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Miscellaneous - 65 BRIGHTWOOD AVENUE 4/30/2018
-65 BRIGHTWOOD AVENUE 2101066 OOO.D I I �` I Date... ............................ OF NOR7H,ti0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies thatck LV4- eo 0 0 ............................................................................................................................ 2r-'.......`..1' has permission to perform. . .�...�t,-\TC,,j Qpvotd 4&t', ... ................................................................... wiring in the building ....................................................... at LO'J .—G.......... ...... .............Noah An er,Mass. Pee P,'.a..............Lic.No. 19,11H. ......i. ........ ............................ ELECTRIC N OR Check I �2 --4 -7 Commonwealth of Massachusetts official use onl y Department of Fire Services Permit No. O . Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Oy 1021 ?_0(5_ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (05 ef_jLy+T W ppb crUfr Owner or Tenant (��NEQ — �t�►Ti 101�lN SIJ 000 I-1Z RSO Telephone No.07798-43-70 Owner's Address Is this permit in conjunction with a building permit? YesNo El (Check Appropriate Box) Purpose of Building ►2�sz�FUTzL_ Utility Authorization No. Existing Service 'ZOO Amps IZO/ 2-40 Volts Overhead ❑ Undgrd❑ No.of Meters 2- New New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: - 91r 0JAil-rc % -TO -VkiE_ EY,TSTtt�llr LT-TCk��t�l lit t.��Q-y w0'M � �PFT+4-K.c3 0 w� � Completion of the followin 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 No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency ig mg _ rnd. rnd. Battery Units No.of Receptacle Outlets Q3 No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices -� No.of Ranges No.of Air Cond. Total Tons g No.of Alerting Devices No.of Waste Disposers Heat Pump Number I Tons IKW No.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances K`,1, Security Systems:* No.of Devices or Equivalent \P No.o Water KW o.of o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent _ No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: No.of Devices or E uivalent Ct OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value ofElect 'cal Work Z1500, (When required by municipal policy.) Work to Start: ON OZ ZotS Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cert,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:?f.6kC-eS&TJI)E ELE.(TeU_P L, SEe LIC.NO.: 1$(yL{y Qr Licensee:Ck"STykµ. 1L1 L4-ZWA Signature LIC.NO.: (If applicable, enter "exempt"i i he license number line.) 3 Bus.Tel.No.:S�3 39'1 $3Zd Address: C1JNC��� tJ. Ems, NVQ 0,92A# 1 Alt.Tel.No.:(45, ?OZ St60 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety "S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ -- 1 i ti � i� Fold,Then Detach Along All Perforations r ;COMMONWEALTH OF-M. us :: ::5:'z :` BOARD OF ,EI:ECTR I C I ANS >'< ` SSUES ,THE;.:FOLLOWI NG 11CENSE AS A REGISfifRED MASTE.R :ELECTRICIAN PROG:R.ESSIVE ELECTRICAL SERVICES :._ 'CHRISTIAN K AROCCA W 95 NEW BOW< LAKE fiOAD �J .BARR 1:GTQN . NH 03825 6224 F f t 564+',;::A: .. 07/3 ./a 6;:., 55008 9 • Fold,Then Detach Along All Pa.foradons 4'COMMONWEALTH OF M.`$ HUS :'t »' o @10`990 09 mi WHOM ;BOARD OF ELECTRICIANS I S S U.E..!S:,..jT HE FOLLOWING 11 CENSE, 'UOURNEYMAN' ELECTRIC[ASI a 'a GHRi:�T I AN K LAROCCA 95 NEW BOW LAKE W .1H 03 82 -6224 8I1RR I NGT:Ot�; 5 3703a'E':: '>.. 62727 r "tdl'i•Y9Ly.�•1a�17��a:iit�+eioi• The Commonwealth of Massachusetts Department of IndustrialAccidents a , - 1 Congress Street, Suite 100 Boston,MA 02114-2017 °t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / L Please Print Legibly Name (Business/Organization/Individual): Pte'o4e C e S r -C F( , -C LTi-.C G 1 �-e,✓i c-e S l Address: e©K C QLJ City/State/Zip: L<< & µ 6-;9( ( Phone#: 603 3�7 -- 0--46 Ar eyo an employer?Check the appropriate box: Type of project(required): 1. m a employer with 02.. : employees(full and/or part-time).* 7. New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.FJ Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. _ $Conizactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. gg n Insurance Company Name: Ike 1�e Lite_y 44� ey 7 v►C. Policy#or Self-ins.Lie.#: C-t©4 0 0 13�(��—D"7 Expiration Date: Job Site Address: 1.<- 9,r E,ti f Li") Y-c City/State/Zip: Noe-4 u4Jy,,•ev- (k Attach a copy of the workers'c mpensation policy declaration page(showing the policy number and expiration date). Failule to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. L—dSi nature: Date: i Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of ' Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation'policy,please call the Department at the number listed below. Self-insured companies should'enter their' self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.. .�� ....... 11 192 F N�RTh� TOWN OF NORTH ANDOVER ° s p PERMIT FOR PLUMBING ,gBACHu`3�� This certifies that.... has permission to erform.....,.n:............ plumbing in the buildings of 'N .t�. �. ,O ................ at.. .! ... 1.. !v ...............e...., North Andover, Mass. Fee' .......Lic. No. 1251....... .................. ............................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE TIPERMIT# JOBSITE ADDRESS WNER'SNAMEu POWNER ADDRESS -CTO TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCE PRINT J CLEARLY NEW: RENOVATION: REPLACEMENT: Q '�� NOD! FIXTURES Z FLOOR- BSM 12 3 4 I �1 3 14 BATHTUB _I I ____..J i CI`- �p,� � CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM _ _._J DEDICATED GASIOIL/SAND SYSTEM L=l - DEDICATED GREASE SYSTEM _ . o _ 1 C�., �J`v. h As DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i _._ .__J .,_-_,___J _-T( ___-� ._ f�C, ✓�t� -t�'L hs�- ( j ` DISHWASHER ! J -- -i — �4 . ---1 DRINKING FOUNTAIN ( ______I ._._.J FOOD DISPOSER �f .___._1 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ F � l __. 6 _ �.,"�I � i I _ 1' I l .__ i _..._._i'l KITCHEN SINK LAVATORY 1 _ _ I __ ..__..� .__ _—[ __-__7 _._.___..I ____ ( ___-.[ .__.__J ___..__I _.__-.-J ( ►. -_._-__I ROOF DRAIN i I i .._ _ SHOWER STALL SER,!/ICE/MOP SINK l __.J _____( ..___f __j _..._1 _-.__ I _._._J --j ----Ji _..i ..__-i _:_--J i TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATERPIPINGH_ _-j OTHER � f I--_.J _._G .—i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ..1 NO Q IF YOU CHECKED YES,PLEASE INDICATE TH= PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY1 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 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are nd accurate he be my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m nce Z PLUMBER'S NAME LICENSE# SIATURE ine vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �{Y, _�kc/ - � _ 1 S J I M _T— �o MP W JP Q CORPORATION 0#PARTNERSHIP D# t LLC : n COMPANY NAME ADDRESS 3 S GO •�c I. CITY t1L ..- JI STATE IV NJ ZIP I D FAX —�CELL _ -- EMAIL UGH PLUMBING INSPE TION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r r� Y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY: ®` f?/ r�r/l/'i MA DATE J ��_( PERMIT# JOBSITE ADDRESS l"• WNER'S NAME POWNER ADDRESS TEL _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 01 EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: D PLANS SUBMITTED: YES E11 NOD FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CM,MIMI CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _I DEDICATED GREASE SYSTEM _.._._1I ^- IL DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i ____..__1 .._._...__{ _.. _._.I .__.! _. f .______{f -_! DISHWASHER DRINKING FOUNTAIN _ i ..___.-.{ ! .____E ._.__-_( _-.._.-_I ____--t --.__.E ,__-- -.1 .._.......f --. ._..1 _...__1 -11[7-L FOOD DISPOSER i ._.---.1 __-.___I ___-.._( __._ ; I ..---...._f ...____._l _.___.I ___.._l _E. _.--.-I _._.1 I FLOOR I AREA DRAIN ) 1 __-- ! f s _-__-� - 1 f __.._f f ..._-1 { INTERCEPTOR(INTERIOR) KITCHEN SINK ? _. _--( ------ LAVATORY ----LAVATORY ROOF DRAIN _ _► J __-f ._—I _._ [ --_.JI { SHOWER STALL f .__._! ..___1 .I ..___ f _. ._�I I _.l _.-. 1 _- I __ C SERVICE/MOP SINK � -1 �._( ( ( _{ _...__f f -_-__f _k � -_� 1 ! .__ _f _:___! i TOILET URINAL ___-[ __j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _f ( I f WATER PIPING 6THER _ � . f € 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 INDICAT7TPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE OF INDEMNITY I 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 F—] AGENT ID SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are nd accurate he be my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m nce wit ine vision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ til;L �__ .LICENSE# 1 SKMATURE (VIP pr JP D CORPORATION n# D# LLC `v n COMPANY NAME _ _ - �y L L L-; ADDRESS CITY STATE ZIP C� _ l _ _ �� TE FAX - 11 CELL L EMAILLX UGH PLUMBING INSPE TION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES -71 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �r t The Commonwealth of Massachusetts Department of Industrial Accidents a. w;: ; =-• d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1Please Print Legib Name(Business/Organization/Individual): , 1 , LG. Address: S �� City/State/Zip: V� /��( Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Fj Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. F1 Demolition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] 7. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit'this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit in such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-coniract'ors have employees,'they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif d1hepains and altie ofper'u at the information provided above is true and correct Si natur Date: tal Phone#: U — 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#: Y Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatiod'policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia .................... Date. .! -�.�.. RT TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s`QACHU RqvAC, This certifies that ......................-1..................................................................... . I .2.5 has pemussionttor gas ihstallationZ�A.��)��..�........................... in the buildings of -dvl.�.69..q............................................................. . at... .4............... North Andover, Mass. Fee.).U,p.......... L i c. No. ..... ..................................................................... GASINSPECTOR Check#2 1 0021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY ,.i�� //1 j MA DATE �!_11 PERMIT# 0 �l�ZA JOBSITEADDRESS (o '/„S�yr,�� r�U��i' vL�II OWNER'S NAME GOWNER ADDRESS TE _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL PRINT CLEANLY NEW:[,1 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ED �.-- --- .._ .. � -----I -- ---�1 f ED CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER —--_._ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENOED ROOM HEATER WATER HEATER tab OTHER (— INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y 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. CHECK ONE ONLY: OWNER 0 AGENT 0, 1 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and a ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia it all Perti pr sio e Massachusetts state Plumbing Code and Chapter 142 of the General Laws. PLU�7MGF ASFITTER NAME y.T��,f/ �/�r e LICENSE# Z`� SI ATU MP El JP _ ) JGF ( LPGI CORPORATION # PARTNERSHIP �--�—�—�—�� [�,] [� � � ��� TN RSHIP®#��( LLC _ I#�_.!I COMPANY NAME: Z12 7� (� ADDRESS CITY STATE L&MZIP TEL — 21 FAX , CELLEMAIL _ �:vvn_L;i om ROUGH GAS INSPEC N NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES .t The Commonwealth ofMassachusetts Department oflndustrialAccidents _,r W 1 Congress Street,Suite 100 Boston,MA 02114 2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print LePdbl Name(Business/Organization/Individual): Address: 11 City/State/Zip: fit f01+V_3".6 Phone#: o Are you employer?Check tfiee appropriate box: Type of project(required): 1. m a employer with V . employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. F!Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.F1we are a corporation and its officers have exercised their right of exemption per MGL C. 14.F1 Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,'tliey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi r thepains a d es o ry that the information provided above is true and correct. Signature: Date: i Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." r An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi•confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ,V,COMMONWEALTH OF MA$SACHUSETT,S WARP Qf PLUMBERS .A1]3 G71SF1TTER5' ISSUES THE FOLLOWING L'ICENS 1i �< t{CENSED AS A MASTER PLUMBE W RkYMO,ND P LABBE 35 COLBY RO DANVILit E ISH 03819-5104 12951 05/0.]/3b.., 2]8]49 jI Date....' -130ll 11382 OF NORTH, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....p4y..LIqLSe................................... #4 has permission to perform.....I ........................ plumbingin the buildings of............................................................................................. at63.......... A u. -,o. .. ................ orth Andover, Mass. ic Fee ..... i c. N o. 7 .......... .. .... .. .... ......................................... P IVIBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P I' CITY D� MA DATE ` - PERMIT# JOBSITE ADDRESS r/G OWNER'S NAME �,y �✓l� POWNER ADDRESS 11TELI 1FAX TYPE OR OCCUPANCY TYPE COMMERC EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES Q NO FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i ___ CROSS CONNECTION DEVICE _.,--_._ [ DEDICATED SPECIAL WASTE SYSTEM ( _ _ DEDICATED GASIOIL/SAND SYSTEM �_ ( ___r _._.._j ._ _( DEDICATED GREASE SYSTEM _jPF—I DEDICATED GRAY WATER SYSTEM f _ [ i [ I ( 1 I ( [DEDICATED WATER RECYCLE SYSTEM 1 J ( 1 [ J [ f r l E _..._..[ PP DISHWASHER ___._DRINKING FOUNTAIN i i l [ [ [ i i ! ( 11 _._.._..' FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK [ __1 __ k _._.1 ____._j _____-._( ______J I l ..__-._ LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK __.[ ) [ [ _ _[ i � -_-._-� -- _-[ � J --JIF .-_[ ..---I TCILET URINAL Wf,HING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF NO f1 IF YOU CHECKED YES,PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ._ I OTHER TYPE OF INDEMNITY Q 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 Q AGENT 10 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 a urate to the b y kn ledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' nc it all Pe n t pr ion Massachusetts State Plum ' Code and Chapter 142 of the General Laws. PLUMBE ' AME ,�1 v l Ori/ ,�1 '� LICENSE# - �� I SIG 11 [VIP JP Q CORPORATION Q#PARTNERSHIP Q# _ E LLC D� COMPANY NAME , L, LL G ADDRESS CITY '-ter c i-�--- STATE ZIP TEL 3 FAX �— [ CELL ���EMAIL 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 s t ti The Commonwealth of Massachusetts Department of IndustrialAccidents Congress Sheet,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia ce Affidavit:Boulders/Contractors/Electricians/1'lumbers. 'Porkers'Compensation insuran TO BE FILED WITH THE PERMTTTING AUTHORXTY. Please Print Le bl A �licant Information J Name(Business/Orgariization/Individual): e [� Address: C'J3�'(Gl Phone#: �d 3 2 City/State/Zip: �► N, <} . : Are you an employer?Che'&tlie appropriate box: Type Of project(required); 1. am a employer with f employees(full and/or part-time). 7. ❑NeVv doristructlon 2F]lain a sole proprietor or partnership and have no employees Working forme in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4. 1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no eiriplo Ie 12�[]Plumbing repairs or additions 5.❑I am a general contracto<and I have hired the sub-contractors listed on the attached sheet. 11 F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 14.0 Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. _ 152,§1(4),and•we have no employees.[No workers'comp.insurance required.] *Any applicant that check's box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether cr not those entities•have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. d job site I am an employer that is providing workers'compensation insurance for°my employees- Below is the policy an information. Insurance Company Name: Expiration Date, Policy#or Self-ins.Lic.#: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a foie up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. c v hereby cert der th pains andpe ofp 'u tlaat the information provided ahov is true a d.correct. Date: �v Si ature: Phone official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• 1 J Information. and Instructions IMassachusetts 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 We, express or implied,oral or written." r' 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 enferprise,and including the legal representatives of a deceased employer,or the receiv6for trustde 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 regi ui'red." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter intp 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 Pleasb 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of 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"fob 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 requited to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia R Date10.. � F .................. . OF r►ORT{q,� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING S`4ACHU5� S- _L This certifies that .�'?.nit. TLA•-:.:.: ... °. '. .................................... has permission to perform ...'-1- ....Ti. c2........ -. .E`er wiring in the building of.. ................................................. at ....(P.1...... ..............>North Andover,Mass. Fee ." ...:..........Lic.No. 9A H .................. . ELECTRICAL INSPECTOR Check 4 � Commonwealth of Massachusetts Of ljcial Use Only Department of Fire Services Permit No. 12 117%' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: kpl k q j 201 S City or Town of: NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (09; NTtAOc1� Alit_. Owner or Tenant n--r4oNU F=NO r.L+12Ae-y Telephone No.(q-lb)-1 S0-qS-, Owner's Address 7 APOLLO wA,4 1 SALEM. t�, H Is this permit in conjunction with a building permit? Yes �- No ❑ (Check Appropriate Box) Purpose of Building MULTL fAnj L�( �E �y-� � Utility Authorization No. Existing Service ZOO Amps 12.0 / Z-LJ0 Volts Overhead R Undgrd❑ No.of Meters 2 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &: Ft c>c)y- All- mEw wmex>Atoc AS NEEDS Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires (� Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Detection and No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers eat Pump Number Tons KW No.of Self-Cii-n--tained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Omer Connection No.of Dryers Heating Appliances KW Security ystems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ZI }/ (When required by municipal policy.) Work to Start: 1p 1 q +l Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 A undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: RuxeeSSxuE Et.ECrt=C, t_ SN LIC.NO.: ISU448 Licensee: CAeX&TX4w {[, Signature LIC.NO.: (If applicable, enter "exempt"in the license number line) Bus.Tel.No.:UO3 M1 5737-0 Address: I CoKLof-D k4b 1 LZ-P— 1 tA" 03$C.¢ 1 Alt.Tel.No.:lab3 7eZ 5180 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 0 0 ,h y The Commonwealth of Massachusetts z . F Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ( Please Print Le0bly Name(Business/Organization/Individ+ual):�1,,e i7i S er )Ll! Z,7 f >..� y-6•i �� Address: f C�� C , Rd City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(Tequired): 1.❑I am a employer with employees(fulland/orpait time).* 7. E]New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.-❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Fj Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 152,§t(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,tliey must provide their workeis'comp.policy number. 1 am an employer Mat is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: g 6 h ,,^ c Y Y mc Policy#or Self-ins.Lie. 15 00 Expiration Date: Job Site Address: �7 `)�� i�e o U fl'&-(_ City/State/Zip: Ajo ifr h.t a. Attach a copy of the workers'60.mpensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaldes of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of lire, 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 shallwithholdthe 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 foi•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 bottoni 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia y I ` O1IAINIONWEQi:TH OF Mj� gCHUSEx BOAFi�3 L XT I C'1 AN S ISSUES., THE FOLLOW. tN0 I CEtVSE � A5 A RI G JOURNEYMAN ELE.C�TR '„ N TERRANCEtu N GAGNON °, a W 28 GRE`E.NLANU RD „ 1�1`A o 564 26id E y► %kORTH Q�SSLED , 6 0 �9SS�1CHUSES 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION L DATE:== G `� Tel #: ZOV FROM. ADDRESS: C� 6C Complaint Against: 0 ELECTRICAL: PLUMBING: GAS: BUILDING CONTRACTOR: PROPERTY OWNER: ILe �k�tc,-C, Cl,jj ex OTHER: I ( to °"� �� l d o v�, lyse Signed: -�eaR11� ��I i �5 �v��4e.A rJ 4 . O O ,,Vorth Andover Board of Assessors Public Access Page 1 of 1 O HORTM North Andover Board ofAssessors . O � Y "SS�cNuSEt '_. Property Record Card Click Seal To Return Parcel ID :210/066.0-0029-0000.0 FY:2014 Community : North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Ar Search for Parcels Search for Sales �;, t�� ,� Chi J3kf Summary Residence Detached Structures h Condo 65 47 BRIGHTWOOD AVENUE Commercial Location: 65-67 BRIGHTWOOD AVENUE Owner Name: NUTTER,KENNETH A O Owner Address: 62 BRIGHTWOOD AVENUE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 0.10 acres Use Code: 104-TWO-FAM-RES Total Finished Area: 3278 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 282,900 294,300 Building Value: 141,100 1.52,500 Land Value: 141,800 141,800 Market Land Value: 141,800 Chapter Land Value: LATEST SALE Sale Price: 185,000 Sale Date: 01/27/1987 Arms Length Sale Code: Y-YES-VALID Grantor: NUTTER,LESTER C Cert Doc: Book: 02416 Page: 0047 O http://csc-ma.us/PROPAPP/display.do?linkld=2436613&town=NandoverPubAcc 10/9/2014 t. Q Residential Property Record Card PARCEL ID:210/066.0-0029-0000.0 MAP:066.0 BLOCK:0029 LOT:0000.0 PARCEL ADDRESS:65-67 BRIGHTWOOD AVENUE FY:2014 PARCEL INFORMATION Use-Code: 104 Sale Price: 185,000 Book: 02416 Road Type: T -Inspect Date:— 09/13/2002 Owner: Tax Class: T Sale Date: 01/27/87 Page: 0047 Rd Condition: P Meas Date: 09/13/2002 Tot Firi Area 3278 -Sale type: P Cert/Doc Traffic M Entrance: ••• X___ NUTTER,KENNETH A Tot Land Area: 0.10 Sale Valid: Y Water: Collect Id: RO Address: Grantor• NUTTER;LESTER C Sewer: tris ect Reas: R 62 BRIGHTWOOD AVENUE - P NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L%100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: DK Tot Rooms: 9 Main Fn Area: 1395 Attic: N13HD CODE:5 NBHD CLASS:5 ZONE R4 Story Height 2.35 Bedrooms -5' Up Fn Area: 1883 Bsmt Area: 1395 "Seg Type Code 'Method Sq-Ft Acres Infl6-Y/N - Value Class Roof: —` G" Full Baths `�`3` AddFnAtea: ... FnBsmtArea4 '1 P 104 S 4410 0.100 141,843 - Ext WaIL AB Half Baths___'Unfin Area: Bsmt Grade: VALUATION INFORMATION MasonryTnm.-f' Ext Bath Fix -0'"Tot Fm Area: 3278 Current Total: 282,900 Bldg: 141,100 Land: 141,800 MktLnd: 141,800 Foundation ST Batti'Qual T RCNLD: 141108 Prior Total: 294,300 Bldg: 152,500 Land: 141,800 MktLnd: 141,800 " -' Kltcti Qual "T Eff Yr Builfi 1970 Mkt Adj: Heat Type:' ST Ext K_itch: Year Built: 19004 'Sound Value: Fuel Type: G _ rv't;rade A-- Cost Bldg: 141,100 Fireplace: 0 Bsmt Gar Cap: Condition: A Alt Str Val 1: Central At: N Bsmt Gar SF: _PctCornplete:' Alt Str Val2[ Alt Gar SF: -..._ °/Good P/F/E/R: /100//75 Porch Type Porch Area Porch Grade Factor 162 50 112 SKETCH PHOTO g 25 11F OUBS 1395Sq.R 15 52 - 13 17 7 et 3 65-67 BRIGHTWOOD AVENUE 112 Sq.R Parcel ID:210/066.0-0029-0000.0 as of 10/9/14 Page 1 of 1 0 0 0 0 -65 BRIGHTWOOD AVENUE 066.0-0029 Complaint Detail Report Printed On:Thu Apr 23,2015 Complaint#: CT-2015-000021 Status: Closed GIS#: 4177 Violator: Kenneth.Nutter 4�rcrraiaa Address: -65 BRIGHTWOOD AVENUE Map: 066.0 Address: 31 Corbett St. w '.• Date Recvd.: Oct-07-2014 ITime Recvd.: 03:12 PM Block: 0029 ANDOVER,MA 01810 Category: Housing Lot: Type: Residential GeoTMS Module: Board of Health District: Trade: Recorded By: ILisa Blackburn Zoning: Structure: Description Complaint: Tenants at 67 Brightwood Ave.2nd floor is complaining of security issues,electrical problems,leaking toilet.Health Dept.will do an inspection on Thursday 10/9/14 at 3:OOpm. Tenants moved and the building was sold and is being renovated.Case closed. Comments: Inspector Assigned to Complaint:I Susan Sawyer Contacts Contact Type Date Time Name Phone Best Time To Reach Recorded By Response Tenant Oct-07-2014 3:12 PM John&Heidi Hood (978)208-8336 Q Lisa Blackburn Follow-Up by Health Director Actions Taken GeoTMS Module Status Date Time Response Type Action Taken Comments Board of Health REFERRAL GeoTMS®2015 Des Lauriers Municipal Solutions, Inc. Pagel of 1 Location S "7 Sp(4,Vcvocd Ao-c- No. Date 0/, f7'0 � NOR7hTOWN OF NORTH ANDOVER f � 3?O�•. " :••'blot F 9 + Cert1ficate of Occupancy $ CH Building/Frame Permit Fee $ a �. Foundation Permit Fee $ -i Other Permit Fee $ TOTAL $ 3 Check # ��dy ' " Building Inspector i A% TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING fLA BUILDING PERMIT NUMBER: r� DATE ISSUED: �( �/ SIGNATURE: A ,- ic Building Commissioner/I ctor of Buildings Date SECTION I-SITE INFORMATION 1.1 Property Address: 1.2/Assessors Map and Parcel Number: It � l/l Map Number Parcel Number 1.3 Zoning Information: W K%((���/ /t! 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record /5� �� - S� r `e-- f Name(Pnnt) Address for Service Signature Telephone Q 2.2 Owner of Record: Name Print Address for Service: 0 z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address ,.G Expiration Date Signature I Telephone �. 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number r Address Expiration Date z Signature Telephone 6) SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. —Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-'ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OgCl�, 7SE p ,y_ Completed by permit applicant Multiplier O Building 1. Building � a Permit Fee 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e) X(b) 4 Mechanical HVAC ,�-- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUMMING PERMIT as Owne uthorized Agent of subject property Hereby authorize to act on My behalf.in all matters relative to work authorized by this building permit application. —Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 Print Name Signature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I 2 kD 3 SPAN 1 DIMENSIONS OF SILLS I DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE K y R The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 '..�r Workers'Compensation Insurance Affidavit Please Print Name: Location: Ci D l/ Phone __ 0 am a homeowner performing al work myself. �I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address i City: Phone#. s Insurance Co. Policv# Company name: Address City: Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and pen s e ation rovided above is true and correct. i Datenature Sig d f f / Print name Phone#' Official use only do not write in this area to be completed by city or town official' E] Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board p Selectman's Office Contact person: Phone#: Health Department Other FORM WORKMAN'S COMPENSATION NORTH TQED O ® - 4 L over No. o Ala -:t!- . z ; � 12 o Z- 4 dower, Mass., 9e— -O COC MIC 0 > A �V ORATED ,N? C7 . S H E BOARD OF HEALTH PER. MIT T Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT........../ OAP........ .............. .�'"......................................................... ........................ ...... Foundation has permission to erect �S_6 / lj�Gvoa� p ............ ...... buildings on ................................................ ........................................ Rough to be occupied as...... ��1 I.. / / Chimney ....... ... N . ...... (� .............^. .��' ........................................................................... 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. (. 6/a 9f �/3�- _ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. yo Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR / Rough l ...................................................... 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. Location 60{rfP ccoc No. ./ Date c . K..,M TOWN OF NORTH ANDOVER o� n Certificate of Occupancy $ _ Building/Frame Permit Fee $ �S ' Foundation Permit Fee $ "us Other Other Permit Fee $ Sewer Connection Fee $ ' Water Connection Fee $ TOTAL $ Building Inspector 13362 Div. Public Works PERMIT NO. C>)O APPLICATION FOR PERMIT TO BUILD******** RT1I ANDOVER, NVIA iNIAIIIN,I>.�' LO'rNO. 2. RECORD OFOWNERS11III DATE BOOK PACE LONE: �s, SI1RDIX'. LOT NO. LOCATION rep PURPOSE OF BUILDING - ROOF'_ p OWNER'S NANIE i'� '4ti�i 1 / �" NO.OF STORIES SIZE x.71 N� ',I O\1'NF:R'S:tDDNESS �r� t`12 i $�L� BASEMENTORSI.:tII lICIIIIECI'SNAME -ted �_�E= 7 . SIZE OFF'LOORTimBERS 2ND 3RD BUILDER'S NAME <i'5, jJ �y � SPAN DISTANCE TO NEAREST BUILDING 7 i DIMENSIONS OFSILLS DIS'CANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE IIEIGIITOF FOUNDATION THICKNESS IS BUILDING NEW A ) SIZE OF FOOTING IS BUILDING ADDITION ,�✓ ® MATERIAL OFCIIININEY IS BUILDING ALTERATION D LS BUILDING ON SOLID OR FILLED LAND 1 WILL.BUILDING CONFORM TO REQUIREMENTS OF CODE •, � IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BIIIL_DING CONNECTED TO TOWN SEWER IS DLIILDING CONNECTED TO NATURAL GAS LINE , INS"IIJCTIONS 3. PROPERTY INFORMATION LAND COST - EST. BLDG.COST nO. no 1'a C:F: 1 FILL OUTSEC'f10NS 1-3 EST.BLDG. COST PER SQ. FT. EST. BLDG.COST PER ROOM ELECTRIC DIETERS\LAST BE ON OUTSIDE OF BUILDING SEPTIC PEILnIrrNo. a"I'I*ACIIED GkR CES NIIISTCONFORAI TO STATE FIRE REGULATIONS 4. APPROVED BY: rg PI.A.NS NIIIST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR DATE FILED OWNERS TEL$ CONTR.TELH 7�'�� SICNA"1"LIRE. OFOWNER(1R A1171IOR1"LED AGENT" CONTRAACH j 7 3 FEE $ �— I I.I.C.l� � PERM ITGRANNTED e� l 'c� 19 12evise�l S/S/99 .Illi --- - — - - — �AORTFI ® Of ` ° over Olt No. ~ x _ :A Al CoCH� dower, Mass., °� / G `� er ORATED p'off—in � S SG 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT......11. a !V !c BUILDING INSPECTOR tIA0J .....c.......................................................................... Foundation has permission to erect.�15*9..p................ buildings on ........,(p...4 0.........��.. /t�✓�.A,j�w.�.C�..A(/�'� Rough to be occupied as...{... rue 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, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough M ( ` PERMIT EXPIRES IN 6 MONTHS Final to _ UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR RoughRrc ... .... ............... ............. 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Mas 't .. .t ') ® ,y r- o•..A O i�r �„ 7`�'€� c �,i4 iso Rt..��7 �kd; } f!f'` f u Y �,:a fii t �; m ;...�n '3 ;^ rt a :Mr- r � ,' !h E t 3 h rc �!. .1It 6 - . ., ,<. " -}a i as g i ^' '".. ":e :� 5 - N asr N 1 1 9 S }_+ }f. ....t J u � +^"' " : - ; r' /;,"'} '7 rn . k p F sa+°p t !' a i ,,,,,T^ k+e - i h rR. m •' % Yt Y f g F f 4 t } i 7 , {' .. t 3 I B . t 11 I f r €7S rV.T !' R3"x•. _ ,fir } '1 .. t i,f i t z + ` is u . J' F 4 i1.t , c b.. € ! i. 1. x } i 1 Y {C F i i i t, t L Jfl �Yt} I _ f S E: i "� t i i }Ef t, t # r ey i S.; t Y lVf i/1 J - S i 4 . IL '.i T 1.tlf5,'L -7!f i' if, t�'ETt 4 E p + i r Y 1. 3 t FYI is i Fj is R ] , [ ;, :? •."� . 1. f.. 4 J l.. fy i$. 3 1. 7 } {'�" i,�f7. A i j ' . ! d i 9. 4i 3 y ti I€ 1 i f li.�iz � P ... r ..i,i. a ij .`.1 �.. ..i s i,.-;t} ; Sppiax.gr,.�'y*,<f�„4rR:F t i ff- .z s f :t t ''� �. i. x i .{ y�!r .$4�+' S '�f 67a+'�Y"t .l" a.: '.i .'j 'S c) y.!- ,:F'.$,p:'a 1. .Y 4 f "t t. i. Pt i.iS i'3§ 64�«#,`if*'['At. �{ 4f1.''f F is.t t.. 3. i, ,,I) 3- f i...,l . }[ 1.;. S i:'f p4't t :7'... t{ �'f 1 i S �p,.7 ;"!'.'1 t S €,:' '� ! - {' 4x4 r s k Y "fst e l Sn>`,f .Yf A 4 t i,F i 4f , .. r ' q�+ t Town of North Andover NORTH ' OFFICE O ��O ,r io ,e'e O COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 01846 WI,LIAM J. SCOTT �Z3ACHU`r Director (978)688-953 1 Fax (978) 688-9542 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) gnature of Permit Applicant 0 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project throug-h the Office of the Building Inspector BOARD OF APPG,x-LS 682-9541 BLILDING 683-9545 CONSERVATION 683-9530 HEALTH 683-9540 PLA-1,NING 683-9535 Fax:6034326414 'Sep 10 '99 13:54 P.01 09/10/99 , PRODUCER THIS CERTIFICATE ISSUED AS MATTER OF INFOR- FINANCIAL INSURANCE MATION ONLY AND CONFERS NO RIGHTS UPON THE SERVICES, INC. CERTIFICATE HOLDER; IT DOES NOT AMEND, EX4 PO BOX 950 TEND OR ALTER COVERAGE AFFORDED BY THE POL- DERRY, NH 03038 ICIES BELOW, COMPANIES AFFORDING COVERAGE: (603) 432-6414 COMPANY (FAX) 432-3852 LETTER A ASSURANCE CO. OF AMERICA COMPANY INSURED LETTER B GUARD INSURANCE PRO BUILDER & SALES CO. COMPANY C/O FM PAPPALARDO LETTER C 71 BRIGHTWOOD AVENUE COMPANY NO. ANDOVER, MA 01845 LETTER D COMPANY LETTER E COVERAGES: THIS CERTIFIES THAT INSURANCE POLICIES BELOW HAVE BEEN ISSUED TO THE ABOVE INSURED FOR POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR DOCUMENT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE HEREIN IS SUBJECT TO ALL TERMS OF SUCH POLICIES. CO TYPE OF POLICY POLICY POLICY ALL LIMITS IN LTR INSURANCE NUMBER EFF DATE EXP DATE THOUSANDS A GENERAL LIABILITY SCP33599045 08/18/99 08/18/00 GEN AGGREGATE $1,000 X COMMERCIAL GENERAL LIABILITY PR—CMP/OPS AG $1,000 CL MADE XOCCURRENCE PERS&ADV INJUR $500, OWNER'S & CONTRACTORS PROTECTIVE EACH OCCURANCE $500, FIRE DAMAGE $50, AUTOMOBILE LIAR MEDICAL EXPENS $10, ANY AUTO CSL $ ALL OWNED AUTOS BODILY INJURY (/PERS) SCHEDULED AUTOS $ HIRED AUTOS BODILY INJURY (/ACCID) NON-OWNED AUTOS $ GARAGE LIABILITY PROPERTY DAMAGE EXCESS LIABILITY EACH AGGREGATE OCCURRENCE OTHER THAN UMBRELLA FORM $ $ B WORKERS ' COMPEN- PENDING ISSUE 08/21/99 08/21/00 STATUTORY SATION AND $100, (EACH ACCID) EMPLOYERS' LIABILITY $500, (DIS-POL LIM) OTHER $100, (DIS EA EMPL) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS JOB: 65 BRIGHTWOOD AVE, NO. ANDOVER, HA CERTIFICATE HOLDER -- ---- CANCELLATION - ------ -----------------____ ------------------------------- BUILDING INSPECTOR - SHOULD ABOVE POLICIES BE CANCELLED BEFORE NO. ANDOVER, EXPIRATION DATE, COMPANY WILL ENDEAVOR TO MA MAIL 10 DAYS WRITTEN NOTICE TO CERTIFICATE FAX #978-688-9542 HOLDER (AT LEFT); FAILURE TO MAIL NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE: FORM 25—S (11/85) i