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HomeMy WebLinkAboutMiscellaneous - 490 WINTER STREET 4/30/2018N O ? p3 cc A � D Z, o -i o � N � -� o m o � 0 977. t Date .1.. Z":-. K.... e� .o... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ........................ has permission to perform .....................Win?.�,.................. wiring in the building of ..............J.. .................................... apt ...........w7"i ........-)7.— ....... ................ Norrtth Andover, Mass. -" r- Lic. No......t.-���/ 7 :............ /' .. .. . ..... v , ELECTRICAL INSPECTOR V.. / Check #' 6 i Y Commonwealth of Massachusetts Official Use Only Department of Fire Services Perm" No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 u.� (PLEASE PRINT WINK OR TYPE ALL INFO City or Town of: By this application the undersi ed gives not' e of his or Location (Street & Number) V% Owner or Tenant �'�,j -�- L;✓,�'� Date: To the Inspector of Wires: intention to perform the electrical work described below Telephone No. Owner's Address "Aole Is this permit in conjunction with a building permit? Yes ❑ No ❑ BLDG PERMIT # Purpose of Building "f f 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 Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires -••.T..----.. No. of Ceil: Susp. (Paddle) Fans rrtuy ue wucvea oy the inspector of wires. No. of Total . Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges No. of Air Cond. TonsTota g Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW ntained FDetection/Alerti in Devices No. of Dishwashers Space/Area Heating KW icipal❑Other nection No. of Dryers No. of Water Heaters ' Heating Appliances Kir No. of No. of Signs Ballasts Security Systems:* No. of Devices or E uivalent Data Wiring: , No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelWiring: No. of Devices or E uivalent OTHER: .. °f t,$;1V114✓11- attacn aaaltmonal detail f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this application is true and complete - FIRM NAME: Ajer��i -,? LIC. NO.: 9"5-17 Licensee: 7� Signatur47W ` LIC. NO.: ,ij'T (If applicable, enter " empt" in the �li� ense number line. Bus. Tel. No.: Address: /(i -01 � �q Nt Sf%� W �l t 31p Alt. Tel. No.: *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ �� 3 e?3 ELECTRICAL PERMIT NO. INSPECTION REPORT: rr ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — [ ) Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION: Passed —4f_ Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ) Failed — [ ] Re -inspection required ($50.00) - ( ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. 0 The Commonwealth of Massachusetts Department o f'Industrial.Accidents Office of Investigations 600 Washington Street t Boston, MA 0211.1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,egibl Name (Business/Organization/Individual):, Address: City/State/Zip:, Phone #: 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).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. [] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. 11 Insurance Company Name:. Policy # or Self -ins. Lie. Job Site Address: Expiration Date: 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify under thapains andpena[ties ofperjury that the information provided above is true and correct Signature: Date: Official use only. Do not write in this area, to he completed by city or town official City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. EIectricaI Inspector 5. Plumbing Inspector 6. Other C ontact Person: Phone #: Location No. • S41 Date Z -z y c �OR,M TOWN OF NORTH ANDOVER 0 �. - • L Certificate Occupancy $ • ; , of J^CMUS <� Building/Frame Permit Fee $ le; a ✓ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building r' pector Date.. 3. f/C.� ....... °• t�.ao ,°� ti° o? �` TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION - ��SSACHUSEt This certifies that 7 ...................... . has permission for gas installation ...!?c .... .. ........... in the buildings of .. . .. ?: ... ... ......... . at ....�t...�...�%. ! ... .*.� .... , North Andover, Mass. Fee... 3.a... Lic. No.. ......,. ! -. -,, ..... . GAS INSPECTOR Check # W' 7 A476 1 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date %^ — • City, Town Permit # Building Owner's AT: Location 99 _ L�1 ;.^�,- S Name—:111' in Type of Occupancy: A je New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ (Print or Type) Installing Company Name TnSmeEan& G;1 Co Tnr Address __ 27 Cherry Street nanrora, MA 01923 Check One: ® Corp. ❑ Partnership ❑ Firm/Company Business Telephone 979-777-0701 Name of Licensed Plumber or Gasfitter Certificate I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner; Agent I have a current liability insurance policy to include completed operations coveratte. ❑ By Title City/Town APPROVED (OFFICE USE ONLY) TYPE LICENSE: ❑ Plumber ® Gasfitter ❑ Master ❑ Journeyman ■111■111■■■■1111■11111■■■Nona 11■ ��������/11■1■11■11■1■1■111■■ (Print or Type) Installing Company Name TnSmeEan& G;1 Co Tnr Address __ 27 Cherry Street nanrora, MA 01923 Check One: ® Corp. ❑ Partnership ❑ Firm/Company Business Telephone 979-777-0701 Name of Licensed Plumber or Gasfitter Certificate I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner; Agent I have a current liability insurance policy to include completed operations coveratte. ❑ By Title City/Town APPROVED (OFFICE USE ONLY) gnat f Ltcensed Plumber or Gasfitter License Number TYPE LICENSE: ❑ Plumber ® Gasfitter ❑ Master ❑ Journeyman gnat f Ltcensed Plumber or Gasfitter License Number N2 3� 95 NORTI� 0 O F ;,SSACNUSEt Date ... Z / ....`�%......... TOWN OF NORTH ANDOVER This certifies that .......'"'`-'�' PERMIT FOR WIRING has permission to perform n - — -'` '` -� wiring in the building of ........ i;-/ ......7 ............................ . North Andover, Mass. Fee ..S ......... �)... Lic. No .............. ` ..... 'f. :...11! :............... /I t `'ELECTRICAL INSPECTOR Check # 42' LYS WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 office use only t3WJ "4 Permit No. O� �� Occupancy k fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK. All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 e (� (PLEASE PRINT IN INK OR 'TYPE ALL INFO,RDat `iiATION) City or Town of N9(ZT/f Q/�ZA_& To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street Owner or Tenant L wn Oer's Address � / —1 Yes No ❑ (Check Appropriate Box) Is this permit in conjunction with a building permit: q Purpose of Building S [%f GLC �f L Y Utility Authorization NO. 02 3 r Existing Service t'l"(/ APs i �O Volts Overhead Undgrd ❑ No. of Meters� New Service GNPs ��� / ��� Volts Overbead� Undgrd ❑ No. of Meters Number Feeders and Ampacity G /-i�r_5z7-&lG /2Q/Y Location and Nature of Proposed Electrical Work 0 v Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVp No. of Lighting Fixtures Above ❑ In- ❑ Swimming Pool Above grnd. Generators KVA No. of Emergency Lighting Nu. of Receptacle Outlets N,,. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices Heat Total Total No. of Sounding Devices No. of Disposals No. of Pum s Tons 1\W No. of Self Contained Dishwashers Space/Area Heating � Detection/Sounding Devices Net of Municipal I] Other El No. of Dryers Heating Devices Local Connection No, of No. of Low Voltage No. of Water Heaters I`I7 Si ns Ballasts lWiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INS COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations CoverageKia s substantial equivalent. YES ❑ NO ❑ I have submitted talidofroofofs me to this checking office. the ;Ebox' If you have checked YES, please indicateYP 9 /16/'00 INSURANCE g BOND ❑ OTHER ❑ (Please Specify) Expiration ate Estimated Value of ElecU ical Work S P Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME CONTINO ELECTRIC & CABLE, INCSignature . LIC. N1*1. A11983— -- -- LIC. N0. Licensee LOUIS CONTINO Bus. Tel. No. LIC. Address , plt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts Gral L(Pleaandcthat my s ignature on this permit Agent application waives this requirement. Owner Telephone No. PERMIT FEE S v Signature of Owner or Agent The Commonwealth of Massachusetts N- a Occupancy k Fee Checked % Department of Public safety 3/90 (kaw blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TIDE ALL INFORMATION) Date TI,Z City or Town of AJQ, P` rjf 4 /-70 VL To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 7 ! / t� S 7— Owner or Tenant S V L L Owner's Address �vlJEE Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building F `gFJI LLjr(.K Utility Authorization NO. Existing Service / C/ Amps C GC% / 27cs 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 No. of Lighting Outlets No. of Hot Iubs No. of Transformers Total KVA No. of Lighting Fixtures No. Swimming Pool Above in - g grnd. ❑ grnd. ❑ Generators KVA No. Emergency Lighting Receptacle Outlets No. of Rece P No. of Oil Burners BatteryUnits No. of Switch Outlets No. of Gas Burners £IRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Cond. tons Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal Other Local ❑ Connection No. of Disposals No. of Heat Total Total p� s Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers HeatingDevices KW No, of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or, its substantial equivalent. YES ® NO ❑ I have submitted valid proof of same to this office. YES IL NO ❑ If you have checked YES, please indicate the type of coverage by checking the approp tate box. INSURANCE ® BOND ❑ OTHER ❑ (Please Specify) 9/16/9 7 Expiration Date Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME CONTINO ELECTRIC & CABLE INC. LIC. NA.A11983 Licensee LOUIS. CONTINO Signatur LIC. No.E26788 Address 1 DONOVAN DR. WEST NEWBURY, 01988 Bus. Tel. No. 08) 363=5T= Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent Date. ....... ...........,?. 517 ...... H 0 9 NoRTN D TOWN OF NORTH ANDOVER PERMIT FOR WIRING US This certifies that . .......................... ......... has permission to perform--�-�'� .... 7:7.. e ................... wiring in the building ........................................ I ...... at ............. -V..........- ... z. ....... _16� .............. . North Andover, Mass. Fee.1U .... . ..... L i c. N ....................................................... ELECTRICAL INSPECTOR C.,41 0 7&00 MID PINK: Treasurer Applicant CANARYAW09741 t. ""N2 2 Date. d� TOWN OF NORTH ANDOVER ,, ,..•.. a OL p PERMIT FOR WIRING This certifies that - - 5m a f ( �' l Q,-_1 D ........................................................... ................. has permission to perform .....�........ .......................... wiring in the building of ....... .:. ..................................................................... at ......l1 ..(— : .......................... . �No h Ando-yeGr-^�--Mrte9 s7 Fee..rr.�.. Lic. No. c� �, L`LECTRICALINSPECTOR C WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .E" 0 �Z U�tP LIIIIIIItDn1U£IIl office use only Gl� II�A55c�th1I5P5 Permit No. of Ehpartnirnt of rublil LIIfrig Occupancy Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 {leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK O ' T/YPE. ALL �JFORMATION) Date �1— to — G 0 City or Town of_�// ' �� LE,�'d�✓i To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street 8 Number)y Owner or Tenant -S c. /A yar Owner's AddressIs this permit in conjunction with a building permit: Yes 9 No ❑ (Check Appropriate Box) Purpose of Building /r Utility Authorization No. Existing Service /U AmpS _� Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work L✓ v �`; �¢ r No. of Lighting Outlets J. I No. of Hot Tubs I No. of Transformers Total KVA No. of Lighting Fixtures / ( Swimming Pool Above ❑ In' ❑ ( (/ ornd. grnd. Generators KVA No. of Receptacle Outlets 1p I 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 Detection and No. of Ranges / I No. of Air Cond. Total tons Initiating Devices No. of Disposals I No.of Heat Total Total r Pumps Tons KW No. of Sounding Devices No. Of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heatino Devices KV Municipal Local (_— Other _........_.. -- Conne�:ion . No. of Wa!er Heaters KW Nc. e' No. of Sions Ballasts Low Voliaye`—-._.—•-__.—_.�r Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachuse:is general Laws I have a current Liability Insurance Policy including Cor-ipleef-Operei ons Coverace or its substantia! equivalent. YES QRZ-_ I have submitted valid proof of same to the Office. YES NO C If you have checked YES. please indicate the type of coverage by check no the ap�pro�pn�e�-box. INSURANCE GIBOND ❑ OTHER O (Please Specify) 9 G C/ (Expiration Date) Estimated Value of Electrical Work S F' Work to Stan ( " G G i Signed under the✓�ennalties of perjun oo FIRM NAME 1' Z, Licensee Inspection Date Requested: Rough �' �/ C�� LFinal _ LIC. NO. 3� LIC. NO.�F� Address -r Bus. Tei. No. Alt. Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee doe of have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waves this requirement. Owner Agent (Please check one) r Telephone No.did PERMIT FEES (SiScafure of Owner or Acer.:; F Location .A q / l'Uwl-�F/Q S7 4 - No. 1 a Date �oRTh TOWN OF NORTH ANDOVER i • OL 9 Certificate of Occupancy $ A Building/Frame Permit Fee $ JACHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 911 Check # /78 96) 13712 Building Inspector t 0 r.4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: A DATE ISSUED: ®® SIGNATURE: "w & &~&O� Building Commigioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION - 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so 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.L.C.40. 54) Public 0 Private 0 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Prim Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Ok al' `12•t \ ) oC,&tai Licensed Construction Supervisor: s c-okk Address L& � Signature �• (� Y� �� Telephone Not Applicable ❑ 0 U a License Number q f 5�7 j -� Expiration` Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name "_kr( � < t * j v \ \ / 4 \ l V Registration Number r7/ P V Address LQ 0 (� �- Expiratfoon Date Sig'na'ture Telephone t 0 r.4 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. l Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ` ) SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant (')FFIGiAL USE ONLY_ 1. Building (a) Building Permit Fee Multiplier (� l0 2 Electrical C, . G© (b) Estimated Total Cost of Construction r 3 Plumbing r Building Permit fee (a) X (b) Q / 4 Mechanical HVAC 5 Fire Protection 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 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, �A � e �t l c t ` � as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief j M AQ-',e— Print Name Signathre of Owner A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS iST2 ND3KD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE BUILDING DEPARTiYvENTT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Signature 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 ACORD n„ CERTIFICATE OF LIABILITY INSURANCE DATE 03/29/2000v PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9 WAVERLY ROAD HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER, MA 01845-241 P:978-686-2266 F:978-686-6410 INSURERS AFFORDING COVERAGE INSURED INSURERA: TRAVELERS PROPERTY CASUALTY Michael V. Rodden INSURER B: 47 Prescott Street INSURER C: INSURER D: North Andover MA 01845 - INSURER E: CnVFRAnF3 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDNY) POLICY EXPIRATION DATE (MM/DDIYY) LIMITS GENERAL LIABILITY ❑ COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE ❑ OCCUR ❑ EACH OCCURRENCE $ FIRE DAMAGE (Anyone fire) $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ ❑ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: O ❑ LOC 70 POLICY I0 PRCj PRODUCTS - COMP/OP AGG $ AUTOMOBILE ❑ ❑ ❑ ❑ ❑BODILY LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY ❑ OCCUR F101 CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ A WORKERS COMPENSATION ANDTS EMPLOYERS' LIABILITY 820UBB49K419500 01/01/2000 01/01/2001 WC STATU- OT ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. 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K� N C z CT7 VJ n O fz V J C n 0 O —• N O Q N C1 0 C O 00 C m n m m n Cin m Z O• .C.. 03 � CD G T CD ao'd o tm4 co CD Nco Go -, to O OZyCJ •m: C H a no o: CL C� CD N m C7= C G CD m C* N N:o Op3 CL H N `C C .9 CD co . m C m cc C f7 m O N CD Co n� N CD d o m c m d CL M nom: CO) c o O � 3 C 10 N n? o?? i1i n o r r � c c Cly n = c EL o: c cr y O x 0 0 o x n y 0 V 7 i � � 1 - . . L z- r c MASSACHUSE � � S U�+i� G:�4i A?? .:CA i !ON FOR PEr�1�i t A C UO PLUMBING n.\ (Print or Type) �� ��U�,eT ,Mass. Gate (- 19 c Permit 3 i YG Building Location 1-/ /A) 7- Cwnes✓s Name 1,744 Type of Occupancy S1 "/&-C New C Rencvation Replacement Plans Submitted: Yes CZNO ❑ FL URES Installing Company Name, Address 2 /_ h//, Check one: Certificate G l M'CCorporation - /'l5 /—� �+/`�L (� ❑ Partnership Business Telephone—S' a ❑ Frm/Co. 1 Name of Licensed Plumber INSURANCE COVERAGE: 1 have a curren!,Wbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. -Yes Eff No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability *Insurance policy l!d'eIOther type of indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter -142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner O Agent O or 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the ermit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapte 42 a General Laws. r Tiue Signature of LIEffsed Plumber Type of license: Master Journeyman O City/Town APPfiOVFJJ FRC USE ONLY) License Number 42A3 V w (n a a x u• . 21 W Q t �l dl N ti� .! al ;t i J GI }- d Y Ot C !L Z —;d,�� S yI i�r Y } IU1> 'r O; -1i �ivf `��-, d11-Q'jC! d p OI p in 2 _ —; d W W 1- Q it p� Y V1 W •• =t yIy i d'r CdI 3t14 aa; yl GI �� + !-I J; N JI U. d C �1 5 d 3J C C' 41� CS O .^. -:{ i SUB—ss.AT. I I { I BASEMENT :ST FLOOR 2N0 FLOOR 3110 FLOOR 4TH FLOOR I I I I I I I I ! I ( I STH FLOOR 6TH FLOOR { I ! I 7T4 FLOOR I I I 8TH FLOOR Installing Company Name, Address 2 /_ h//, Check one: Certificate G l M'CCorporation - /'l5 /—� �+/`�L (� ❑ Partnership Business Telephone—S' a ❑ Frm/Co. 1 Name of Licensed Plumber INSURANCE COVERAGE: 1 have a curren!,Wbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. -Yes Eff No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability *Insurance policy l!d'eIOther type of indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter -142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner O Agent O or 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the ermit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapte 42 a General Laws. r Tiue Signature of LIEffsed Plumber Type of license: Master Journeyman O City/Town APPfiOVFJJ FRC USE ONLY) License Number 42A3 f rm f is - > > o � # z � C ra m N i 3440 Date. A TOWN OF NORTH ANDOVER 8 PERMIT FOR PLUMBING N This certifies that .. /1.Vt.M ceA/. x ............ � +r has permission to perform ... P eX, 4 ................ f � plumbing in the buildings of ............. at .. '. . ('o.k.'/e7lt .... .. o5h Andover, Mass. Fee. Lic. No.9 ... .. �. ...... . PLUMBING INSACTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer I o MASSACHUSETTS UNIFORM APPLICATIO FOR PERMIT TO DO PLUMBING (Type or print) Ff NORTH ANDOVER, MASSACHUSETTS DatePV Building Locations �zaf W�All 717 Permit # Amount Owner's Name New 0 Renovation� Replacement 0 Plans Submitted l , FIXTURES (Print or type) Check one: Certificate Installing Company Name/� Jy��"/t/ �j��✓d�1"C�iii�r/� Corp. Address ZD 7���,�`�� /� ��� Partner. r� Business Telephone SDS 6 L Firm/Co. 9 e n n r Name of Licensed Plumber: rA UG //- 1,) ) CI— lf—, 6,61, Insurance Coverage: Indicate the finsurance coverage by checking the Liability insurance policy Other type of indemnity ❑ box: Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett_s.4tate Plumbing 2de and Chapter 142 of the General Laws. (Title ;D (OFFICE USE ONLY Type of Plumbing License "Pt �l Icense Slum er Master Journeyman , • (Print or type) Check one: Certificate Installing Company Name/� Jy��"/t/ �j��✓d�1"C�iii�r/� Corp. Address ZD 7���,�`�� /� ��� Partner. r� Business Telephone SDS 6 L Firm/Co. 9 e n n r Name of Licensed Plumber: rA UG //- 1,) ) CI— lf—, 6,61, Insurance Coverage: Indicate the finsurance coverage by checking the Liability insurance policy Other type of indemnity ❑ box: Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett_s.4tate Plumbing 2de and Chapter 142 of the General Laws. (Title ;D (OFFICE USE ONLY Type of Plumbing License "Pt �l Icense Slum er Master Journeyman , V ►' 3687 Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .�,--.... —� has permission to perform ................. (/ ,. plumbing in the buildings of`f.•. ''�� .......... . 4 at ... �9 ��-r� . , North Andover, Mass. Fee`s'? ...... Lic. No.. 4?` 7P . ............................. . PLUMBING INSPECTOR 04/23/48 14:03 15.00 PAID (�,/ D'✓ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer O n z 0 0 z Z m r � r m m r y> > > m 0 0 m m . m 0 T i x r r m 0 0 c c m m m n n o 2 z U) to N W z N M c n -I 0 z N A m w i > u y> oI o H O m m> i i i Z zrr, m c m c O m i i> r 0 I m .t7� m (1:.2 r 0 0 m So 11 O O r O r O 0 z n ' > z n A x Cl 4 z m D m i .ii _ z 0 _ z 0 z _ 0 r Oi m m 0 m -4 0Op 0 O >' y 0 2 i 1 -ml Z>> O m ` m 0 7 9 A A w 0 w i y i y> oI o H O m m> o i 0 r N 0 zrr, m c m c m c> m i i> r 0 I m .t7� m (1:.2 0 0 m So r r O r O 0 m z n z n z n A x m 4 z m D m I > r O _ z 0 _ z 0 z _ 0 r Oi m m m m m H i >' a Z" o Z>> O z 0 0 O 2 > m O O; n r 0 O m i; m i> m .m m Qi Z A -� p A m N 1` > i � > i O 0 z i A m m. m41 ; Z , zi C I Z Z i 0 H ( - o m c r _ > m O m O 0 /A O 2 i s m y J 3 c � \ p m z CAm 0' p 0 A m Z m m i D > m 0 m 0 N m m m m m m m m > -f fA m m x O m 3> _W N m z 0 c N c c c c m0? z z m Iq tl>l m 0 T 0 0 0 0>" i m m H m 6z1 iz1 z Lzi 0 0 0 ,, Z m r 0 i O 0 0 n 0 0 0 Z ,1 n I i z c ,Oi z m A 0 c m m m m Z 0 i HI m p 0 0 m m m m O 0Z 1 p m m m A m 0 p O O O m I T Z 0 0 0 ! m m r I m iI i i Z f Z m 0 I = _ A > rm m * r > z 0 > * m > -4 m O _m N 0 A x Z m D z x i s O -i m 6 (0 I P Q m a CL, 0 W o O D v Im i O a m0 4. U1 WW UI Z a0: y0 _a �I Z�z 0 I IL Z0 ooa N Z :) Om W. U W LL WO IL low �Z ON UNI QZF W WO �W 3oN 1 ILU NWR W �Z� ZaN ONH UWW W - N :i W N N SFOQ F-JIt 0 ��77FTT y Z Z0O O02 Q m O rOOZ Q _ Z Q > Z Z O 2Q r=r zx Z O� Z z O V OD O-� u V S dS d O 7 LL O C) O O vWZ V Q O O dOHOaQZQ..-QWO � 9Zy u�2Om TTT I IN vi 0 1 1^I I I FFF I I M a Ua z O r o} c N Y r m d' H Z O Z J O O 0 Y Z W W Q Z O Q W Z W Q� W O d_ <Q S G y In W y O O O Q Z 1L y 0�O O O .� o z Qo=no00 Z N y z z 2000 V - S Z Q c90 O vi mf< O1 ry m d N OZOm6 O� 'Q �Og Q W VuQ N QQ �d$Qap 10 O fuW+O IHy� P Q �ZIS UO3'"�%yymm Va�t/m��On oU000 V yN (�(���3yro[ m^ FORM U - IAT 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: �e�d,� .l s ��I A id A, Phone 75r -2Z0 LOCATION: Assessor's Map Number ® Parcel Subdivision Lot(s) Street G� St. Number ************************Official Use Only************************ RECO DATIONS OF TOWN AGENTS: C/ h Date Approved l� d Conservation Administrator ctei �" Date Rejected Comments V Town Planner Date Approved Date Rejected Comments Food I ctor-Health Date Approved Date Rejected pti Inspector -Health Date Approved Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 199 ���m0©" .'lli��f 3.1`9�� momm II�I:IIII.T:17 [mom mlm.- �Mmm.- �mmm.- I�lmm.- 1u 72 Q pg05t J A 8JAM kl I ►� TE � �rr�E~V'r AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATEDIN NOriH AtJPOVErY i HAD 75. / zml W Ikj iell 5`T AS PREPARED FOR ,J�r-IES �jUU.ivp.�f DATE: A Pj�.) L ZLt -19 9 -7 SCALE: I '. 40' MERRIMACK ENGINEERING SERVICES, INC. `` 01997 PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS " PARK STREET 0 ANDOVER, MASSACHUSETTS 01110 or TEL (617) 473.3333, 05721 aA V- O z h Cd 8 O F. O E a a ID i tf, a w+ O � a C C '� c � O N A v C 4 •CL A w 2 CD 0 O CL O d U CoC m C o� di u ,c o Z m or. E U w C pG w cmc a°4 8 O F. O E Xl� a ID i tf, Z w+ O � O � C C '� c � O N 0 Fa C •CL A � • CL'o CD 0 O CL O d C W IM CoC m C 1l�\• ,c o Z m C 0 C..3 E O C C cc cmc CL r O d, N Ec � C= �? o ". a $ tv .: o �m N cm �p m J Q � Q -• •' m tr R -0 • � � N E� aC" N m m 4 cm" r- • 0 y O c ao Q � N O C Z � O CLS d � W C O "oS17CZ � r N •m CL=�� OnaCD Ur COL �.� c co 10 r dr m 8 O F. 49 • N O E Xl� a i i tf, Z w+ O � y C C C '� CA ID 0 Fa W A O CD 0 O CL O d CoC .i a w Z m C 0 C..3 E 49 • N qw O E Z w+ O � y C C C '� CA ID 0 �E CD m m O CD 0 O CL O d CoC cc v Z m C 0 C..3 CL O C C cc CL qw st ... oil ;�, �' 1,d,L,z. - #3<-� office Use Only The Commonwealth of Massachusetts Ferolt No. as;g Department of Public Safcty Occupancy b Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 lug t (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK A I work to be perfotmed In accordance with the Mawchusetu Eler:trical Code. 527 CMR 12:00 I (PLEASE PRINT IN INK OR TYPE (ALL INFORMATION) Date City or Town of %t! L,;,1 < its To the Inspector of Wires: The undersigned applies for a permit ,�""1 to perform the electrical work described below. Location (Street b Number) �% I;�; J11i e— � , Owner or Tenants ru. 11� OU k t/r,—e,. Owner's Address e Is this permit in conjunction with a building permit: Yea ❑ No [g (Check Appropriate Box) Purpose of Building Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ 'Und'd ❑ No. of Beaters. New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of deters Number of Feeders and Location, and Nature of Proposed Electrical Work It 31 No. of Lighting Outlets 8h B No. of clot Tubs Total No. of,Transformers KVA No. of Lighting Fixtures Swimmin Pool Above In- g grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of 011 Burners No. of Emergency Lighting Ba Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local 1:1Municipal Connection ❑ Other No. of Ranges 8 Total No. of Air Cond. tons No. of Disposals No. of peaats Total Total ` —Tons No. of Dishwashers Space/Area Heating Ill No. of Dryers heating Devices KW No. of Nater Heaters KW No. of Signsf Ballasts WiriVQltage No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or 1 .9 substantial equivalent. YES � NO [] I have submitted valid proof of same to this office. YES& NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE LI'J BQND ❑ OTHER ❑ (Please Specify) (Expiration ate Estimated Value of Electrical Work S i Work to Start Inspection Date Requested: Rough Final V— 13 Signed under the penalties of perjury: FIRM NAME Addres It. TdT-. No. j -o GT OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage ors is stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this, req%iirement. Owner Agent (Please check one)+ Telephone No. PT•.rilIT Ira s J� Tt.a i'n.«r«nn,Ironlflr niATnccnrlrncoHc city i^t1�.11111'�yiOri� T.T. Tn_crmanrP ftiiiifnaliV o0I Wf'PS( Ctl Thi x ;:: rAtta� ch�ditio� naL�cet.i eecman Failure to secure coverage as required under Section 25A of 11GL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or WORK ORDER and a fine of 5100.00 a day against me I understand that a one years' imprisonment as well as civil penalties in the form of a STOP copy of this statement may be forwardedto the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the painsan penalties ojperjury that the information provided above is true and correct Date Sienaturc [ hone' ,I .3 i Print name S e _ - ofiicial use only do not write in this area to be completed by city or town otrcial permit/liccnse>; • • f'1BuildingDepartm _ - city or town: _ [3Licensing Board C]Selectmen's Office !� C3 check if immediate response is required []Health Department F' phone ft; Mother contact person: l..yi.ed i,'04 PJAI Inforination 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 Iicense 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. klitionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the erformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. L-s►r,J-•_o,'L .'-carij-J�1J:.n�'+:'�'.�'+ai.aJ4r�%yr.,�r. r.�::.: �ti��.'Y-�'i'�''=-- �v.!L�"�'d�;-��=-:.'r'; t'f.1 �"�_t'}•,••�.._,,-•.` '•'tiJ'�_...5:.;-n :�clTSi. ^'b•'�.rio.:'��-+. .:.=--�':�_..: .�.'-:�:... �.l C: � er'=v..�.-r,-.: ��:1�' .4 �...�._-m.��T.^•: .y,.� �. /� 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 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 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. r-. ...:;�._: ..... .. ...::.r•'•.,.. .. ,�� ..: w�i ,.::t=.r•'�..-..++r i+.rv.�'-_:r ._�;5..• :2`::"_'y'+ 17�'c:--„j�.-.:'rc'~�. �.. i7-� :r:-: +..:' J. � �.- w �S•.i..Mt :�T.'^+�” �� J•i .. �5~ .a� ^•!'..,.- i.r/'.t � t' 1 v`•i:,,�� :'h'� w^�'�'•' s��.� .n �_: Si' ��:^ �` i�� ���_.-er � .�� _.• �i:_�,.—.��:\-ra.�'+T.`.^.•:....-r:��.ri•!�y�.. 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. .. �tY�Y�`'a.?" Ws� � ±l. C..._ ��aylPw+��'.^. �+1.i�V"A ! ✓' w'. ��.!.-�� i=�%��Y'�'rt�,�"t �Y.�'�P.fsSz`_l�..T...�.' �:i��v2,...,.-,�,.I��ti's.'=��i-r;:I��.,.::�_z•_�-r:_.��.�.-�3>i��_-.'.r_i�•. . +_..�..._�J3 :.._ _ .�J The Department's address, telephone and fax number:. _ _.- _ - --- — - - • - _ - - _ - The Commonwealth Of Massachusetts _ Department of Industrial Accidents office of lnyestigations 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 est. 406, 409 or 375 'N TO Date.).Q LR.ft /FY? !J- 887 0. 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING C u HU This certifies that .....................................................................e jj�� .......1!; has permission to perform ....... !A.Ii.(� .... ................................ wiring in the building of ......... ...................... at .... North Andover, Mass. Lie. No. 147fhc� . ............................................................... ELECTRICAL INSPECTOR 'I- k Go ;)-)-- ' 04/29/97 15:20 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer