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Miscellaneous - 66 STERLING LANE 4/30/2018 (2)
`\ c� n � i ���.. - f Date . . .��: �l- t. Z_ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . ,� has permission to perform . . . . . . . . . . wiring in the building of . . . . .W)4 7� at . . . . . . . . . . . North Ar*over Mass. Fee . Lic. No. . . .9.3 4. ELECTRICAL INSI?ECTOR V:heck l 11134 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.P.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 corporafion statedxon 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 ofongoing construction activity,and may be.deemed-by-the Inspector_of-Wires abandoned.and-inxalidifhe—. .- 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 entitystated 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. Aule 8—Permit/Date Closed: _/ **Note:Reapply for new permit.( 0 Permit Extension Act—Permit/Date Closed: II PO Box 55098 _ T - Boston,MA 022055098 -61-7=951-0600-. - -- --. : - — _ Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall N ANDOVER, MA 01845 N ANDOVER, MA 01845 ` RE: Insured: DAVID WAINWRIGHT - r Property Address: 66 STERLING LN,N ANDOVER, MA ; Policy Number: HMA 0340020 Claim Number: BOS00050818 Date of Loss: 2/20/2015 1 Company: Safety Indemnity Insurance Company I Claim has been made involving loss, damage or destruction of the above-captioned property, , which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and'include a reference to the captioned insured location, , policy number, date of loss and claim number. I i Marc Savosik Claim Examiner 2/24/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3543 Fax: (617).603-4849 Email: MarcSavosik@Safetylnsurance.com i Commonwealth of Massachusetts Official Use Ornly / Permit No. I Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT 1N INK OR TYPE ALL INFORMATION) Date: /G — �/ —/ 2-- City City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givers notice of his or her intention to perform the electrical work described below. Location(Street&Number) v/ Owner or Tenant !✓ 6t/ i Telephone No. Owner's Address r� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ,iV c e ' Utility Authorization No. Existing Service?�/� A ps /.zrJ /z d Vo Overhead ❑ Undgrd No.of Meters100, New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters +Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work: /„r ` �U! c �— �-�i� Com letion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires 11V No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. Elrnd. ❑ Batter Units No. of Receptacle Outlets -L No.of Oil Burners FIRE ALARMS I No. of Zones No.of Gas Burners No.of Detection and No.of Switches Initiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons g No.of Waste Disposers Totals: Number Tons KW.... No. c Self-contained ������ Detection/Alertin Devices eMunicipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other 0 Heating Appliances KW Security Systems:* Q No.of Dryers No.of Devices or Equivalent No.of Water No.of N .of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equi valent 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: (When required by municipal policy.) Work to Start: /U -Y-/Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation”coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties of perjury,that the inform tion on this application is true and complete. FIRM NAME: . v .Si7 e l �� LIC.NO.: 3� Licensee:��y/c t /� ��-. Signature LIC.NO.: 993 (If applicable iter "exempt"in the license number line.) Bus.Tel.No.: Address: iii �--10— - Alt.Tel.No.: *Per M.G.L c. 147,s.57-6 1,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Si2natur _ Telephone No. `� h .xd4U T F CT O T: e nixed 50.00) .� 'aileB�C3e-xuspeetzoa x g ($ " %,spBet oxs'c eats: -- 1 •:. Lrr a•,-.••'• •. •- date _ (7[uspec oxsy gna no�n(tials} .. •-• '�'aiTet�--� � �e-xns�ectioxtxequixe� 0)w[ � 3n5�ectarS'cop�m.ex�.ts: a Fate 1 ps&ctoxs'Oignat"'a-110 Wf ials) , 1 1 3,rT�IDNRGpOum:W:gR C�` ig- � ate-fn.speetZo�.xet� 0.40)"[ I . ?assed—Z ] �'ailec�--I � • as�ectoxs'coxnmex�ts; • � atuze"oto f�ftiaT.$) ]ate c.I.nuntoxs sign NAME,- caiottxequixe ( 50.00) ,�ectbxs'eopzib.epfs: . Fate (Wspectorg,migngtnxe-AoWiaxs) ` f � FC7CZOx*7-OT33YOU" .,( � 'ate�nsp ectiott xequ?x'eq{$50.0 D)-•[ � 0CtOZ5g C4Jla717.�71tS: - � - 1Pate. ors,signatare.no 5nyaalls) N_o 1 1b3 Date.....701 R f MORTIS " TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,s$AC14 This certifies that ST v�� V L �ed c C ...................................................................................... has permission to perform l � -5 --f aJ j. ........... r ........................ wiring in the building of.......C....v d.t.r� c��'......(e S.!............................... at.. ... �..... .....��..j!i ......L N./................ . h Ando e Fee...::��..�'P.. Lic.No.."' ...�U........... ...... ....R..�.,.rrf.... ................. LECTRICALINSPECTOR C 07/13/99 7/13/99 14.53 50.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer %rats \llauti &U14 llf:ULUJ Ll 74 UL12sttt""13XIM Office Use Only Department of Public Safety7v �6/ Permit No. 1p- BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy a Fee Checked 3/90 k) (leave blank) PPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT` All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 Q (P E PRINT IN INK OR�TYP/E ALL INFORMATION) a Dat Cry or Town of /1/tJ6� f/0,/��y�" �" To the Inspector of' The dersigned•applies for a permit to perform the electrical work described below. 461611 'tC cat n (Street & Number) �6i �'7iPL//l�t� r or Tenant CG6L/.or1E (20NS/Uh%l�l/(� CO• r'Dl i/ owner's Ai�ressD /5iv-o6d-r2 ST /VO. Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) // Purpose of Building Utility Authorization No. (��OY Existing Service Amps / Volts Overhead ❑ Undgrd No. of Meters= New Service /rte/t/ Amps /_ado Volts Overhead ❑ Undgrd E No. of Meters Number of Feeders and Ampacity /i a Location and Nature of Proposed Electrical Work ��1��/rTI�li✓Y S 2/��s'G– r6� aws,; TOTAL No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA Above In- No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Conditioners Tons Initiating Devices Heat I-cital TotalNo. of Sounding Devices. No. of Disposals No. of Pumps Tons KW No. of Self Contained --- No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local[]. Municipal ❑ No. of Dryers HeatingDevices KW Connection Other No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wirin a No. Hydro.Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws J I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent.YES lel NO O 1 have submitted valid of same to this office. YES U NO (J If you have checked YES, please indicate the type of coverage by checking the appropriate/b�o�x. INSURANCE E�BOND ❑ OTHER❑ (Please Specify) AW772, lI e— (Expiration i Estimated Value of Electrical Work $ ^° Work to Stan Inspection Date Requested: �� O -Rough' Final Signed under the penalties of perjury: J�n FIRM NAME `d�'✓�O/� Ec���.TOZ�CJ �1`�LIC. NO. SA;) LicenseeyC»✓ou 1--�/� ti Signature / LIC. NO. Address ��–� rwir.�(Q� b I Bus. Tel. No. Alt. Tel. No.9J� OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachu: General Laws. and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Teleohone No. PERMIT FEE63 — QP,. 2435 Date...6A�AU..... 0. TOWN OF NORTH ANDOVER oo0 PERMIT, FOR WIRING 49 SACHUS This certifies that ..... ........ P clt .................... has permission to perform ........ .......................... G, wiring in the building of... ............ ......................................... ...... . ... at.... ......o ................... .... ..........................................�,North Andover, Fee.. ...... Lic.No—L'3 7 ....................... LECTRICALINSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Official Use Cnily IL Department of Fire Services Permit No. 3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Co, t 4 - 06 City or Town of: 9vOcA-V\ (:�0 A-6Ver 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) f p(p S—1-e r L f �_Q,,) f, Owner or Tenant (aper ` �.sp�d ,, ��n Telephone No. q 7F-�,F3.$57/ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No. of Meters New Service Amps ! Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a r L&r,n. r- N Completion qfthefiollowing table may be waived by the Inspector of Tires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No. of Hot Tubs Generators KVA bove In- No. o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. ❑ rnd. ❑ 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 A. Initiating Devices No.of Ranges No. of Air Cond. Total No. of Alerting Devices Tons 1' Heat Pump Number Tons KW No. of Self-Contained No.of Waste Disposers Totals: — - Detection/Alerting Devices ' No.of Dishwashers g S ace/Area HeatinMunicipal P b KW Local ❑ Connection El Other No.of Dryers Heating Appliances KW SecuritySystems: o. or Equivalent 33 No.of Water KW o. of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER Attach additional detail if desired, or as required by the Inspector of JVires. 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:) (Expiration Date) Estimated Value of Electrical Work: /8'79. (When required by municipal policy.) Work to Start: 6/1&/tf d Inspections to be.requested in accordance with NEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ADT Securitv Services 111 Morse.Street,Non4od,MA 02062 LIC. NO.: 1533C Licensee: John S. Bassett Signatur LIC. NO.: 1533C (If applicable, enter"exemp"in the license naniber line.) Bus. Tel. No.: - - j Address: Alt. Tel. No.:603-594-.59 resi OWNER'S INSURANCE WAIVER: I am aware that the Li ensee does not hate the liability insurance coverage normally ONLY required by law. By m}.signature bolo«?. I hereby ii,aive this requirement. 1 am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERAHT FEE: $ ,3 J, Signature Telephone No. 06/14/2012 09:42 FAX 617 371 3796 CANACCORD ADAMS Cj001/019 44109CMADAW 99 Ho S..t>``���egqt.��9��.?th Rwr BOBWn 1A 0211 Y 917-871-mm phone 817-371-3798 ft rdLNhffle ii LL1.J • tta T�c AIWO f 914 rpjwTuf(-" +� . •,� �88 - �/� of z,�, Z c aur t4D,ft%vbw oft�C 13FhmP4q* a AJ ZN. IJ /"T 7-12, -H Zcopj 0 V'k—("AJ 06/14/2012 09:42 FAX 617 371 3796 CANACCORD ADAMS IR 002/019 n. _ y I Commonwealth of Massachuseft Title 5 Official Inspection Form subsurface Sewage disposal symurn Foran-Not for Voluntary Assessments 66 STERLING LANE Property Address Robert and Mellissa Greene ----� owner owner's Norm Wormation is MA 01845 4x7!10 _ required for North Andover State e9p Code Date of In9peCdon every page. Cityrr6 I Inspection results must be submitted on this form.Inspeatbn forma may not be altemd In any way.please see completeness checkrot in the end of the form. Impam"touA. General Information forms on the computer.e8" 1. Inspector. only the tab key icmove your Benjamin C.Osgood,Jr - cur2or'do not Name of Impactor use the reWrn key, none ca-panFis=— VILA 16 Hillside Avenue Unit 3 Company AOress 01913 Amesbury MA - �., (;ttylTown Stets �God4 505-326-4633 670 Telephone Number Lloense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information repotted below is true,accurate and complete as of the time of the inspection.The inspection was performed based an my training and p experience in theproperfunction pursuant bmaintenancenfonf on sitof sewage disposal systems.I am a DEP rd proved sy mP Title 5(310 CMR 9$AW).The system: Passes ❑ Conditionally Passes Q Fails �] Needs Further Fvaluation by the Local Approving Authority I 4127110 sa SlgnsLure DO* The inspector shall submit a copy of this inspection report to the Approving Authority(Board system aced system Or stem is a sh _if the s Y� this in 'on y of Health or DEP)wltftln 30 days of completing speck has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer.if applicable,and the approving authority. '"*This report only describes conditions at the time of Inspectionand under the conditions of use at that time.This Inspection does not address how the system will perform In the future under the same or dUferent conditions of use. 06!14/2012 09:43 FAX 617 371 3796 CAN ACCORD ADAMS 2003/019 CDmm011Wealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 66 STERLING LANE --- --�� Property Address Robert and Meltissa Greene Amar ownees Name fnlbrmatien b AAA 01845 q,�7110 rxgWred for f�ortil Andover st ft ?jp __ date of Inspadbn -%rY"(0- cttyrrown B. Certification (cont.) Inspection Surnmary.Check A,B,C,D or E/alWays complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are Indicated below. Comments: a) syewm Conditionally Parade: ❑ One or more system components as dewbed In the"Conditlonal Pass"section need to be repiaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check me box for"yee,'no"or`not determined"(Y,N,Nd)for the following statements_If'not determined;please explain. The septic tank is metal and over 20 years oto`or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exMiration or tank failure Is imminent System will pass Inspection if me existing tank is replaced with a complying septic tank as appy Y the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avallable. El y, ❑ N [IND(Explain below): I i I 06/14/2012 09:43 FAX 617 371 3796 CANACCORO ADAMS 1004/019 Commonwealth of Massachusetts Title 5 C3fficial Inspection Form SubsurbeSewage Disposal System Form-Not for Voluntary Assessments e 66 STERLING LANE Prgm ly AddnM Robert and Melrose Greene Owner Owners Nam9 '"formatio North Andover MA 01M5 4127110 requlme for te CV- Zfp Godo Lite of In9p dbn every POP. B. Certification (cont.) B) System Conditionally passes(cont.): ❑ Observation of sewage backup due ro aaout bro chigh n hstatic water settled or unevenlevel in the distribution box.Systemdue will to broken or obstructed pipe(s)or d pass inspection If(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N Q ND(Explain below): ❑ obstruction is removed Q Y ❑ N Q ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N NO(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed POW).The system will pass Inspection it(with approval of the Board of Health): ❑ broken pipe(s)are replaced [] Y © N ❑ ND(Explain below)- � N ❑ NDIain below): f p abstruotlon is removed Y D (Explain �1 C) Further Evaluatton is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the,system is falling to proted'public health,safety or the environment 1. system will Paas unless Board of Health determines in accordance with 310 CMR 15.343(1)(b)that the system is not functioning in a manner which wilt protect public health, safety and the emrironment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh 06/14/2012 09:43 FAX 617 371 3796 CANACCORD ADAMS 0 005/019 Commonwaakh of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal 5y9tem Form-Not for Voluntary Assessments 66 STERLING LANE mpe AAddrew Robert and Mellissa Greene _ C wear owner's Name qa In mulr for North over h AndMA 01W 4!27110 Maryed for clgdrown tip . Siete code Date of Inspaotlon e,rey B. Certification (cont.) 2. System will fail unless the Hoard of Health(and Public Water Supplier,if any) determines that the system 19 functioning in a manner that pratee%the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS Is within a Zone 1 of a public water supply. ❑ The system has a septic tank end SAS and the SAS is within 50 feet of a private water supply well_ ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: .. laboratory,for conform This system passes if the well water analyses, performed at a DSP certified ry, bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or is are triggered.A co of the analysis must be that no other failure oaten PY h+ legs than 5 ppm, Provided gA attached to this form. 3. Other i i i 1 D) System Failure Criteria Applicable to All Systems: You must indicate mYes"or"No"to each of the following for all inspections: Yes No Cl Backup of sewage into facility or system component due to overloaded or clogged SAS or cess" ❑ Discharge or ponding of effluent to the suftce of the ground or surface waters due to an overloaded or Gagged SAS or cesspool ❑ Static liquid level In the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool Cl Liquid depth in Cesspool is less than 6' below invert or available volume is less than%day flow 06/14/2012 09:44 FAX 617 371 3796 CANACCORO ADAMS 0 006/019 Commonwealth of Massachuse is Title 5 Official Inspection Farm Subsurfaes sewage Dtoposal system Forth-Not for Voluntary Assessments 66 STERLING LANE - Praparty Address Robert and Mellissa Greene Owner owners Name fnfornWon North Andover MA 01845 412V10 required p for o /Town p�of Inspection every Pape. nY B. Cerfiftcatlon (cont_) Yes No ® Required pumping more than 4 times in the last year NOr due to clogged or obstructed pipe(s).Number of times pumped' ® Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes If the waft water analysis,perfomred at a IEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitMen and-Mtrate nitrogen Is equal to or low than 5 ppm, pnwfded that no other fallum criteria are triggered.A copy of the analysis and dish of custody must be attached to this form-1 The system is a cesspool serving a facit'dy with a design flow of 2000gpd- 10,000gpd. The system Dift-1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fads.The system owner should contact the Board of Health to determine what will be necessary to oosreet the failure, E) Lange Systems: To be considered a large system the system must serve a fatft with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either yes"or*W to each of the following,in addition to the questions in Section D. Yes No 0 the system is within 400 feet of a surface drinking water supply C the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped pone 11 of a public water supply well If you have answered"yes`to any question in Section E the system is considered a significant threat, or answered Pyee In Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section 0 shall upgrade the system in accordance with 810 CMR 16.304.The system owner should contact the appmpdat° regional office of the Department 06/14/2012 09:44 FAX 617 371 3796 CANACCORD ADAMS 16007/019 i 1 I 06/1412012 09:45 FAX 617 371 3796 CANACCDRD ADAMS 12008/019 . Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal systom Form-Not for voluntary Assessments 66 STERE.ING LANE Propeft Addrr m Robert and Melllsaa Greene '-- Owner Ovmeta Name Infonnalkm is North Andover MA 01845 Ate of i required faf t`. rrGvm dfete Zip ca09 Date Cr nyppdion W"page- C. Checklist Check d the following have been done.You must ind'i%b`yes'or IrW ss to each of the following. Yes No ® ❑ Pumping information was provided by the owner,Occupant,or Hoard of Health ❑ ® Were any of the system components pumped out In the previous two weeks? ❑ ties the system received normal flows In the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as pert of this inspection? El Were as built plans of the system Obtained and examined?(It they were net available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the sepoo tank manholes uncovered,opened,and the interior of the tank Inspected for the oondiWn of the baits or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)Provided with ® ❑ tnformatim on the propel'maintenance of subsurface sewage disposal systems? The size and laxation of tht;t Soil Absorption SYS(SAS)an the alta has ween determined based on: ❑ E3dsfmg information.For example.a plan at the Board of Health. Determined in the field(if any of the failure crilelia related to Part C is at issue ❑ & appro)amation of distance is unacceptable)(310 CMR 15.302(5)] D. System lnormation 'a Residential Flow Conditions: - Number of bedrooms(ar,Wan- Number of bedrooms(design): 440_ • DESIGN now based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms); i 06/14/2012 09:45 FAX 617 371 3796 CANACCORD ADAMS 12009/019 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form-Not for Voluntary Assessments 86 S'TERUNG LANE Property Address Robert and Melllsse Greene Owner owners Name iMarmatffo isrequIreNorth Andover MA 01845 4127110 O"tY pop- CiWTU" state Zip Code Date of InspecHan ' � D. System Information Description: 4 Number of Current resident$: Does residence have a garbage grinder? ❑ Yes No Is laundry an a separate sewage system?[if yes separate inspection required) ❑ Yes No Laundry system inspected? ❑ Yes No Seseonal use? ❑ Yes 14 No Water meter readings,if available(last 2 years usage(gpd)): Detail: sum pump? L] Yes No P Current Inst date of occupancy: oats Commerotalnlniustrlal Flow Conditions: Type of Establishment Design flow flow(based on 310 CMR 15.203): Genaspar day(Apd) Basis of design now(se WpersonstsgA,etc.): Grease trap present? ❑ Yes Q No Industrial waste holding lank present? ❑ Yes ❑ NO Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,ff mvallable: 06/14/2012 09:45 FAX 617 371 3796 CANACCORD ADAMS 2010/019 Commonwealth of Massachusetts Title 5 Official Inspection Form $ubsurface Sauvage Disposal System Form-Not for Voluntary Assessments 66 STERLING LANE u - Propmty Address - Robert and Mellissa Greene Omar owners Name atlon N mgWr North Andover MA 01845 4127110 e"ryad pap-for g� — Cltyrrown Zip Code Oats of Inepedtion very D. System Information (cont.) Last Me of occupancyluse: Date --° Other(describe below): Genami intonnatlon Pumping Records: u Source of o torrnation: Fall 2009 owner was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: 9 How was quantity pumped determined? Reason for pumping: Type of Sysftm: Septic tank,diMbutlon box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) Q innovativelAltemetivs technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest Inspection of the UA system by System operator under contract ❑ Tight tank.Attach a copy of the DEP appraval. ❑ Other(describe): 06/14/2012 09:46 FAX 617 371 3796 CANACCHD ADAMS R011/019 Commonwealth of Massachuseft Title 5.Official Inspection harm Subsurface Sewage Disposal Syetem trorm-Not for Voluntary Assessments B$OTERLING LANE Pmp"Addrm Robert and MWIMa Greene Owns► Owner's Name 'mq��� North Andover MA 01845 4127110 every Ae6e- CityrTOwn Soft Zip Code Data of Inspedlon D. System Information (cont.) Approximate age of all oomponents,date installed(if known)and sourne of infomflOn: Bunt 2000 per Board of health records Were sewage odors detected when arrir►ing at the site? Q Yes ® No Building Sewer pocats on site plan): 1.5 Depth bebN grade: ret Material of construction: ❑cast Iron 40 PVC other(explain): well or Suction fine: NIA Distance from private water supply 680 Comments(on condition of joints.venting,evidence of leakage,etc.): P• a looks new In basement Septic Tank(locaba on site plan): 1 Depth below grade: feet Material of construction', ®concrete ❑metal ❑fiberglass ❑Polyethylene ❑otter(explain) If tank is metal,Cyst age: yearn �— is age confirmed by a Certlficate of Compliance?(8113ch a COPY of certificate) ❑ Yes ❑ No 1500_ Gallons Dimensions: 2" Sludge depth: i - 1 i 06/14/2012 09:46 FAX 617 371 3796 CANACCORU ADAMS /2012/019 Commonwealth of Massachusetts Title 5 Official Inspection Farm SulUrface sewage Dispa"t System Form-Not for Voluntgry Assessments 66 STERLING LANE — Property AddfM T Robert and Miss Greene – Owner Owner's Nems Infannat P Is North Andaver MA 01845 4127110 mquUW for CftyRown stata 23pC,ode Dam of Inepedon every Pew. D. System Information (cant) Sepal Tank(cant) 28� Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness gn Die:tance from top of scum to top of outlet We or baffle DMince from bottom of scum to bottom of outlet tee or baffle Ur MWsure Stick How were dimenWons determined? Comments(on pumping recommendations,inlet and ouftt tee or baffle condition, structural integritY, liquid levels as related to outlet invert evidence of leakage,etc.): Tank in good condition.mm Maes in good condition Grwe Trap(locate on site plan): Depth below grade: W Material of conduction: ❑concrete ❑metal ❑9wrglass ❑polyethylene ❑other(explain): Dimensions: � Scum thickness �^ CgMnce from top of scum to top of outlet tee or beffle Distance from bottom of Scum to ballon of outlet tee or baffle Date of last pumping: Date 06/14/2012 09:47 FAX 617 371 3796 CANACCORD ADAMS 1a013/019 Commonwealth of Maswchusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunbsry Assessments 66 STERUNG LANE _ Robert and Mellissa Greene ow"r owre es Name " "' for a North Andover MA 01846 4127110 a"rlred $tete Zip Cads Date orlWecWri �ery page- a- CNy/TOwn D. System Information (cont) Comments(on pumping recsommendatlons,Inlet and outlet tree or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,ebo.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade- Material of construction: ❑concrete ❑metal fiberglass ❑polyethylene ❑other(sxplaln� Dimensions: Capacity: gWW4 Design Flaw. psoons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dow Comments(condition of alarm and Nowt switches,eta): i I I `Attach copy o4 current pumping contract(required).is copy attached? ❑ Yes ❑ No 06/14/2012 09:47 FAX 617 371 3796 CANACCORD ADAMS 2014/019 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dloposal SydWm Form-Not for Voluntary ASsessrrrents 66 STERLING LANE —�--- Propedy Addmw Robert and Mellissa Greene owner owner's NHme mquir for at is North Andover MA 01845 4127/10 every page- Date requircityrrown State zip code of bmpncbm D. System infofrnation (cant_) Distribution Box(if present must be opened)(locate on tilts pian): Depth of liquid level above outlet Invert Comments(note if box is level and dWbutxm to outlets equal,any evidence of solids car ,Yover,any evldenee of leakage into or out of box,etc.): Box in good condition Disbibutieon equal No evidence of soilids carryover or leakage in or out Pump Chamber(locate on site plan): Pumps in working order. Q Yes [I No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber,condition of Pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): if SAS not located,explain why_ i i i 4 06/14/2012 09:47 FAX 617 371 3796 CANACCORD ADAMS IA 015/019 Comrttonwasith of Massachusetts Title 5 Official Inspection Form Subasurtace Sewage Disposal System Form-Not for Voluntary Assessments 66 STERLING LANE Propegy Address Robert and Mellissa Greene OWrW Owners Nene I"r0i"euOn Is North Andover MA 01845 4127110 required for state z0owe Debs of IW=Uon eery D Carlrowe D. System Information (cont) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number: ® leaching trenches number,length: 2-5D'trenches . ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ Innovative/altaemative system Type/name of technology: Comments(nota condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetaitlon,etc.): Area 4f leach field baka normal.No wMence of g9nding.damp or unusual vagets0on. Cesspools(cesspool must be pumped as part of inspectim)(locate on site plan): Number and configuration Depth—top of liquid to Inlet Invert Depth of solids layer Depth of scum layer i Dimensions of cesspool Materials of construction 4 Yes No Indication of groundwater inflow ❑ ❑ I i 06/14/2012 09:48 FAX 617 371 3796 CANACCORD ADAMS 16016/019 Commonwealth of Massachusatt8 Title 5 Official Inspection Form Subsurfdte Sowage Disposal SysWn Form-Not for voluntary Assessments 66 STERLING LANE Robert and Mellissa Greene Owner Owners Name - — kftmat required for on Is North Andover MA 01W Q27/70 y� Ep Code 0aW of lmpec tkm e�Y page- �D. System Information (corn.) Comments(note condilaon of sat,signs of hydraulic failure,level of ponding,oondigon of vegeb%on, eta.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soft,signs of hydrault failure,level of ponding,condition of vegetation, 06/14/2012 09:48 FAX 617 371 3796 CANACCORD ADAMS Z018/019 Commonwealth of Massachusetts Title 5 official Inspection Form Subsusrface Sewage Disposal System Form-Not for Voluntary Assessments 66 STERLING LANE property Address Robert and Mellism Greene Owner owners Name InkrequiTedfo awn ar North Andover MA 01845 &27110 _ required for St2tP Vp coo Date of lowaton ev0ry page. GIyl1'own D. System Information (cont.) Site Exam: ® Check Slope Surface water JZ Check cellar ® Shallow wells estimated depth to high ground water feet please indicate all methods used to determine the high groundwater elevation' Obtained from system design plans on record If checked,date of design plan reviewed: We ® Observed site(abutting property/observation hole within 15o feet of SAS) El Checked with local Board of Health-explain: Checked with local excavators,installers•(attach documentation), Accessed USGS database-explain: UN§maps- You must describe how you establF.gted the high ground water elevation, System built in an area which was raised between 4 and 5 feet above old existing ground m constructed 4 feet above d water Before filing this Inspection Report,please see Report compk"nessss Checkilst on next page. 06/14/2012 09:49 FAX 617 371°3796 CANACCORO ADAMS Ia019/019 Commonwealth Of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposes System Form-Not for Voluntary Assessments 66 STERUNG LANE Proverly Addrom - Robert and Mellfta Greene Omer Ownara Name at rmuirNorth Andover _ _ 4127/70 required ffoor MA di 845 GrY"go. cay/rom - — T State Zlpcd Cada Data orinspeetlan E. Report Completeness Checklist ® Inspeccdon Summary:A,B. C. Q,or E checked ® Inspection Summary D(System Fellure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 4 N2 227/ 4 Date....Z....�:.rz)....... f pORTh 1 0� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACHU This certifiesthat ..... ...,, ..p:B1:� -:sem .......: . -;�................................... has permission to perform .............................. ......... wiring in the building of.... :'. - '✓��:: ......................................... at Ai e. ..- --G:%�..... -'�- ...... ,North Andover,Mass. Fee !�....'"..... Lic.No:....�.�f. .. 1... /'�,c..L' .. .. ................ / ELECTRICAL INSP. E.C..T.OR.... WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THEC0II 0AffEILTHOFARMQRIS= Office Use only DEPARTMEVT0FPVBLICS4= Permit No. �6 @ill BOARD 0FFTREPREVE7VI70NRE UL4TI0A SR7CMR 12DO ' Occupancy&Fees Checked C < APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date .2"-z Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) (� .S'�F�'G/A-� G Z A"AC Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes=No r7 (Check Appropriate Box) Purpose of Building A / Utility Authorization No. Existing Service Amps / Volts Overhead M Underground a No.of Meters New Service Amps / Volts Overhead F-1 Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work i - No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and at Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices 1 No.of Dryers Heating Devices KW Local r7-1 Municipal a Other Connections No.of Water Heaters KW No.of No.of signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OT TIER lnstrar=Cv as RuslarltIDdlemWmaZdMwmdlsetlsGffoaI Lam lhmcaamatLi bhyh-trans Poix,ytndtdtgCar CaxrdWcrdsst# e4uvafat YES r7l NO F Ihmestbmb2dvandpmofofSame1otheOT=YES F71 Noa IfyuhawdvJcedYES,pkaseutk&theNrofaAraewbyd=krtgthe mxoptialebcx r---.l, BOND o OU]ER o ftase ) EWdDate E4naWdVah�ecf work$ WakoSw y"Y' _ I D&-RwsWd Rail Fatal Sig ed tarderTr R rtaltim of FIRM NAME 4A114 � oc�EI Liomse% CV uml 4rT So== ���:GG��--ZLG1sf/�y��--Lic�r>Sel to --2�7. Y'7 &messTeLNa �7 -272 �/dZ-A•'tJ.O 7�. /fid!/ f/!/L� /f� AiTeLNa OWNER'S INS1R,WAIVER,Iana%wedrattheLierisedomMtmEthe ireraneoaaageaosstig3teieq valattasm*mWbyMamxhf 1s Oral Laws and thatmyWatt menthispantappfiicabaiV i%csd>israw'Sna1t (Please check one) Owner Agent Telephone No. PERMIT FEE$c�5 � J 3 S 0 Date. NpRTH TOWN OF NORTH ANDOVER pF4 .co ,tip 3= ' O PERMIT FOR GAS INSTALLATION F s io • 9 SSAC HUSEtt This certifies that has permission for gas installation . . . . . in the buildings of . . . � .� `1. .�.,�. . . . . . . . . . . . . . . . . . . . . . at s. . . . . . . .{, North Andover, Mass. J Fee. .�.J .:. . Lic. No../ .0—7!.'� I . . . . . . #AS INSPECTOR ` WHITE:Applicant CANARY:Building Dept. PINK:Treasurer I?, , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ° ' (Print or Type) t elle, Mass. Date �� —0?�7 ,dd Permitk Building Location , �3 Owner's Name �'l7d l�� � cb��' �°e•-cC G5 E� �c c �-ct/ Type of Occupancy Newl j Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ W W 'tn u) Q � Cr Q W w Cr O OU m �� i W z O w Q cr Cr z Z) O Z Cl Cr CO w Q w w O o_ CC W Q = z ►- O > W U) w W w z ¢ z m CC W � W ~ WW F- _ � 0 F- z J F- z W w O Q > w U � W Q W > Fr W Z Q X Q °D O O W E O WF- (L = O C7 M u. S 0 C7 U X > a 0_ F- O SUB-BSMT. " BASEMENT t 1ST FLOOR 1 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR . FLOOR L00R Installing Company Name ��< e L"(z'u Pau U Check one: Certificate Address �_1 n r� (r 1( 7 y ❑ Corporation 'l (/ �cQ ( �.. �(.��3 0 Partnership Business Telephone .PKPirm/Co. Name of Licensed PlumbeC or Gas Fitter r L �.(A C /u uy INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes ' No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Owner n Agent ❑ Si nature of Owner or Owner's Agent 1 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 performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By T 'pe of License U Plumber Qfjj�"i Title ❑ Gasfitter Signature of Licensed lumb r or Gas Fitter ,y0 Master Journeyman 10 517 own t�r���r.,� �r�� � Journeey man License Number r FEE j NO: APPLICATION FOR PERMIT TO DO GASFITTING OWNER: NAME & TYPE OF BUILDING LOCATION OF BUILDING: PLUMBER OR GASFITTER: LICENSE NO: i . i PERMIT GRANTED o DATE: 19 GAS INSPECTOR i r N! 2 '173 ....... ORT TOWN OF NORTH ANDOVER 0 $- PERMIT FOR WIRING "S CHUS This certifies that ......... ...... ............................................... has permission to perform ......_.... .. .t.............................. . wiring in the building of.... ......... at.Z . 1 1 ..... .............. North Andover,Mass. Fee,R�5..f��... Lic.(:N04,1—-.V(-)... ..................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Rough Service Final 014c GQIIUIIonwralt4 Of Aussac4twettB Office Use Only Department of Public Safety Permit No. dl BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy 6 Fee Checked. 3/90 Ileave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat City or Town of /�i T /9Nr�1J � To the Inspector of Wires) The undersigned•applies for a permit to perforih the electrical work described below. n Location (Street & Number) Lal— 3 & Owner or Tenant �Dd L/dG �'�/US%� �/�% Og n �6' �y� /� !�Y Owner's Address ��o ��2 ST. Ala 191Vla1�1/c2_i /`_�I7 6yf Is this permit in conjunction with a building permit: Yes \No (Check Appropriatte�Box) Purpose of Building '4 e al COSI, 51IL166 `ILA- /, 7 Utility �6t� / �L,� Utili Authorization No. ,( Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters m s iao /�Volts Overhead ❑ Und rd No. of Meters / New Service �f/IC/ A p B Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work TOTAL No. of Lighting Outlets No. of Hot Tubs No.of Transformers KVA Above In- No. of Lighting Fixtures Swimming Pool 9md. ❑ rnd. ❑ Generators KVA No.of Emergency Lighting No.of Receptacle Outlets No. of Oil Burners BatteryUnits No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones d To&T No.of Detection and No..of Ranges No. of Air Conditioners Tons Initiating Devices Heat Total TotalNo.of Sounding Devices. No. of Disposals No. of Pumps Tons KW No.of Self Contained Detectiord5o No. of Dishwashers 5 ce/Area HeatingMunicipal uniDevices ci Municipal Local❑• Connection ❑Other No. of Dryers Heating Devices KW No.of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: t. INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent.YES NO O 1 have submitted valid proof of same to this office. YES U NO U If you have check YES, please indicate the type of coverage by checking the appropriate box. INSURANCE [ BOND ❑ OTHER❑ (Please Specify) ( xpiration Date) of Electrical Work Estimated Value $ i Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME [� lZGE 42 LIC. NO. Licensee�1621A1 Signature 61�-� LIC. NO. p Address 6:-Z� X�, 0�F,�76, Bus. Tel. No. 9 Alt.Tel. No. OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws,and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Date. .�. .1. . .`.`'. N2 430" 5 NORT., TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING l r i y ,SSACHUSf This certifies that has permission to perform . . . . . . . l�vfz plumbing in the buildings of . .. . . . . . . . . . . . . . . at. .G. l. . f-w.11 . . . . . . . . . . . . ....loulm' ., N-o-rth Andover, Mass. Fee. . > Lic. No.. ./0. 9/7. . . . . .� /1��..'. . . . . BING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Flint"«iypel Mass. Date 10C Permit it. 4/ ?(5J r Building location Flo Owner's Name Type of Ocf;u cy New Renovation O Replacement ❑ P ns Submitted: Yes O No O FIXTURES z i N z Y } y N N b 0 O z z W W W Y J Mu < N a N Q N = H < C Q 2 C N _ J U N - N y I H h' W N Y C d V < 0: m 1A r < F 14 = < N rt: R 16 u = a W 1 < W ra = c u s 0 7 < yf N tt J O C 66 W !� r W O O J p. < Y W IL Y W W < t S a 2 I Y a O Z Z ►- J U I t < < i '" < < o i j o < ¢ ¢ aWc < o < r a m o v SUB—BSMT. / BASEMENT r IST FLOOR ' AND r1.aon 3110 FLOOR 4TH FLOOR STM FLOOR 4TH FLOOR 7TH FLOOR ATH FLOOR Installing Company Name /Ll �o tri f�c uJ_ Check one: Certfticate Address P t7 n k 7 ! O Corporation n ver c er 19 At Q O Partnershlp (justness Telephone 9.ti"'7- /ys` 7 -,Q-Flrm/Co. Name of Licensed Plumber M r c er to Met V o e( A INSURANCE COVERAGE: I have a current liability Insuranc* policy or its substantlal equtvalent which meets the requlrcments of MGL Ch. 142. Yes't- No O, If you have checked_W. please Ind(cale the type coverage by checking the appropriate box A Ilabllfty Insurance policy Other type of Indemnity' ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am awar* that the license* does not Have th* Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my Signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ Slonatute of Ownw of en's Agent I hereby certity that all of the details and inlotmalion I have submitted(or enlaced!in above application are true and accurate to the best of my knowledge and Utat all plumbing work and installations petlotmad under the permitwed for this application will be in compliance with all paninanl provisions of the Wssachuselts Stale Plumbing Code an apt142 o e laws. By gnaluce of Ucansodum t Tice Type of licansa:btaslu`EV .loutneyman❑ City/Town USEZRLY1 Ucense Numba( /O / ,z _ Location 16-13 No. 5 Date z C)ki NpRTq TOWN OF NORTH ANDOVER n Certificate of Occupancy $ 41 Building/Frame Permit Fee $ Qf w Foundation Permit Fee $ SJAC04USE Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ate i Building Inspector 3447 Div. Public Works PEI2M IT NO. APPLICATION FOR PERMIT TO BUILD^^ "r-,* ^NORTH ANDOVER, MA Flu Nu— V I.OTNO. 2. Itk:COlinOFo11'N Itsuu' 1):1"I'E BOOK PACE r7 a I)11'. 1.(11'NO. -- ���/7 ; v✓// / //�,,�n - /, r I.111111()St:()1:I31111.1)IW( VRL 7�E/i7/�/�./ ��S��CNc(`— l!/�% 3 �� L-�✓`7�c/7 !//U�Gr/�('-� 11NrR',N:1NIr: Q��C -TRUS% No .c)FsrOI11Es SIZE I)WNrR'SAODUFSS ozw /j/D. h`/UDQ(L HASEMENTORSIAll AIWIII I t:C is N'ow �F�ALD � 611_10 slzE Or FI.oO1t rlNnu:Its o2,(��� ' o�X/U 2N° ul:u urR';NANIt'. SI':1N A/ �)I;f.,Nc-1.:TI)KL::,It 1.:51 IttIII.I)IN(: CYC�^� ��// .� I"'L�//7 --- I11I,I f.N51ONS OF SII.1 �} ..._IIISI:,\(T I'RONI SI'Itl:t:'I' �'6 /J;_TACM `� ��I7 --DIMEiN'SION'S OF POST O�-' '/,2 ' UI;T.v\'('k:1 1(0:11 I.OT 1_1W4SIM.,S �J ItL':1CLt SIT- T- o CN yJ o9Ch�" 1)t1It:NSInNs nr cllluElts / / _ '7 X )� AIt1: F A OLOT -- FR0NT.kGE��� �/T//T,pc,(/yam �>,o � III::1(:uTOr rounu.aTIOw �� / '1'I IICKNCSS IS 11011.01\C NEW 16` Y7 /1'C' C✓� SIZE OF FOOTING -u BUILDING ADDITION C�6 � NI:1Te111AI.OF cutNINt:1 I\Illlll DING ALITALA11ON IS BUILDING ON SOLID Olt I It.LED LAND —. 1111.1.111111.1)ING C'ONFORM-rO ItIC(plit ENI LN'rs m..cm)L Y6a Is 11UILDINC CON'NEC ID1 E *0'1OWN\I':11TR I;t �Itl)i)F AI�I�I:.(IS A('IION', IL ANl' w lam/d K �J IS I3lIII.IIINC C(LNN'L(:"Ita)'li.)'I'O\1'N sE11'Iai ,�//0`]„ _ ��/ iVc� IS IiI111.11L\'C CON'N[C'I t:U lY)N:\'fUR:1LG:1S I.IY�ta� � __ YES —----_ — -------—---------'------- -� I I 1 D COS I I\1111( I'IU\1 ,3. I'I OI'lil('I'1' INGO121\I:\'PION 3q;t / I..ST. 111 DG. COST y, D !TuAn Ftl.l O(ITSk:c mms 63 EST.III.uc.COSI PER SQ. ET. J,17 -2 Es I'. Rl.uc. COS F Pl:R ROOM A'& 07TV9b � j; IIICIRIC:1It:rFits NIUSTBEONOtrrSIDEOFR11HA)INc SIT TC111A IT No. III 11'1('111'1)(;.%1zm:Ls MUST('ONFOIiNI'r0 ST:kTF.FIRE.REGIII.A'1lONS -t. :U'i,mm'k:l) II1': it III 1\S NIIIS'I'.M. 1:11.1?1):1N'O APPROVED 131'I311ILDING INSPECFOR � � IMII.OING INSPEC OR + li 111I1.'I ILIA) OWNERS 111.11 -- �� CONTIt.TI.:1.4 9�7,p —6190— = 21 lorn , is �/��f /J _ 5 ;I(:\\-wlI r. OF O\1'NEttUIt:\UIIIO111ZI<I).1CP:N1 G� / L 1� __ - CON'rlt.I.Ic�l ,/ / A�kSBUILDING DEPAR MENTI II rr.l: 5 -- r; i! I'I It 1111 Ult:1\II:U 1 ( Itcvised 5"'img .II\I -t�— -(—S-/-coe � r �2o x a�' 39a bs a 41 8 O 41 �d 8o bs via o >11 c2R Ll a �d lI'7� 5 rr (o 4/ g o xao gb 4.�- a a U o x/.`Y ya s e� b ? 9 O G-cSa i 5 a bCGu P, r �2e ' HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston , Massachusetts 02108. HOME IMPROVEMENT CONTRACTOR F Registration 105351 - TYPe - PRIVATE CORPORATION xPiration 07/17/00 COOLIDGE CONSTRUCTION CO . , INC . David V . Zaloga 401 Andover St N Andover MA 01845 s= k { DEPARTMENT OF PUBLIC-:SAFETY w 6 CONSTRUCTION SUPERVISOR LICENSE s Number: Expires: Birthdate: ' j CS -8.8.6355 85/21(-2698 85/21/1946 Restricted To: 86 > DAVID V ZALOGA } " �.. 6 PENDANT CT :ANDOVER, 'NA 61611 . . ..,., �f r-� �r The Commonwealth of Massachusetts Department of Industrial-Accidents -� Office of Investiciations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name CO6L ® COIL- STl�I/6770A,) Please Print Jame: Location: Cit,/ Phcre T Fj I am a hcmecwrer pe.icrming all work myself. aI am a sole proprietor and have no one.working in any capac:i`i I am an em.clover rrcvidira workers' compen c on fcr, y err.plcvees working on this job. ll ,/ f�C==orf!!! eanv name: L�J6L/!,r?'L—� Address 7'Igz A4!/O6&1z Cih; /V z2GUDOVI-x /`�w �/TVS Phcre--7 Insurance Co. Z/1/Sl//e/�/t/C L'G. Pclic';m Comoanv name: Address Cih;: 'hone Insurance Co. Folic-;T Failure to secure ccverace s recuirec urcer Semen 25.A cr VIGL 152 can lead to the EmccsAicn of c imirsi penalties cr a rine up to 51.500.CC andler one years'impcscrment as•.veil as c:vii Penalties n't:e form cr a STCF`NCRK CRCER and a;ine cf(51 CO.Co)a day against me. I understand that a copy cf;`is szaterrent may ce ror,varcea tc the Office cf Investieadcns _. :`e CIA for ccverace yerifiicaticn. I do hereby cerfiiy under s- d pe aloes of pe.jury that.he information provide^accve is-fnue and c:.rrec.. Sionature nate Print name Phone r Onic:al use eniy do not write in this area tote comcle!ed byc:-,/cr:wn aricai Cty or Tcvn P�-rmit"Ucensirc Building Dept ❑Check f immediate response is required [j Licensing Board r—, Se!ec,man's office Contac:Terson: Fhcne health Department Other - '�, '. - "' .." �4 . i, az�:' �. ..."-ij 1�;;..t&j.' ---I.I._'.. �I . I .I�!.'.':I'll , , "i, � : ,j� ' -' -�� ;�'..j �_' -;;-'� � ..;L��':"�: , ,I-, . I; 7: . . '..-�.., .: - " '. - - ? ��f:, , . 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I . : .1 -.'r"; : . � . :_ ::'��' "' ..".� "..." -�4....1. "" - - . - i '� :: , .;.. , ' ; 1;�.:1?�':.;.%,, . - 1; � ' !'.": .. .7�Z' ''L'' " ' ::'.i.11 :. - ' 'f � ".� ", �ilz_:�.. , , -, , - .�;r-: t� - I �' �-� _&�-; - . .. .. � - . . . . ' �i , . �.1- I 'i -5 - - -.I. . . , . � � ,-** ' '," --,."�`t'.'*' , . . '-'�--'.-'�' ---.-'-."---- . I� 1 . . , , ': , .;-,- � .i,, , ,.- ; I . . . : *!, r. - -�� . I - , ;- 1. �. � . . � ,. , 11 . ; ' ' I ", .. � �w I . � �: :' 1. .. _ .. _:_; ; � ; . - L � I 1. -,1.-, . t .. . . . I p i 4 m'%.,1 t�� " % i .' , : I ,: � .. � - . 1:;!; , :,."I , . I . . ; ,: I•. - . � ROBERTS INSURANCE AGEN TEL 508-6833147 Oct 20 '99 9 :57 No 013 P .01 !4i'rl� "` " ► `sM'•+#Elf w ilk�lil f ►a+ .rra ::: ,3i;n .... 10 2 0 9'� :�«:.,.,...:.,;r:.:...:..,.:..:,.;::..:.:,.>:,..,..... ..,«... INFORMATION ONLY AND ,.»>1::..:::<.::.;:;<:x.:sa«,„•w .<..r:: .•.. ...:.. THIS CErMlgCATg W ISSUED AS A MATTER OF CONFERS NO RIQHTE UPON THE CERTIFICATE HOLDER. YHIS CERTIMCATS ODES NOT AM9ND, ZMND OR ALTZR Tf41t CoVrRAQE AFFORDLD BY THE Pougg BELOW. M.P. ROBERTS INS AGCY INC COMPANIES AFFORDING COVERAGE 1060 OSGOOD ST ...... . ...........:........... ............. ................•.......... NO ANDOVER MA 01845 MPAgNY MARYLANDCASUALTY.......................... ..................................... pOMPAPOY B .... ............... . .............. OVER I COOLIDGE CONSTRUCTION C406MANY C OAK TRUST 401 ANDOVER ST 0 NO ANDOVER MA 01845 .......................:........LEGION...INSURANCE...CO.........................................:.............::..,.. #yE MARYLAND CASUALTY RIOD ..,..Y.,.I.I.... n w..i.. r..t::.,.. xt. .i;jW..}i.:. ...e..:q<}i,..•:�.,.'r.:Y.i:..:.. ..4:j;.;:u •.. �y� .,,,-%.••..::. +f":.,:;•s;.:.r. •r�•ians;•so-..: r..n•,,,,!.:.:.%.s'.:....:+}�.A.a,+::%:. ��} J••E:1• e'kN a, »'nrN.:,•:•XWCRr:'1:•s!:....:.,•.•....,•l.....SY 4:w.,........ ... 'o-::......r:n..h,•........ ...... TSS(B To CERTIFY TMT THE POUCIE6 OF INSURANCE UI OR BELOW HAVE AW ISBUI:G TO THE INS R DO ;JMENAMED ABOVE FOR THE POLICY Pi INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CE APPON OF ANY CONTRACT OR OTHER ppHEREN WITH JECT CT TO WEIGH THIS 09111 CATS MAY YE IS&= OA MAY PERTAIN,THE INSURANCE AFFORDED&Y ENE POLICIES DESCRIBEDPADCL HEREIN IS 8USJECT TO ALL THE TERM6. EXCLUSIONS AND 0ONDITION8 OF SUCH POUOIES. UMITB SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .................•...... .............. .......... ...............................I................ .........I................•...........,....•........................................................... CY EI*1C11YE:POLICY!K/MT1011: I.�AIIi % TM OF aatuMAMC� DOLICV NUww OATD t*01»1^R ' DAW PAWO/m aElls+uL LN�utY RGP 21236295 :12/13/98 12/13/99 igZNeP!LAQQRE<a!!!TE 0.•. .,.,..... : �s•ooMProv ACIo a 000 000 . 'PROD x oa+.�• 1>l l .wuRv �..a,4 0 OLAMa >F;: MAW x ....ON ....... Nil' �CCDIN ...........• ......... 1.,..0 0.,..000 . MRl�rce o OAYHEIrs A CONTRAOr *PROT• .............. Powe DAN�IAos fAro ats wl :150',0 0 0 ........ ........................ UAKM ' ADN-5269103 11/28199 11/28/00 commevswam 'a tmm ............... ... :ANY AVM ALL Qwmw Aum BODILY IWVRY 500 00 000....,.. o9*4110{M.SD AVroa 1111 ..............:............. KIM AVTOa aCDa,Y"JURY a IPP►004100" iNON OM?I�AUTOa ... ..........................................:.......r............•.t•..,........... eArml UA§Ww PROPeRry DAMA46 x100 000 EACH OQWRFt"g i trona LJAR+fr .............:i:............. OOMILLA PaNim ,...Qnswts ;:.. INMaRKLA voles on�eR TAM :. 12/0b/99 X WC4-0118087 12/06/9$ srATur.oRrwrra . . woRlcslPs volr�Il+•new iACNI AoolD...rr 4500-l-q99... ACID piaei►se-PcxIcv ul o S 0 0 ( .................... ........... ............... ow4hvww v p;�i: 0APLOYt :6 5 0 0 0 0 0 EC 86814176 j 9J28/99 9/28/00 BUILDERS RISK �OII oa o��uIATIowaA ow►nowavlwcLsaAPeaI.N.I,flurs LOTS 1 — S STERLING LANE NORTH ANDOVER MA 01845 ". FAX NO. 685-7878 ..:.:::::. ...,,,.:::,c::. ! �..1:111:., .. :<:r x ••ie:e: y� arr ,. r o-.... 111:1/ .>a.%::>•Y..r .x.>a:. �'^l.•CR OWN..:. V' SHOULD ANY OF THE ABOVE oEsCFtaEO, POLICIES BE CANCELLED 1110ORE TUC EXPIRATION DATE THEREOF, THE ISSUINA COMPANY wuL ENDEAVOR TO MAA10 DAYS WRITTEN NOTICE TO THE CKFFrWICATE HOLDER NAMED TO THC TOWN OF NORTH ANDOVER LacFTt_6y�r,'AIWRC TO MAIL SUCH WYME BHA"""POSE NO qp AT10N OR ATTN t BUILDING INSPECTOR .NAsltmr of ANY KIND u COMPANVY,ITS Aa Baa mEr**vNTATrrts. MAIN STREET NORTH ANDOVER MA 01845A. Mich Ro r ..........n......: :. .:.. •.,,.,.,r.,.l..:... ..,!1111.x... h•;r•;::.%4o-.,rx.. :^�•n.%l.,,.:.;%., .:,:4%x4 s�'r.G�, ;k. RR1C� I!l� .:. 'a Ricao-,.�+rtl::l�ex''•txss%:,:•:rtak:o-n:..«: '.«:»Xaa:nuxye:»'r mK axx�:w»%..,< ^%r�i�.+.r•%, >F<•„< :.Al� %1111,,•.>:v...», ' '. <•�•:>.1111..f.;r t : MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2 . 0 Checked by/Date CITY: Lawrence STATE: Massachusetts HDD: 6235 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 10-21-1999 DATE OF PLANS : 11-24-94 TITLE: Single family house with 3 car garage under PROJECT INFORMATION: Lot 3 Sterling Lane, No. Andover COMPANY INFORMATION: Coolidge Construction Co. , Inc. 401 Andover Street No. Andover, MA 01845 COMPLIANCE : PASSES Required UA = 727 Your Home = 609 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 1880 38 . 0 0 . 0 56 WALLS : Wood Frame, 16" O.C. 3184 15 . 0 3 . 0 213 GLAZING: Windows or Doors 570 0 .350 199 DOORS 147 0 . 350 51 FLOORS : Over Unconditioned Space 1880 19 . 0 89 FLOORS : Over Outside Air 32 30 . 0 1 HVAC EFFICIENCY: Furnace, 90 . 0 AFUE ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code . The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 1250 of the design load as specified in sections 780CMR 1310 nd 4 .4 . Builder/Designer Ticel DateV 6e Z� �`"'�� MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2 . 0 Single family house with 3 car garage under DATE: 10-21-1999 Bldg. Dept . Use CEILINGS : [ ] 1 . R-38 Comments/Location WALLS : [ ] 1 . Wood Frame, 16" O.C. , R-15 + R-3 Comments/Location WINDOWS AND GLASS DOORS : [ ] 1 . U-value : 0 . 35 For windows without labeled U-values, describe features : # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location DOORS : [ ] 1 . U-value: 0 .35 Comments/Location FLOORS : [ ] 1 . Over Unconditioned Space, R-19 Comments/Location [ ] 2 . Over Outside Air, R-30 Comments/Location HVAC EQUIPMENT EFFICIENCY: [ ] 1 . Furnace, 90 . 0 AFUE or higher Make and Model Number THERMOSTATS : [ ] Adjustable thermostats required for each HVAC system. AIR LEAKAGE: [ ] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. Recessed lights must be type IC rated and installed with no penetrations or installed inside an appropriate air-tight assembly with a 0 . 5" clearance from combustible materials and 3" clearance from insulation. VAPOR RETARDER: [ ] Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors . MATERIALS IDENTIFICATION: [ ] Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values, glazing U-values, and heating equipment efficiency must be clearly marked on the building plans or specifications . DUCT INSULATION: [ ] Ducts in unconditioned spaces must be insulated to R-5 . Ducts outside the building must be insulated to R-8 . 0 . DUCT CONSTRUCTION: [ ] All ducts must be sealed with mastic and fibrous backing tape . Pressure-sensitive tape may be used for fibrous ducts . The HVAC system must provide a means for balancing air and water systems . TEMPERATURE CONTROLS : [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: [ ] Rated output capacity of the heating/cooling system is not greater than 125. of the design load as specified in sections 780CMR 1310 and J4 .4 . MISC REQUIREMENTS : [ ] Refer to 780 CMR, Appendix J for requirements relating to swimming pools, HVAC piping conveying fluids above 120 F or chilled fluids below 55 F, and circulating hot water systems . ----NOTES TO FIELD (Building Department Use Only) ------------------------- N2 904 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. 19 Application by the undersigned is hereby made to connect with the town water main in ✓l"I-ltC Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. (� 'P� - Street or subdivision lot no. ✓ q (�a 6,4 Owner Address Contractor Address Applica�V s Signa ure PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main ate Street subject to the rules and regulations of the Division of Public Works. Board of Public Works By Inspected by Date See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4�/z foot rod and brass plug type cover. TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 Telephone(508)685-0950 Fax(508)688-9573 NORTH O��t�a° •69ti O A # - y 9SSACHIJs�t�y t DRIVEWAY PERMIT Date: LOCATION: BUILDER: phone: OWNER: ��( �Ccc--zV S4 phone: The North Andover Superintendent of Highway Utilities&Operations MUST be notified of the grade and set-back from street established in any driveway entry onto any street or way maintained by the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. Remarks: Approval: q FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approvals/permits from Boards and Departments having.jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS S> CTlON*********************** APPLICANT (/1,�J/iOGE lie- ��-� T�'� PHONE 917-1 LOCATION: Assessor's Map Number 10(x(, _ _0�9 PARCEL SUBDIVISION LOT (S) _ STREET=J ST. NUMBER **** OFFICIAL USS ONLY RECOMMENDATIONS OF TOWN AGENTS: &015 CONSERVATION ADMINISTRATOR DATE APPROVED r DATE REJECTED COMMENTS TOW PLANNER DATE APPROVED C DATE REJECTED COMMENTS /0/1c//g r a fi—c (AA l FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED S T INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERfWATER CONNECTIONS L v Z7✓� q 'l ✓V DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Growth Management Bylaw Exemption Statement Town of North Andover Building Department This fort shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of,North Andover Growth Management Bylaw. The building applicant shall provide all of the necessarf information as requested below. Name of Applicant an Building Permit(below) Address of Property for Permit(below) Map and 4P rcel O 3 1 Purpose of,Application (check below) Rhone Number o�Appilcant: J Single Family Two Family `� lD lO� — I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit ig issued. above lot, in the building permit application and associated attachments, complies with one or more of Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the the following sections as indicated by a check mark. is is an application for a building permit far the enlargement. restoration, or reconstruction of a dwelling in ;tsl ca as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s)were/was created prior to May 6, 1996 are exempt from the provisions of this Sectien 8.7 of the Zoning w. This application is for dwelling units for low and/or moderate income families or individuals,where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents,where occupanc7 of the units is restricted to senior persons through a property executed and recorded deed restriction running with the land. For purposes of this Section"senior"shall mean persons over the age of 55. I This application is a part of a development project which voluntarily agreed to a minimum 400%permanent reduction in density,(buildable lots),below the density, (buildable lots),permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland.The land to be preserved shall be protected from development by an Agricultural Preservation Restriction,Conservation Restriction,dedication to the Town,or other similar mechanism approved by the Planning Board that will ensure its protection. adjThis application represents a tract of land existing and not held by a Developer in common ownership with an acent parcel an the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year,one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my kno edge or not, is grounds for refusal by the Build' g Department to issue a Building Permit. 1.41J q4 J E +ElS!ltureof her or A hcnz$d'Ag nt who'signed the Attac, d Budding Permit Cate C This form mini be atta hed to the uildin�-,Permit upon ppiication for such permit f i f` recorded at the Essex North Registry of Deeds. j' All application fees must be paid in full and verified by the Town Planner. The applicant must meet with the Town Planner in order to ensure that the plans conform with the Board's decision. A full set of final plans reflecting the changes outlined above, must be submitted to the Town Planner for review endorsement by the. Planning Board, within ninety(90) days of filing the decision with the Town Clerk. The Subdivision and PRD Decision for this project must appear on the mylars. j) All documents shall be prepared at the expense of the applicant, as required by the Planning Board Rules and Regulations Governing the Subdivision of Land. 2. Prior to any work on site: a) Three (3) complete copies of the endorsed and recorded plans and two (2) certified copies of the recorded subdivision approval, Covenant. (FORM 1), Right of Way easements, Aid FORM M must be submitted to the Town Planner as proof of filing. b) All erosion control measures must be in place and reviewed by the Town Planner. 3. Prior to any lots being released from the statutory covenants: a) applicant must comply with the Phased Development Bylaw, Section 4(2) of the - wn of North Andover Zoning Bylaw..This project is exempt from Section 8.7 Growth Management as the preliminary plan was filed prior to May 6, 1996 and the definitive plan was submitted within seven months. However the exemption will only nin for eight years from the date of the endorsement of the plans as set forth under Mass. Gen. Law. b) A complete set of signed plans, a copy of the Planning Board decision, and a copy of the Conservation Commission Order of Conditions must be on file at the Division of Public Works prior to issuance of permits for connections to utilities. The subdivision construction and installation shall in all respects conform to the rules and regulations and specifications of the Division of Public Works. c) All site erosion control measures required to protect off site properties from the effects of work on the lot proposed to be released must be in place. The Town Planning Staff shall determine whether the applicant has satisfied the requirements of this provision prior to each lot release and shall report to the Planning Board prior to a vote to release said lot. d) The applicant must submit a lot release FORM J to-the Planning Board for signature. e) A Performance Security in an amount to be determined by the Planning Board, upon the recommendation of the Department of Public Works, shall be posted to ensure completion of the work in accordance with the Plans approved as part of this 2 t BUILDING DEPARTMENT DEBRIS DISPOSAL FORM_ In accordance with.the provisions of.MGL c 40 S 54,a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: V( ,4 Location of Facility i tore of Peo' Appl• it 5f rC-- Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector M ! C pRT►y 33 own o Andover 0 No. Xto /#7,QO,SIPzAKE SIP - 0 ndover, Mass., O79F/sp 9P 'Q COC NIC ME WICK � '�Si9Ssq TE DU�G,`'(� 1 CH 44 IT FOR EXCAVATION AND FOUNDATION THIS CERTIFIES THAT ......LAK......T .... V ................................. ---.. .............. ......... ..... ..... .... has permission to excavate and pour foundation at .191t� �dwl ��hl; �N-� . ........... ............ ....... ............... ..... .•cactifor the purpose of.1 �Op !�.� ..4804....3... V !� .... ..' ....... The person accepting this permit must return to the office of the Building Inspector a certified plot plan show of building thereon before Foundation will be inspected. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS The holder of this Foundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS assurance that a permit for entire building structure will be granted. c ./.....� ... . .............. ....................... ........................ BUILDING INSPECTOR NORTH own O OL Over 0 X09 o�ACOCHI- dower, Mass., ORATED S 5` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...........©�.�.... V S 7� II Foundation has permission to erect................/.................... buildin s on... 4... .... .�.....�S.fl/1..4+. .....1 Rough Wh9nto be occupied as..l Q.... 0. .� .... ... . .. *d )/ IV ��� ey p +, ..3....................... ................................. ........ 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 I'» 104 4 PERMIT EXPIRES IN 6 MONTHS Final 3 ELECTRICAL INSPECTOR aj UNLESS CONSTRUCTIONS ART C 0 Rough / �� o•- BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, 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. � - �. r .�; '�jr'Y'y �"%+,rnr`,,�Sb..r,� •a� �rff�::�'�i`,�w'��,' w � '• L t 7-W 5Te,RL i /3 E �/ r -171 0,4 .. .4. A. • � VVV _ klrr it Location ,� - - No; / Date NORTH TOWN OF NORTH ANDOVER Of tt. o •�4. i y Certificate of Occupancy $ ; ttt'' Building/Frame Permit Fee $ ' �ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �- Check # 4- 13 - 31 / Building InspeEtor 1 I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. ® DATE ISSUED: SIGNATURE: Building Cornmissioner/12g=tor of Buildings Date SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: - Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard z Required Provide Required Provided Required 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 ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of ecord� /� J Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: f r ?Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Address Expiration Date Signature Telephone 3.2.Regi stered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address ^� Signature Telephone Expiration Date tl/ 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.......❑ SECTION 5 Description of Proposed Work check au 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 � QFCIAi USE QNLY Completed by permit applicant xx 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)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 BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTIOrN 7b OWNER/AUTHORIZED AGENT DECLARATION I, ze-'r Cr— as Owner/Authorized Agent of subject _proVerty Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 5'Ufr�.y C6 ti1V,1-'t . Prin Name 119 i ature of O er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SITE OF FLOOR TIMBERS OT 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS e 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 FORINT - U -. LOT RELEASE FORM 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. APPLICANT ASSESSORS MAP NUMBER LOT NUMBER D`U SUBD[VISION o T199 CR /^O��S�1�= LOT NUMBER STREET ZAW/ ' STREET NUMBER OFFICIAL USE ONLY /L CONI ENDATIONS OF TOWN AGENTS `3 a� �stx DATE APPROVED Al ONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE W� LOT 2 J in LOT 3 1 T.0.F s?' !►,p EL=143 0' OT 4 FOUNT DATION 1 1 �WW BUFFER ZONE 147.0• REFERENCE PLAN: NO. 13035 FOUNDATION LOCATION PLAN M THE ,L SEMCK Mar MMM M=M7M CUENT: COOUDGE CONSTRUCTION CO., INC. SUCH AS CO W.ORDERS or majavy"m- THRs CERT#-=TM IS A" AND L/WED I= DMWW SMAU Wr AE USED BY ME aJEXr FOR ANr PURPOSE OYM TO THE AWVE CLEW. PES INSS�i a F�&°�r��Gr wm� n� FURYMOMMM TINS DMWM1c /S TIRE !M%YIOMED PADPEW OF aANSrMAM t SEIM AUG AND ANY U M AIDI VID USE AS PRO1A WIMC M3714NSEN t SERO► rAA'ES Aro MEMNSAM" FON TIA< 1NrAU111DA'D3D USE or TFAS OR ANY#FOR- r LOCATION: NORTH ANDOVER , MA. '"110N 00NrM "1°K1O1ArC �,P`1H oF,ygs Ml sycy SCALE: 1 !-- 60' DATE. 12/2/99 0 s � p CHRISTIANSEN &SERGI "O.3 180 SMMW ST. NAVEIMIIA4" 01N30 TEL 978-373-0310 T p 1M NY api15/MNSEN t SEW NUG °tiQ 0?4005 " AORTH Town of dover No. 307 LA dover, Mass., 46 "a 7 00 COCMICHEWICK ADRATED S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......0 .t .. .......... N ... ........................................ ........................................... Foundation has permission to erect.../ 10........ buildings on .... ..�......5' ./s.�.I.f I�t.A.L lA~. Rough to be occupied as.............. .. ....... ....14A....���� O� ��� '� ........... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application n 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. CPLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. �� _ Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N ST TS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. 94 + 4 .........�7 t N�oTM 1 7.1°!,"oot TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMU- 1 This certifies that .......... ......GI. .........0-�?... ;............................... f. has permission to perform ........6a ...F.... .....l.n.(.�j .................. Bad ��� wiring in the building of.................... ............../.�.......................................... r t SPF ANVrth Andover,Mass. 4 ..-- EFee... . ............ Lic.No.... �.. ........... .... .... .. . ...... .. rr \ ELECTRICAL INSPECTOR E Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] Qeave bank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORKAll work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PAW flV INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER By this application the undersi ed To.the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) to C S-/ .- P �I L/{/ 7A' / an �Ndmug/L 1`7li Owner or Tenant ,�d Gn e" Owner's Address /4117 Telephone No. Is this permit in conjunction with a building permit? Yes ® No 19do � ❑ (Check Appropriate Bog) Purpose of Building Utility Authorization No. Existing Service ,U, U Amps /2-v 0x61 Volts Overhead ❑ Undgrd ER No.of Meters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: n T/y!9Ce711^4/ /3&E1- ZCXr AEC Y //f S! /'117 F /-✓t6MT 'C�� O'l /2 f/* Completion of the olio ' win table m No.of Recessed may be waived b the Inspector o Wires, sed Luminaires f No.of Ce' iL-Soap.(Paddle)Fans o.of Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Above �_ Swimming Pool o•o . mergen cy tg ❑ g d ❑ d• Batt U No.of Receptacle. mss Outlets No.of Oil Burners FIRM M4 1lTre ._ mf Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Initiating Devices No.of Air Cond. ° Tons No.of Alerting Devices No.of Waste Disposers eat p Number Tons KW o.of Self-Contained Totals: �._ Deteetion/Alertin Devices No.of Dishwashers Space/Area Heating KW ��❑ Municipal ConneclI u ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of No.of Devices or Equivalent Heaters KW No.of Data Wiring: Si s Ballasts. No.of Devices or Equivalent No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunications Wiriag; No.of Devices or E uivalent OTHER: C Attach additional detail tf desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: f 2aa Work to Start (When required by municipal policy.) �/_j U 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 g BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: Licensee: C0/7/1^/CJ-applicable, enter /:�. LIC.NO.: ( y Signature LIC.NO.: 41-21-7 If r "exempt"in th lice a numbed line.) Address: _� Bus.Tel.No.2- 2 fr ?Sr'33^ *Per M.G.L c 147,s 57-61,security work requires Department y/8-y3 Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the iccens a does noSaft havty 1e'the liability Lic.No. rance normy required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner co❑ owner'agent. Owner/Agent Signature Telephone No. PERMIT S'�'i'�E-i�✓ Gtil S -�.�,.s'��� U., � MO ,(3L ) IV,1V 0/ v`ovnl 0/ ,01? w�l/ A/O.&V /ALL !3001 Cs 1,21V C) lx7cvit.P.1' ,otos I The Commonwealth of Massachusetts Department of industrial Accidents ' Office of Lnvestigations _600 Washington Street Boston, AM 02111 www mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQi<bly Name (Business/Organization/Individual): Address: City/State/Zip: 1 1-1Gti2 fjg6 - 1AII Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am-a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2. I 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.❑ 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) I3.❑Other Any applicant that checks box#1 must also Pili out the section below:showing:heir workers'compensation policy infbrm.-tion. 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 their workers'comp,policy information. I am an er emP to that is row' Y p uling workers compensation insu f P ranee or my employees. Below is the policy and�ob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: r Job Site Address: Ciiy/State/Zi P I Attach a copy of the workers'compensation policy declaration page(showing the policy..number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. �I do hereby certify nder the pai and penalties of perjur,�y that the information provided above is true and correct Mature: Date.: Phone#: �?� E 28_ - � 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 r� 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. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the perimit 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 4 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 Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia i