Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 55 FARNUM STREET 4/30/2018
55 FARNUM STREET / 210/107.A-0056-0000.0 • ` Permit Listing Report Date Range:Issued between 01/01/1994 And 08/29/2017 by Permit Type Printed On:Tue Aug 29,2017 SQL Statement:(Street like"FARNUM STREET"OR Work Location like"*FARNUM STREET*")and([Type of Permit]="Building") Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 12 FARNUM STREET YAROSLAVSKY,ILYA&ANNA Residential Alteration $12,000.00 107.A/0044/ 040-14 Expired Jul-10-2013 PELLA WINDOWS/WILLIAM R.NICHELS 8 Replacement Windows,2 Entry Doors $144.00 8809 121 FARNUM STREET Paul and Catherine Hutchins Residential Alteration $17,800.00 107.A/0059/ 1007-2016 Expired Mar-28-2016 DAVID GULEZIAN Build a 18x20 Deck,Install Patio Door $214.00 7448 110 FARNUM STREET BURNS ONE FAMILY TRUST Residential Alteration $3,600.00 BURNS,JOHN&EILEEN TRUSTEES 107.A/0074/ 1023-2016 Expired Apr-01-2016 Peter LeBlanc(978)407-7638 Airsealing and Attic Insulation,Ventilation $43.00 7742 62 FARNUM STREET GOOD,JOHN J CAROL GOOD Residential Alteration $2,001.00 107.A/0086/ 1057-15 Expired Jun-23-2015 Next Step Living(978)860-5345 Air Sealing and Insulation $30.00 602029 55 FARNUM STREET DECLERCQ,EUGENE R&A PATRICIA Residential Alteration $14,900.00 JAYSANE 107.A/0056/ 128-15 Expired Aug-06-2014 Vincent Colangelo(978)656-8497 Strip and ReRoof $179.00 2051 73 FARNUM STREET DIMILLA,SALVATORE J ROSE E Residential Alteration $7,480.00 DIMILLA 107.A/0055/ 182-2016 Expired Aug-13-2015 Castricone Roofing and Siding(978)683-3420 Strip and ReRoof $90.00 3007 GeoTMS®2017 Des Lauriers Municipal Solutions,Inc. Page 1 of 13 Permit Listing Report by Permit Type Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone 4) Work Description Fees Paid Check;1 Building 62 FARNUM STREET GOOD,JOHN J CAROL GOOD Residential Alteration $2,100.00 107.A/0086/ 279-15 Expired Sep-18-2014 Dave Bancroft(978)664-6642 Install Jotul Woodstove and installation of chimney system $30.00 1172 55 FARNUM STREET DECLERCQ,EUGENE R&A PATRICIA Residential Alteration $7,500.00 JAYSANE 107.A/0056/ 05-2017 Expired Sep-27-2016 Jaime Morin(617)966-0412 Replace 5 Windows - $90.00 6925 38 FARNUM STREET DIGIOVANNI JR,RAYMOND R KELLIE Residential Alteration $13,000.00 ANN HOUTS 107.A/0088/ 336-15 Expired Oct-08-2014 DIGIOVANNI JR,RAYMOND R KELLIE Remodel 3 Season Porch ANN HOUTS $156.00 1193 181 FARNUM STREET LAVOIE,PAUL&SUSAN Residential Alteration $10,500.00 107.A/0049/ 383-14 Expired Oct-24-2013 Stephen Delarue(617)512-2197 STRIP AND RE-ROOF $126.00 1077 55 FARNUM STREET DECLERCQ,EUGENE R&A PATRICIA Residential Alteration $28,059.00 JAYSANE 107.A/0056/ -l3 Expired Nov-08-2012 Steve Keisling(978)314-8157 Remodel Two Bathrooms $337.00 3109 96 FARNUM STREET PANGIONE 1I,ROBERT H MARGARET A Residential Alteration $5,980.00 PANGIONE 107.A/0075/ 418-14 Expired Nov-07-2013 Duval Roofing(978)664-2557 New Roof $72.00 1611 GcoTMS®2017 Des Lauriers Municipal Solutions,Inc. Page 2 of 13 4. Permit Listinz Report by Permit Type Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 230 FARNUM STREET CHADWICK,MICHAEL J&MAUREEN T Residential Alteration $39,270.00 CHADWICK 107.A/0101/ 473-2016 Expired Oct-27-2015 Valley Siding(603)819-5158 Vinyl Siding of House,Replace Windows $471.00 3945 146 FARNUM STREET SHEEHAN,KEVIN T DIANE M SHEEHAN Residential Alteration $7,943.00 107.A/0071/ 481-2017 Expired Nov-09-2016 Window World of Boston(781)932-4805 18 Replacement Windows $95.00 19169 1 181 FARNUM STREET LAVOIE,PAUL&SUSAN Residential Alteration $45,035.00 107.A/0049/ 504-1.4 Expired Dec-16-2013 Woburn Construction(781)929-5776 Den Renovation I $540.00 1085 (247 B FARNUM STREET) HUGHES,RANDY Residential Alteration $80,000.00 // 548-14 Expired Jan-15-2014 HUGHES,RANDY Renovate Existing Home $960.00 3274 I j 55 FARNUM STREET DECLERCQ,EUGENE R&A PATRICIA Residential Alteration $4,327.00 JAYSANE 107.A/0056/ 559-2016 Expired Nov-05-2015 Quality Insulation(603)689-6667 Insulate and Air Seal attic $52.00 933 181 FARNUM STREET LAVOIE,PAUL&SUSAN Residential Alteration $44,800.00 107.A/0049/ 567-14 Expired Feb-03-2014 Woburn Construction(781)929-5776 Kitchen Remodel $538.00 1095 GeoTMS®2017 Des Lauriers Municipal Solutions,Inc. Page 3 of 13 Permit Listing Report by Permit Type Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 163 FARNUM STREET ANDERSON,ROBERT E LOUELLA M Kitchen Remodel $25,000.00 ANDERSON 107.A/0037/ 568-12 Expired Jan-27-2012 Scott Lemay(978)815-7876 Remodel Kitchen $300.00 546 210 FARNUM STREET BURKE,RICHARD M&JACQUELINE Residential Alteration $11,420.00 BUSSIER-BURKE 107.A/0102/ 598-15 Expired Jan-14-2015 Nexus II Services(781)760-2031 Build a 13x16 Room in Basement $137.00 6155 207 FARNUM STREET SCHWALM,MARK W SARA W WEISS FOUNDATION 107.A/0052/ 619-2016 Expired Dec-01-2015 MIXON,THOMAS F. Foundation Only for 24x24 Garage $100.00 165 397 FARNUM STREET FARNUM,BENJAMIN A JOHN C Residential Alteration $3,000.00 FARNUM 107.A/0041/ 625-14 Expired Mar-13-2014 FARNUM,BENJAMIN A JOHN C FARNUM Repair of Siding-Barn $30.00 7819 163 FARNUM STREET ANDERSON,ROBERT E LOUELLA M Residential Alteration $12,000.00 ANDERSON 107.A/0037/ 656-13 Expired Apr-10-2013 SUTERA,MARK Basement Remodel,Enclosing laundry and mechanicals, adding a play area $144.00 3039 (247A FARNUM STREET) DUNCAN,JOY Residential Alteration $10,000.00 H 674-15 Expired Mar-02-2015 DUNCAN,JOY Finish 3rd Floor-2 Bedrooms and a Bath $120.00 1035 eoTMS&2017 Des Lauriers Municipal Solutions,Inc. Page 4 of 13 i Permit Listing Report by Permit Type Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 247 FARNUM STREET DUNCAN,JOY ANNETTE DANIEL P Residential Alteration $4,500.00 (247A FARNUM STREET) HEYSTECK 107.A/0278/ 734-15 Expired Mar-30-2015 BB Carpentry(978)479-0970 Remove and Replace Drywall and Insulation affected by ice dams $54.00 1082 207 FARNUM STREET SCHWALM,MARK W SARA W WEISS 2 Car Garage&Great $84,000.00 Room Over 107.A/0052/ 794-2016 Expired Jan-25-2016 MIXON,THOMAS F. Construct a 2 car garage with a great room over garage $19000.00 2669 I 210 FARNUM STREET BURKE,RICHARD M&JACQUELINE Residential Alteration $8,100.00 BUSSIER-BURKE 107.A/0102/ 811-2016 Expired Jan-25-2016 Nexus Il Services(781)760-2031 Emergency Roof and Fascia Repairs to Rear First Floor $97.00 6721 I 240 FARNUM STREET GULEZIAN,ROBERT P Residential Alteration $167,432.00 107.A/0100/ 874-15 Expired May-05-2015 The Home Depot(401)935-2633 Install 5 Windows $201.00 10298 280 FARNUM STREET PERNA,GEORGE D,JR DIANE KAY Solar Panels $209116.00 PERNA 107.A/0096/ 960-2016 Expired Mar-09-2016 Sunrun Installation Services Inc.(978)793-8584 35 Rooftop Solar Panels,9.625 KW $241.00 2220133 GeoTMS®2017 Des Lauriers Municipal Solutions,Inc. Page 5 of 13 Permit Listing Report by Permit Type Permit Type s ork Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/BIocWL Permit No Online Permit o Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 55 FARNUM STREET DECLERCQ,EUGENE R&A PATRICIA Residential Alteration $10,000.00 JAYSANE 107.A/0056/ BP-2004-114 Expired Aug-19-2003 DECLERCQ,EUGENE R&A PATRICIA REMODEL KITCHEN JAYSANE $100.00 ON RECEIPT 122 FARNUM STREET ARAKELIAN,KARL Residential Alteration& $155,000.00 Repairs 107.A/0073/ BP-2004-631 Expired Apr-27-2004 ARAKELIAN,KARL ADDITION TO HOUSE $1,550.00 ON RECEIPT 241 FARNUM STREET GARDELL,STEVEN&CYNTHIA J Accessory Bldg shed, $17,150.00 GARDELL garage 107.A/0057/ BP-2004-675 Expired May-11-2004 GARDELL,STEVEN&CYNTHIA J 2 CAR GARAGE GARDELL $170.00 ON RECEIPT 241 FARNUM STREET GARDELL,STEVEN&CYNTHIA J Residential Alteration& $17,150.00 GARDELL Repairs BP-2004-675 Expired May-11-2004 GARDELL,STEVEN&CYNTHIA J NEW GARAGE GARDELL $180.00 - ON RECEIPT 241 FARNUM STREET GARDELL,STEVEN&CYNTHIA J Pool $23,590.00 GARDELL BP-2004-743 Expired Jun-09-2004 GARDELL,STEVEN&CYNTHIA J POOL GARDELL $240.00 ON RECEIPT QeoTMS®2017 Des Lauriers Municipal Solutions,Inc. Page 6 of 13 1 .. Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .�!'.�.Y . . . . /�K r` �^�� . . . . . . . . . wiring in the building of .. . . . . . . . . at . . .5�,� . .,��H -�r� r� N? . . . . . . .S�". . . orth Andover, Mass. Fee'. Lic. No. y 3..3 . . . . . . . . . . . . . . .. . ELECTRICAL INSPECT4� i Check# /3 �/ y �`�I 128 5 ❑ 2012 Massachusetts EIectrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§.3L,the }�permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.01 c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shalLbe limited as to the time of ongoing construction activity,and maybe deemed_bytheTnspzctoi of_Wires abandoned_and.inyalid.ifhe—.. or she has determined that the authorized work has not commenced or has not progressed during the prdceding 12-month period.Upon written application,an extension of time for comp"va caf-cork shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certairrpermits-and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was m effect or existence during the qualifying period byinning on August 15,2008.and extendingtbrough August 15,2012. ❑Rule 8—Permit/Date Closed: Note:Reapply for new per ❑Permit Extension Act—Permit/Date Closed: 3D-\ Commonwealth of Massachusetts Official Use Only Permit No. / `S Department of Fire Services 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(NEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: /z — Z —/' City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant c1 h c rr c Telephone No. Owner's Address ,S/f Is this permit in conjunction with a building permit? Yes P-- No ❑ (Check Appropriate Box) Purpose of Building I 11rf�!'�� �� 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: P✓, t- �f,llt� IJT / , - Completion of the ollowin table maybe waived by the Inspector of Wires. No.of Total No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Swimming Pool Above ❑ In- ❑ NO.o Emergency Lighting No.of Luminaires s' g rnd. rnd. Batter 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 � Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices ` No.of Waste Disposers Heat Pump Number.Tons KW No.of Self-Contained P Totals: """-"'- """— Detection/Alertin Devices S ace/Area Heating KW Local❑ Municipal ❑ Other No.of Dishwashers P g Connection No.of Dryers Heating Appliances KW Security SNo.of Dystems:* evices or E uivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring. No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent OTHER: Attach additional detail if desire4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: /a (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' rce,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,under the pains and penaldes of perjury,that the information on this application is true and complete. FIRM NAME: . J/t• Z _al�- v Z/C. LIC .NO.: Licensee: -. , ZI Signature LIC.NO.: (Ifapplicable,a er "exempt"in the license number 1' e.) Bus.Tel. Address: e�r �� rAlt.Tel.No.: *Per M.G.L c. 147,s.57-61,se 'ty work requires Department 61f Public Safety- S"License: Lic.No. OWNER'S INSURANCEWAIVER: 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 eat. Owner/Agent PERMIT FEE: $ d i �����+••,.o .Telephone No. � /�o ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors' omments: Z—�✓_ (Inspectors'Sig tore-tinitials) Date Z.FINAL INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ J Inspectors' comments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—( ] Failed—[ J Reinspection 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: 1' (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. PO Box 55098 Boston,MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: A. PATRICIA JAYSANE and EUGENE DECLERCQ Property Address: 55 FARNUM STREET,NORTH ANDOVER, MA Policy Number: HMA 0352849 Claim Number: BOS00049930 Date of Loss: 2/12/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed.$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Marc Chizauskas Claim Examiner 2/20/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3526 Fax: (800) 297-5212 Email: MarcChizauskas@Safetylnsurance.com Date .��:�-3 �a. y TOWN OF NORTH ANDOVER ' to PERMIT FOR WIRING This certifies that . . . . {`. . . . r. . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . �: . .: . . ., , . �r ... . . . . . . . . wiring in the building of . . . . . . . . . . . .. . . . . . . ,No h Andover, Mass. . . �iLic. No. ./� '�e' ELECTRICAL INSTOR Check# 4 11214 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the-Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be;V the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of-ongoing construction activity,and may be_deemed-by.the-Inspector_of_Wires abandoned.and_invalid if he__. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extens=on of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act fiufhers this f purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying per��i��od be ' ' g on August 15,2 and extending through August 15,2012. —Permit/Date Closed: G- � _ `.'�**Note:Reapply for new permit PO Permit Extension Act—Permit/Date Closed: a. Commonwealth of Massachusetts Official Use Only y . Department of Fire Services Permit No. r Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (ieaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORAMTIOA9 Date: //- 13 -/Z_ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 f /y Alt, k Owner or Tenant lJg r/r n >= /'e ��� q Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building /"— ./L Utility Authorization No. - Existing Service Am / 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: /i✓. - ���r�N� Com le on of the following table 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 Z No.of Hot Tubs Generators KVA No.of LuminairesSwimming Pool Above ❑ In- E] No.o Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches Z No.of Gas Burners No.of Detection and Initiatin2 Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices k Tons No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: ..""."""'............""""'........"'"""'.. 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 KW No.of 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 E uivalent 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: //—/,7 /-L 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 certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . ell IC.NO.: 9 S 3 Licensee: o� f r „ Sig ature LTC.NO.: (If applicable,en r "exempt"in the license number line.) Bus.Tel.No.- 9'T- Ge7- z/G Address: Gl/ e /j r Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security rk requires D artme 'f Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIV : 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. $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an l✓ electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?1 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed ❑' Re-Inspection Required($.)❑ , Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pas • Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass® Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 °Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• E]New construction . 2.❑ I am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. Demolition ❑ working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ 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 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' 13.0 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors 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 Vormation. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: fob Site Address: City/State/Zip: kttach a copy of the workers'compensation policy declaration page(showing the policy number and 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 .me 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 )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 Investigations of the DIA for insurance coverage verification. !do Hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ijtiature: Date: 'hone#: 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#: c r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the 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. ,F 1 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia 1 I No 9662 Date.l.1. . !3'!Z. . i f NORTH,, TOWN OF NORTH ANDOVER ` F p PERMIT FOR PLUMBING SAcwUS This certifies that .�' S c 1/A� has permission to perform �. . . . . . . . . . plumbing in the buildings of . . P<<<<r5. . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . , North dov r, Mass. FeJ� Ca. . .Lic. No.903 6. . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 1 z, 1 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � — _ I MA DATE j 1 _ /ti PERMIT# JOBSITE ADDRESS OWNER'S NAME e� { POWNER ADDRESS — �'t '.___ __� i TEL -�— FAX t TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ©i RESIDENTIAL PRINT CLEARLY NEW: _.., RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E9 NOD! FIXTURES 7 FLOOR- BSM 1 2 3 4 5 J67j 8 9 10 11 12 13 14 BATHTUBCROSS CONNECTION DEVICEDEDICATED SPECIAL WASTE SYSTEMDEDICATED GAS/OILISAND SYSTEM ( _._ .,I 1 I ........... DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM -._E DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER J .,_ _..-.-( _ .. ..! ..--- . .-f FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR KITCHEN SINK _..._.__( __...__...1 LAVATORY __..._I _. _.._J _-- .._J ...___! ._..__._I ...._...-._i ._._._...I ...._._._( i .__.._.� _.__._.1 _._I _3 ROOF DRAIN I ( _. ..___f . f SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION il J I WATER HEATER ALL TYPES _ - --- WATER PIPING — I s r , 1 L—A i r 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 i BOND I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER E] AGENT JEJ hereby certify that all of the details and information I have submitted or entered regarding this application a e a acc ate to th best of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be i com li a with II Perti nt pr ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C � yJ�••,•� LICENSE# . � C. SIGNATURE MP El JPCORPORATIONS#� -__ PARTNERSHIP# LLC COMPANY NAME iCclt If � ,`, — ADDRESS CITY tl � STATES ZIP _d ! TEL FAX =CEI _�1d...7 .Lj _--_.,- i EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFPfCE—U'SE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ n FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 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 Leg><bly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: - Are you an employer?Check the appropriate box: 1.El am a employer with 4. El am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. .insurance 5. 9• F1 Building addition [No workers' comp. ❑ We are a corporation and its required.] officers have exercised their 10.EJ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no insurance required.] employees. 12.❑Roof repairs [No workers comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: ob Site Address: City/State/Zip: ittach a copy of the workers' compensation policy declaration page(showing the policy number and 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 ine 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 ,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 nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i nature: Date: hone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: D Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dna Date.... fl....... NORTI� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SSAcMUSEt This certifies that ...........Rf�/..../.LSC..G.k.,ej11�`r... ............................ has permission to perform .... wiring in the building of..... / .-............................................. at..... sl.........5.7 ..........fiEcrRiCA North Andover Mass. i Fee..�,�:........ Lic.No.,;;4 6.S rD........... y�............ L INSPSE-'TOR/ Check # `10449 Commonwealth of Massachusetts official Use only Permit No. l) Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),MW 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector oftires: By this application the undersigned gives notice of his or her intention to perfotm the electrical work described below. Location(Street&Number) SS F irn(A.,., Owner or Tenant n4r,` r n V% Sin a Telephone No. -S- ,b Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Na,A-q e Utility Authorization No. Existing Service /by Amps /JZO/ I-/UVolts Overhead [2;__`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: OPD.,f r .b ra erA_, S e r- Gin k M t e! rl/o t n .S4/'t-, Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Lurni sires No.of Ceil:Susy.(Paddle)Fans No.of TotalTransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators TVA , No.of Luminaires Swimming Pool Above EJ 'In- ❑ o.o Emergency Lighting nd. rnd. Battery Units -- No.of Receptacle Outlets No.of Oil_Biapniers F PX.A.L.A. MS 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 No.of Waste Disposers Heat Pump I lumber Tons KW No.of Self-Contained Totals: -'-***"*****'**""'**'I'*"*"'******'*'*"'**I'*'*"*'*'*"* Deteetion/Alerting Devices ' Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ElOther j No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KWNo.of 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 E uivalent 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:_ / Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penal es of. Jury,that the information on this application is true and complete. FIRM NAME: 6,, d r, e r, ��,` LIC.NO.: X505 S D Licensee: A Signature LIC.NO.: r.SO SO (If applicable,enter" em in the lice'se number line.) q Bus.Tel.No.: -`/ 3 SOtI/ Address: _ 'y < !S a k /S-/3 �., —11 03 4 Alt:Tel.No. *Per M.G.L c. 147,s.57-61,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 agent. Owner/Aaent The Commonwealth of Massachusetts Department of Industrial Accidents r �f Office ofInvestigations _ E! V � 600 Washington Street .� Boston, MA 021'11 www.hwss gov/dia . Workers' Compensation Insurance Affidavit: R iiIders/Conn-actors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Address: City/State/Zip: Phone#: . Are you an employer?check-the appropriate box: ' I.❑ I am"a employer with 4 Type of prgject(required): ❑ I am a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6. ❑New cotistr❑ction 2.❑ I am.a.sole proprietor.or partner- listed on the attached sheet.1 7. ❑Remodeling ship and have no employees These su&eontractors have working for mein any capacity, workers, comp.insurance. $' ❑Demolition. [No workers'comp,.insurance 5. ❑ We are a corporation and its 9• ❑Building addition 3.❑ required.] officers have dxercised their 10.❑.Electrical repairs oradditions f I din a homeowner doing all work right of exemption per MGL 11.x3 Plumbing repairs or additions myself.[No•workers'comp. .c. 152, §1(4),•2nd we have no ] insurance•re required.]t 12-E]Roof repairs q .employees.[No workers' camp.insurancerequired.] 1300ther *Any applicant that checks bo)'#I must also fill out the sectio $Conhactors that check this box rtrustattnched an addin below showing their workers'bompensation policy in t Homeowners who submit this affidavit indicating they zz doing all work and then hire outside contractors must submit a new*affidavit indicating such. tional sheet showing the name of the subcontractor and their 4ierka 'den p,policy infor„rahaa. I aw an e loyer that is pr.gYzd!ng:workeP.y'co�iaPer�s®t ri irasarreoace ot° a In ees: �elosv is tlse otic and'ob site informaatiom f �' y P Y ! Insurance Company Name- Policy ame 'Policy#or Self-ins,Lie..# ' • Expiration Date: Job Site Address: • City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- line 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify under the pains andpena/ties ofper,jury that flte information proved above is true and correct: Signature:. Date: Phone#: Official use only. Do not verde M MLY area,to he c0,;,p'9 ed by Girt or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town•Clerk 4.Electrical Inspector 5.Pl 6.Oth6r umbing Inspector Contact Person:— Phone#: AdwhkL Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall N ANDOVER, MA 01845 N ANDOVER, MA 01845 RE: Insured: A PATRICIA JAYSANE and EUGENE DECLERCQ Property Address: 55 FARNUM STREET, N ANDOVER, MA Policy Number: HMA 0253929 Claim Number: BOS00025674 Date of Loss: 10/29/2011 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000:00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.' If anynotice,under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 11/4/2011 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 32,13. Fax: (61-71.) 531-8891 Email'- AlJlan"Leavrtt@STafetyInsurarice com ' L Location �� f��N U 0 No. Date E—R-0-3 NORTH TOWN OF NORTH ANDOVER O 10 • ; ; Certificate of Occupancy $ /00 Building/Frame Permit Fee $ s�CH Foundation Permit Fee $ Other Permit Fee $ 4 TOTAL $ D01 � T Check # 3 c/co 6635 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 77, TII1S " f01'UfiC .U ' 7. BUILDING PERMIT'NUMBER. DATE ISSUED: ., ` / M O 2 rn SIGNATURE: ..' Building Commissionerfl for of Buildings Date Z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: :6- ir9e.Il01" SleeT !o7 ODSIo Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqttired Provided Required Provided v 1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record F,! ysA G�Ne�e ct��k �"S F�,�Nv�► S'ieee Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Si nature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ P/le,y ieelsC/.y L-1- Licensed Consstru/ction Supervisor: O t`t U-t P nuc e (� NG f}A1%041P/L *,r,Q. License Number Address `S/,8Y5? 2—,16 2-00-6-Expiration Dateic Signature Telephone '..r 3.2 Registered Home Improvement Contractor Not Applicable 0 v Company Name v/. M .SS�nt e p _v e- Registration Number r Address Y�G7 r aQ- 2OOy z Expiration Date ^ Signature Telephone YI 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. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all licable New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: Ty 6o a-%.Ai vl"- eet'ic Ile ri --ope aj '&y/A C- 0am L4JkJ_ 7 . gee SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building 41i dv (a) Building Permit Fee /O Oda, Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) / 4 Mechanical HVAC O 5 Fire Protection 6 Total 1+2+3+4+5 /O Oci?. Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,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 �• s 1, P//&,J as Owners orze Agen f 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 4e t. s& ,u tr Print Siature f Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIlvMERS 1 2 3 SPAN DIN ENSIONS OF SILLS }. DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 1ff:IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Farm DECLARATIONS PAGE 1 Family CONTRACTORS ADVANTAGE SPECIAL Casualty Insurance Company POLICY NO. 2005XO431 ® Gienmorrt,New York' ME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591 EPHEN KEISLING JAMES W UGONE GLENCREST DR FARM FAMILY INSURANCE ANDOVER MA 01845-1315 10 S MAIN ST STE 208 TOPSFIELD MA 01983-1832 978-887-8304 NEWAL TRANSACTION EFFECTIVE 03/21/03 LICY PERIOD FROM 03/21/03 TO 03/21/04 12:01 A.M. STANDARD TIME AT THE LOCATION OF THE DESCRIBED PREMISES E NAMED INSURED IS: INDIVIDUAL SINESS OF THE NAMED INSURED:; CARPENTRY-NOC '-ATION OF DESCRIBED 68 GLENCREST DRIVE PROTECTION CLASS IS: 04 EMISES NO. 01: N ANDOVER MA 01845 CONSTRUCTION IS: FRAME :MISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMEN.T STORAGE 3INESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN INSURANCE PREMIUMS PREMIUMS JILDING 0 0 0 JSINESS PERSONAL PROPERTY 5,000 46 46 JSINESS INCOME AND EXTRA ACTUAL LOSS SUSTAINED NOT {PENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED 3INESS LIABILITY COVERAGE: JSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT BODILY INJURY/PROPERTY DAMAGE 500,000 PER OCCURRENCE 1,000,000 AGGREGATE 500,000 AGGREGATE FOR PRODUCTS - COMPLETED OPERATIONS HAZARD MEDICAL EXPENSE 5,000- PER 'PERSON FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE )DE DESCRIPTION PAYROLL TERM PREM ADDL/RTN 342AA CARPENTRY-NOC 20,000 379 379 IE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED. 5% ON AN ANNUAL BASIS DURING THE POLICY PERIOD. ;TUAL CASH VALUE (ACV) - BUILDING OPTION DOES NOT APPLY. )UCTIBLE: $250 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS. INTERSIGNED BY: 30 05 01 98 INSURED COPY PROCESSED DATE: 02/14/03 BC CALC®2003 DESIGN REPORT- US Thursday,August 14,2003 08:52 ROME' Double 13/4" X 91/2" VERSA-LAM®3100 SP File Name: BC CALC Project:F801 Job Name: Description: Address: Specifier: City,State,Zip:, Designer: Designer: Customer: sic.s�ts� Company: i� Code reports: ICBO 5512, 16R 629 Misc: 1 Standard Load-30 psf 110 psf Tributary13-06-00 BO 61 2363 Itis LL 2363 lbs LL 978 lbs DL 978 Ibs DL Total Horizontal Length-07-00-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. S Standard Load Unf.Area Left 0040-00 07-00-00 Live 30 psf 13-06-00 100% Member Type: Floor Beam Dead 10 psf 13 06-00 90% Number of Spans: 1 1 Unf.Area Left 00-00-00 07-00-00 Live 20 psf 13-WW 100% Left Cantilever: No Dead 10 psf 13-06-00 90% Right Cantilever: No Controls Summary Slope: 0/12 Control Type Value %Allowable Duration Load Case Span Location Tributary: 13-06-00 Moment 5845 ft4bs 41.9% 100% 2 1 -Internal Neg.Moment 0 ft-lbs n/a 100% End Shear 2585 lbs 40.2% 100% 2 1-Left Total Load Defl. U815(0.103") 29.5% 2 1 Live Load: 30 psi Live Load Defl. U1152(0.073") 41.7% 2 1 Dead Load: 10 psi Max Defl. 0.103" 10.3% 2 1 Partition Load: 0 psf Duration: 100 Notes Disclosure Design meets Code minimum(L240)Total load deflection criteria. Design meets User specified(0480)Live load deflection criteria. The completeness and accuracy of Design meets arbitrary(1")Maximum load deflection criteria. the input must be verified by anyone Minimum bearing length for BO is 1-12". who would rely on the output as Minimum bearing length for 61 is 1-12". evidence of suitability for a Entered/Displayed Horizontal Span Length(s)=Clear Span+12 min.end bearing+12 intermediate bearing particular application. The output above is based upon building Connection Diagram code-accepted design properties Bolts are assumed to be Grade 5 or higher. and analysis methods. Installation of BOISE engineered wood Member has no side loads. products must be in accordance Connectors are:12 in.Staggered Through Bolt with the current Installation Guide and the applicable building codes. a=2 To obtain an Installation Guide or if b=2-1/2" d b you have any questions,please call (800)232-0788 before beginning c=3-1/4" d 24" 8 product installation. No = BC CALC®,BC FRAMER®,BCI®, BC RIM BOARD-,BC OSB RIM BOARDTm,BOISE GLULAMTm, C VERSA-LAW,VERSA-RIM®, VERSA-RIM PLUS®, VERSA-STRAND- • VERSA STUD®,ALLJOISTO and AJST"'are trademarks of Boise Cascade Corporation. Page 1 of 1 -- 7k C�o»v�scoozroeal�t a�./ aaaac%uaelk BOARD OF BUILDING REGULATIONS I License:f ONSTRUCTI.ON SUPERVISOR Number-IGS 027489 e Bit"We7/18/1953 s igV14- 07/18/2005 Tr.no: 13929 I = W STEPI-IENM KEI$Llt `.,- ( «� I. 68 GLENCREST DRQ, N ANDOVER, MA 01845' Administrator ____ � �✓fee �ovnnzo9Uvea� o�./�aooac/uiael�a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regist'r_at n-_1.01846 ! ! Exp tion: 6/29/2004 M-_Z�Cype: Individual _ r !i SW~PHEN M KEISLIN .Y v + phen Keisiing4 = `- 68.Gienncrest Dr. .i N.Ahdover,MA 01845 Adm►ms -afor 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) 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 G k The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name �.�. Please Print Name: -Y/f P1710 N / Is A G �'S ... Location: City NU 11-A&©veA 1214 Phone I am a homeowner performing all work myself. 21 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: -- Address City. Phone*. Insurance:Co. Policy# Company name: Address C•rty Phone#: Insurance Co. Police# Failure to securecoverage as required:under Section 25A or MGL 152 can lead teethe imposkion of c 6mhW pew of a,fineupto 3?, � .. and/or one yearsimprisonrnenLas vceAm coM pmatt in-lbe-ftm da-STOP fine-aA$ MM)- WaY� lner understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. /do hereby eerfify under-the pains andpenaltier of perjury that the inform dw provided above is true and correct - Signature Si nature Date - O Print name PO/��•J �f'Li� Pbone.# Official use only do not write in this area to be completed by city or town officiar City of Town PerrnittLicensirw. air;tiling DelCheck if immediate respons a is rill meed ❑ LICenS/fI BD ❑ Selectman's Contact person: Phone# Health©epai ❑ Other V 9 > Y 7 -4- 1 'V ti L' L Ile -F— J F Light squares= I foot at V4-inch scale Bold squares = I foot at V2-inch scale It is permissible to photocopy this page for personal, nonprofit use. AORTH ` � E . Town of Andover 0 y R'`} dower o Mass. T =� �AES o 1 COC MIC WICT( 0RATED p'PGtCC lv H `` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... . ..... .P 4a �� �� ���t ���IP �' ......�... .................J...............�............ ...........................�......... .................. Foundation has permission to erect.....R,0?.VPC1p ./buildings on ... ���... i�.l�.�L.?.U s' J............ ......... ................ Rough to be occupied as......./..� LIL.!p.&.)./....... .2� A ..................�.^' ................!:n.... ./ '`''!.�e.0 �Q�� y (N C r►�j /4- Chimney 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-Ls relating to the Insp ction, Alteration and Construction of Buildings in the Town of North Andover. /0 /,) 7 S�6 /too-- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough In...' ............................ .............................. .......................... Service BUILDING..INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR j Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No LathingD Wall To Be Done or � FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke net. SEE REVERSE SIDE Date. p'.".O�':-14,p TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING 41 ,SSACHU$ This certifies that . . . . .J.. . f?.�.� F. .t s . . . . . . . . . . . . . . . . has permission to perform . . .h. S. . D w . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at . . .� .? . . !`�!?`�?mss.% . . . . . . . . . . . . . . . . North Andover, Mass. Fee. . Lic. No.. . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # I//e' 4 57 '15 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING / (Type or print) Date � � NORTH ANDOVER,MASSACHUSETTS / n � 3 Building Location -�S /- /"�/L+ti It,H ^.�- Owners Name Oe C I e K c Permit# /a Amount Type of Occupancy New Renovation Replacement �' Plans Submitted Yes 11 No El FIXTURES H a � z w � kr� w W a a a a H a x PASUVENr ISE>D M FUM 4MHIM 5M ILOCIR 6M HDM MiFum M boat (Print,or type) `� /� Check one: Certificate Installing Company Name (� �) /�y.� r l Corp. Address U r ` Partner. Business Telephone E - x ' Firm/Co. /J Name of Licensed Plumber: --�- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond El ' Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent E] 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 instaII20ons performed under Permit ISS))ed for this application will be in compliance with all pertinent provisions of the Massachuse s Sta '{lumbi ng C and Ch e� R General Laws. By n e o ncens um er Type of Plumbing License Title 3 =' City/Town rce aum e'er Master Journeyman 0- APPROVED(OFFICE USE ONLY BUILDING PERMIT t1oRTtl q TOWN OF NORTH ANDOVER O q�1 ED �• APPLICATION FOR PLAN EXAMINATION '- h * 0 4y Permit No#: 405 X0)? Date Received "/!�n —9 / — e)o d �SSAC Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION S CLr- AV VvL !�U��Cl Print PROPERTY OWNER vc, t n J- VV yn .p, Print 100 Year Structure yes no MAP PARCEL OV 57ZONING DISTRICT: Z Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ©'One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 2'Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Y � ��,c-c 5 � I.�►c��cv.5 �- r1 � S T� t�vru � � -� Identification- Please Type or Print Clearly OWNED: Name:-{v i_e -1 XV �s�t4 ,e Phone !71-e/7,S-ZykO Address: 5-Sctrnom Sf, vr4 140doulc, G At� l Contractor Name: Stf tm Se. 1 I1 O rt 0 Phone: 3,57t - Z Lt y Email: _ Address: r, e. o 1 bora, 0l Supervisor's Construction License: C1U 1 Z Exp. Date: Home Improvement License: ( -2o 1 ' Icy Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 06 Total Project Cost: $ 71 �d�. �g FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREMEPA_RTMENT Temp)®umpster.omsite ,yes Locatedlat ,124�MainsSt�eet - FireiDe_partmentsignature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location J-S �C-�U ' No. Date ��� l�dl I • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 9A Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#,0 �l f Building Inspector F_ 1 NORT#� _ _ . w. .. . . _ s ve. . 0 oh ver, Mass, • �I A- COC MIC NlWKK �� S U BOARD OF HEALTH PERMIT _ T LD Food/Kitchen Septic System THIS CERTIFIES THAT .......:'A4.0.0.".E � � BUILDING INSPECTOR has permission to erect t I.kq* l/�1 .br Foundation .......................... buildings on ..... ..... . ........... ... ............... Rough { .. .Ab� ..of to be occupied as ..x!!11 NI ...... .................. ........... ......................... Chimney 1 provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC,31419911 ST S Rough Service .. ........... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. Renewal Agreement Document and Payment Terms byAnderwn. dba:Renewal b Andersen of Boston Y Eugene Jaysane Legal Name:Renewal by Andersen LLC 55 Farnum St HIC#170810 North Andover,MA 01845 WINDOW RE LACEYEF f 30 Forbes Road I Northborough,MA 01532 H:(978)975-2480 Phone:508-351-2200 1 Fax:(508)986-7072 1 RbABoston0perations@AndersenCorp.com Customer(s)Name: Eugene Jaysane Contract Date: 08/19/16 Customer(s)Street Address: 55 Farnum St, North Andover, MA 01845 Primary Telephone Number: (978)975-2480 Secondary Telephone Number: Primary Email: deelereg6bu.edu Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen LLC d/b/a Renewal by Andersen of Boston("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,Notice of Cancellation,Itemized Order Receipt,Terms and Conditions of Sale,Lead-Safe Form,Owner or Builder,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $7,500 By signing this agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $0 Balance Due: $7,500 Estimated Start: Estimated Completion: Amount Financed: S0 8-10 wks 1-2 days Method of Payment: Credit Card We schedule installations based on the date of the signed contract and secondarily on Notes: the date in which we complete the technical measurements.The installation date that Visa we are providing at this time is only an estimate.We will communicate an official date 2499 @sign and time at a later date. Rain and extreme weather are the most common causes for 24990start delay. 2499@completion Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understanding changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO OWNER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 08/23/2016 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN N �f'IPS RIGHT. Castomer(s) a:Ren An ersen o Boston Signature of Sales Person Signature Signature Duncan Fields Eugene Jaysane Print Name of Sales Person Print Name Print Name 08/19/16 Page 2 / 10 Renewal Itemized Order Receipt Andersen. dba:Renewal by Andersen of Boston Eugene Jaysane Legal Name:Renewal by Andersen LLC 55 Farnum St HIC#170810 North Andover,MA 01845 WINDOW RE IACEMENT 30 Forbes Road I Northborough,MA 01532 H:(978)975-2480 Phone:508-351-22001 Fax:(508)986-7072 1 RbABoston0perations®AndersenCorp.com D• ROOM: 201 Room 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, EXTERIOR Canvas, INTERIOR Canvas, Glass: Sash All: High Performance SmartSun Glass, No Pattern, Hardware: Canvas, Screen: Fiberglass, Half Screen, Grille Style: Grilles Between Glass(GBG), Grille Pattern: Sash All: Colonial 3w x 2h, Misc: Non 202 Room 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, EXTERIOR Canvas, INTERIOR Canvas, Glass: Sash All: High Performance SmartSun Glass, No Pattern, Hardware: Canvas, Screen: Fiberglass, Half Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: Sash All: Colonial 3w x 2h, Misc: Non 203 Room 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, EXTERIOR Canvas, INTERIOR Canvas, Glass: Sash All: High Performance SmartSun Glass, No Pattern, Hardware: Canvas, Screen: Fiberglass, Half Screen, Grille Style: Grilles Between Glass(GBG), Grille Pattern: Sash All: Colonial 3w x 2h, Misc: Non 204 Room 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, EXTERIOR Canvas, INTERIOR Canvas, Glass: Sash All: High Performance SmartSun Glass, No Pattern, Hardware: Canvas, Screen: Fiberglass, Half Screen, Grille Style: Grilles Between Glass(GBG), Grille Pattern: Sash All: Colonial 3w x 2h, Misc: Non 08/19/16 Page 4 / 10 Renewal Itemized Order Receipt byAndersen. dba:Renewal by Andersen of Boston Eugene Jaysane A�� Legal Name:Renewal by Andersen LLC 55 Farnum St HIC#170810 North Andover,MA 01845 w�Roow RE u►CE.ER. 30 Forbes Road I Northborough,MA 01532 H:(978)975-2480 Phone:508-351-2200 1 Fax:(508)986-7072 1 RbABoston0perations@AndersenCorp.com ROOM: DETAILS: 205 Room 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, EXTERIOR Canvas, INTERIOR Canvas, Glass: Sash All: High Performance SmartSun Glass, No Pattern, Hardware: Canvas, Screen: Fiberglass, Half Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: Sash All: Colonial 3w x 2h, Misc: Non WINDOWS:5 PATIO DOORS:0 SPECIALTY.0 MISC:0 TOTAL $7,500 UPDATED: 08/19/16 Renewal by Andersen is committed to our customers'safety by complying with the rules and lead-safe work practices specified by the EPA. 08/19/16 Pages / 10 b;Z4va derserr. ,.. WINDOW' REPLACEMENT FvlAndeTaett(:nmf/nnp '-Mbwrvv , Woad/Vinyl Composite IF t r:gCaMfz Dual Argon Low E4 SfnanSun Double Hung -1 �e 100-00473518-010 -ENERGY PERFORMIM R TURGS U-Factor (UU.S)/!-P Solar Heat Gain Coefficient ADDITIOIRIAL PER:oR;r1; SCE RA MOS Visible Transmittance Manuhwuw 4114P Yaa that thew raft•confnfnntoappFcable NFTIC pr.osdsraa tw delerminlfpwlwN produet podwmaes.NFAC rafnpsar.detam bod{era road wf M*.v*,nfwfd.taondi1Taas and aapac product ai:e. NF;do"OM"commend any pfodu l and dn.t net wa nt the wlabaky daey predtwt Tp any ir"cfio uae, CMM amu&worw`s monann for other pmdaat p.donwncs infom,uion, wwy�nftao 8aat.anvsanmaaai "J=r.��A ��� �elandardaaatsminp anagy �w..w_a'• t' �'•'.iro ' .ffcincy,hawy mtlas In r i.._„�...'.r•• •�y,•A ths ham.and ash Rte. i0fnata M Paef an a and '�•d- .. ., Y�eonnfmvMueational - ,. _ DESIGN PRESSURE(PSF) WSW RbA DB' Sloped Sill DH IN TrieeutfA$Q2aMMJWUMut�ItOFAS7UlOL6 Ma[tAldtra ac oaramwnan roa BeaoMeWlaxae. Ho•N er saz.sOi M.EC.,C.E.C,�LEC.C.Air Ia1GRratinn rpui.meMs ViLM1A tfafmarkCeR/imYon Pfegram. The Commonipealth of Massacl usetts i r-�= Depart►nent ofludastrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 62111 r�u wwip.mass gotildla Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricialus/Plumbers Applicant Information Please Print LegIbIX Name(Business/Orgsnizmion/lndividuai): Renewal by Andersen Address: 30 Forbes Road City/Slate/Zip:Northboro MA 01532 Phone#: 508-351-2200 A,re�ou an employer?Check the appropriate box: Type of project•(requit•ecl): i]d 1. 1 ata a employer with 30 q. ❑ 1 am a general contractor and I employees(full and/or pmt-time). s have hired the sub-contractors 6. 0 New construction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7.19Remodeling ship and have no employees 'These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp,insurance comp.Insutance.t 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical mpairs or additions 3.0 I am a homeowner doing all work offrcom have exorcised their 1 I.0 Plumbing repairs or additions myself,[No workers'comp, right ofaxemplion per MOL 12,0 Roofrepairs insurance required]t ernployces¢[No workers'have no 13.0 Other_____, comp.insurance required,) May applicant that cliects boot#1 most also till odd tiro section below shaeina their workers'compensation policy information. t Haamwnero wbo suimiit this nnidovit indicating they ars doing all wank and then biro outside contraesom must nibmit a new ullfdavh Indicating such. rCcotmeters that cheek ibis bac must staehad an additional shoes shoving the now of the sub-contmelors and state whether or not those toddes have emploqus. If ft sabrcontmotors bac employum they raust provide their workers'comp.poticy runt bar. I ant on employer Thal is providing rporkers'compensaflon bisarance for/10r enployeu Be/vw Is the Polley ft0U1 Job site h fbrnlaflem. Insurance Company Name:_ Old Republic Ins. Co. Policy#or Self-ins.Lic.II:_MWC 3Q543700 Expiration Date: 10/1/16 IobSiteAddress: 55 FARNUM STREET City/St8W&lp: WORTH AN MA 01845 Attach a copy of the workers'compensation policy declaration page(showing tate policy number and expiration date), Failure to secure coverage as required tinder Section 25A orMGL c. 152 can land to the Imposition of criminal penalties ora fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ore STOP WORK ORDER and a fine of up to$2A.OD a day against the violator, Be advised that a copy of#lis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert oder! pnhts mid petaltles of perla{p that the ht/ornr/r1/on prmldel above is true sed correct. 09/19/2019 Phone#: -22011 aw wily. Do no/tprile hr this area,to be completed by city or tolpn offlelnl, City or Town: Permit/Lfeense# Issulog Authority(circle one): 1,Bonrd of Realth 2. Building Department I Clty/rown Cleric 4,Electrical inspector 5.Plumbing inspector fi.Other Confect Person: Picone#: ` i I .,.�""'� /INDECOR-Ot YAO�IVIfp �..�� IBM oiti THS t:ietTT=lZ IS MUED AS A NIATTTR OF WPORtI6ATION ONLY AND CONFM NO MM UPON THE MnFICATE Habl*T?ll5 CFAMCATE DOW NOT AFF~Trd&Y OR IIMT*'VLY AWSM. EXTEND OR ALTEIR TSE CORJE WE AVOCrj ED ay-ME FOLK= NEWW. TM CBMFLCATE OF WSURANCE P= Wr CONSTiril1'E A CONTRACT OffTWEEN THE WBUM ffWRWR)A AUTHOMM REPRESENTATIVE OR PFCOM13L AND THE CER IFTCATE HOLUM RMORTANL• lE Ilra oerClbete iroldet waeAODA1WiALUISI>tiBb.thpotl es)asst6fr■rdorsrl. tittlJ6pOt;ATtpN19WWAIVMIsubJpott4 to tNI'm rid ora>"Qnr at the PollW,4Wtl9n pafdsa mq rlW*s sI,srrdanleroard.A sWmRsrrt an this ss�Icrda gees net eoWsr rlUher m tlra oertM@m 1o*W In nm o[sLmh rsoosa wink taartfooft Carder VAft d!=Ino. a&73Td 4EY.M MaelNll�BMd 1It Aeloao�soaae� Iyaer m=WWA.'am Rsoubftfrraemnce CknImEii4'f Rswag by Andsmn LLC C 30 P j Rnsd aUY C c KcaboraMb,NA Of= IM:1NesRr: azWtl9R� EX1 CERTtRCATE NLMMERs RE MON NUt7o t TH44 IS TO CERTIFY'1HAT TW poUGES CF N311RM CE LISTED MLOW HI1VE SEEN NUEO M THE INSOW NAMEOANWE POR THE P4L1CY PERIOD INDICATm NlYT1MTHSTANWO ANY REaIWRENT,TERM OR CONDMON OF ANY COMTMW CR CTHER DODi TygTH R TOVYFIICII TH18 CERT!¢ifATE MAY a5 IMM OR MAY PERTAMI,THE I<iSlJRANCB AFFORDED BY THE POLM'dE5 DESCRrEED HEMWJS$,=l CTTOALJ.THETERMlk OWLIMOMS AND CONOITIC.Ya CFSUCH POLICIES.LIMITS SHDft]MAY HAVE J EEN RWWM$Y P1MD CLAM vw �IE 7OP11/tlMNC! Pomy ummmmlr 9= Lmmulr uwm r�ocasseercE i 1,00 «Ae 0eoLRYst4o 1010tAQ1a itwlaae s Pal NKAwwou rn ; 1,ow aL'Mt AGORE�A7EpW�ITAPPtIBa AEIt F ucy Q a ClLOC 2X0THM C FrU7DUare-COrL'9GPAID[! ; �QQp. A41Oma"uRmum A 7C Awmmylle=96433 t01o1replb 1tW1f:Ot6 eemLYauapri�ww+.1 s Sam m a w iomw BOl71LYlNIQQi(ryr A H m mm AtRa$ s FE MnaMs AGNMWE s wpsssasapsrettA7raw a Aso®vrrFWUA aalr Tin. X A WPMWBRGUEWW ga�om MIA 7C6 10t0112p16 1iy01gp1i FLEaglAGC1DLPrr wy n4Meparmp lr ��EAAZIONE ELQieCy1P6-51 E oS6149e.PaUGYurm • 1 OF�adPepr oFarprArloiwlLoonnoha/vneoLtaeµraowo 17yAU�e�flHrarir�aRyaabe!_•aR�o»y�T.�yorn:4 CERTIFICATE H LANCE LLATM Tm ppuym OR THE ASQVE Dllmom 1OLa"W COVAU.0Pm Tl DRAW=SE DjApYW?W Q=jjjj � A � IN pE ACORA Z tg"4101) T4rQ�Ct73tO ntar tsred iagc„ra rLB CORPORII?IOAL All rim . I; I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS4)90125 JAEM L MORM.;- 86 GARDEi= ST LYNN hU 01W Expiration Commissioner 10/06/2016 Q9L let Of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR istratigm.."'llmlo Type: Supplement Card RENEWAL BY AND,'11 JAIME MORIN 30 FORBES RD r NORTHBOROUGH,MA 5�2 01' Undersecretary -7