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HomeMy WebLinkAboutMiscellaneous - 61 LANCASTER ROAD 4/30/2018 r, / 61 LANCASTER ROAD 210/104.D-0177-0000.0 Date . . t(73.-71 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ' This certifies that . . .773m. . . . .D has permission to perform . . .�'`�S. . . `, , , , , , , , , , , , , , wiring in the building of . . . . . � �.!f`f�9 . . . . . . . . . . . . . . . . . . . . at . . . �9?v .!7sr .l. . / North Andover, Mass. Lic. No. .lc�f��r. . . . . . . . ® . . . ELECTRICAL INSPECTOR Check# �>/LOz { 11253 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.GI c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stag on the permit application. Such entity shall bt�,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 maybe_deemed_by the_Inspector_of_Wires abandoned_and_invalid_ifhe—. ._ 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 Chanter 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 f purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending1hrough August 15,2012. rPermit Permit/Date Closed: Note:Reapply for new per ' xtension Act—Permit/Date Closed: // Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I I Z:C3 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 aeaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMA 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: 1Z a j�- City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned giv,s notice of his or her intenti n to perform a electrical work described below. Location(Street&Number) / L"�.� S T-e—ro� Owner or Tenant �f f q ems, p Lo G i' ii O Telephone No. Owner's Address 5 P Is this permit in conjunction with a building permit? Yes ❑ No r (Check Appropriate Box) Purpose of Building �(�_,ar, Cl •-I. 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 1 Location and Nature of Proposed Electrical Work: uJ c rP q S j P S e r Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.0-rTmergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis osers Heat Pump Number Tons W. No.of Self-Contained t p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Dr Heating Appliances Kir Security Systems:* 3' No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent WirinNo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or E u valent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. TQC!• f1 D Estimated Value of El ctric 1 Work: (When required by municipal policy.) Work to Start: ���.��t a 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:) X certify,under thepains andpenalt es of rjury,that tJze anformatio on this application is true and complete. g FIRM NAME: "% �.5 J t'/GC. 4 0 : G LIC.NO.: l- / Licensees ��L'�d f�� l�� Signature �i -�r� LIC.NO.: (If applicable,enter "exempt"in a license nu er line.) �� Bus.Tel.No.• Address: S` S �u f y e .�tt6t` )BUS Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department o 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 rARMITFEE:$ 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ' SERVICE INSPECTION: Pass n Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: ` r Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: 19 Pass Z, a Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 ,< www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individuaall): s e ! Address: City/State/Zip:�z�� c(s-,5�eeg.�� dl�6P)Phone#: / '� S�'o�o� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 F1 New construction employees(full and/or part-time).* have hired the sub-contractors Sham a sole proprietor or partner- listed on the attached sheet. ? E]Remodeling �g-and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 131-1 Other 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 their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site forniation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Nestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is trruu land correct: nature: Date: lone#: 9 7�,` (os- r 20 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 i of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. . The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 021.11 Tel. #617-727-4900 ext 406 or 1.877-MASSAFE Fax 4 617-727-7749 evised 5-26-OS \EnxnaF mace csn17/rlin DateLED TOWN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . 4 has permission for gas installation . . . . . . . . . . . . . , . in the buildings//of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . .(ten./ . .4-. .(� ,C Ir-A . . . . . . . . . . . , North ndover, ss. Fee .26 0. . Lic. No. 1213.q. GASINSPECTOR Check# / T 8400 i s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ 0� II MA DATE J PERMIT# JOBSITEADDRESS1_...i`f�r�e��-t rP - OWNER'S NAME /l Gfl�►e — I) GOWNER ADDRESS TEL —��FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E-11 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEWT-1- RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES _-_I NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE �_E _ _ ,T .. _ _ 1 ...........----- ._.�� —r( DIRECT VENT HEATER -r__-I LII[- I �J .. �--I�� .-1 -_ ( �_ DRYER FIREPLACE FRYOLATOR _ ( . _ I _ FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS - MAKEUPAIRUNIT OVEN E. E POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT -4- —t,.__._1 = G - I I =- - :.m.. TEST _ I I_ ) I I_ 1 _ J n f ___.J I (. _ I(_ __ J _—J _____-.J --- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ---�-------__.____.--__._ .----------- < «--- :��-- --_, .__J,_ _ Wil_ _-��: -= - - � ----1 - ��_- -►:----� --- r INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES g?/NO _[j_( IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND ([ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. \fir CHECK ONE ONLY: OWNER 0 AGENT �I SIGNATURE OF OWNER OR AGENT 1 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 01 Z&int provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME e,!_ ..�(,�5 .?�____ LICENSE#�aa�93d SIGNATURE MP i MGFI� JP [�} JGF a LPG]0CORPORATION[]# ,�� PARTNERSHIP D#L. LLC # COMPANY NAME10S. ADDRESS( !s+ _ ✓�C-_.__....__-_____.____......._____.__.._fl CITYVt✓L -. - -_ _-- -- .___-� STATE ►ZIP FAX CELL �- a9y EMAIL r� ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r� � � r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ( v C Address: City/State/Zip: (i? Phone Are ybu an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11. lumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs insurance required.]1 employees. [No workers' comp. insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. i am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ._ `insurance Company Name:_20 f ?olicy#or Self-ins.Lic.f#:/ L /� \ Expiration Dater- � Q ob Site Address: 1 l�l[/(C G�7 l,�` City/State/Zip:-Norl.44 /4# kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). aiiure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine if tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvNtigations of the DIA for insurance coverage verification. do hereby certify under therms and penalties ofperjury that the information provided above is true and correct. i nature: Date: hone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: .J 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 bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture y% (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www,mass.gov/dia � COMMONWEALTH OF MASSACHUSETTS- COMMONWEALTH OF MASSACHUSETTS_-L PLUMBERS Aft G GASFITTERS PLUMBERS AND GASFITTERS LICENSED AS A Jr-lJRNEYM:,AN PLUMBER, (( REGISTERED AS A PLUMBING CORP. ISSUES THE ABOVE LICENSE TO: 1 ISSUES THE ABOVE LICENSE TO: KE ITH . OSBORNE 1�.� KEITH OS13ORNE .I " OSBORNE PLUMBING LLC ( 29 ABBOT BRIDGE DR 29 ABBOT BRIDGE D., ;�, ANDOVER , MA 0: 810-1,142 .ANDOVER MA 01810-4042 .3f352 p 05/01/14 156470 I 25017 05/01/14 156477 Commonwealth o€Mas usetts COMMONWEALTH OF MASSACHUSETTS ' �vis�onafRegit Board orPlu{nbi PL JMBERS AND. GASFITTERS LICE1I9ED AS A MASTER PLUMBER Keith Th m rye ISSUES THE ABOVE LICENSE TO: i 29 ABBO w 'KITH OSBORNE ' . a. ANDOVE��l \q 2: ABBOT BRIDGE DR Maste'rPlum ,r e� EMAIL SFO WHEN .05/01/2014 A�`t'OVER MA 01810=4042 004779 I ' License No. Expiration Date. ' Serial No. ± 12930 05/01/14 156479_ i{ Date. . Of aNOR TM 11. o? �` TOWN OF NORTH ANDOVER ti 9 • - PERMIT FOR GAS INSTALLATION 9 SA US This certifies that . . �'�h. . .�7� . has permission for gas installation . in the buildings of . . G U�/4y�l9JO� at . . r�/ Girl e-rS I r ./`,`-":. . . orth Fee ZO,.' v Lic. NoA 7 x' . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# y7�S�3 8158 (� •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f - CITY MA DATE 1 d -Id j PERMIT# JOBSITE ADDRESS Q++C �r OWNER'S NAME _ kC 9 GOWNER ADDRESS qtr _ TE - - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONALE] RESIDENTIAL PRINT CLEARLY NEW:E--1 RENOVATION:O-I REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER :j .. _. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ( �_ FIREPLACE FRYOLATOR FURNACE _ _ 1� �I—Al L GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TESTI_ UNIT HEATER UNVENTED ROOM HEATER ( ( )__ L-- I—AL r1 WATER HEATER [-�I 1.---.I OTHER F INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Wf OTHER TYPE INDEMNITY E3 BOND I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a urate 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' n ith rtinent pro vi ' f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ; - � LICENSE#IQ&7fg SIGNATURE 1�. .._. MP 0MGF0 JP 01 JGF LPGI�_I CORPORATION A# PARTNERSHIP[3# LLC 0#� COMPANY NAME: Cqh�^ �r ,I„ + ADDRESS r. --- - CITY _ r�1t ...m. .- _ . _._.I STATE M ZIP - TEL FAX CELL(-�� I�......�.�—� LEMAIL_-� -r- -t l_a ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE O Y FINAL INSPECTION NOTES �es No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# dq L 2 ?, PLAN REVIEW NOTES A4 1 The Commonwealth ofMassachusetts Department of industrial Accidents Office ofInvestigations 19 ..600 Washington Street Boston, MA 02.111 . 0 www.mass gov/dia Workers' Compensation Insurance Affidavit: BuUders/Contractors/Electricians/Plumbers APPlicant Information __ 71111111 1 Please Print Legibly {� Nan].t3(Business/organization/individual): r%141ti 01 — ll,'✓' u���•'• }-' ���`� . Address: City/State/Zip; Q Phone#:_ V-S\ [2.E01 re you an employer?Check the appropriate box: Type of project(required):' ❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).*' have hired the sub-contractors 6 ❑New construction I am a sole proprietor or partner- listed on the attached sheet �• ❑Remodeling ship and have no employees These sub_contractors have 8. ❑Demolition worldng for me in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12,❑Roof repairs insurance required.]t employdes. [No workers' COMP.insurance required.] 13.❑Other 3'Ep??'cant th.:t chec'zs box#1 must also fill out the section T Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors must submita 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 Compiny 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 required under 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify er a pains and penal ' i information provided above is true and correct Sienature: L� I Phone#: Date:9�6 "���2�5 y�� • 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: h 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 6r implied,oral or written." An employer is defined as"'aa 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 Ao 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 Iocal 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 coxnpliance 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 ' '��,�.va ;j.,- 7.� al.,,c tt. t'C^ce.t rA.�it•Q L.-_ S.,i.•bmi-g^requesttid,�4At the l�=p-�•-T[.'•1't e!1t Qf �a-T:� Et7 t_Pa City Cir t�Rru tua�.w,y app t-"s `amu fur thS per }ng.P, F e o n 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 Iegibly. 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibatong 600 Washington Street Boston,MA 02111 Tel. #617-72.7-4900 ext 406 or 1-8.77 MAS.SAF'E RavionA S_7s,� IIS Fax 4 617-727-7749 Date . bw�rtxpr�m',. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . .V-', '-Q . . . . . . . . . . . . . . . . . • has permission for gas installation . . ✓C�� . .�.-�.��. . . . . . . . . . . . . . . ' r` in the buildings of. -L- r 0. . . . . . . . . . . . . . . . . . . at . . G l . .�-.C�` s.S k,r• • • • • . . . . . . . . . . . . . .North Andover, Mass. Fee .; o. . Lic. No. . O. . . . . �..., J^. ,,, GALS INSPECTOR Check# , 8341 f •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY � - 0 � _ MA DATE� ERMIT# 0 '/ JOBSITE ADDRESS _ ,..-__,4[Z OWNER'S NAME GOWNER ADDRESS TE44� �FAX ~ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:ff" RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ___( NO APPLIANCES 7 FLOORS-- BSM' 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATORS GRILLE INFRARED HEATER --_._ C-- l—.! -_—,-1 C- G I —_ — LABORATORY COCKS MAKEUP AIR UNIT OVEN —_--= POOL HEATER ROOM/SPACE HEATERL= ( h._- -((T- — [_ ROOF TOP U NIT __ TEST JI - -lJ UNIT HEATER UNVENTED ROOM HEATER L—_(! .__._.I_ L w� F_..J I_._ WATER HEATER OTHER I11-TY I ,I —D F 77 J I_,.=1 i —I L=.=]--I-s_I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _ 0 [�f 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER OTHER TYPE INDEMNITY D 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 01 AGENT [�1 SIGNATURE OF OWNER OR AGENT 1 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-GASFITTER NAME �'� , �QLICENSE#F1 �3O( SIGNATURE MP�I MGF JP ( JGF[ LPGICORPORATION[f# PARTNERSHIP 0#=LLC I# � COMPANY NAME: ADDRESS CITY STATE zip JTEL FAX L CELL.- EMAIL 6 - �/ �r ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No �f THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES - s t n ` The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street z V- 0 Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): V Address: �Ol�a'fi r V-,C City/State/Zip: Phone#: Are yV an employer?Check the appropriate box: Type of project(required): 1.Ekf am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.F1 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.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers' ompensation insurance for my employees Below is thepolicy and job site information. l Insurance Company Name:. gvlgl d Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: �� L 414 L�_�;-f l� City/State/Zip: �-ylci0✓t� In A 0 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 certlo and airs and penalties ofperjury that the information provided above is true and correct. Si ature: Date: ' Phone#: — 0 0 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.EIectrical 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 ofhire,• express or implied,oral or written." An employeiis 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 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 Commonwealth of Massachvsetts DDpartraent of Industrial A,ccxdonts Office ofInvestigations 600 Washington Stroet Boston,MA.02111 TO,#617-7274900 ext 406 or 1-877-MASSA.BE Revised 5-26-05 Fax#617-727-7749 wwwmass.gov/dia A i Commonwealth oiMas usetts Division of Regi§In i,•,86ard:of.Rlumbi .' Keith Th me x 29 ABBO� _ � � o AN DOVE Master Plum r �W EMAIL SFO WHEN :.05/01/2014 004779 < License No. Expiration Date. ' Serial No. N2 9596 Date 9.`$2 MORTp •��c TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING' ,SSAcmus� c ►+to 0S This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . V ti{-�^^. . .�° �. . . . . . . . . . . . . . . plumbing in the buildings of . . . . ! . , ,�.... J ti.-.. o at. .(?(. . .L.. '^ c 5 SSI--r. . . . . . . . . . . . . . . .. North And ver, Mass. Fee 50 . .Lic. No..1.a.T ?.,0 . . . . . . . . . . . . PLUMBING INSPECTOR Check # 77-1 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE _� PERMIT# JOBSITE ADDRESS OWNER'S NAME 44 POWNER ADDRESS TEL FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: Ell RENOVATION: REPLACEMENT:D PLANS SUBMITTED: YES E9 NOD FIXTURES 7 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 1-11-_..._._ 1 I DEDICATED GREASE SYSTEM —1 -.--_-_-1. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN i .__--( --_.-.J ___i __ i _...P FOOD DISPOSER _._) _ _l ._. .. -! - - FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL __f ...._._1 I J J I } _.._._._} ...__._! .______J SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION -1 WATER HEATER ALL TYPES I _a . J _.1 _1 I WATER PIPING _.__} __ ) IL INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO D IF YOU CHECKED YES,PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND D1 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 D AGENT D SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ i� S C1r✓1 LICENSE# ! — SIGNATURE MP JP Eil CORPORATION 15"I' PARTNERSHIP D#� �!LLC EIV COMPANY NAME� p�n� vwt , ►, �.�.C, ; ADDRESS q tir -- - CITYjoyLl�__ 'TSTA E a/yj ZIP Qlfl/(� --� TEL d� d ! } p - L t _ �_ vim.FAX CELL ._. _ . - - - __. S o.._YI c.. r� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 94,0 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `^ Please Print Legibly Name (Business/Organization/Individual): Ul -e. v - 61 ' 41A Address: 0 f c fc e u City/State/Zip: l(� Phone#: 97��� Arepu an employer?Check the appropriate box: Type of project(required): 1.LJ I am a employer with ( 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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.]t employees. [No workers' comp.insurance required.] 1311 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tam an employer that is providing work 'compensation insurance for my employees. Below is thepolicy and job site information. r� Insurance Company Name: Or t ?olicy#or Self-ins.Lic.#: Expiration Date: 104r* 64 13 fob Site Address:. j C G S,'I e 1 City/State/Zip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). .,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ane up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ►f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certify under thiolpains and penalties of perjury that the information provided above is true and correct. )i nature: Date: 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: w 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, usub-contractor(s)names address es and hone numbers along with their certificates of supply PpY ( )�address(es) P ( ) g � ) insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-$77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www,mass,gov/dia r 91 r i; Commonwealth ofM,as ' n usetts ":'. . . Division 6f Regi§trati 2oard of•Plumbi 64= Keith Th i -M, (� 29 ABBOT 4� ` ANDOVE Master PIurt' EMAIL SFO WHEN 05/01/2014 M 5 e 004779 License No. Expiration Date. ' Serial No. a � Date .?.`1.'l. . . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . Ac' �. . . . . Y �''� .� .. .. . .I . . . . . . . . . . . has permission to perform . .�!:.�. . . . . :.f�. // r. e. . . . . . . . . . . wiring in the building of . . .X v.c,. . . . . . . . . . . . . . . . . . . . . "4t . . . . .;/ •,t 6,f j. !.!t. . . . .,!�. . , North Andover, Mass. Fee . J. . . . . Lic. No. •/��.7� . ✓ . . . . • ELECTRICAL INSPECTOR Check# 3 ely 1104 a Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. // / G Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC) 527 C 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: �'d Y/1.)— City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfo the lectrical work described below. Location(Street&Number) 41 rf� `+ C<S t' 2 Owner or Tenant M,5t_14 e f/od tai I U Telephone No. Owner's Address Is this permit in conjunction with a b 'lding permit? Yes A �o ❑ (Check Appropriate Box) Purpose of Building ���� '?S 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 ork: ` / / e 1 ` Completion of thefollowing table may be waived by the lnspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA AD No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lig tingNo.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ BatterUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection andInitiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers HeatPump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices Municipal ElOther No.of Dishwashers Space/Area Heating KW Local EJConnection No.of Dryers Heating Appliances KW Security Systems:'' No.of Devices or E uivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: ` Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ad1l. d-0 (When required by municipal policy.) Work to Start: " �_Inspections to be requested in accordance with NEC 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: 1NSURANCI� ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties of rjury,that tyl e i ormatio^ on-this application is true and complete. FIRM NAME: LIC.NO. Licensee:/ d,..1G 01 J !/G/`Jeb; 0 i Signatur LIC.NO./7�l 9 2,9 (If applicable,enter "exempt" 'J"Vthe license number line.) , us.Tel.No.• ������ Address: !f &VL1, Z Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,secur' 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: $ Signature Telephone No. l 1 f i • .YiJJ-�JL'(�AJ.�-4��.•[{,{(/�yTT����(J'�.'r���-If■J,yA��®w 'rry`��{ye�-/' �/'�p}��{ �.'-+.{��J.:[Y�J+..+S.�J.•.x.'d+1Ji.®��� I ftssec�-� �ns�ectpxs'�opune�ts: � ' (X'nsp eetore Signature-.,o knit als} o•� of d►s�' Pate .Z �� �•�9�N'.��7�P�t;3CT+D�7; �'asse�-- �+'afIet�--� � � ate Sns�eetzoxtxe�uixe����0.00)-•� � . �st�iectoxs'c xnmenfs: . Z 7—/Zn ftspadors'gxnqaA no U-mals) Pate 'assec�•-� ] �'ailet��j � ate-xnspeetzo�xe[�uixer�(��O.UO)�[ � aspectoxs'cwments; , (�nspectoxs',�ignatuxe-no?siffas) Pate . sser --r I a'rIeu•-Z Re-Inspection required pox 0) 1 �,pectoxs'eoxaixtepfs, ' (�aspectoxs',�zgnatuxe��onitials} date 'e�~C � �+,'aiSec�•,[ �. 'ate�nspectzottxequire�( 56,00)�[ � - 2CtOx�g C4LTlTTl.�llt3: _ . " (14s_p ectoxs'signature••3ao xttivals) Plate r.r s-.-.t �.r.+, s..-...--.".r n•.�•.-t•r.YYY•a-.� .•-.Yrra-. f.�Yz..v...-..--i.-,-r.r-.•n•r•i-t-rmr,.rw-t f-a-rm-1 1•a-,`1-f l M/l.'llYi YT7CYTb':f T'lP'PM1T'E'e Y!Y•nY�M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PleasePrint Legibly Name (Business/Organization/Individual): -''''`z f V �GLi��^ 5 47 Address: PAreCity/State/Zip: r 4 6K Qz&a2 one#:�j ;)P— Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ees(full and/or part-time).* have hired the sub-contractors E]sole proprietor or partner- listed on the attached sheet. t 7• Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]1 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. 1 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 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. 1 do.hereby certify u r the pains aannd/penalties of/perjury that the information provided above is true and correct. Si n ature: ,�C �`j/� Date: /' P/z Phone#: --GS 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 i 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." i 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 confurnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 C Date.. . ......................... f NaRTN 1 o o � TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSEt This certifies that-70.................... ....... ..............................f................... has permission to perform .. ...fc�I/�..l f�l.l........ .... !^- .. ?!.�?..... wiring in t e building of....6At ....... U</ -v✓, ... .................................. at............ .......�.G'.!. ..a a ..... v .PLEC�r ,North Andover,Mass. oFee.. r�.... Lic.No..,�C.?..�... ..� f ................. .... . .. ..... . ...... 1 ICAL INSPE R Check # �?" 9ULr9 s -� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. O � BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: C ea` G City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned iv s notice of his or her—intention to perfojrmZthelectrical work described below. Location Street&Number) C'a S ` r /�Owner or Tenant o L U C •z Telephone No. Owner's Address ��`� Is this permit in conjunction with a building permit? Y / es No ❑ ((Check Appropriate Boz) Purpose of Building ��,(�� !�e .t Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: S l �11 SS�� v� � Completion o ;f the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA I No,of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig g d• rnd. Batte Units No.of Receptacle Outlets No.of oil Burners FIRE ALARMS JNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges ENo.ofSa ond. TotalTons No.of Alerting Devices No.of Waste Disposers Number ,Tons KW _ No.of Self-Contained `-_ _..._.. Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances , Security Systems: No.of Water No.ofO. No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or E uivalent d Attach additional detail if desired, or as required by the Inspector f Wires. Estimated Value of Electric I Work: �r a?U 0• Q 4) (When required by municipal policy.) y Work to Start Z401� d 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 insur including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covers m force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) tify, I cer under the pains d penalties of perju ,that the infor non th' NAME �`r S nth/ ,gyp ticatJion is true and complete- FIRM e� �/ ` c• LIC.NO.: l—? Licensee:/hdlg 6S �) i^tA��� r Si9.2at le 9 LIC.NO. (If applicable,,enter "exempt" ' e license number line.) • Address: .S v' ,I e ,�1�� Bus.T e L No.: 5 '0 Te *Per M.G.L c. 147,s. 57-61,securi work requires Dep "S"License: Alt.Tel.No.: artrnent of Public Safety Te Lic.No. aj� 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.$ «: �..:, /` 1` . � f � - o � � �� � � �ppp . r/ l _r The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washing ton Street * ri Boston., MA 02111 { ' www mass.govldia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plambers Applicant Information Please Print LeQlbly C Name (Business/organization/individual): AddressCf . v c/ City/State/Zip:_ f>/�°rI vt .1rJ� 1 r/1�O ) Phone (b o�o� Are you an employer?Check.the appropriate box: 1.❑ I employer with 4. ❑ I am a general contractor and I Type of project(required): mployem(full and/or part-time),* have Eared the sub-contractors 6 ❑New construction 2. I am a.sole proprietor or partner- listed on the attached sheet._ �• ❑Remodeling ship and.have no employees These sub-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. g ❑Building addition [No workers'comp. insurance 5. F-1Weare a corporation and its required_] officers have exercised their I0.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions r myself. [No•workers'comp. c. 1.52, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required..] 13.❑.Other i 'Any applicant that checks bort#l most also fill out the section below showing their workem'bompensation policy in t Homeowners who submit this affidavit indicating they ate doing all work and then has 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 ant an employer that is providing:workers'compensation insurance for information, my employees: Below is the policy and job site Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation pollicy 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. Ido hereby certify under the pains and penaltiof perjury at the information provided above is tate and correct • Signatore: 11 Date: l l Phone#: C�- t7ffuial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing use (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. plumbing Inspector 6.Other Contact Person• Phone#: u. 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 tr 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-ins C -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 bum leaves etc.)said person is NOT required to complete this affidavit c The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, , please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4904 ext 406 or 1-977-MA.SSAFE Fax#617-727-774 Revised 5-26-05 vvww.mass.govIdle Date -. "ORT" TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING SSA US This certifies that ,. . . .�. ... . . . . .uL . . . . . . . has permission to perform . . .. . .... . . . . . . . . . . . plumbing in th buildings of .... . . . . . . . . . . . . . . . . at l/ -- — . . . . . . .. North Andover, Mass. Fee. . . . . . . . .Lic. No.el/.��5 ;/``� �� / . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # _ 82z+ 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date j Building Location 61 J C /( Owners Name Mr, I -/q- ! / Permit #-.Y Amount sje .'� _Type of Occupancy r New Renovation Replacement Plans Submitted Yes ❑ No L� FIXTURES Z o w x o w Cn O C4 � S�BgVIC RASEVUgr 14 ffi" I T1III MM �i~TACit 4M FLOCIt SIH FI11Cl2 61H HAOM - 7IH FLOOR SIHII+j0CR i . (Print or type) Check one: Certificate Installing Company Name 1'1 r c "' n (,r i C orp. Address W✓1 3❑ Partner. Business Telephone Firm/Co. r Name of Licensed Plumber: _� ( /n_L/G�hn Insurance Coverage: Indicate the type of i surance coverage by checking the appropriate box: Liability insurance policy Other type of indemnityElBond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p orm d under Permit Issued for this application will be in compliance with all pertinent provisions of the sa usetts State umb' g C and Chapter 142 of the General Laws. By: a ure oy 7-71-MiTu nomner Title Type of Plumbing License City/Town rcens Numour MasterJourneyman ❑ APPROVED(OFFICE USE ONLY r The CommontiM,ealth of Afassachusetts k� )� Department of.industrial Accidents Office of Investigations r 600 N ashington Street Boston, MA x2111 c ' www_naassgov/din Workers' Compensation Ins trance Affidavit: Buflders/Contractors/Eieatrici$as/Piembers A Iicant Information Please Print Leeib lName (Business organization/Individual); V Andress: eityisttz ,: e •� 3�Phone Are yo an employer?Cheek.the appropriate box: 1. I am a employer with ZQy- 4. Type of Project(required): employees(foil and/or * � I am$general contractor and I 6, D 13ervv c coon part-time). have bired the sub-contractors 2.[] 1 am.a sole proprietor or partner- listed on the attached sheet t 7. emodeiing ship and have no employees Theso sub-contractors have working for me in any capacity, workers' comp.insurance. 8. Q Demolition [No workers'comp,insurance 5. ❑.Weare a corporation and its 9. M Building addition am Irequired.] officers have exercised their 10.0 Electrical 3.❑ arra s homeowner doing all work right Of exemption per MQL 11.�] Plumbing repairs or additions myself.[No-workers'co grepahoradditions rnP M L52, §1(4),'and and we have no 12.[] Roof M1X1rs insurance rulurred-]t .employEes. [No workers' COMP• insurance required..] 13.M.Other 'Atry applicant that checks bmC#tmutt Wso:Ml out the section below showing their workets'ii ompmsstion policy information. t Fiomeowneta who submit this attidavit indicating they ars doing an work end then hie outside contractors must submit a new affidavit indi (Contractors that cheek this box mustataohed an additional sheet show' eating such. tug•t he nanrE of the mh-cotrnactots and their wott�s cost.Po -FF.i I ant an errtplpl,er tk2 ts' ... r n&nnation. p'�~w utg:woPkers'conrperrsmtiori insuran'eforfenPontformatonYeeBelow it he po& y and job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Late: Job Site Address: Attach a copy of the workers' cont ChY/State/Zip' pensation policy declarafioo 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 ina fine up to$1,500,00 and/Or one-year imprisonment,as wen as civil penal }ties of a ties in the form of a STOP WORK ORDER mposition of criminal penalties and a fine Of up to$250.00 a day against the violator.. Be advised that a cof th Investigations of the DIA for insurance coverage verification. opyis statement may be forwarded to the Office of I do hereby cerYi the p and pen of rjary that the information provided above is&M rect Si two.- and cor �f Phone -------------- #• are DJy- Do not write An this area,to be co nrp ezed by city or town o�rx� C ityr Town Permit/License# Issuing Authority(circle one): rd of Health 2 Building Department 3.City/'I'own Cierk 4.Electrical Inspector 5. Plumbing inspector ct Person: Phone#: Information a end Instructions Massachusetts General Laws chapter 152 requires all emp lloyers to provide workers'compensation for their employees. Pursuant to this statute,an en ployee 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,assodiation,corporation or other legal entity,or any two ormore of the'foregoing engaged in a joint enterprise,and includisreg the legal representatives of a deceased employer,or the receiver ortarstee•of an individual,partnership,association or other legal entity,employing employees.'However the owner-of a dwell' house having not more than three artments and who � g ap resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work m such dwelling house or on the grounds or building appurtenant thereto shall not because of sueb employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state as-local 6edust'ng agency shall withhold the issuance or renewal of a license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compiiance with the insurance coverage required" Additionally, MOL chapter 152,§25C(7)states"Neither tike commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work- until acceptable evidence of compliance wi tb the insurance requiremerris of this chapter have been presented to the covivacting authority." . Applicants Please fill out the workers'compensation-affidavit rwmpkem-tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)acid 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 orpartners,arc not requiredito cavy workers'ecoosnpensation insurance. Ifan 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,notthe Department of Industrial Accidents. Should you have any.questions regarding the law or if you arc required to obtain a workers' compensation policy,please-call the Department at the number listed below. Self i*rsuared compPniec should enter+heir self insiaance iieense number on the'appropriate lire. 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/licerrse applications in any given year,need only submit one affidavit indicatingcurrent policy information(if necessary)and under"Job Site Addr-ess"the applicant should write"all locations in (city or town)."A copy of'tbe 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 fixture 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 perrnit'w bum leaves etc.)said pers6n is NOT required taccomplete this affidavit The Office of investigations would Bice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of lmdnsiziat Ac.6daats Office of Iaveafigations 600 Washington Street Boston, MA 42111 TeL #617-727-4900 ext 406 or 1-9.77-MASSAFE Revised 5-26-05 Fax 4 617-727=7749 www.man.gov/dia Date. ..-. � . .G �.. . . HORTh o? °` TOWN OF NORTH ANDOVER f � A PERMIT FOR GAS INSTALLATION e1CMUSEt This certifies that . ��?. . . . . . . . . . has permission for gas installation . . ./. .C?r. . . . . ./!f .. . . . _ . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at . 1,/. . . . . . . . North Andover, Mass. Fee. . .'. . .:. Lic. No..% . . . . . . . . . . . .... . . . . � . : ..s . . . . . . GAS INSPECTOR Check# A i 56 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print at Type) / .. \�, CS1r�t' Mass. Date (� 'L.t� ami Permit a Building Location— e�L,.�x..- �e<' Q� - Owner's Name JQArimc C Of OcCtlpanCy '/ ers t�r-i4+ New ❑ Renovation ❑ R cement Q , Plans Submitted; Yes❑ ° No❑ N W N W N X x C o N (� W w o�c a as m }- y r 'A sa � a� c eti H a W < _ _ E- W > p w U m a+ W j -K us us w T J = W o: Cl + iL tw" }. W O > ,. W b! i us ac w ~ s i C C uc U. a o a v > c e. o sue—RSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH MOOR 6TH FLOOR 7TH FLOOR aTH FLOOR Installing-trtampany Name CALLAHAN AIR CONDITIONING 6 HEATING ,,.,/Check one; Certificate it Address 91 BELMONT STREET Y/ Corporation Nn ANDOWR-MA_n 1 R4 S •❑ Partnership Business Telephone 978=689=9'233 ❑ Firm/Co. Name of Ucensed-Plumberor Gas Fitter JOSEPH K.CALLAHM INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes B No O ' It you have checked des. please Indicate the type coverage by checking the appropriate box A liability Insurance policy ted' Other type of indemnity❑ Bond 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance ca erage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requiremenL Check one; Owner❑ Agent C3Signature of Owner of Ownet's Agent 1 hereby coldly that an of the details and Wa inalion I have submitted for entered)In above application are true and aeauate to the best of my knovdadge and that all phsnbing wo*and hul;allaUons performed under the permit Issued for this appAcadon w!q be in compnance with all Pertinent provisions al the Massachusetts Stale Gas Code and Chapter 142 of the oral Layvs. t3y Tj of License; Plumber =,Numba 00 nsa Plumber at as Ater Title Gaslitter M=3440 Muter Gly/To" .loumeyman BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION FINAL INSPECTION SKETCHES FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPS OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG N0. PERMIT GRANTED DATE GA:3 INSPECTOR Location XIA N(AS7'`,, ; Q) No. _ f�✓ Date 'V-0.0—O)DOf HpRTq TOWN OF NORTH ANDOVER 3: � • pG f A Certificate of Occupancy $ ,SSACIN Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a 5 r Check # !— 41 Building Inspector r 0 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING .� .F€ . MW � BUILDING PERMIT NUMBER: DATE ISSUED: /1—IDO D ` W ic SIGNATURE: MzQ / Building Commissi er for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: to � U I r? Map Number Parcel Number 1.3 Zoning Information: 1 1.4 Property Dimensions: RO ` Q�1Cu"L l C1 C— O�,CY6 1�G Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided v' L-- z t`a75 t i5,6 I A� - a 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public a Private ❑ Zone Outside Flood Zone ❑ Municipal B� On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record Name(Print) Address for Service: Sig re Telephone 2.2 Own cord: PAW me Print Address for Service: .y Si re Telephone p� SECTION 3-CONSTRUCTION SERVICES 70 3.1 Licensed Construction Supery Not Applicable ❑ In ar�_ c P� �� s Licensed Construglton Supervisor: License Numberaan Address �N 9AA, > q-nAn q7� Expiration Dat icic Signa re Telephone r 3.2 Regis d Home Improvement Contractor Not Applicable ❑ Oro Company Name � t'c, l Registration Number zsr 1 Ad s �&k C�7 " 5� Expiration Date A Signature Tele hone YJ SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Descrition of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) TAddition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: t SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be flIYA ,US Ory Completed b rmit a licant , s,:',j $ r �....x .,.. ,. _ 1. Building (a) Building Permit Fee �U GC.) Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)X (b) 4 Mechanical HVAC �,[ �- 5 Fire Protection V 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT Off!:i�i'��TQRLAPVJJES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property ZHereb thorize to act on be ;i i all matte relativ to wor au onzed b this bui mg permit application. 3 A-1 /U v Si is o caner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION L. M as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief -PCA, Pri c-� c.) , Siatur o wner/ ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 SPAN a DEMENSIONS OF SILLS DM4ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING - ) '` X MATERIAL OF CFMANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ACORD CERTIFICATE OF LIABILITY INSURANCE DATE .M 04/10/2001 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NORTH ANDOVER INSURANCE AGENCY, INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NORTH ANDOVER MA 01845-2415 INSURED INSURER A:NATIONAL GRANGE MUTUAL Michael Rodden INSURER B:TRAVELERS PROPERTY & CASUALTY 47 Prescott Street INSURER C: INSURER D: North Andover MA 01845— INSURERS COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MMIDD DATE MMIDD A GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE An one fire $ 500,000 CLAIMS MADE 0 OCCUR MPP37395 02/01/2001 02/01/2002 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JPECOT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ COMPENSATION AND TRTU EMPLOYERS'LIABILITY IMS OTR EL.EACH ACCIDENT $ 100,000 B 849K419 01/01/2001 01/01/2021 EL.DISEASE-EAEMPLOYEE$ 100,000 EL.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDERADDITIONAL INSURED;INSURER LETTER: CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Building Department EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT North Andover MA 01845— FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURETa OR REPRESENTATIVES. AU OR NT._TIVE ACORD 25S(7/97) ©ACORD CORPORATION 1988 *,,INS025S(9911) ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2 i � t I J E YA J If �. � e FORM - U - LOT RELEASE FORM Y V Y 4� INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. �............................0W ■..................................1/........■ APPLICANT PHONE ASSESSO MAP NUMBER lam_LOT NUMBER I I SUBDIVISION LOT NUMBER 1 STREET [n f CZ (eco� e STREET NUMBER ........... ............... OFFICIAL USE ONLY........�..�............ ........................................................................... . RECO;:f K DATIONS OF TOWN AGENTS DATE APPROVED 6 G CO SERVATION ADMINISTRATOR DATE REJECTED COMMENTS 1 1� �t��5�^ti �t' f - lt�l r\ 0^ �l► Q �"� DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR-'HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED CONPAENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE J rn C� N s�. Ci o F� J 0 W rye. �qc� g?os PAVED DRI PF loo PA 710,, - OO O O O O F�y i9a AREA "'� o O — 92 Q� 90 , ,\ j \ 0 -7- 90 88 f6 l�O 778 �- zo REA ' 1. 0 162 FA U / ---� LOT 777 50'NO-BUILD ZONE WA f ' WA AL WFA 10 -- -- \WA 11 AL WA 8 �---25'NO-DISTURBANCE ZONE F NORTH Town of over No. DSA CaC„,� f�y dower, Mass., DRATED S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT V �. ........ . . M O..................................... ................. .... .......................................... Foundation a Xia l A r has permission to erec �.......�................/... buildings on........ ........................N.... .�.�....�.. ................... ............. Rough K �t�N sin tob8 OCCUpled as ............................................................................................................................................ Chimney ............................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alter tion and Construction of Buildings in the Town of North Andover. I 0,4 TZ 118 p ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ` Q ! Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR N Rough .................... .��. :.,. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. L13cation /, l ' ' , " Date 7 r NpRT� TOWN OF NORTH ANDOVER f 1 3? � SOL � D Certificate of Occupancy $ ov �ss�cMustt Building/Frame Permit Fee $ / Foundation Permit Fee $ Other Permit Fee $ A TOTAL $ Chgck # (2 Building Insp for ._._ _. ....._.r....__-__........._. I'1?ItMIT NU. V� APPLICATION LICATION ["Olt I'll',RM IT1'O 13UII,U NOIt'I'L1 ANDOVI'it ' MA MIrNN. d �oY� 0��� 1�)I.Nt). Z. lit(olmos owmus1111 -- _ I):1I : BOOK PAGE - /t)n1. — SIIU It1Y. l t)I Nq). -- / ego 077 (h..NLR'S NAML M).(Am sit VIES tl1tN1:R�SAlAa�ias �� N�S � IIASLMLNrlxiSIAI! gRt'1Ill E CS NAME SIM(11 11.(xx:11MULHs 1 Z 3 Ti 1!1111 1)EH S NAnIE1. ��/ �� SPAN - — IHSIAIAT It)NLARFS1 UUII.1)IN(; D f Moll:NS1014S 1'Sill s IMS IAMA-IH0111SIRIA;I' I7inI1NSImSt11(ISIS - -- UISIANCE-FROMLUrLINL:S-SINES REAR to Ill All:NS11)t4s0I (;IRUI:Its — AREA(x=1 r IMMJIAGE /<5-I NEu;IntlFLx1N1>nnt,N TIIICI:ss — --- . is'lUll.b1m;NEW SI/I-' Itx111N(i X ' IS UyII.ol"o Al-1LRATION Is UUII.UINti( Soul)( F111 EI)LANI) Wit 1-011111)IN(iC(x,iF(xtMTORI:(,XlIR[n.lf::N1SC3('C(x)E ISIIIIIIUIN(iC(NdNI•C'ILI)1(llO\VNWAIFR IIS1)I;ll.1)117(;C(MJIJLC-lG1)10NAR)RAI.GASI,I14L ---- IN51 I1('11UNs 3. 1'ROVLit I Y INF(lRMA LION IANI)COS l' ESI.UI.IX;.C(Xir Aw 1'4(;E 1 FII I.(xlrsECNt1Ns 1-3 ES 1.U1.1 X;.Ctri1 MR SQ.1'I. _ -ES 1.1311x;.C(riI PERRtx1.1 LI ECrHiC MI:1 LRS n111ST BE ON(x Il SII)E(7F 131-1111DINGSEI'1IC 1'LRL11l IJU. AI-IACIIEI)(;ARAt;ES1.111S1 C(1ll: M II rOSFAIEFIRERB;1li.All()NS 1. APPROVED UV: — 11I.ANS MUST UE I II Lb ANI)APPROVIA)UY Illlll.l)IN(i INSPECIl1t IIIIII.1mo;INsI'1:(:1 oil DAIS 1111:1) 1 i GSC%- �d uwNERs1Ia a 5 dae--9,azlo L ON I R,It-19 --------- 909 ('t14IR.IH'N SIGMA 1111M t M 1) I:R 1 2 Al l 1 h /1/1/)AAtt;1 1; E JAN 1 9 I 1 1 1s L /i V,��^'� Cir//✓ �L 1'Ilinll t' A1411 1) IBUILDING DE,'--U31' LENT a I I - - FORM! U - LOT RELEASE FORM =- Cr l 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. - ** *** ****AFFLICANT FILLS OUT THIS APPLICANT PHONE O'-d:V 0 7 LOCATION: Assessors Niap Numbera7/D D 7J PARCEL o?�O SUBDIVISION LOT ISS �Oy�✓ 4/7� STREET ST. NUMBER O� ****** OFFICIAL USE ONLY RECO _ DATIONS OF TOWN A ENTS' /v7 ✓,!PC✓/C4 CON /RVATON ADMINISTRATOR ATEAPPROVED G1- A 1 -6 ���—/d � DATREJECTED aS Q1CJ ° 9 -'V'tise COMMENTS &41 M_ AQ g I i OLf TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INS °ECTOR-HEALTH DATE APPROVED DATE REJECTED SE 1C I PECT -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUELIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED EY BUILDING i,I1SPECTOR DATE Revised 9197, im MORTGAGE SURVEY PLAN LOCATED /N NO. ANDOVER. MA. - / 4 0 DATE: 4/26/94 SCALE Scott L. Giles R.L.S 50 Deer Meadow Road North Andover, Mass. A �v�DIV tS Q .F. i O U ii w t , T. BU/LD. _� 4r t /.. L13/3 LOT 29 -} . y w, �r;ta =merf csrF�z r__ 01 5. n ��aYi •4-�„ `skikP'I c,.,.4.u.r, ! - r .. "� 00. O `•lA L - ANC f i M �S-AND ,• ' .— .- S{ yi / •J ,� LOAD = L yY • f 1. 6 i p'�1': .2 1 .' i t�� �c H�.s �iy 1 t Louis . S Luciana & `JoanneM Lucianno �~ TO Boston Sa£ D "noG, t iD /?'S .T/TLE/NSURER � q THIS L..OT/SLNQT/N`!J FLOOD fWAR02'uNE = /_ CERT/FY THAT' OFFSETS SHOW711 ARE FOR THEOSE THE OFFSETS OF THE BU/LDMIG INSPECTOR ONLY Y SHOWN COMPLY AND SUCH USf"/S FOR THE - W/TH THE-ZONING DETERM/NAT/ON OFZON/NG «' BY LAWS OF CONFORM✓!/TY Ofp, NUN-CONFORMITY Na AWHEN COWS i'RUCTED. ti11 WHLL N 4U/L T. F c v r w!L SuwtrAt�,rWTfAv"x L,L r P!R lAJrT lDMM.LiL1E'!p� 6/�Y�N~r At"/1740 �+•sj .� 3� t om/ "-1X)FA(INSO QY POOL IS, WNW I �r-q 3-03&-- iN 49N0 MIM �/9Ei•/F/E I 7DP OF SI VO SEAM— e %Acr r?"AIME htOL ^ J t.7' "• ` MAX./E.r YwILL i •t RES. �NO/Y/NG 90ARL' �-' �' ;. NA?Zwu I y Aw .;7,. } . SIfE7Y:fA.E/ g;•.;�, •O.c,eorr Wars W.40 Or c6vA/ - --- (r•R - 6Aawo r ,L 4/1bDE S•M/6L.t - 6ARS I ; :LfY4'•O' \ 1►3 SOPS®L a—C cur d..,,,45:;tr£O �Jl AM/NDRAJN S7Anc \ S ewlar I — CaNNEO'DrRE4 7V PUMP RELEFwiwe '� -/Fv RESIMNTJALIf LOMMSWJAL �•,yNlkmp ' A - Ur a-F A[TiPAN7E tCLaW r BAPS fL�7 Y-O• �saceFY[E �_ Y w�TTJeJOD6 s EGEY 7=9" �• GEK�O' P/T QL mrw NMYS Sz 7"- .STANDARD WALL 7/OSI/ zY — is7a+AsiYaC. ••°" e«r _CONSTRUC7/0N NOTES } o GENERAL REIMAO)C/AG STEL�L T t ecONSMUMON SHALL 4XVA,PM 7a WY 9E,-7- Ac ALP-9 .€S.ILETY 1CQL/ STq ypggL(j 7V 4S.7,44 DES/G NAT/OHCS /1 1E RA•30S- G' a OIViNG DOA/PD M77_PERAl17ED OA, /btlLS LAPS SMALL BE .4 Al/,V1AIUM Ar 7W/,P7)-j • r Ou/T IL.ESS7A",v ,IT GQARD. D/i f-fr&X3• 4W'&'iYMERE SOL/CES ALEtA�lbrfflFE Pm U/RED JSP OCGUR T/ r'.' _'_ L 1rU/y/TE GD/1tS•Ti�r D/V ours • ;"-—_ I Ems'6N— • 6UN/TE S.WLL AdF M4CV/NE.N/rED .4No •,TN/S DES/4N APIL/ED lfVAVA AT/DALLY• M/a'SAW.4 QE _ CIV AvrALP 7D LOGIL CDCAE AVD O/VL P,I,Pr C.F"NT 7D /DILP�UVD A WCF cam"dwLy 6Al7JAVOCLWP AND AP A �ON,�LY LlYEL J/7F PAR7T S4VO /•4�E ULT. alWR JWE4 7W- • 1=A WZW,L- ZW,,.VO W/7AVN 2FST 34W Rai dP ae Rr4YS Of AUTOMAT/C SURFAG£SK/nrMe/7 :�•.• :WiLG "'ar M— SIjPALBA,NTV Zr O1rVL� WATER CFA0'ZV7',q,/T•t7 X4'&Z AVT'�d PAFJ/6V 3/1 Gats WAMW cP;r X r_&Rr C SWiWT r ieAa(e J►) FENCE • CU,PE WW17F 4W.4 L/G,yT krArF,P JOANw loo • OIVNp,+SHALL PROP/AE 14 MCAS/N L[G/PL/AM1r_E TAS-- 71AKr-4 WY.;dr ZMV AIAT (LDER NATER L/SVT W1771 Z=a C/n"4W;VWiY OA'LYNAACE OTE c a ^ 04W70 AF SFLF t7AT/AA5 C[,47'LWV/MB. TTdC•aW 7sdT 17AN oRAwitfS • ELECTR/CAC SMALL CONIVIM TO.MM7 HtAAT t` A,VO WCAL RB7UiTEA/ENr a .; sows 4101c. �o. O /OrN WNW N/ntP10tSTw77c STANRD S0,9 '.o,' •D: -P•• JA- �i�. l✓/MM/NG POOL Flii A N Mr --- - - CptLioN ------ — - Tl/sE /FRw. •'" e3'�'tNot'nrAs� /A4�RELd: • 3 nMoTNY SS. --- ----—- "' =4W1 <!4 Vii'. - F WALKER N SCALE: "AIS APPROVED 8r T 6RAiLS(/Aba -ANo.CIVIL 6 0 DATE: f-11- y2 UC"= PROs IMI AL Dwom REI/. L7 • C'ST4-, TIMOTHY WALKER - CONSULTING ENGINEER MAJN ourLFT ii tJs'OMAIL"G' 19 WOODSIDE AVE. WESTPOW CT 0Mna -- --- Gelpf/r�.Y SAAO/IE Gutvilir/txG ueeJs�. omwma MuwER !2 M�70LlY Jl^ �O �" n_jp-OJ ,YCR77r B/L.LCATJGA 11.9 'tr'ft>0/111Oif ttAap -11.t7 Ay 00 11--9A06 31 J 7 a I 7 6 7 4 .DEPARTMENT OF PUBLIC SAFr-,TY-- 176715 - - -- - --ONE--ASHBURTON PLACE: RM-'t-301---.--------- :- BOSTON ' MA 02108-1618 CONSTRUCTION SUOPERVISOR LICENSE = Number: Expires: - CS 056070 05/13/2000 5%T3 19�a5 ---......... -... Re tt-ir.f:ed -To: 00 fiOfiFF2"f F GUARTP•!0 MAY 1448 __ .........._. -- 1121. IdA.IN STREET OUNSTABL;_, MA 01.82! K:?:;•I, ton for recti i-!fir; -i id ch.3m-p- �7- p 0K i '✓fie Vi ��,/�'Ga�GaceQ HOME IMPROVEMENT CONTRACTORS REGISTRATION , oard of Building' Regulations and Standards One Ashburton Place - Room 1301 ! Boston, Massachusetts. 021.08 j HOME IMPROVEMENT CONTRACTOR Registration 105485 Expiration 07/17/00 ----------=----------------------- Type - PRIVATE CORPORATION ! Registration -105485 SOUTH SHORE GUNITE POOL & SPA INC . Type - PRIVATE CORPORATION ROBERT E. GUARINO i 12 HADLEY ST Expiration 01/11/00 i t-i. BILLERICA MA 01862 ' SOUTH SHORE GUNITE POOL b SPA ! t ROBERT E. GUARINO 12 HADLEY ST j G� wILLERICA NA 01862 W� The Commonwealth of Massachusetts _ c Department of Industrial-Accidents Office of Investigations Boston, Mass. 02111 \`' .4,✓✓' Workers' Compensation Insurance Afflidavit Name 1 Please Print Name /� /S / Cfif�/✓O ���� 1-YYi�L,7 Location: Citi �� dGG1�GPhone I am a homeowner pe tcrmina all work myse!f. a ! am a sole proprietor and have no one werkina in any capacity I am an employer providing workers' compensation for my employees working on this job. ���C---cm��� oanv name. 2L Address / o? i�.dCL Citi: L�ls.�rC Phone T - 7.7, 3 Insurance Co. / Policv m I Comoanv name: Address City: Phone Insurance Co. Polis✓Y Failure to secure coverage as recuirec under Section 25A or ivtGL 152 can lead to the imposition cf cnmiral penalties of a rine up to$1,500.00 and/or one years'irnpnscnment as ,veil as c:vii penalties in the f.crm cf a STCP WCRK ORCER and a fine cf(5100.00) a day against me. I understand that a copy of.his statement may be forwarded to the Office cf Investigations cf the CIA for coverage verification. l do hereby certiry un r the pain and penalties of perjury that the information provided acc e is true and correct. Sionatur Date Print na e Sl�G� Phone Official use only do not write in this area to be cemcleted by city crown cric:ai C'ty or Town Permit/Licensing Building Dept 71 Check d immediate response is required ❑ Licensing Board C Se!ectman's Office Contact person: phone;�k, health Department Other AORT#q Town of Andover 331/ * Ao dover, Mass., 07gn 3 0 CO C MICKEwICK y�. ADRATED `S BOARD OF HEAL PERM IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ .. .!5................ .. ..�i►. .i. ..................................... ............. Foundation p , , 4.. NCI. b /. � Rough has ermission to erect. buildings on /4 ........................ Chimney to be occupied as..........................y............ .............................................................................. provided that the person accepting this perm shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, A eration and Construction of Buildings in the Town of North Andover. I A0 r to , r Y PLUMBING ECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. rn /D�� /�� Rough M A � N* i I � PERMIT EXPIRES IN 6 MONTHS 3`� Final 1 c M'O m ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T P♦��J Rough ................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GASINSP TOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPA ENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke D . •Locations 'No. /�L,,4� Date TOWN OF NORTH ANDOVER p� � o y stip A Certificate of Occupancy $ . . R Building/Frame Permit Fee $ 1SJACNU`+Et Foundation Permit Fee $ Other Per It ee Sewer Connection Fee Water Connection Fee $ "' TOTAL $////,A,'S U l� 66`1d-!6g nspector 7132 Div. ub�c`I}Norks Location �� ✓r' /1 7 ! J t No. 71- Date 1 J of M°"T;�tio TOWN OF NORTH ANDOVER ? s . � •, �L p Certificate of Occupancy $o'. � r Building/Frame Pej it Fee $ U^ o ,ve • 3 s,4cHu'"'•°pit Found�aon PermtY6e. $ u, B Othd(t/' P�ait Fee Y,t, $ 5 v/ Sewer 0�ection F $ 436 'S3 /,Q:5'Water Con(�ction Fee c� $ H 0 TOTAL ,y �� '� $ 02 / / V' I/V 01 �7 Mel 7,38 L`Building Inspector l Div. Public Works 'Location +No. G,�— Date A . NORTH TOWN OF NORTH ANDOVER ? i '° O r. o Certificate of Occupancy $ i U •0 U Building/Frame Permit Fee $ Foundation Permit/Fee $ 0 U s�CHus t Other-Permit Fee $ — _s $ewerConnec.tiah Fee $ Water Connection Fee $ Building Inspector `� Div. Public Works L Location / 4•rc. ��e r P� /,, /¢/ No. / Date NORTH TOWN OF NORTH ANDOVER r...S.0 A Certificate of Occupancy $ �a + Building/Frame Permit Fee $ 'ss+cMusEt� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ /©Gb�J wg1ter,Cora ection Fee $ TOTPFf`l'Tp,Q $ 3 0 Building Inspector Div. Public Works f PEwAtIT-t2NG'._ � uu ,_ s — APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. le-0L /'j W �Z i PAGE 1 'MAP KVO. I LOT NO. ///- 2 RECORD OF OWNERSHIP iDATE (BOOK PAGE — ZONE SUB DIV. LOT NO. LOCATIO RPOSE Of MOILDING /y OWNER'S NAMENO. OF STORIES SIZE ! a OWNER'S ADDRE BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST OC 9 9 !y •,6 2ND 9X�D 3RD BUILDER'S NAME .�� � SPAN 1,e74.1 /f DISTANCE TO NEAREST BUILDING 'Q / DIMENSIONS OF SILLS 1�1- DISTANCE FROM STREET POSTS // V --- DISTANCE FROM LOT LINES-SIDES `! REAR //,f GIRDERS AREA OF LOT ' (L FRONTAGE HEIGHT OF FOUNDATION THICKNESS !d// IS BUILDING NEW ,.�` SIZE OF FOOTING / X .J IS BUILDING ADDITION MATERIAL OF CHIMNEY S� IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER t BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS s PROPERTY INFORMATION + SEE BOTH SIDES C LAND COST BLDG. PERMIT fm— EST. BLDG. COST ®' aw-A O. V PAGE I FILL OUT SECTIONS I - 3 LESS FDA FE "U EST. BLDG. COST PER SQ. FT. * DUE KRFtfl�l� EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 �UG FRAME Pf �rZ �«. SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING - 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR • DATE FILED - p BOARD OR HEALTH --NATURE OF gVfNER OR AUTHORIZED AGENT FEE y�,/�Y,,�/'J v © � PERMIT GRANTM OWNER TEL qf2„4�_—7,3Y9' PLANNING BOARD CONTR.TEC. i Is CONTR.LIC.# BOARD OF SELECTMEN INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY OFFICESTHIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 13 CONCRETE BL K. BRICK OR STONE HATER PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULLFIN. B M'T' AREA FIN. ATTIC AREA NO B M T FIRE PLACES HEAD ROOM _ MODERN KITCHEN 1K 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. :e Ys r,•y ' t` STONE ON MASONRY WIRING STONE ON FRAME SUPERIORI� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING 3ABLE I I HIP BATH 13 FIX.) AMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER L ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO C 6 FRAMING I 11 HEATING WOOD JOIST l/' PIPELESS FURNACE .' FORCED HOT AIR FURN. � ... TIMBER BMS. &COLS. STEAM 1 STEEL BMS. 6 COLS. _ HOT W'T'R OR VAPOR """"" "` t WOOD RAFTERS AIR CONDITIONING mow•,,,,,,-„w,,.,...�.•»u +(�%t•,...I RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T2nd _ ELECTRIC 1st 13rd NO HEATING y o v , FORM U - LOT RELEASE FORM y INSTRUCTIONS: This form is used to verify that all necessary i approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or ' landowner from compliance with any applicable local or state law, regulations or requirements. } ****************Applicant fills out this section***************** + APPLICANT: ;/zLPhone 11 ;7 �� y LOCATION: Assessor's Map Number OD Parcel /27 Subdivision Lots) � - Street /I St. Number ----1 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved 409�- Conservation Administrator �[ Date Rejected • Comments ,,,( 'py3 G Csl'( iWeit2S Date Approved R, Town Planner Date Rejected ` Comments Date Approved �J Health Agent Date Rejected Comments Public Worcs - sewer/water connections - driveway ,permit Fire Department Received by Building Inspector Date JUN 2 9 FL-e---, A--j p 4_0' TAS 29� 199 3 ` '✓ S crcr--r- �•G I�.�s e.cr.S. - t t r �2 443 0° /9 4 t3 00 lJo C uT 3C� ''yes � I � t k's t4-0 i I sC y o N CERTIFIED FOUNDA TION PL AN + LOCATED /N SCAL E.- /"'_ DATE •l3 g3 Scott L. Gi/es RL.S. 50 Deer Meodow Rood North Andover, Moss. LOT 14 44-I3Z3 SF 1 L V I 23 S� Lat 13 o �4 N GASTF � c���•'S, ' LA R , JUL 2 0w LE�ae�DINV�EP.4,, e / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE- THE SETHE OFFSETS OF THE BUIL DING /NSPEC TOR ONL Y SHOWN COMPLY AND SUCH USE/S FOR THE W/TH THE ZONING DETERMINATION OF ZON/NG BY LAWS OF CONFORM/T Y OR NON- CONFORM/T Y I�lD..AN•DCAI M,MA. WHEN CONS TRUC TED. at u WHEN BUIL T �� NORTIy E 0 of ��� R , Andover /��) dower, Mass., w Wit A � 19c. '.; DRATED G '�C, '9S H BOARD OF HEALTH AL Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... ... .......ot&.Lwevox .......A T..... r...................' Foundation t ' .. buildings on � ... � has permission to erec ......... ..... . ...... Rough to be occupied asAf Aho� .. �� ....� �.�. �. � ..�.� ..46 himn y C e provided that the person accepting this permits all in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover.,f pt#0••N i it 1949 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. FMI IN FOjIQN ONLY Rough PERMIT EXPIRES IN 6 MC W PARA. 114J Final UNLESS CONSTRUCTION 'S ``'� ELECTRICAL INSPECTOR p' Rough PERMIT FOR FRAME/BUILDING .. Service BUILDING INSPECTOR Final DATE . �`° FEE P�IQ� 1 •Pe rmit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINALCONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FI NALd a�` q*DRIVEWAY ENTRY PERMIT Location � T.�I Cf No. =� Date 3 NORTH ' TOWN OF NORTH ANDOVER p Certificate of Occupancy $ * Building/Frame Permit Fee $ �at'on Permit Fee $ ermit Fee $ ,fie . Connection Fee $ l• Water Connection Fee $ '094bTA L $ 0-S V 6e ming Inspector r 7 r l3? Div. Public Works . /�'ill�• IIL111.1)IN(. �-;: :/: hl: ;; iIii :c IIv �Iti•I C:c)NtiI:I tVATION \'" � I)I\•I:;h IN l)1 Il i l i l iti'i•I i i'f 1'i.�\NNINc� 1'l,ANN1NG & (;t)!li[►il!NI"1'1' I)1s�'1sl,t)1'l111 N'1' KAI ,FN, 1 1.1 '. NI:l.ti( )N. I )11 t1:(:I t )I t • CHIMNEY APPL1CAf1014 ANO ITKA11' ATE 1' PERMIT. #� �. OCATION .LINER'S NAME: A,Gy 1 tti t e 1 I F T 1I LDER'S NAME: ISON'S NAME: � � yBv ASON'S ADDRESS: &UP V, //e ZaAle, .SON'S TELEPHONE: (��� '0, nq ITERIAL OF CHIMNEY: IFERIOR CHIMNEY: EXTERIOR 011AWEY: Ih1BER AND SIZE OF FLUES: / l 2l>C')d J-)o IICKNESS OF HEARTH: ' jo iu chullnw 0/1. 6.AenCnce conOaam tv .thQ ur •t.lte COd (1)Id 11ctVC - 1.110 (111d igutatiow been necebed: -- _-- :GNATURE OF MASON: =RA{IT GRANTED: �l S,� ��� FEE alp ')BERT NICETTA ' 1ILDING INSPECTOR 1SPECTEU: -MARKS: SOLID [CLUCK IZE1tEU THIS PERMIT 111LIS1- GE U1SPLAYLU 014 ME- PUMAS PE9111T NO. a���.� APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 940. I LOT NO. 2 RECORD OF OWNERSHIP jDATE IBOOK ;PAGE — ZONE SUB DIV. LOT NO. < LOCATION OSE OF BUILDING OWNER'S N E NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES ST. BLDG. COST /J PAGE 1 FILL OUT SECTIONS 1 - 3 Ll EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE ED ��� BOARD OF HEALTH - :n OWN R R AUTHORIZED AGENT op FEE 40;2,5-. o o OWNER TEL.# PLANNING BOARD PERMIT GRANTED CONTR.TEL.# CONTR. LiC. 19 -- BOARD OF SELECTMEN ✓ BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY rOFF Ou1Es THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ _ DRY VJ _ UNFIN. 4 3 BASEMENT 11 AREA FULL FIN, BM'T AREA _ V/ 1/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS II 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMtAC;N VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BIK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR (� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 M. ( = GAMBREL MANSARD TOILET RM. 12 FIX.) FIAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING tAORTH Town of �+oAndover 0 to No. 0 LA ' b dover, Mass., 19 py E COC HIC MEWICK Al Of?ATED F' BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............ .4.kr............................................................................. Foundation has permission to erect. 1W&0.rZfA1V .. buildings on k/A4,fA.1er,0".AfX.je P ........................ Rough to be occupied as........d��lA1!r00_4tT*#*)*A Chimney ..eA provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-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 MONTHS ' Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR /1"p-41 _�e: 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 PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER F1 NAL DRIVEWAY ENTRY PERMIT i r\0R1 } { �> own of �� �o over - ,Q �' dower, Mass., 19 f� ORATED !! 1ST H C: BOARD OF HEALTH PERM IT TO Food/Kitchen Septic System a BUILDING INSPECTOR THIS CERTIFIES THAT........ � !. N. .......�..o..T.....�.. �.................. ........ .. ...... ...................... Foundation has permission to erectOWM ........ buildings on WOr� ... .f Rough ll/ 04y--7y4 to be occupied as,010 S r04..1. o4�.. Chimney Provided that the person accepting this Permit shain every respect conform to the terms of the application n file in y rl 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. I VIP A• •N ♦ 06904 PLUMBING SPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. FOUNDATION ONLY �R° gb , T 3 tFILJITED PIIRII. 114.8•S. 9.0, PL1Zh,11. I' E ,1'I�ES IN 6Iu�l��a q U N LES ELECTRICAL.INSPECTOR Roughll1-� ,1 PERMIT FOR FRAME/BUILDING ........................... Service ' BUILDING INSPECTOR Final ,�•/G ' DATE 'a� FEE P I • �v_ I'ciiitit R(, ztir-c,d to Oc:(i(py I itilc.ling of `'/�j'/ 3 -- -- - -- - -- ----- -- - --—- 7GA �NCTDR SPE R 6_�d?, Display in a Conspicuous Place on the Premises — Do Not Remove ,- IC* No Lathing or Dry Wall To Be Done FIRE DVP RTMENT Until Inspected and Approved by the Building Inspector. Burner ) PLANNING 1 FINAL CONSERVATION ✓ I FIN treet No. 01,�6 hO Smoke Det. 1 l i qFWFR/WATERS _`' FINAL�a�` �� DRIVEWAY ENTRY PERMIT �'' CERTIFICATE OF USES & OCCUPANCY Town ol Nmlh Andover Building Permit Number 264 (1993) Date APRIL 26, 1994 THIS CERTIFIES THAT THE BUILDING LOCATED ON 61 T ANCASTER ROAD MAY BE OCCUPIED AS SINGLE FAMILY DWLELING W/3 CAR GARAGE IN ACCORDANCE & sunroon and deck. WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. i pp1Tq CERTIFICATE ISSUED TO A. J. Maillet { O it 6 ADDRESS 61 Lancaster Road 94.1 ' f`� Building Inspector N°- Date.......... .. .......... p� N�orM 1N 3: <;�``...•�.ao� TOWN OF NORTH ANDOVER - p PERMIT FOR WIRING SSACMUSE� This certifies that '.................................` '' =`''' "`'� ...... . ...................... G f has permission to perform ............................................................................... wiring in the building of....�... :�� -���� ................................................................... at -•;"' , ` `� ..../ .................,North Andover,Mass. Fee .... ....... Lic. ...... ........................ ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer l ommonwa.all�t o�/Y/a99ae%eednllf Official Use Only l Permit No. �1� _ �J¢Rarin+nn1 o�Jira J¢rvic¢� — Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rcv. 1 1/991 flcavc blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachuscus Electrical Code(" CC) 527 COIR 12.00 (PLEASE PRINT 1N 1NK Olt %ffE"I ,!, 1tVl 01, 770N) Di1c: � C� l To the Ins pector 0 1•Yil•es: City ot• •ro„•lt �f: � f I By this application the undersigned gives notice of his or her intentiotl t perform the electrical work described below. Location (Street fi \t tuber) S r r ' J /l Owner or Tenant CMZ 0 fi 10- �) ' / l[/1 Telephone No. ��JU Owner's Address Is this permit in conjunction with a building pernti t? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Scrvicc Amps / Volts Overhead ElUndgrd ❑ Nu. of deters /) Volls Overhead Undgrd Meters.' New Service Amps / ❑ o No. of Number of Feeders and Ampacily Lonatiun and N ,t\urc of Proposed EI ctrical 1Vork: Po UI !1 din Corn lelior or( jolL�n•in¢table Mao be wois•ed by ilrc Inspector orIVires. No. of •1•otal No. of Recessed Fixtures o.cif Ceil.-Susp.(Paddle) Fans transformers KVA No. of Lighting Outlets No. of Ilot Tubs Generators I`VA Above ln- o. o Emergency Lighting No. of Lighting Fixtures Stsimmint,Pool orad. ❑ t rnd. ❑ Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS N'o. of Zones t o. of Detection and No. of Switches No.of Gas Burners Initiating Devices TotaNNo. of Alerting Devices No. of Ranges No.of Air Cond. Tons r No. of Waste Disposers Ilcatlloirtt�p > .umber I:o_ns. .... KN _ No. of elf- ontaittcd Detection/Alerting Devices tllunicipal No. of Dishwashers Space/Arca Heating KW Local ❑ Connection E] Other Healin-,Appliances IC�V Security Systems: 1o. of Dryers No.of Devices or Equivalent No. of Nater No. of No. of Data Wiring: Henters KNE Sighs Ballasts No.of Deviccs or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No.of Motors Total IIP No.of Devices or E uivalent OTHER: ilttach additional detail if desired, or as required by the Inspector of Wires. INSUR.ei,NCE 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:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MLC Rule 10,and upon completion. I certify, under the limns nod penalties of perjury, that dee information nn this app cation is true and complete. NAME: \111' L-.L./464 �Lr✓�7-/Zll _�H41-- . LIC.NO.: 9•/(0 3 Licensee:fin rlfon if P EL P1r+O14_ Sibttature _,y LIC.NiO.: —'976 / S (If atrplicob!�Penter "evempt"in Nee license nruuber line.) Bt+e.Te1.No. ( AddressQ �?1X �U� L�f9�L�tS��/21.1 twl* r9llak : ffXTel.No.Q• zF.1.5-6 S�d� ON-'NER'S INSUI::\rCE WAIVER: I am aware that the Luensee does not bare the liability utsurancc covera+�c normally 1 required by By my signature below, 1 hereby waive this requirement. I am the(check onc) ❑ owner ❑ owner's agent. Owner/Agent Pi:Rt1IIT FEE•: Signature 1'cicphunc No.