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Miscellaneous - 59 HUCKLEBERRY LANE 4/30/2018
59 HUCKLEBERRY LANE 210/065.0-0218-0000.0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK P _ CITY ji&r- 4111606�-- __ MA lug DATE F/-;-7-d1_1 S"_. IIPERMIT# JOBSITE ADDRESS Yu C /�.f�,�r Y OWNER'S NAME rn GOWNER ADDRESS S' TE J�$^'02��'� �FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONALD] RESIDENTIAL,O PRINT CLEARLY NEW:[Q RENOVATION: REPLACEMENT:,M PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1. . . - I. . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE — FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �I OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER .z I WATER HEATER OTHER I _ _ ED�I. J I E= I __J ► _ .1 _ 11�- - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 14 NO E] I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' ce with all Perti �prlon of the Massachusetts State Plumbing Code,and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# 6 ( dC SIGNATOR MP El MGF 0 JP JGF LPGI 0 CORPORATION E]#[:=PARTNERSHIP 0#=LLC®#I _.. COMPANY NAME: e ' ,�� 10.E ADDRESS o, I CITY STATE ZIP _PZ. ,1l �I TEL �5 FAX ---- CELL !EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVH;W NOTES 14 ham- �5�0%.,� ✓` ;fJ� — ,`j —' // cs �, � � 1 w` The Commonwealth of.Massachusetts F Department of Industrial Accidents M . . _.`�+�� X Congress Street,Suite 100 Boston,MA 02114-2017 .�� -~• �t www mass.gov/dia o1M S��V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/l'lumbers. TO BE FILED WITH THE PERMITTING AUTHOPJT Y. Blease Print Legmlbly A ''licant Information Name(Business/Organization/Individual): A ddress- Phone#: City/State/Zip: xo nate box: FEN ect(xequired) Are you an employer?Check the app p em to ees full and/or part-time).* onstruction 1.❑I am a employer with P y 2.❑I am a sole proprietor or partnership and have no employees working for mein deling orkers'comp.insurance required.] • lition ow any capacity.[N o workers'comp.insurance required.]t k myself addition i am a homeowner doing all worC� 10 Building 3. I ❑ 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11❑Electrical xepaurs or additions ensure that all contractors either have workers'compensation insurance or are sole t' UIlTb311g repairs Or additions " proprietors with no employees. 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11❑Roof rep airs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that check's box#1 wrist also fill out the section below showing their workers'compensation policy information: 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 state whether or pot those•entit;es have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: f�G Expiration Date' Policy#or Self-ins.Lic.#:. City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). olation 0-00 Failure to secure coverage as eas well ased civil ivier llp25A is enalties?inthe form of ST Pa criminal LWORK ORDER and a fine of p to $2050.00 a and/or one-year imprisonment, day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA fox surance coverage verification. es of perjury that t/ie information provided above is true and correct X do hereby certify under the pains and penalti . Date: Signature: Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permi-t/License# Issuing Authority(circle one): 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 6.Other Phone#• ContactPerson: 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 def 6d 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 receivetb r trustee 6fan individual,partnership,association or other legal entity,employing emplbyees..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 b6 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 applicantwhd has not produced acceptable evidence of compliance with the insurance coverage xegnired." 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 certificates)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 IndustrialAccidents. 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 i 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. Anew 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MA8SAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia • ~ Commonwealth of DepartMe Massachu nt of Public setts License. PJ- Safety 299631 Pipefitter JOuneym wpp GEORGEs, *� 1 REyA °D S�TTY, ERE MA 02151 ,y.. r � .v — • -�-____Commissioner Expiration: 0810412017 Ll12015 16:34 Sabatino Insurance Agency TAX)617 544 6007 P.0011001 bP CERTIFICATE OF LIABILITY INSURANCE °�'�`"12/2'"I' 12 21 15 IMS CERTIFIGATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES RFI AW. THlft rFRTIFIrATF nF INAIIRAN(tP flAFA NnT rnNATITIITF A rnNTRAeff PPTWPPM TNF IRAIIINE; IN.gIIRFR(Jt), eln'MnAI7Fn REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. —IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED,the policypes) must be endorsed. If SUBROGATION 13 WAIVEID,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certiflcate holder In lieu of such endorsemen s. PRODUCER Sabatino Tnsurance Co NPHONE (617) 381-9186 564 Sroadwsy JAZOnUd), (6171 387-7466 .M Everett, MA 02149 AODR se: IN R9 AFFORDIN3 COVERAGE NAIC fl INSURER A:Travelers Insurance INSURED INSURER 0:Commerce Insurance Castle Bee Refrigeration INSURER C: Bryan Castillo INSURER D: 94 Lynnway INSURER E: Revere, MA 02151 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WFFH RFSPFCT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPEOFINSURANCE ADDL USR POUCYNUMHER LIMTS A GENERAL LIABILITY 68000474007 8/12/15 8/12/16 EACH OCCURRENCE S1,000,000 X COMMERCIAL GENE PAL LIABILITY S 300,000 CLAIMS-MADE ❑X OCCUR MED EXP one ereen 1 5,000 PERSONAL@,ADV INJURY $ 1 000 0 GENERAL AGGREGATE $ 2,000,000 GEN'L AGO REGATE L IMI T APP LIE 8 P E It PRODUCTS-COMPIOPAGO S 2,000,000 POLICYPR LOC $ B AUTOMOBILE LIABILITY DZL137 7/24/15 7/24/16 eectleeM ANYAUTD BODILY INJURY(Per person) $ 100,000 ALLOWAUTOS X AUTOSSCHEDBODILY INJURY(Per xcidenl) S 300,000 NON-OWNED PR PERDAM erelMHIREDAUTDS _AUTOS $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ExCE98L1A8 CLAIM84MDE AGORLGATE S N RKERS Co NSATION ATU- TH. AND EMPLOY 'LIABILITYPo ANY PROPRIETORIPARTNERIEXECUTNE YIN �qFFIt�R1MEMSER EXCLlAED7 NIA E.L. S (Myyendeaory In NH) E.L.DISEASE-EA EMPLOYEE III al DES�RIPTIONUOF OPERATIONS below I E.L.DISEASE-POLICY L IMR DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Addltlonal Remarks Schedrde,If more 4psee I&requred) CERTIFICATE HOLDER CANCELLATION SNOUL .k oFTNEA DE SC RIB EDPOLICIESBECAN CELLE D5EFORE THFjg PIRATION DATE TOF, NOTICE WILL Be DELIVERED IN Town of North Andover A oR Nce WITI I THe POLI= ROV161ONS. Attn: Jim Hurley Gas Inspeotor 1600 Osgood St A THORrzE PReseNTATIve Building# 20 Suite 2035 iNorth Andovgkj2. MA 01845 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone; Fax. (978) 623-8320 E-Mail: Date....12......�/...... ..}....... N°arH °� •,~ TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING t s$,CHUS� �Z r� ... ............... �- This certifies that ........... .. ...................... �........bG/ �.{............. has permission to perform .........T. e'vA:P�........`�.........G1Q �- ....................................... wiring in the building of...................,f�1... �1.........�.........e................................................... at ..........5 ....... l.. .e`.. �. .... ..tiLf,North Andover,Mass. Fee..2T---- ........Lic.N��.Zr.I .L.. .. .. ................................... ELECTRICAL INSPECTOR Check# . . � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: !�O- 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) 59 &e-A--le, be c,,4 Z/7 Owner or Tenant Telephone No. Owner's Address c 0 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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: Co letion of thefollowing table may be waived by the Inspector of Wires. `J No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total V Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency Lighting rnd. " grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat PumpNumber Tons KW No.of Self-Contained Totals: ...I•..•......•"'•"'•".....................•...•... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:` No.of Devices or Equivalent No.of Water 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 Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3GYJ. 4/ (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. d CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Icertify,under the ains and enalties ofperjury,that the information on this application is true and complete. FIRM NAME r LIC.NO.: /x/2./7 Licensee: Signature LTC.NO.: !` (If applicable,ent exemp in the license number line) Bus.Tel.No.• ��T Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-6f,securi wor requires Depa ent 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 — Signature Telephone No. PERMIT FEE. $ 5S ❑ 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 M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ �f Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass 0 Failed '❑ Re-Inspection Required($.) ❑ ,• Inspectors Comments: •- Inspectors Signature: Date: — S DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAceidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Orgar&ation/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.F-1 lam a employerwith employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.F1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. • 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q we are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 state whether or not those entities have employees. If the sub-coritraciors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: 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 MGL c. 152,§25A is a criminal violation punishable by 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.'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 ofpeijury 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 shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-'contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 9 COMMONWEALTH OF MASSACHUSETTS • • , • • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING L`ICENSE::: AS A`REG ';JOURNEYMAN ELECTR;GC`1 AN 4 �LEQNARD :A 'BE-RUBE 30 MOUNT `VERNON pfd �� a u PELHAM NH 03076-2352 28186 > 07/31/11.6 29841 IN a DATE AC40RL)"® CERTIFICATE OF LIABILITY INSURANCE 8/3/2015 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONACNAME: T S@1@Ct Dept. Eastern Insurance Group LLC PHONE 800-333-7234 x66807 AIC No:?S1-586-8244 233 West Central Street -MAIL ADDRESS:selectwork@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERA:Travelers Inc of America 25666 INSURED INSURERB:Travelers Indemnity Co 25658 R. & L. Berube Electric Service Inc. INSURERC:Tray. "Ind of CT 25682 P.O. BOX 537 INSURER D: INSURER E: Dracut MA 01826 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157661269 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER MMIDDY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �{ COMMERCIAL GENERAL LIABILITYAMA N PREMISESETO EaREoccuTErrence $ 300,000 A CLAIMS-MADE Fx_1 OCCUR 68012338982 7/31/2015 7/31/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY 7 PRO- JECTLOC $ AUTOMOBILE LIABILITY COEa aBINED/SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED 4A261616 7/31/2015 7/31/2016 AS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Medical payments S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 5,OOC 1CUP0296YO83 7/31/2015 7/31/2016 $ C WORKERS COMPENSATION X I WC STATU- OTH. AND EMPLOYERS'LIABILITY Y I N DRYANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) UB4A250767 7/31/2015 7/31/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Electrician Evidence of insurance for insured while acting in the scope of their normal operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Wiring Inspector AUTHORIZED REPRESENTATIVE 27 Charles Street North Andover, MA 01845 John Koegel/KH3 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 mmnnr�m Tho A(:OPn nama anri Innn ara ranieforari mmrlre of Ar:0I7r) The Commonwealth of Massachusetts •- --1 Department of Industrial Accidents _!o Office of Investigations 1 Congress Street, Suite 100 f: Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation I nsuranceAffidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,� L '"L w Etc,c-J'Y` — Address: PD S.s City/State/Zip: ©rte , M 4 o tYZ-( Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. E] I am a general contractor and d. * have hired the sub-contractors 6• ❑New construction employees(full and/or part-time). 7. 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition ees and have workers'lo mpy working for me in any capacity. e9. F-1 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ .I am a homeowner doing all work officers have exercised their 1 LE] Plumbing repairs or additions myself. [No workers comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152. §1(4),and we have no employees [No workers' 13.❑ Other comp. insurance required.] `Any applicant that checks box#1 must al so fi l l out the sedi on bel acv showing their workers' compensation policy information. t Homeowners who submit this affidavit indicatingthey 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 state whether or not those entities have employees. If the sub-contrartorshaveemployees,they must providetheir workers oomp.policy number. I am an employer that is providing workers' compensation insurance for my employees. Below isthe policy and job site information. Insurance Company Name: �t\U v-e-I e- ------ — Policy#or Self-ins. Lic. #: U �� 4 A 71 So 7 G 2 Expiration Date: �V?�6 Job Site Address: City/State/Zip:_ Attach a copy of theworkers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine 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. /do hereby certify under the pains andpena/ties of perjury that the irrfornration provided above is true and correct. Signature: Date: Phone r ial use only. Do not write in this area,to be completed by 667 or town ofFcial.or Town: Permit/License# ng Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. F,lectrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 10648 Date.......P .6....!�z Y MOR7/, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CNUS This certifies that ......... il.L .. has permission to perform ................�.�..Tv ................................. wiring in the building of......... rU.,...................................................... at....; ...: ... ....�7.rJ�,�( .��c!� 12�</....�! .. ,North Andover,Mass. Fee.(A...�.r Lic.No., .1�..z-..................... . . .. A ..... E ELE RICALINSPECTOR s Check # � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTMINK OR TYPE ALL INFORMATION) Date: 10 s'' /� 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) 59! t c'`,1 A,c/ z Owner or Tenant Telephone No. Owner's Address 2 5 Is this permit in conjan tion with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building J !/l�'i[� Utility Authorization No. Existing Service o2o—rj Amps / Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead`❑ Undgrd❑ No.of Meters Number of Feeders andAmpacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeR:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ICDA No.of Luminaires Swimming Pool Above El In- ❑ o,o Emergency Lighting nd. rnd. Battery Units Receptacle Outlets No.of OR Burners F)1RW 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/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* rY No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: " Heaters Signs Ballasts. No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or Equivalent OTHER: or? Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El ctrical Work: (When required by municipal policy.) Work to Start:260IXInspections 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 t ains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: is LIC.NO.: Licensee: t Signatur � LTC.NO.: (If applicable,enter"ex pt"in the license n b r line.) / / Q 2���Bus.Tel.No.: Address: S-Zle 0V0& ��!/1 CO/C��P� �G� J Alt.Tel.No.: 1 77A.51Y *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic. 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: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i itil ` 600 Washington Street 4 Boston, MA 02111 11-1 wwwanass gov/dia , Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bIv Name (Business/organization'/Individual): Address: City/State/Zip: Phone#: . Are you an employer?Check.the appropriate box: L❑ I�ram a employer with 4. ❑ 1 am a general contractor and I Tye of pro (required): employees(full and/or part-time),* have hired the sub-contractors 6 ❑New construction 2.❑ I am.a.sole proprietor or partner- Iisted ori.the attached sheet.x �• ❑Remodeling ship and.have no employees These sub-contractors have 8. [J Demoiition working for me.in any capacity. workers' comp.insurance. [No workers'comp,insurance 5. 9• ❑Building addition ❑ We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions y myself.['No•worke'rs'comp. c. 1.52, §1(4),'and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required..] 13170ther "Any applicant that checks bor!'#l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mut submit a new affidavit indicating such. ;Contractors that check this box irrustattached an additional sheet showing.the name of the subcontractors and their workers'comp.poliy in:ornadon. I am an employer that is providing:worhers'compensation insurance for my employees: Belowth is e policy'and job site information ' Insurance Company Name: ' 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- 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 of perjury that fire information provided above is true and correct Signature: Date Phone#: Official use only. Do not write in airs area,to be con�deted 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 S.Plumbing Inspector 6.Otber Contact Person: Phone#: Division of Professional Licensure: License Search Page 1 of 1 e The Official Website of the Office of Consurner Affairs&Business Regulation(OCABR) Division of Professional Licensure . Mass.Gov Mass.Gov Home State Agencies State Online Services _.................................._..................._._.._........._... _ _.............f.........._.........._......................._...._........_.............-...-..................... Home>Division of Professional Licensure> SEARCH � ........... Check A Professional License Office of Consumer Affairs I Search By the Division of Professional Licensure r LICENSEE j ONLINE SERVICES j Name:DUANE A. RICARD Check a License MANCHESTER, NH i Locate a Licensed Professional NEW SEARCH I b �; y Online AAdress dress Change � � i 3 +-v Contact the Agency ' Licensing Board: •ELECTRICIANS More... l License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: JR i I License Number: 2372 j REFERENCES& RELATED INFO Status: CURRENT I ' Disclaimer Regarding Expiration Date: 7/31/2013 Website License Searches Issue Date: 11/26/2007 j Enforcement Process j Exam Date: Glossary i School: i Help on License Search i More... I i This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. I The page above has been generated by the Division of Professional Licensure web server on Tuesday,August 23,2011 at 10:28:31 AM. O 2007 Commonwealth of Massachusetts Site Policies Contact Us Site Map http://license.reg.state.ma.us/public/PubLicenseQ.asp?board code=-EL&type class=JR&li... 8/23/2011 N°j Date.NN . ..Oz/�-7 r pORTM "00` TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACMUS� This certifies that ................... 1i has permission to perform N o wiring in the building of...... .................... ti ........... .North Andover,Mass � Fee.. .t7 0....... Lic.No..f17:............................................................. ELECTRICAL INSPECTOR C t( WHITE:Applicant CANARY: Building Dept. PINK:Treasurer ` Office Use Only v �' re 14e &=911=4IIfttBttt4miEtti Permit No. f3 11cpartutcut of Public eufag Occupancy,& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date _ 14-;7 _67' 51 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. (� Location (Street & Number) Zf /Z Lc C� G�d1YY.t, Owner or Tenant .%_tui etrV4 �/�/• Owner's Address cl&41 fn'at fC k (� X Is this permit in conjunction with $ building permit: Yes k No ❑ (Check Appropriate Box)), Purpose of Building %e St1,.A tJ tj!% Utility Authorization No. Vld 13 7 Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service -ZOO Amp^V/ Zy4 Volts Overhead ❑ Undgrnd.,03e No. of Meters Number of Feeders and Ampacity _ Location and Nature of Proposed Electrical Work / No, of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners - Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal ElOther ❑ Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Compt led Operations Coverage or its substantial equivalent. YES NO ❑ 1 have submitted valid proof of same to the Office. YES t�NO ❑ If you have checked YES, please indicate the typOlbf coverage by checking the ap r priate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start /. 7"'Q;Z - Inspection Date Requested: Rough/ ��./r Final Signed under the P nasties of perjury: FIRM NAME �'l°rV _ LIC. NO. / Licensee �r Signature LIC. NO. �� J, Bus. Tel. No. ��d "6tZ % Address _ � t' �A� All. Tel. No. OWNER'S INSURANCE WAIVE : Ia�are that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agen (Please check one) Telephone No. PERMIT FEE $,! � — (Signature of Owner or Agent) x•6565 N°- '� 4 b L Date 0'............................. oTM OOL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACHUS� j This certifies that .......• :...... a..... ......... ............ ' ................................ has permission to perform .. .. ..f . �-f.�:�..:----......... wiring in the building of... ....................Z ,North Andover,Mass. rJ Fee...'.:?...•............ Lic.No. . ............................................................... ELECTRICAL INSPECTOR 03/02/98 10:02 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer doThe Con�rT�onwe�altla V p+lassacltusetts —___1__ Officrt Use Only Department o/f'trb'ir 7� • "_ �� •�„i Safnfy Fr,, o., E30ARD OF FIRE PREVENTION REGULATIONS 527 cmn 12:00 ,i Fon c1,9ck" (leave blank) ___J APPLICATION FOI"•i PF.:R11111-i" TO PERFORM ELECTRICAL Vu p R K All work ro be p.rrntmad in accomenc.w u,n,e Ma�sn�r negro eloomear , (PLEASE. "'llIT IN INK OR TYPE ALL INFORMATION zrcMAr Date_/ City or To. of ffvZ1Zme-The 1.111-01,1,111,J - I ` applies for a permit to the Inspector of wires: electricz.1 lres:elctricz.lworkdercih,d below, Location (' h et h Number)_ S.. ( _ Owner or 79r,antV� C+vner's Ad,irn. 2 oc;, �� ' J- r --_ Is this permit in conjunction with a huildinq permit ro Purpose of Building (� �' 1 C ppropriat9 Box) t11Q Authorizatlor Existing Service 0^+9rhead Undgrd El -- flew Service grd ❑ tic- of F.letnrs - -Volts Cverhpad ❑ Und - Number of Feeders and AmpicIty tic. of Meters i lomilon and NaY"e of Proposed Electrical Work.___ - - _No. of lighting Outlets --�---- _---��-- - -�-�_- -------No,of Hct Tubs '-"-- - No. of Llghtinq Fixtures _-_ _ - INo. of Transformers �TOTA( Swimrninq Pani Above in - - -_ KVA_ ---- -_ grnd.U Generators No. of Receptacle Outlets - �'--- KVA ----- No. of Cil Burners NO. of Emergency Lighting -- No. of Switch Outlets --'--- -----` Botta - ---_-___._-,-_ ry Units _ Nn. of Gas Burners tic. of Ranges __'----- - - FIRF ALARMS No. of Lone@ .................. JNo. of Air Conditioners TOTAL No. of Detection and _--__TONS __ IniftatinNo. o! D(soosals HFAT �TOTAL9 D.v,ces of PurnpsTONSKyy o- of Sounding Devices No. of Dishwashers tJfSeif Conrtine i ce/Area Hearin DetEction/So6nding DevicrtsNo. of Dryers -- ---- _- MVllr Devices K- htunicipal (� � --- No. of Water Hooters KW PN • of No. of Connection LJOther ns_ Ballasts I--of Hydro Massage Tubs V____-_of Motors Total JiP 1 ------ OTHER: ------------ INSURANCE COVERAGE: Pursuant to it,-07—req"ir9monts of Massarhus9tts r9n9nl La vs _ I have a current Liability Insurance Policy including Completed p '---"- --- valid proof of same to this office. YES ❑ NO ❑ Feratlons Coverage or its substantial equivalent. YF:, It you have chocked YES, pleas@ Indicate the typ9 of coverage by checking the appropriate box. L7 NO C] I haave subrnittnd INSURANCE ❑. BOND El O THER C_] (Please Estimated Value of Electrical Work B _ (Ezpiratlon Onto)) Work to Slart Signed under the penaltfee of ar'u -' Inspection Datn c,tqu9sted: Rough_ P l r Final NAMyE-. �44A ,�VAL�Cf_- -Signature ,3 Address�Q B -- _--- LIC. No. !._'� F h' ' - C's�Cir'tr '�,' -�' /'E— r /t i .� A! '' d� -----_Bus. 191. 1`40.6LaL C VNER'S INSURANCE WAIVER: I am aware that the Licenri,, (:I not have F.1:--,chuserts General Laws, Ihn in�urancn rover r 9 or Its sAlt. Tel. No._ and That my signature on this a."CI' �tlrn roaivns tJ,ia rn g �bstantlit 7wival9nt as rry---- _. T luirernent. ONnar Agnnl (Fln•eg9 chid cnnj'rirnri by 'E>R)IR Ho APPLICATION FOR PERMIT TO BUILD HURL" ANLIUVER, Fw'►sa. • ' MAP#40. LOT NO. t RECORD OF OWNERSHIP 10^TE rfk •PAGE ZONE SUQ DIV. LO NO. �- 1 OCATION HI Vck� J 1- -0. PURPOSE OF BUILDIN SG OWNER' NAME I� OF STORIES size OWNER'S ADDRESS n BASEMENT OR SLA■ ARCMITECT-B NAME- ./1/1 7 �� - -- flz[ OF FLOOR TIMW[RS IST •T`' IU !ND �'1 SRO 1 BUILDER'S NAM[ B►AN .� Lel 1P�w /Pl' f1� �i.Jotr� /y+nt-J` __ •� DISTANCE TO NEAREST BUIL J NG "'- DIMENSIONS OF SILLS DISTANCE FROM STREET --- POSTS �A DISTANCE FROM LOT LINES — SIDES -� f•'•'� /("� REAR - - GIRDERS X )� AREA OF LOT �� � PTC/ FRONTAD[ HEIGHT OF FOUNDATION s THICKNESS �l IS BUILDING NEW y1/il� - BIZ[ OF FOOTING rU� '� X IS BUILDING ADDITION � MATERIAL OF CHIMNEY IS BUILDING ALTERATION C�fJ If BUILDING ON SOLID OR FILLED LAND ) WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IG BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY If BUILDING CONNECTED TO TOWN SEWER vz-11 Ig IS BUILDING CONNECTED TO NATURAL GAG LINE S S PROPERTY INFORMATION INSTRUCTIONS LAND COST SEE BOTH BIDES EST. SLOG. COST LET. SLOG. COST ►ER SC. I - PAGE I FILL OUT SECTIONS 1 - S EST. SLOG. COPT P" ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 B[PTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUr*IDE OF BUILDING A APPROVED BY ATTACHED GARAGES MUST CONFORM TO STAT[ FIRE REGULATIONS _r PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR OATS FILED • 06ILDIpm INiPiLZD# SIGNATURE OF OWNER O# AUTNORIz[D AGENT 1 Owners Tel b6�/- S 6 211 f E t5 -- Contrac� Tel# g • KAYIT OAANTZD �p, �. � Z -- Contra. Lic # b5�30 � -i at. / LESS M� Z C� - �� _ HIC 4 O S g DUE FRAME PERM$ . 3i :!S-llAffl NO �,�.1OF*Tjy Town of ` - _ over L No. %5'8S%5'8S'08 _ . - m * Z=- * � dower, Mass., 1 (//9 19`3 �O9 COCMICNEMICK'y~-�`` '9s Oq.4 E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT...........................................pup.gWoo.4BUILDING INSPECTOR.,..,,,,,,,,,�.��• Foundation has permission to erect.................I.................... buildings on....... . (4K�.. .............. Rough tobe occupied as.......................................... � .,C .......�.1.f,441.. .. ....................:.................................. Chimney provided that the person accepting this permit shall in every respect conform to 6 terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MO S Final UNLESS CONSTRUCTIO - ELECTRICAL INSPECTOR Rough .................... ................ Service ... ... ... .. ... . ........................................ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Stnoke-Det. i FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out thi section***************** APPLICANT: -Y-A 42 AI a ��- Phone LOCATION: Assessor's Map Number Parcel } Subdivision43,s Lot(s) 1� Street V� C e n� St. Number — ************************Official Use Only************************ RECO NDAt ONS , F OWN AGENTS Date Approved ___� z �2 Conservation Administrator Date Rejected Comments �"� Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Septic Inspector-Health Date ApprovedDate Rejected Comments I Public Works - sewer/water connections �L,3 -?A 1?7 - driveway permit ?7 Fire Department Received by Building Inspector Date Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit below) Address of Pro erty for Permit(below) Map and Parcel : Purpos of A ica & n (check below) la of Applicant: _L-Single Family _Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the'requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration,or reconstruction of a dwelling in existence of the effective date of this by-law,provided that no additional residential unit is created. The lot(s)were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals,where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents,where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section"senior"shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40%permanent reduction in density, (buildable lots),below the density, (buildable lots),permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland.The land to be preserved shall be protected from development by an Agricultural Preservation Restriction,Conservation Restriction,dedication to the Town,or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits),and the Development Schedule does not accommodate issuing a building permit in that Year,one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply,whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a BuiilldinI Permit. Signature of Owner or Authorized KgryWho signed the Mached Building Permit Ole/ This form must be attached to the Building Permit qfidn application for such permit. !•S�// X07 '�/Z 2� � +O.SOBigC. i' -to 2�3 Q � A UOUL ��.IiWoSdO �v1E' Letssiov avQ pGOT p4 q/�/ �N SLAOF �o. .0.voe sic JEFMV jowww"w FO.P 110�11Al11�f a'3 �✓.e.ectccv /�wv..�C.oe�?" �ICi838't r., ea ii 7 /'redo' �✓ ��/997 J I S -✓af a. ,�'�r�►sem a E.�ra►a�.r..�s .�rrtrr z -d Woad wd£S°£ L66t-8t-tt CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number v Date c - •k: THIS CERTIFIES THAT THE BUILDING LOCATED ON 4 a&IS MAY BE OCCUPIED AS Z-441 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STA BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO ADDRESS ;'�''•:•a Buildkg ector = cNust • R R a of over 4 No. %.178S- - over, Mass., tli9 —199 0 -% - LAKE 0 f'9 oACHICHEWICK -4rEb WARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT...........................................PLIP.g.W.40.0..............1)e.L) BUILDING INSPECTOR ................................................................ Foundation has permission to erect.................I..................... buildings on....... ........t44.cw.K4X..P4i rwA.4.. .............. 90:u;pagge __/ �y 7-/9/98 to be occupied as....................................'...... ........ .r... .. ....................................................... Chimney provided that the person accepting thispermit shall in every respect conform to ms of the application on file in �FinalZ- this office,1 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 INS EC-Iblk VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MO I_11ELE&FMICAL SPECTO UNLESS CONSTRUCTIO ....................... ... .... ......... ............................................................ BUILDING INSPECTOR QcyuPancy Permit Required to Occupy Building GAS INSPE R Display in a Conspicuous Place on the Premises = Do Not Remove Rough No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIR EPARTMENT Burner Street No. o�ke _ � LT g _r