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HomeMy WebLinkAboutMiscellaneous - 565 TURNPIKE STREET 4/30/2018 (5).......... 328 Date. .>. I pFNpRTM , TOWN OF NORTH ANDOVER .ao tip PERMIT FOWME.OFiAWWAL INSTALLATION D This certifies that .j. l .1.��:.� :.. ... y .... has permission for mechanical installation���!'�' in the buildings of ................. at .... / 1 � ^, ... ........... , � north Andover, Mass. Fee.—;5 5? Lic. ........ GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer lcx The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 UT www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): El Te C, ,i D N Se 121% i C- S Address: P6 8&)x y City/State/Zip: Pe l I Am AJJf 650 i6 Phone #: 663 6 3,s' — _3 (Z d Are)wu an employer? Check the appropriate box: 1. LVA I am a employer with I �- 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. ❑ 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [Kemodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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 a:re doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date):. Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well .as civil penalties in the form of a STOP WORK ORDER and a fniq of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y do hereby certnder the pains and penalties of perjury that the information provided above is tfue and correct. Phone #: .60-3 d,33- 1 W 3 1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 #• 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 pglicy 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 }fear. 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 bum 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 CorxumonwealthofMassachusetts Department of ludustrial Accidents Ofte of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wFvwaxxass,govldia • ..':..�. ice. .0 N �% ', ,.yry 5 Fi p a Date......................1.................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ rp- has permission to perform...................................................................................................... wiring in the building of..... , tsJl1 �Cc,,,,,,, „„ .........................F�� ........................................................... }e_ at ..... W ....:...l. t/Le�.1. .�w2 � ......................... .North Andover, Mass. .................. Fee:...� `--'....... Lic. No........... ........... ............................. ELECTRICAL INSPECTOR 'Chock #�� S Offl.64 U e Only Commonwealth of Massachusetts Department of Fire Services Permit No. PDX Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 1 "\ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL !WORK a All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATI011� Date: — 2 l 3 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) Sg 5 T<rn Q tke 54-ree--t s4c 73 t \+ Owner or Tenant F ✓� ' f` j h c� lL,l' ' . !n9 ;� Telephone No. Owner's Addresses O Is this permit in conjunction with a building permit? Yes Rr No ❑ (Check Appropriate Box) Purpose of Building _ , ,a eA- Tt C.,,_ 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: Ve t, e lqj �� u d c e ��-� S Completion of the following table may be waived by the Inspector of Wires. t Attach additional detail if desired, or as required by the Inspector of Yvtres. Estimated Value of Electrical Work: /0700 ®Q (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 cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o Emergency Lighting Batter Units Battery No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number "' ' ' ' "'' Tons """.'" "' "' KW ''"""'''"' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecN . of De ices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Licensee: Signature LTC. NO.: (If applicable, enter "exempt" in the license number line.) / Bus. Tel. No.:��/' Address: e y/ kl a -7 Vt!j MW 0 9 Alt. Tel. No.: Dsw -&AS -�./5; ) *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/Agent PERMIT FEE: $ i Signature Telephone No. ❑ 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 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 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: M Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL, ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: t. Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL, LNSP Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: �� Jam, ; a l/ Date: — 27 /3 DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 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. ❑ 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.] t 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.❑ Roof repairs 13.❑ Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine = . of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: 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 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 shallnot because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) 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 lndustrial Accidents Office of Investigations 6 00 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax # 61.7-727;7749 Www,mass,8ov1dia RI C I A } ISSU S T E FOLLOW ~ A O U N\ + L GT :CENT d NA � , ! 0 I d % '91 KENDAL:' R D 0187§/l\ l �� ©'loin . d« 07/ll 64 . . .. . 10166 Date . 1 .1811 - .... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING •ice This certifies that--.-.. �-A AA . K0 V!°1.A,-J.,O ,.................. has permission to perform . � ..��. f,� ,}. 'vI 4�; plumbing, in the buildings of .. .S.e. Gs. Q- .Af?t . at ...5US............ North Andover, Mass. Fee . 4 ��.�`?. Lic. No. .�3................ .... ... PLUMBING INSPECTOR Check # 4ni-7-7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORE( - CITY # MA DATE C - ) PERMIT # I 9 •- JOBSI.TE ADDRESS -- f '� OWNER'S NAME _ � Q%+-�'-� POWNER ADDRESS ' fr t` Wit' TEL o4 AX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Dal," PLANS SUBMITTED: YES E9 NOF FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM! DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ! - E (A. t J ---j1= DEDICATED WATER RECYCLE SYSTEM DISHWASHER I 1 _ ( ! ! . Y_! J ___._ .__ DRINKING FOUNTAIN FOOD DISPOSER — ► _! __.____! .__A! _.._- ! ! _ I .----- ___-._J .__J -.--1 FLOOR I AREA DRAIN i ; J _ i I .__. J ____j ..__.__I _._._-_-! ..._—_) ! __.-- INTERCEPTOR INTERIO) J SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I __..-___(_ URINAL WASHING MACHINE CONNECTION WEER HEATER ALL TYPES WATER PIPING THER r f moo v-. S't N K INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES M NO IF YOU CHECKED YES, PLEASE INDICATE THE T E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q 4 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E-11 AGENT SIGNATURE OF OWNER OR AGENT y I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the }Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ u �9" I LICENSE #1 - S3 I SIGNATURE AAP JP E-11 CORPORATION f� # fb$�b _ PARTNERSHIP #r --LLC! j COMPANY NAME '2o iApr , =tJ L . ; ADDRESS (q (p iL(-e I C'- ! CITY I9_�-�_ _------- -----__.-._STATE ZIP TEL (c!_C , wAWNI FAX CELL �� EMAIL v ►' t v- o a N.Q C JIV r— sl The Commonwealth ofllassachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.rnassgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers Applicant Information Please Print Legibly NaMe, (Business/Organization/Individual): i"1 2p 1n�� N C--) V' -k e - Address: C o Co Ar VA k� t� r? I G t - City/State/Zip: 20 0 CS f --Q— U.(s o -1 1 S I Phone #: (o a ` 3 "401 (3 Are yyn an employer? Check the appropriate box: Type. of project (required): L I am a em to er with S - p y 4. ❑ I am a general contractor and I 6. � New oonstruction ` employees (full and/or part-time)." 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. x �• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. F1 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions required.] officers have exercised their 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 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they 2te doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees..Below is thepolicy and job site information. ; , x I— • I Insurance Company Name:. - Y 6 ' Policy 4 or Self -ins. Lic. 9: �(� ��J _ i �S ExpirationDate: l I L Job Site Address:_ City/State/Zip: Nof t{--- Cl w c, a�/ Q V Attach a. copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations oft e DIA for insurance coverage verification. Ido hereby ertify nde thepains penalties ofperjury that tl information provided abo a is tr a and correct. Si fur . , 1 Date: / � J( &i) alq3 u9 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License ff Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown CIerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 ofthe 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 ofits political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be, returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' . compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials --Please be, sure that -the aff idavitis -complete -and printed legibly: The Deparimeiithas 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: Tha Commaw.oaltf1 of Tassacl?v.,setts Dapaitment ofladusWal .A,ccideats Office ofWestigatiom 600 Wasbiiagtou Street Boston? , 021, X i, Tel, # 617-727-4900 at 406 or 1:-877-MA"SSAFF, Revised 5-26-05 Bax# 617-727-7749 4 COMMONWEALTH OF MASSACHUSETTS "i am PLUMBERS AND GASF; i TcRS LICENSED AS A. MASTER IPLUMBER 3. ISSUES •THE ABOVE LICENSE TO. KURT 'C ROMA140 # &6 'AM L I•.A P L pu k REVERE MA`02151 95 s ..� h 15'.'53 05/0.1/14 165;;11 6322 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ........... has permission to perform ...... , ? 2 ... y ...... S.� �_Z . ... ............... ...... wiring in the building of ...... M ...... AA: ................C at 7' Aotc .... ........ North Andover, Mass. Fee ..... Lic. No. ............. ELECTRICALINSPECTOR Check # J, <C11 -\Commonwealth of Massachusetts Official Use Only �ZZ Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (►,ave 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 (PLEASE PRINT IN INK OR E ALL I ORMATION) Date: City or Town of• e. ✓ �. To the Inspector of Wires: By this application the undersig ed gives no ' of his or her #tention to perform the electrical ork described below. Location (Street & N mber0s Owner or TenantT �Sa/A. �/ . /LJ Telephone No.9��r�� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility 4uthorization No. Existing Service Amps / Volts Overhead El Undgrd El No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing 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 No. of Hot Tubs Generators KVA No: of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers p Heat Pump 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 g pp 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: 4 y611 — 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 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, tender the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: ADT Security Services, Inc. LIC. NO.: 1533 C Licensee: DOUG BUCKERIDGE —SignatureLIC. NO.: 2306D (If applicable, enter "exempt" in the license number line) us. Tel. No.: 603-594-5900 Address: 18 CLINTON DRIVE HOLLIS N.H. 03049 Alt. Tel. No.: 603-594-5930 *Security System Contractor License required for this work; if applicable, enter the license number here: SS CC 001594 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance covera"e 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: $ Date.... ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �1(A ` f f ��l has permission to perform wiring in the building of ....�1,..!%1�!�.,r l!(.� J%1../✓. ,�:. ........ t at ..... r<J.� ,<. / ;North And�v�r, Mass. 1 Fee . Z�.Lic. No! I ZI................ .............. . .............................. Ic 1W8PECTOR Check # 4895 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TC All work to be performed in accordance with the I! (PLEASE PRINT IN INK OR TYPE ALL INFORMATION City or Town of. North Andover I By this application the undersigned gives notice of his or her' Location (Street & Number) 565 Turnpike Unit # 73 Official Use Only �Permit No. 14 !Occupancy and Fee Checked f [Rev. 11/99] (leave blank) PERFORM ELECTRICAL WORK ssachusetts Electrical Code (MEC), 527 CMR 12.00 1 Date: 11/21/03 To the Inspector of Wires: to perform the electrical work described below. Owner or Tenant Dr. Incampo's Telephone No. Owner's Address Dr. Incampo's, 565 Turnpike Unit # 73, North_ Andover Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Office Condo/Dentist Office Utility Authorization No. N/A Existing Service 100 Amps 120/208 Volts Overhead ❑ Und rd g ❑ No. of Meters 1 New Service Amps Volts Overhead ❑ Und rd g ❑ No. of Meters 0 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Unit 73, Dentist Office No. of Recessed Fixtures 20 No. of Ceil.-Susp. (Paddle) Fans No. o Total V Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures 9 Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting 6 Battery Units No. of Receptacle Outlets 30 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches ,10 No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges No. of Air Cond. 1 Total 5 Tons No. of Alerting Devices 2 g No. of Waste Disposers Heat Pum Totals Number Tons KW No. o el - ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ®Other Connection No. of Dryers Heating Appliances KW Security S tems: No. of Devices or Equivalent No. o Water Heaters KW No. o No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors 1 Total HP 1/2 Telecommunications Wiring: No. of Devices or Equivalent OTHER: livacn aaamonat aetall ty desired, or as required by the Inspector of Wires. 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 N BOND ❑ , OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: 11/24/03 Inspections to be requested in accordance with MEC Rut 0, and upon completion. I certify, under the pains and penalties of perjury, that the information on thi plic n i true and complete. FIRM NAME: East Corp. Electrical Services LIC. NO.: A17107 Licensee: David W. DeBeaucourt Signature, L3C.-NO.: (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: (978) 250-1156 Address: PO Box 146 Chelmsford, MA 01824 Alt. Tel. 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. FPEJ?MITFEE.$125.00 Date..f k • f NOR7M , TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING a i a This certifies that . �O t� �.'e. �.� `�. �. o` v .......................n...r ry 1- a. ....G %-t`I Cie Z ro 1, 4— has permission to perform ........ . r 1' N C v"t a ..S plumbing in the buildings of .....-..........� .............. . S.. �' �!`^'.►��, .�`� s , North Andover, Mass. at .... .............. Fee. %36 'ic. No.. 3I?.7. -1 ..-.t07-L 1 V1MtGuI� -� PLUMBING INSPECTOR Check # 5816 W • MASSACHUSETTS UNIFORM APPLICATION FOR`PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS / Date Building LocationS� j// / f 01 -:23 New 1:1 Renovation El Owners Name of Replacement FIXTURES Permit # Amount 1,5- 6. S c .Q. Pons Submitted Yes No ❑ (Print or type) / / Check one: Certificate Installing Company Name Corp. Address Partner. z``� �r ""� e `� —A usmess Telephone 917 7 %3rYa Firm/Co. Name of Licensed Plumber: ^d".1 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policyEl M F1 Other type of indemnity Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have anyone of the above three insurance Signature Owner El' I hereby certify that all of the details and information I have submitted (o tered best of my knowledge and that all -plumbing work and installations p ed undi compliance with all pertinent provisions of the Massachu Sta n C� By Signarure 01 Llcensea'yjum er Type of Plumbing License Title. le3v 0 City/Town License Mumner Master APPROVED (OFFICE USE ONLY Agent ication are true and accurate to the d for this application will be in 142 of the General Laws. 5 Journeyman ❑ / •I 11' M-MMM-MMMMMMM-MM-MMMMMMMI OF,00iort--t,MMINIMMMMMMMMMMnMMMMMMIFAMMIUMI ------®-----------------' , I 11:' MMMMMMMMMMMMMMMMMMMMmmmmI 11:' ----------M..M----------I mr,ii.-Our.re"mmmmmmmmMMMMMMMMMMMMMMMMMI :1 11:' mmmmm®---mm-m-m--mmm-mmm1 (Print or type) / / Check one: Certificate Installing Company Name Corp. Address Partner. z``� �r ""� e `� —A usmess Telephone 917 7 %3rYa Firm/Co. Name of Licensed Plumber: ^d".1 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policyEl M F1 Other type of indemnity Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have anyone of the above three insurance Signature Owner El' I hereby certify that all of the details and information I have submitted (o tered best of my knowledge and that all -plumbing work and installations p ed undi compliance with all pertinent provisions of the Massachu Sta n C� By Signarure 01 Llcensea'yjum er Type of Plumbing License Title. le3v 0 City/Town License Mumner Master APPROVED (OFFICE USE ONLY Agent ication are true and accurate to the d for this application will be in 142 of the General Laws. 5 Journeyman ❑ Location No.Date NORTN TOWN OF NORTH ANDOVER f � Certificate of Occupancy $ ' ' Eta' Building/Frame Permit Fee $ 3 CHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $� r Check # 16 8 8 8Buil `ding Inspec, C/ ` TOWN OF NORTH ANjP -.-il rARTMENT APPLICATION TO CONSTRUCT REPAIR, RENO v OTHER Repair(s)` i HE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING ❑ fWO-FAAHLY DWELLING x � :.e+i#-Y=-O`� ,fid '1tlgKLc"G . - , $ TFnn .bSa �'. s, n a.^ s�4�:.. T)hl$'..-. ;.s a.€ �. .-•-CIRI Use DIIJ 'r� i' *:1 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: 4 , Building Commissiot ► r/I or of Buildin Date SES 1.1 Property Address: j P% 3 5 7 t2? sire"O', 1.2 Assessors Map and Parcel Number: r Map Number Parcel Number L!, Zoning Information: 1.4 Property Dimensions: D�/« Cordo Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard "red Provide Required Provided Required Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ 2. er of Recon to �nc�mpa Name (Print) Address for Service: Signature Telephone 2.2 Authorized ent R, a u l /�?o rY, s 6)(M r A y bund Name Print Address for Service: Signa a ({Telephone 9M.,Qit 3.1 'tensed�struction Supervisor Not Applicable ❑ . /Paul Mbrri'� 6 Yy3U 0 Address `l License Number &Kmv �wKSb kq , In� re b. V Licensed Construction Supervisor: Expiration Date Telephone 3.2 Registered Home 'lImprovement Contractor Not Applicable Registration Number Company Name Address Expiration Date Signature Telephone m 4 — _ - 14 A A Failure to provide this affidavit will result in the denial of the ;Workers~Compensation Insurance affidavit must be complett.. _ _., � .��� issuance of the buildingpermit. '"4n=.�- 0 Signed affidavit Attached Yea ....... No ....... El SEC1 IOPI 5 1Plb)SI4 ifESr�1�TiII iST1C"1� iON� , �I�Il�GS"itii"T1S[TB,1 : Tt? CUNSTt1fiCTiOIV C`!� i1;4pi� TC3 `11 Cly 16 1�G�iA �5, G�?21PIC1FiSId�3PAt L) :: ....... • w 5.1 Registered Architect: K-tS Name: 1/O Address Signature Telephone'' RTK.�.`Tr{T 4JAI�q�� �A�4 b � • Area of Responsibility Name: Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Registration Number Address Signature Telephone Expiration Date Name - Area of Responsibility' - Ir Address Registration Number Signature Telephone , Expiration Date Name Area`of Responsibility Address Registration Number Signature Telephone Expiration Date _ i �� ,G � �o�s�>��cf opt Ca. ��• Company Name: Pau ' � 6 y t6 / S Responsible in Charge of Construction l Not Applicable ❑ j New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) . Addition- 11 Accessory Bldg. ❑ Demolition _ ❑ Other ❑ Specify Brief Description of Proposed Work: AN i al e ri &r l.0 r 6 14 cludeo, s 1)66 71-f U Cp i I i h q Plum h�°ria dad le c f7'i Ca l l g J 5qj fi . - .Y.s '4rY: BUILDING? AREA.,. EXISTING if applicable) PROPOSED Number of Floors or Si,2ries Include Basement levels fi G 6 h e Floor Area per Floor (sf) /0-yq 1h 91q Total Area (sf) Total Height (ft) Independent Structural Engineering structural Peer Review Required Yes ❑ No SECTION 16a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT y I, as Owner of the subject property Hereby authorize ' to act on My behalf, in all matters relative two e'ork authorized by this building permit application Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ All ❑ A-2 ❑ A-3 A-5 ❑ ❑ IA 1B ❑ ❑ B Business 2A 2B 2C ❑ ❑ ❑ C Educational ❑ F Factory ❑ F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ M Mercantile '❑ 4 ❑ R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ S-1 ❑ S-2 ❑ U Utility ❑ M Mixed Use ❑ S Special Use 0 r' Specify: Specify: Specify: CQMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: I *� ti Existing Hazard hide =780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: 5qj fi . - .Y.s '4rY: BUILDING? AREA.,. EXISTING if applicable) PROPOSED Number of Floors or Si,2ries Include Basement levels fi G 6 h e Floor Area per Floor (sf) /0-yq 1h 91q Total Area (sf) Total Height (ft) Independent Structural Engineering structural Peer Review Required Yes ❑ No SECTION 16a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT y I, as Owner of the subject property Hereby authorize ' to act on My behalf, in all matters relative two e'ork authorized by this building permit application Signature of Owner Date I Cas Owner Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Prini Name C . ............... Signa o Owner gen Date Item Estimated Cost (Dollars) to be Completed by permit applicant I . Building (a) Building Permit Fee Multiplier 2 Electrical j . 06 (b) Estimated Total Cost of J Construction from (6) 3 Plumbing L Building Permit fee - (a) x (b) 4 Mechanical (HVAC) 600 5 Fire Protection A /A 60 6 Total (1+2+3+4+5) Check Number NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 No 3RD SPAN DEMENSIONS OF SELLS DEMENSIONS 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 R W M ptOpTh Oq 9eNug CERTIFICATE 0F.'USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 336— Date / - /a _a o o `/ THIS CERTIFIES THAT THE BUILDING LOCATED ON Jr -7'v n� A c (s�- s.,4,- /7 MAY .,4• - MAY BE OCCUPIED AS ^'ta J 4 c le - IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO �a b) O j7,U C.4 M,00 � /yl Z) r13 Building Inspector 7O z 0 1 1 x A 4 z v M 04 �• u w w u co o v w cn A v o o co A. o w o o' w o cn cn Al o m c o s O C o G) a C . O A = � O O :.0.. Cc 2: "ECD CFa :®oa :r: E_ c 41: Co u S lmm�a Q: CO � N N m 3 'c u N �- � m -T-*. N C •� L C cN O O mcm_ p,Ct •_ V Ncm Z O c C •a. CO). ~• y0. NJ m rO+ ~ m t H ascot Z =•m•N O u L E C3 m 0.0 m y a mp=C = A aL • =m C 1— L ai? Cn z O Cf) l 1-4 O v 0 co 0 C L v s Z o Q. O CO) CD cm CO)co 'C MA O O �E m m i O O CL ~ �... . CD cv A 3� O � CD 0 0 L O d CL QM Q o�� O O C.) J .0 D CO2 t; C CD CL �. CO) C — d LLI Q U) CO crW w IrW U) STATEMENT OF PROJECT COMPLETION ARCHITECT/ENGINEER Project Number Project Title 6-F�C" T_tti a+;t kf-ujo Project Location 5&5 -rur V1 � f Name of Building NameofProject 0f-fta4 of- Dr. Paolo Lv1CaMpo In accordance with section 115.0 of the Massachusetts State Building Code, Izke- 1✓6f2iL, - Mtn -;ts _ Registration Number. "7 J'D (,e being a registered professional engineer/architect have prepared or directly supervised the preparation of all design plans, computations and specifications for the above .mentioned project. These plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, acceptable engineering practices, and applicable laws and ordinances for the proposed use and occupancy. I have done the following: 1. Reviewed for conformance to design concept: shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Reviewed and approved the quality control procedures for, all code -required controlled materials. 3. Been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work was being performed in a manner consistent with the construction documents. I visited the construction site during the building permit application process, and/or sent other appropriately qualified -design professionals, and determined to the extent possible that the work was done in accordance with the documents submitted with the building permit application, and the applicable provisions of the Massachusetts State Building Code. - . I have provided the Inspector of Buildings of the Town of North Andover with an original, stamped report for each site visit, scheduled or otherwise. �� et Sign - ate Z 3 �-r Com ,t,� 'Qi Co n nvrealth of Massachusetts � ur x c�c;n Foy _ Date: i2-2�—E"3 Then personally appeared the above named ® a and acknowledged the foregoing instrument to be his/her free act JNotary Public RONALi3 P IVIN"' LO Notary Public Commonwealth of Massachusetts My Commission Expires November 8, 2007 ,Z_ _,.a _ FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fro Boards and Departments having jurisdiction have been obtained. This does not relies, the applicant and/or landowner from compliance with any applicable or requirements. ------" ww*w'ADPL►CANT FILLS OUT THIS SECTION APPLICANT Caf!W-111— _. -) PHONE -O �f qgo(J LOCATION: Assessor's Map Number L_�_ PARCEL'` SUBDIVISION LOT (S) STREET �1�1 {r� ST. NUMBER *****************************OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS s� TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENT DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PI FIRE DEPARTMENT `60/) , RECEIVED BY BUILDING INSPECT Revised 9197 jm Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 Workers' Compensation Insurance Affidavit M oln .aQ Location::) � &) —TU IA %oxe- Please Print City NL (/� Imo, / / Phone # I am a homeowner performing all work myself. WWI I am a sole proprietor and have no one working in arty capacity I am an emplWer providing workers' compensation for my employees working on this job. Comvanv name: CW: Phone #- Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of a*r ink penaWes KM and/or one years' imprisonment_as_wetLas_c bd4wnaniessjo-thelms-fa.SIDPWORKDRDER.and_a>ine�f �p CQ)�a fine up to $1,504.00 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for croverage verificationAVAgainst pie1 . � I db hereby certify under theme and penalties ofperjury that Bye W01mb rr provided above is bw and con cx Signae fi Print name�06 Official use only do not write in this area to be completed by city or town official' City or Town Permittlicensinq El Check Building Dept immediate response is required .0 Licensing Board Selectman's Office Contact person: Phone # i� Health Department ❑ Other NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-W 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: I.e 14 (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this projec through the Office of the Building Inspector JDhs��� N/�ndover, rY��1 Lie. No___3 4 9 Class LF_I IF 11 IF,1V V J_ Expires 7-31-04 Date CITY OF BOARD- Of EXAMIN-ERS CAMBRIDGE.- BUILDING DEPT. LICENSE FOR CONTROL �CF BUILDING OPERATION This is to certify that PAUL MORRIS is duly licensed to takenal th C provisiPer Charge Of Work under ons Of the Building ordinances of the City of Cambridge. Board o e Ae Signature of Licensee (OVER) BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR efAP 7 Number: CS 044300 Birthdate rthdate., `02/22/1966 E xPires: 02/22./2004Tr. no: 16725 R ncted: 00. Restricted: PAUL R MORRIS 682 SOUTH ST TEWKSBURY, MA 01876, Administrator CITY OF BOSTON BOARD OF EXAMINERS Lic.'No: 13-10050 MAYOR THOMAS M. ME.NINO BOARD OF EXAMINERS HEP' iFiE S PAUL.,R-MORRIS . IS DULY LICIENSE016TAKE CHARGE CF - WORK UNDER PROVISIONS OF'i HE ACTS OF 1938. CHAPTER 479; AS AMENOED.i SEE BACK �0123/03 110/23/0'4 A ori CITY OF LYNN BOARD. OF EXAMINERS LICENSE NO ..... CLASS Paul.. R....Morris ....... 7 Boxcar Blvd...... .................. residing it . Tre�-sbury, Ma.01876: ......... I....... ..................... As hereby Licensed to have Charge, Control and Pers OriallY. Super- vise Construction, Alteration or Repair Work I , n the Classes of Construction V #above.. Si EXAMINERS AIRMAN 80t AMINERS RENEWAL FEE $25.00 LICENSE EXPIRATION ............ .............. LATE FEE $10.00 - AFTER 3 MONTHS 14 M 6 z I W O C1 w° cn ° ° v a a F w WEIRI w z Q o c c �a� c O 2 C N O C � c vO O. 1 : O. = C !O O L m C m O • c -w +? cp CD L Q 42 N N c i - c � :o m �•'� c� ca d I'-- N A O E� N m ;�: `' •=L Q �' Q! p C �: C N Q acCD s � ■ C� y O L c o c ~a Q � y p C O = maoN C2 CDZ •H EL.LU e0 C Z m E RO- V N o C-3 a g S :0. CL m a• I �7 p O ai L V z O y c CD cm I O 0 � CO m •CD O co ~ " CD � � L ca cvv o oma',• O *-� c cvCc v J .p c Z � cv o. cc c •� C c CLH ui 0 w LLJ cr W U) Location /�c, r U ' �� (54— No. —,40 // Date TOWN OF NORTH ANDOVER " P, Certificate of Occupancy $ ' Building/Frame Permit Fee $ Foundation Permit Fee $ A sacHusE Other Permit Fee $ Sewer Connection Fee $ -- Water Connection Fee $ TAL $' p Building Inspector 3 J 9 8 to 65. oo PAID Div. Public Works ? x F c.r _ C r z z 7- C C U U = z T U Z/; 0 f Ul W ? Z 4 Z 2 k 4d c > 44 F O r C c V) C C G y '= CA 4 O C UZ Z z O C C = c C to V) L. C U U _ (n C C U V L O Z CC w Y� z o � a I o � o W 4 F m C Qy O ro O +.) rrs U c v U) i� U) H F z_ v C > pq i+ _IZL ro E x` w O a z r. U) rd U z c _ - �4- Z C z Ln Lr ) z N = t R; z L U C C C - � C C VI C C GJ � F _ F C C C U U U L L L c � _ La w w L z L� M N H I co r, ri O �a N M 00 O O t` O Ol U) N — U -1 ? x F c.r _ C r z z 7- C C U U = 0 z 00 w u -v w E v cn 0 U z Q C 0 w p c4 U cz C w" a p �, C FO W U W o C o" o a GO z d 0 ro C H W d w Q W c co V)V) O ' r O •dam C �+ CmN CD 0 CD � Qua Z N O' E c C2 09 �. CM . .� N m f� � U H 3 w c o = C N N m = W C h+� ( E� U wo mrrC/)� W C CC A > a C cm 2 m.=.,p N E.N erC Ocr- H N •d= Z 1 LU E `� m N o co V7 CL = R 3 L- = O fit F- L m CD s ,m ae I a� O CD L O O V Z co CL O ti D C CD cm I o ;2 CD yO .O �E ca cc i O w CLCD O O G O �Q h C o � � cv C.) CD V CD h FORM U ---LOT- RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from - Boards and Departments having jurisdiction have been obtained. This does -not relieve the applicant and/or landowner from compliance with any applicable or requirements. * -*****************APPLICANT FILLS OUT THIS APPLICANT 03;�_,d //� CI PHONE LOCATION: Assessors Map Number PARCEL I SUBDIVISION LOT (S) 7// STREET C' CA) e cS 4 ST. NUMBER * O F F IC 1AL USE RECOMMENDA T IONS OF TOWN AGENTS: /j/ /D /z SND vA �o�v COERVATION ADMINISTRATOR CO MENTS TOWN N zMIVI LANNER ENTS FOOD INSPECTOR -HEALTH S . TIC/INSPECTOR-HEALTH COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED PUS KS - SEYVER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING iI ISPECTOR Revised 919; jm I IOAV 9, DATE Town of North Andover OFFICE OF COMMLWITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 0 S45 WU,LLAM J. SCOTT Director (97 8) 688-953 Q NORT1y O � L= Fax(978)688-9542 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposai facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: v A-7 /!S' T eA aw J J 7-6 (Location of f=acility) Sianature of Permit Applicant Date NOTE: Demolition permit from the Town of Ncrth Andover must be obtained for this project threua-h the Office of the Building Inspector M BOA1R_D 0F APPE:�.LS 623-9541 B[RLDI' iG 653-9545 CONSii2VaTION 683-9530 HE. -:.Tr 633-95-10 ?LAL,MIi C. 68S-9535 Name: Location: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print City Phone am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. Company name: CKB INC. Address 90 Lowell Road l Print name 6-2 ry esu s 1 L �',,E 7- City: Salem NH 03079 Phone # ( 603) 894-5820 ❑ Lincensing Board 0 Selectman's Office Insurance Co. Traveler's Insurance Co. Policv # UB909K424199 Company name: Address City: Phone #• Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the adon provided above is true and correct. Signature Date 9/2 pY l Print name 6-2 ry esu s 1 L �',,E 7- Phone # 1174F91 �5 7131 Official use only do not write in this area to be completed'by'city or town official' E] Building Dept ❑Check if immediate response is required Building Dept ❑ Lincensing Board 0 Selectman's Office Contact person: Phone #: F, Health Department ❑ Other . i.'. � - .. :. s. j j �;. � t �, \ la 09/30/1939 m m IC:31 9782584136 � 1-< 1-� 1� !J 1-� !� I-< 1� I-< N 0 w Q 0 0 w 01- 0 -0 -0'-011 -01-0 'MI m ar i -p IO to m Q0 '4 1 rO co -------------- i to0 Ol M m L- : :: : M .. CIO cn mL') A0 ou G) M.< i. ;9 Ln r m > -M m C) m rn Fh M 0 ch m v7 4 M A c Ch C) m m R3 C! C I > Q z m R cn ' OD -n 0 M 4- (J X 0 -I 0 > I CD ay 0 0 0 N m � I � m� � i� I 1 i � 1-< 1-� 1� !J 1-� !� I-< 1� I-< N 0 w Q 0 0 w 01- 0 -0 -0'-011 -01-0 'MI m ar i -p IO to m 1 co -------------- i .11 � 1-< 1-� 1� !J 1-� !� I-< 1� I-< N 0 w Q 0 0 w 01- 0 -0 -0'-011 -01-0 'MI m ar i -p SAIFUR RAHMAN PAGE 01 • ?A 0 LM -------------- IO m 1 co -------------- i .11 .. i. CO COI ;l 00 M M -I I I , 0 0 0 SAIFUR RAHMAN PAGE 01 • ?A 0 LM -------------- IO m co -------------- i Location � u Y ti,� + )�� 5 UN' ¢ 7 No. Date ya 9 pOi1T" TOWN OF NORTH ANDOVER f �,y O ••�c •r O 0. n Certificate of Occupancy $ Building/Frame Permit Fee $�' o • . ��s'••r"'''tn _ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL �7 Building Inspector I 3 U / 0 04/27/99 13:30 52.00 PAID Div. Public Works E J A. 9 z U x F- X j W Q a �r �— lS 9 Cb F � �g u O FF z --O � W Old u cu U7 2 U w z m m m F Q m ST a �r �— lS 9 Cb F � �.0 30 u O z Old ¢ w O j CH): F ST L2, s Y s m ii F Ooz 6 z w pe 8 w 3 0� v¢ M F H S° N¢ o a a �Z a z a z o ow, ¢ Q ¢ F z F u F p c7 C7 Z p ¢ o p F v a w U ¢ zU z U U z s Q Q Q s O U Ln ¢ ..�� a a, 2 �r lS 9 Cb F � �.0 30 u Old j CH): L2, a, 2 �r lS 9 Cb F � �.0 30 z U O O a, 2 0o Twu w w o w x w z z 4 w x A U C7 � d a z w E d w `n bri c�CO0, -1 Ca � s w �v cc son m ° r. �°U w Cw wvLcw w � V) z am _N L 0 N C cn m C: o, m O cm C �C N CD r O Z 0 O to V ca CDL#* CDL CL CO .�i C O GD v m CL CO 0 Q .Q U) C O V Fo— .0 o co � O O a CL ca J .O O Co Z Q CL y C _o Cn Cn w W W U) y r .0 O o 2 40 ` p N O V V i. cc �[ Q m C o � L % c 1_-e v M 2N E c 3:o`m b V c8 me N O � - d V O r : y -#-a CA -#- .0c y CC `E��TmO y m m �a�pc o. c z mor Z cc9 w; C O p dC m H 0 V) W oC~�Z LL m r.. C r.. .N .Q O H C •N W E w V v m` cc' m!Ec Ni d N t � O` h •O r0. a_.., m _N L 0 N C cn m C: o, m O cm C �C N CD r O Z 0 O to V ca CDL#* CDL CL CO .�i C O GD v m CL CO 0 Q .Q U) C O V Fo— .0 o co � O O a CL ca J .O O Co Z Q CL y C _o Cn Cn w W W U) 1 pEPARTM�r ENT pF ofd a�� �. UBL9C SAI Y��`'Ptt CONSTRUCTION SUPERVISOR LICENSE Number: Epires: Birthdate: CS 022332 09/14/1999 09/14/1939 Restricted. To: . 00 RALPH: G; OELLATTO 24.MARIE OR ANDOVER; MA 01810 °T.� Pom�,tat«o/� �✓tum HOME IMPROVEMENT CONTRACTOR Registration 118950 Type - INDIVIDUAL Expiration 05/08/99 RALPH DELLATTO � 46 � Z " H G. DELLATTO ADMINISTRATOR MARIE DR ANDOVER MA 01810 uDId JOOl E L --JJ ID �l MIR I Im mi lol I C4 /4 e ( C7� C �. �,��a�Qr • r�l� . a Q rn aY e�i �A 55 �_ 2 �o�WE'y f 008467 INSURER: RELIANCE INSURANCE COMPANY 1. INSURED: DELLATO, RALPH M. 24 MARIE DRIVE ANDOVER MA 01810 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GRI 0UB-466X445-8-98 ) RENEWAL OF (6R10UB-128D724-4-98) PRODUCER: HOWE INS AGCY INC 4 PUNCHARD AVE. ANDOVER MA 01810 NCCI CO CODE: 80039 Insured is AN INDIVIDUAL Other work places and Identification numbers are shown in the schedule(s) attached. 2. The policy period is from 12-18-98 to 12-18-99 12:01 A.M. at the Insured's mailing address, 3. A. . WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compen- sation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 12-29-98 RM ST ASSIGN: MA OFFICE: ORLANDO -RELIANCE 825 PRODUCER: HOWE INS AGCY INC 28XDK Town of North AndoverNORTH OFFICE OF 3� Oy t a o e 1 tiO COMMUNTTY DEVELOPMENT AND SERVICES x 27 Charles Street North Andover, Massachusetts 01845�4SSnc►+us�k Cl WILLIAM J. SCOTT Director (978) 688-9531 Fax (978) 688-9542 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. kI The debris will be disposed of in: S 1o h !� /h �e 0 P—Loo,�e�,�Qrr-y on of Facility) �/ d ► Si nature of Permit Applicant �--P�- 11� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICA-NT fiLLS OUT THIS SECTION'"`*****************'k'ri`s`** APPLICANT i 1� \ \ l 0 PHONE a LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET '�- (� �? IQ rr\TI ST. NUMBER RECOMMENDATIONS OF TOWN AGENTS: CO (SERVATION ADMINISTRATOR CO MENTS TO N PLANNER CO MENTS F OD INSPECTOR -HEALTH S PTIC INSPECTOR -HEALTH OMMENTS USE ONLY**kk****�*** DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED. DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWERIWATER CONNECTIONS pi Kf DRIVEWAY FIRE DEPARTMENT RECEIVED BY BUILDING MSPECTOR DATE RMIT d Revised 9197 jm The Commonwealth of Massachusetts Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 Office Use Only rerait :o: Occupancy 6 Fee C eckad� itesve blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All —k to be periormed In accordance with the Massachusetts Electrical Code. 527 CMR 2:00 (PLEASE PRINT IN INK ORE ORM=ON) Date Z ,-r City or Toes of �}'`� To the Iaspee r of Wires: �� The undersigned applies for a permit to perforce r- electrical work 4W -scribed below. Location (Street & Number) / � �2 It CXR u V1 Owner or Tenant eG 4 -e 7_ / s Owner's Address K_eA M IL -7 Is this permit in conjunction with a building permit: Yes_JZ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Haters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Haters Number of Feeders and A_=pacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets 8 8 No. of Hot Tubs Total No. of transformers KVA No. of Lighting Fixtures Swimming Pool Above In— grnd. ❑ grnd. ❑ Generators INA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal❑ Other Connection ;to. of Ranges Total No. of Air Cond. tons No. of DisposalsINo. of Heat Total Total Pumos No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices tai No. of Water Heaters KW INo. of o• of Signs Ballasts Low Voltage Wirin No. Hydro Massage Tubs itNo. of Motors Total HP 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 F]I have submitted valid proof of same to this office. YES ®. NO If You have checked YES, please indicate the type of coverage ec%ag the appropriate box. INSURANCE � BOND ❑ OIHER ❑ (Please Specif �// 7 XSJ Expir cion Dace) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rugh_2kzk Final Signed under the penalties of perjury: FIRM Ic -e 3 Licensee J Signature �' LI N0. Sy 3 3 Address Z /LG 5-/ e !�/ us. el. No. Sak !oy Alt. Tel. No. OWNER'S INSURANCE WAIVER: I an 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) *� l Telephone No. PERMIT / FEE S f �/1C�' (Signature of Owner or Agent G� r Date ...... . 331 "° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSAcMuS� -. A This certifies that .....)T�_�4..... �....1.�.....:....:.. has permission to perform ...... .......C� s.4. wiring in the building of ........ .:?G.f...... f-11;; 4 .. ..... LL at ........I!o..r....� t. ........................... . North, Andover; Mass Feb.7.. �. �O.. Lic. No..... 1� ................................. _ ��` ELECTRICAL INSPECTOR 07/22/% 09:02� �: WHITE: Applicant CANARY: Building De 75 00 Treasurer x A c o V4 v v cn O p z z z Q p o w o rr4 v c O4 v z � o [ O w u a W a c H w � " C c4 C w w w Q x w v 7 m a cn o o cf) F. Z m `m O C E m N R L d. C R O Lm i C O • O y r E Q . a. ' m C t v :... o co a N co O r•+ ca .O.• 7 cm m C N Mm d i:+ v m m N H co 3 H m� C m O H CC , y C C .: cc o N cc m E� o cm G1 m o C = O . c CM caCD o� : GiV•'V� Z O Q mO � Of o c_ : N m C C Q 3o I V 3 m CO N m ~' t c «- Z ca O E O 'O oC J CL �O ' o 'U :W m c c o � O H VO V •Q'fl F. Z m `m O C E m N R L d. C R O Lm i C O • O y r E Q . a. 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