons 6#0 Washineon Street Boston,.A 02111 'wMwasygovIdaa WQrckexs'compen.,sa-donInsurance Affid-avit:BuRders/Coy. actoi.l�lec�rc�iczan�l�'�Yixir�bex� ppX[cantbfor'mation PleasePxzn e ibXy ' Name(BBs1nessf0xgaztizafionlli'nndx`lv1d1uat): Address: a`�� 7 O t,�� Lf City/State1Zp: Ara yoix an employer?Cheek the appx'opriate box: Type of project(required): 1•)] x a employer with-- 4. ❑Z am a general contractor and 1 6. New c6usttactiOn f mployces(iul md(orparE time}.* have nedtho ffah-contractors 7. �Remodeling y2. T am a sole proprietor ox partner listed on the attached sheet.T These sub-contractors have 8. [[Demolition ship and`haveno-employees working forme in my capacity. workers'comp.insurance. 9. El Building addition [No workers'comp.xnsuranee 5• ❑We are a corporation and its 10.0 Blectrical repairs or additions recpuxed.� officers have exercised.their light of exemption tion erMGL 11.[]plum�blugrepairs or additions 3.El X am a hom eowmr doing all work g p p Myself PTO workers'comp. c.1.52,§1(4),andwehave�.o 12,�]Roofxepairs employees..[No workers' insuxancexeguixed.�? 1311 Other comp.insurance regained] Anyapplicantthatchecksbox# n;ustalso flloutthesecfionbelbwshowingtMrworkers'compensWonpolicyWomiation. "►'Homeownerswho submitibisaffldwitindicaf -they eredpingall.worlcandthenhireoutsidecontractorsmustsubmitanDw�dpavit y eatingsuob, xCoatracfors that cheokthis boxmust attached m Mditional sheetshowingthe,=a oftho sub-contractors andfhf workers ca olic information. I am art exnployQN t/iai isp�'ovidi�tg�oPkePS'compefasation znsr�Pa�tce foPYr�y employees ..8'eroW is the,�olicy t�ncija�i s�t'E infarmadon. fnsmauce CompanyName:. Policy#ox sell ins.Lie.#: Bxpixatzon Date: lob Site Address, City/State/lip: Affach a copy of Ito workers'comp ensation-polxey declaration page(showing.the policy mmber and expiration.date). yailure to secure coverage as raVl eunder Saof!on 25A ofMGL o.152 can lead to the imposition of crhAalpenalties of a .fine up to$1,500.00 and/ox one-year imprisonment,as well as civil penalties in flie foam of a STOP WORD ORDFR.and a fne ofup to$250.00 a day again st flia violator- B e advised that a copy of this statement maybe forwarded to the Office o£ Xnvestigations of tine DSA.for insurance coverage verification. X do IiePeby ceYzify uric%PIiepairzs ci�tciperzalfies eYruPy tliaf fIZE i�2fonnafzorz pPovirl dove is iPue ancieoYYeet. - Date: Si afore• Phone#: Official use o try. Do notTM18 in frim area,lobe completed by city or town official. Cify oar Town: Permitf (cense# fssuingAuthority(circle 631e): 1.Board of Health 2.BuJJduag)Department 3.Cityffownt Clerk 4.Flectxical Inspector 5.Plumbing)inspector f.Outer Information and Instructions Massachusetts General L awe chapter X52 requires alt employers to provideworkers'compensation fox their employees. ' Pursuant to this statate,an ergpfoyee is defted as",..every person k the service of another under any contract of hire,• express orhuplied,oral orwxitten" Aa employe is dei7ned as"an individual,parbrership,association,coxpoxation or other legal entity,or any ormore. oftlrei`oxegolngengagedinajointenterprise,andinoludingtbelegalrepxesentativesofa'deceasedemplo ex,.oxtie xeceivexOrt1dsteeofaaludividuatpatinership,assoczationorother legal entity,em to ' employee,s, Tdow"()r he owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house ar onthe gr°ands oxbuilding appurtenant thereto shallnot because of such employment be doomed to be an employer" MGL chapter 152,§25C(6)also states that"every state or local lic�ensbg agency shall withhold the issuance or renewal of a license or liefMit to operate a busmt ess'or to construct buildings in the co., zMoaweth'fox any applicant who has not pro duced.acceptable evidence of compliance with thal e insurance cove Additionally,MGL chaptex 152,§25C(7)states"Weither the commonwealth nox any of rage t fo rany its political subdivisions shall enter ince any contract for the p erfoxmance of public work until acceptable evidence of compliance with,the insurance requirements ofthis chaptexhave,beenpresented to the cQatracting authority." Applicants Please fill out the workers'compensatZon affidavit completely,by checking the boxes that a 1 to our situation and,if incus insurance. supply s Liability Companies (s),addxess(es)a 4ficnenumber(s)along with their ertifxcate(s)of insurance. Limited Liability Companies(LLC)ox Limited Liability pM-tG.Tships(LLP)with no employees other thm the members oxpartners,arenotrequixedto canyworkers'compensationinsurance, li anI C oxLLl?doeshave employees,apolzcyi�xeq*'d. Beadvisedth.attbisafddavitmaybesubmittedtotheDepartmentof l'ndustdal Accidents for confirmation of insurance coverage. Also be sure to sign and data the affxdavitr the affidavit should b e retumedto the city or town that rho application fox thepermit ox license is being xeque ted,nod the D epaxtment of Industrial Accidents. Should you have any questions regarding the law ox if you are xequired to obtain•a*atkers' comp easationpolicy,plea-so call the Department atthe-u mberlistedbelow Selfinsuredcompaniesshouldentertheir self-insurance on t Pxiate license number he a xo ' PP lila. 'City or Town officials Please,be sure thatthe affidavit is complete andpxinted 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 besure to fll inthe permit/license number whichwill be used as a reference number. Zn addition,art applicant thatrirust submitmultiple pezmitllicense applications itz any given,year,meed only submit one affidavit indicating current policy information(ifnecessary)and under"Job,Site Address' the applicant shouldwxite"all locations in (city or town)"A:copy o£the affidavit that has been officially stamped ox marked by the city or town,may be provided to the applicant as prooftbat avalid of ldavit is onfile for futurepexmits orlicenses. .A new affzdavitmustbefilled out each year."Gslbere ahome owner or citizen is obtainin alicense . g ox e to any business or (i.e,a dog license Orpermit to burn leaves eta.)said person is NO xT egnIxed toc omp1 to this af-adavit�excial venture The office of Investigations would like to thank you in,advance for your cooperation and should you have any quest[ons, Please do riot hesitate to give us a call. The Depatiment's address,telephone and fax amber: ()taco 600 Waft TO 617.77'Z-49Q0 e 446 Qx Rovised 5 26-o5 FaIK#617MM749 4 7 ' I -. - ci:.-C ONWEALTH OF >;<> PLUMBERS ANb GAS:FJTTL::RS' j ISSUES. THE FOLLOWING LICENSE r` [GENSED AS A MASTER PL•UMBfI� !r jF z WILLIAM, M SIDERI 244 HOWE'ST (W METHUEN MA 01844-2108 f' 1 1 : 232437 Date............................. .......... =l O�p►OR7►�,�0 ��;• o` TOWN OF NORTH ANDOVER n PERMIT FOR WIRING SSACHUS� This certifies that .......... `!.../!...`.. '.......... `..fes- .................................................................. has permission to perform ...../ ...:.:..`...............��f.��.�...................:...... wiring in the building of.............[...4.. `'!. G at ............t.....7. rye L c 5 ................................................................................. orth Andover,Mass' Fee..��'. ..-.............Lic.No:� /. ..........,r ......1.............. .......... a.................... ELECTRICAL INSPEGWR Check# f U 1 271. � A Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Z 9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: !�,I� City or Town of: NORTH ANDOVER To the Inspector of Wires: J By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)_�'I �t-Lyk f Y Owner or Tenant Mf. �tS, �.c. w\o�t Telephone No. g7f1,-(,,9 y�1 Owner's Address q C 5 j+ Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / j Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: :'A Com letion of the followinigtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnA grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water N f K`,l, o.o No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 4 OTHER: 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: I-(G til 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 co erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE x JBOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties of perjury,that the information on this application is true and complete. FIRM NAME: ,i LIC.NO.: Licensee: (Zyr��,�r {��Q;l Signature LIC.NO.: (If applicable,enter"exempt"in the liceJe number line, tt�� Bus.Tel.NO.; J7t-b 1(-_7I3D Address: a\ �r-ak!4 i)r._ �,tf,r y1't. t X35 Alt.Tel.No.: `0"i-�7G--i(G-2 *Per M.G.L c. 147,s.57-6 ,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent PERMIT FEE: $ S S< `y Signature Telephone No. A � y :� /-� �z j r r Ns- The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA.02111 UV www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print` �iegibly Name(Business/OrgmizatiorAndividual): e _�C'C��✓'�(' Inc,Ir c� \ � t(IV Address: `� k Y cA kve r City/State/Zip: Br�.,� r-rad M k 019,3 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I ' - * have Hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ❑Remodeling ship v eno employeesand'ha These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. t4 We are a corporation and its required.] officers have exercised their 10.[Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. o workers' comp. c. 152,§1(4),and we have no y [N p 12.E]Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they hire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ! Insurance Company Name:_Ur f Ea)1L�TJLVXI` _ Dir ka.— TV\5 Policy#or Self-ins.Lic.#: WE 1��6 19 A Expiration Date: � f.3--1 q Job Site Address: UO 171 vv, (rc S`�. v�g� . -�� City/State(Zip: (�.�v��c tet✓ M o(mr Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL 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 DTA for insurance coverage verification. Ido hereby cert under thepains a dpenaldes ofperjury that the information provided above is true and correct C Signature: ��"r Date: Phone#: of 7 P,– 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#: . *NE 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 g g e ngaged in ajomt enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 TeX,#61.7-727,4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#6I7-727-7749 www.mass,govfdia �. COMMONWEALTH OF MASACHUSETT e e • - • • 1;L1 CTR I Cl ANS li LSSUES THE FOLLOWING `LI CENSE A'S A REC I Tl:RED MASTER ElECTi2:1 C f AN:- ' -' N I VALLEY ELECTRIC I NG r � ; AN A WRiSLE L , � 21 .HYATT ,AVE r 4 0RAI)FORU MA 01835-8221 zo18o A' o % 1:/lb 163131 2 Location �4 -7 /� ✓ � No. G Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ * : Building/Frame Permit Fee $ auradaton=P% oa $ / {S�`.. SACHUSE �Y/',f�-1/ '�'- f / Other Permit Fe $ Sewer Ge Fee $ AiV r Connection Fee $ p TOTAL( 1gg1 $ loveBuilding Inspector Div.Public Works t Location ° No. Date r NORTol TOWN OF NORTH ANDOVER O�t � o y1ti p Certificate of Occupancy $ � Building/Frame Permit Fee $ + ,' " •^a Foundation Permit-Fee $ • sJ�CHU ?her: I Fee $ P Sewer Conne t lon Fee $ r`�lllater nnection Fee $ 140. TOTAL Ver Building Inspector Div. Public Works PAGE 1 PERMIT NO. l(l * APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. MAP 4qO. LOT NO. 2 RECORD OF OWNERSHIP !DATE BOOK !PAGE ZONESUB DIV. LOT NO. 14 LOCATION PURPOSE OF BUILDING ' OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME / i 3nini0 /)' SPAN 1 if') 1004— 4-7 60 ocno Ic- DISTANCE TO NEAREST BUILDING DIMENSIO F SILLS DISTANCE FROM STREET " POS �j ` �7^ •� DISTANCE FROM LOT LINES—SIDES REAR GI ERS 'L AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EBT. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 00, DATE FILED * BOARD OF HEALTH SIGNATURE OF OWNER OR AUTHORIZED AGENT * F E E 1740 OWNER TEL #_ PERMIT GRANTED CONTR.TEL.11 PLANNING BOARD CONTR.LIC. Ste' BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY _ S ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ — - ---—�--» _ DRY WALL _ _ _ r UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA J _ '/1 Tt 1/1 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I-I POOR ADEQUATE NONE —j- 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN, TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING e �IV ��,f,��T , prrp Mpg -� �r�. �R 05 �� u � d'5:. � o ��dL1� eFw� �,� �yORT1y _ T F - owl& J1 a OL nc10q1kvCArh;1— p .I. NO. 0 7 E ,o W-W "', e L C. WT --- - �K er, Mass--��Li . .� 19 be Cr AoR Qa� SS BOARD OF HEALTH PERM. 11 0= THIS CERTIFIES THAT... ........ �� .r..................................................... ....... AC BUILDING INSPECTOR J has permission to er .10.�......... buildings on �1... � .� ....... ... Rough .�. .. • �+ Chimney to be occupied .. .. ..� ..... .. � pf 49.�� ! �J.�'�', � Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TION STARTS Rough Service of Final ...... .. ..... .. ...... .... . ...... ........ BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector °F"onrM, OFFICES OF: o?' Town Of 1 3()Nli fit I SII(• ,I APPEALSNORTH ANDO V E11 N'"'ll' At IO%vr, BUILDING ;,''=:i::; • ,e Mi Is-';i 10 It lHt CONSERVATION se,°"�sE. DIVISION Or- HEALTH I(i17)6854775 PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN 11.P. Nla_SO N, Ulltl:(; I OIt r In accordance with the provisions of MGL c 40, S 54, a condition of Building I'crnrit Number is that the debris resulting born this work shall be disposed of in a properly licensed solid waste disposal laciliiy as defined by MGL c III, S 150A The debris will be disposed of in: (Location of Facility) r Signature of PCrnlit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Location r Elm e f t Y` S' No. 4> Date NORTh TOWN OF NORTH ANDOVER f 1 F w + + Certificate of Occupancy $ �'�J'•^ Eta' Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ Other Permit Fee $ f TOTAL $ 4 Check # 3 qZ 17664 Building Inspector TOWN OF FORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING tz „ BUILDING PERMIT NUMBER: DATE ISSUED: Arr SIGNATURE: Building Conlruissioner/I ctor of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: q17 7-- Map Number Parcel Number (� 1.3 Zoning Information: 1.4 Property Dimensions: Q Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.LC.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHENAUTHORIZED AGENT 2.1 Owner of Record / 7 A �Ieylvz Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si nature] Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ ria V)D, 6', Licensed Construction Supervisor: License Number Ad s L' Expiration Date Sigtla Telepho re r110 3.2 Registered Home Improvement Contractor Not Applicable ❑ ��4f-�•� �= f�f-1r�1,'�l—/'r>yss� y12 -i►- C'/fir S ` Company,Name / (d J Registration Number Address Expiration Date Si nature e Tele one SECTION 4-WORKERS COMPENSATION(M.GJL C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......El No.......0 SECTION 5 Description of Proposed Work check all a hcable New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify � �✓ / + Brief Description of Proposed Work: ")/3>.1/A'V r 'Flo r f- Al !'A e,,orf SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFIIAII.,,USE ONLY,rc , x Completed by permit a hcant 1. Building (a) BuildingPermitFee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) ✓� 4 Mechanical(HVAC) 5 Fire Protection GGG 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r I, Vile ✓1) as Owne�Lilu orized Ag nhof subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION t-i G' ✓i t T 6L asOwn�r9Authorized Agen subject 1 property __._- Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Na Cant o:?7 2g Si ature o er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T1rVMERS 1 sT 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CIIIMNEY i IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts — Department of Industrial Accidents 600 Washington Street, 7th Floor;Boston,Mass. 02111 Workers'Compensation Insurance Affidavit Iicant info ation • wvt _. �. _,...... name: `r G `— / �I L- i7 t location: city /� _-_ll i., C)dti/l — Dhone# ❑ 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. ~ comuanv name address.. city phone insurance co. nolicy# s r - - .. g� � of a sole rie ;genes 1 contralto or homeowner(circle one)and have hired the contractors listed below who have the followingg w workers c mors c pensation polices: comnanvname y N-.f is 0a4 i,u C- C address Dhone#... insuranceco. K U J3. f 76 —�fl t _ �. ,,,,ate.k,:"'.-.� ,.,,• ,.�� w r,�^°1�„ Doiic #- �I ';'q�..,� « �"ti "3� ".e-�,{.ca ^.n,..,-rs :. ._+#:=+p<: ,re�'�n t " ..:^ .re^.fip•°�```� � .r�^i*`y�?K.. 'H`L..�:.=?�y��t comDanyname::: address 777, 1DsuraIIceco 'DOIICY#' .. . Attae Sitio a shee et:essa �-.:.°�;�', `" � � �w• �_ .�� ,, �.. ,.� .� '� Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against 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 penalties of perjury that the information provided above is true and correct Signature — Dateja�� Print name f(� �1 6-16 7-1>2 2%4Q .rtfy Phone# '?-7 official use only do not write in this area to be completed by city or town official city or town: permit/license# []Building Department ❑Licensing Board _ ❑check if immediate response is required ❑Selectmen's Office []Health Department contactperson: phone#: Other .' (mvised 9/95 P1A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 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, 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. mv Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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 per.-rut 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 ,ffiso of Investigations 600 Washington Street,7`h Floor Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617)7274900 ext. 406 C NORTH '9 TOANM of 20°x► 5. 1.7 Lp V -- _ - _- �` _=: - dover, Mass., DIA COCMICEWICK A. ORATED �S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT....... ..tr .. ..........CAPtA....... ..... ... ................................................. ............. ........ � � Foundation has permission to erect...... k'...�...... buildin:�on 7 �. ...... Rough t0 be occupied 8S r �,,,,.,, S I ��4i�r �v Chimney ........f ..r . . . . .. . . ............................................................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Lawsr I Ing to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. S a so PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ON TARS Rough ........ ...................... Service .. . .................................. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 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 c11, S150A. The debris will be disposed of in: (Location of Facility) Sign re of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector RAYMOND E. DAM PHOUSSE, JR. AND SON ROOFING CO., INC. BOX 431 LAWRENCE P.O. LAWRENCE, MA 018421 -. MA. CONSTRUCTION SUPERVISOR UC. #046636 TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING - SIDING — INSULATZ0Ai.,J Date �72 From: (Name) (Address) To: UTNE L DAM06SSE, JR. AND SONS DOOM CO., MC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 1 (we) hereby authorize the Contractor to furnish all materials and labor necessary to Install, construct and place the Improvements described below in-on building located at No. / L;r�C • ' --- - ,--�— Street, City ! J-4,1 �5 State in accordance with the following specifications: C j fiJs.J C J•d3' �` � ��_ //.�7r'r1�,=t i )i + %1�!.i 3 r .1� rJ r/ r.. fi !-t.+ r +/ L... rJ =" r^.•�•-9 t 7 r 'L) r s i t f ,. p 1 j� � 'I~� l"t_ i^� -.,I r _! '/�/ �J' ] L..E.l ��f;` � � , .� �3 i"• r' �. .� I 7 41 j J" All of the above work to be done in a good and workmanlike manner. All men and equipment Insured.. Premises to be left clean upon completion of work. # For the total sum of dollars. ' �_.3__n..,.��w3J 3��Jiw•.w,.._.�.www.ww.w w.lwl:w.w tw nwwwiA w..e.w.wliA nlen .- _ !!!(AAWr\I10�AW