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Miscellaneous - 681 GREAT POND ROAD 4/30/2018 (2)
681 GREAT POND ROAD IM 210/063.0-0026-0000.0 JJJ 1 \ _ Date..... ........ . ......... OF"0Rr#j TOWN OF NORTH ANDOVER PERMIT FOR WIRING N This certifies that .................. ...................e)..Lz.........H ...... ...... ..... 12 has permission to perform3P4 . ..................... .. ......................... wiring in the building of......... ..... ......................... ........................ .. ... at .......................... . ......... North Andover,Mass. ... �273Fee.... .. . ..Lic. o. .1........... .................................. ......... .......... ELECTRICAL INSPEC�& Check# 2 2S 13004 d, Commonwealth of Massachusetts Official Use only Permit No. Department of Fire Services j Occupancy and Fee Checked kip BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: — ` � � � � 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention&terform the electrical work described below. Location(Street&Number) rPJ-XfW6Ar21 Owner or Tenant Carl h Ca u I l I n ck Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No LK (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 Loc tion and Nature of Proposed Electrical Work IVA Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Imo' Security Systems: No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: r No.of Devices or Equivalent OTHER: 3© (SCA eCCf0,- 1 44—v Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6f)Cj (When required by municipal policy.) Work to Start: l pZ— 7>� ff 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 ,D< BOND ❑ OTHER ❑ (Specify:) I certify,under the patip and penaltie of' rjury,that the information on this application is true and complete. FIRM NAME: i r l01 �/, LIC.NO.:3L 1T7 Licensee: Lo L' f ���H-C 61, /•. Signature - LIC.NO.:�°� 3 19 (If applicablent r "eze "in the lice a nu er line.) Bus.Tel.No.: 721- ��'_© S— Address: 6cX/J Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Publ c Safety "S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent I.ca Signature Telephone No.77 1 # "6m- IPERMITFEE: $_ f: 1 _y S g° OMMONWEALTH OF MASSACHSETT .` s ® BOABC3 jb'F :: EI� CTE R1 C I ANS : NS " { . : ISSUES T}{E FOLLOWIN 'ECCE W > �>pURNEYFlAN ELEC _AlI91 A. 4 5 KRIS BEHSMAN � Z 32 CLEMENT AVE h►A o 196o 6130 pf ABpDY 1/16 70435 34185 :�• 07/3 - ,, _ ;�.,�.-- •- COIMMONWEALTH OF MASSACHUSE . �� ® a • o o BOARD OF t S€ 5 TTE F01 t WINO. LICIWsf�AS A i RAdd !► S1 }s LEG�iR1tt, AN _ f W � ti Z 32 � 0M ,K L !`'F!! ,,-,tom` f X. 1�EAAODY l4A 01960 -150 ! 1.2 o 1 <`Y E nit) CJS L'G p t a Go"' EIRJERATOR APPUCATON DATE: Q-jj� l� 1 LOCATION: OWNERS NAME: Lc,& A GENERATOR kw (�J NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: ��5 �e GAS m � �1 PHONE NUMBER: ;M (ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: PLANNING APPROVAL (IF IN WATERSHED) 2-Ig-i� *CONSERVATION APPROVAL; O� �� - mo Date..t��,Vllo......... 10701 cF"oRT"rho TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING � t Bs�cMus� This certifies that...I(AS 4A.......... '� has permission to perform...— ...�� .! ..................................o,.a/ plumbing in the buildings of at...(A.[....... ? ..��nr�............................. North Andover,Mass. Fee.6J..---..Lic. No. 11 N� ................................................................................. PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY -- MA DATE PERMIT# I -761 JOBSITE ADDRESS OWNER'S NAME �� POWNER ADDRESS f TEL E —� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL �]J EDUCATIONAL RESIDENTIAL®� PRINT CLEARLY NEW: RENOVATION: ,REPLACEMENT: Q PLANS SUBMITTED: YES dNO0 FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM PF—I DEDICATED GREASE SYSTEMDEDICATED GRAY WATER SYSTEMDEDICATED WATER RECYCLE SYSTEM .._!DISHWASHERDRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK __.___ LAVATORY ROOF DRAIN --- F-771 F---j ISHOWER STALL ._ .t 4- --j SERVICE/MOP SINK TOILET __...._...{ ( _ } i ! _._.I ..___1 .--_._I __j _- URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER F=--A] =1 ---71 _ _' _ - --i ._._... _...__, --I ----j -- I ---' - — INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ..[�! NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY —I BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER a AGENT 12' SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a rue and accurate to the est of my k wledge and that all plumbing work and installations performed under the permit issued for this application will be i co pliance itl Pertin nt provision,06f the Massachusetts State Plumbing Code and hapter 142 of the General Laws. PL B UM ER',' NAME _ _ _ _ I LICENSE# �. 13 , SIGNATURE I'I MP El JP N-- CORPORATION ]#PARTNERSHIP Q# LLC COMPANY NAME ADDRESS Z v CITY -- - - _II ATE Gt. ZIP _!�j`?3 — TEL IAJ FAX _ CELLQ7 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No QJr , THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES F^ t � The Commonwealth of ltlassachusetts . Department ofInlus€rzalAcca is Office of Invesfigations 600 Washington.Street Boston,MA 02111 www.mass gov/dia Workers' Compensation.bsurauce Affidavit:Buil:ders/Contractors/Electric ians/Plumber<•s�'� Anulicanti information `. Please.Pxin.�Le' xbiy 'Name(Business/Organization/fmdividual): Address: City/State/Zip: ��-rl�5 CA..",c� I�Cc Ol er?Y Phone#: '72 F-- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. []Now construction employees(full and/or part time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• El Remodeling ship and`haveno employees These sub-contractors have 8. ❑Demolition worldn for me in an ca act workers'comp.insurance. 9. g y p ty. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its I011 Electrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption por MGL I L E]Plumbing repairs or additions myself[No workers' comp. c.152,§1(4),andwe have no 12.❑Roofxe airs insurancerequired.]7 employees.[No workers' 13.❑Other comp.insurance required.] XAny applicant that checks box#I must also fill out the section below showingtheir workers'compensation policy information. i-Homeowners who sabmit This affidavit indicating they 6doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workerscompensation insurance for my employees Below is the policy anal job site information. i Insurance Company Name:. Policy#or Self lis.Lic.#: Expiration Date: rob Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requhedunder Section 25A ofMGL o.152 can lead to the imposition,of criminal penalties of a fine up to$1,500.00 and/or brie=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 DTA for insurance coverage verification. Y do Izereby rt under tl p ns a enalties perjury Mat the in•formationprovided above is true and correct. G�/ Date: 'Z Si afore• C Phone#• �1 7d/^3 �-6 - t Z 3 0 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Pers ow• 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 ofbire,- express or implied,oral or written." An employee 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 ixusfee of ari individual,partnership,association or other legal entity,employing employees. Iowever tha owner of a dwelling house havingnotmore than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be,deemed to bean employes." 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.fox any applicant who has not produeed.acceptable evidence of compliance with the insurance coverago 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),addresses)and phone number(s)along with theireertificafe(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,apolicyzsrequired. Be advised thatthisafCdavitmay besubmitted tothe Department of Industrial Accidents for conbrmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please ba-sure to fill in the pen it/license number which will be used as a reference number, In addition,an applicant thatmust submit multiple permit/license applications in anygiven year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town).;) copy of the affidavit that has beon officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavitis on file for future permits or licenses. Anew affidavit must be filled out each year.Where ahome owner or citizen is obtaining a license orpexmitnot related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and shouldyou have any.questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Th(�Co as�achU P . Dep.axi ent of.TndmtriaX Accxdent Ofee ofTwesUaWo7xa 600 Wa,-J* vL Steet Boston.,MA 02111 TO.#67.M-27,4.-00 eA 406 Qr-1-877�:�WE Revised 5-26-05 Fay, 617"727'7749 Date....!g I........�......1.).1...-I laoRro, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU Thiscertifies that .................................... .......... ................................................... has permission for gas nstall tion ... a i .....ioL . .v cj ............................................... in the b *ld* s Of............. . . ............................................................................................... at... ...............!?94................................q............. North Andover, Mass. Fee... ....... Lic. No. 715,....... .... ............................................... GASINSPECTOR Check# (0 V1 1 � I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY U& _ MA DATE I!f_jl PERMIT# l JOBSITE ADDRESS -c,%� OWNER'S NAME r /�✓fi - - OWNER ADDRESS TEL� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL n EDUCATIONAL Ej1 RESIDENTIAL PRINT CLEARLY NEW:E1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESU-19,00 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER �� ^ COOK STOVE DIRECT VENT HEATER DRYER 1 _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE - ---..---- - - - INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN1-�— T� m_ POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER - L--J1 T F-� ..INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES-j No IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr and accurate to the est of my kowledge and that all plumbing work and installations performed under the permit issued for this application will be in co p ince w �1 Pe 'n t provisio f the Massachusetts State Plumbing Code and C apter 142 of the General Laws. J( r PLUMBER-GASFITTER NAME — — — LICENSE# 2l( SIG ATU MP El MGF D JP JGF© LPGI 0 CORPORATION©#[=PARTNERSHIP®#=LLC B�= COMPANY NAME:5 - - ADDRESS CITY _ t STATE ZIP TEL -FAX CEL 6 l 4D UGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES AS Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i' �•e s • _. �. -- _. MMONWEALTH OF MA$SAGHUSEI I CO r ° Ill ° gppRD bF ,PLUMBERS AN'D GAS:FITTER L ' ISSUES THE FOLLOWING LI,CEN,SE LiENSE J AS A JOURNEYMAN'PLUMB R ` In I DA11<tb ,.S HUMPHREY Z P0.B:OX 312 I:I?swicHA 01938 032 04 zr �► ' o �_ Dateq) `' ....................... of NoprN�� 3a; °oma TOWN OF NORTH ANDOVER O T PERMIT FOR WIRING cHU �t�e This certifies that ....... ... has permission to perform :...... .!..... ........ .P..M.,a.��.P.�..................... wiring in the building of........,.. Q /� (.�.�/�............................................................ at .. ....... North Andover,Mass. JY� ........................................ Fee...�51..r....L..........Lic.No. �.�.�1�..!...F... ............. . . ELECTRICAL INSPECTOR Check# -2 T, Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 17-11 tI" Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ,N All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 1 (PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her jnteen torf the electrical work described below. \ k� Location(Street&Number) �j O l L/�j/ps�-P„/J�j Owner or Tenant �` A gk o i 6 rt, Telephone No. q-ts— a2^AW/ 1� Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) l Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und''ggr''d��%%❑ No.of Meters Number of Feeders and Ampacity 2:411 'L) - Location and Nature of Proposed Electrical Work: " Completion o the ollowin table m be waived b the Inspector of Wires. P .f f S may Y P No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total C Transformers KVA KVA No.of Luminaire Outlets No,of Hot Tubs Generators No.of Luminaires Swimming Pool Above ❑ In- Elo.o meLighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Turners No.of Detection and Initiatin Devices 1, No,of Ranges No.of Air Cond. Total Tons No.of Alerting Devices `— No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained �— p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent ' No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: IC.NO.: 7 Licensee: �/'i /� Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No. ,C Address: Alt.Tel.No.:-2 21 -0�,y *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ /---,Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed \ i 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 r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for.the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if hem' or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN PECTION: Pass Failed Re-Inspection Required($.) ❑ ' Inspectors Co ents: 141 Inspectors Signature: Date: FINAL INSPE 'ION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: Z — DEB WEINHOLD ...TOWN OF ME RIMAC,MA. .......dweinhold@townofinerlrimac.com *'4 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name(Business/Organization/Individual): Address:. City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): ❑ I am a employer to er with 4. ❑ I am a general contractor and I _ and/or part-time).* have hired the sub-contractors p y 6. ❑Ne nstruction ployees(full 2. I am a sole proprietor or partner- listed on the attached sheet.t 7. emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. El Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions `. myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]T employees.[No workers' comp.insurance required.] 13.0'other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ace 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:_ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine (if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert under thepains and enalfles ofperjury that the information provided above is true and correct. �A�/Signafore: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: c, Informati®n and Instruction p Massachusetts General Laws chapter 152 requires all employers to'provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who,has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the r applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The 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 Mossachusetts Department ofJndustrial Accidents Office of Investigations 600 Washington Street Boston}MA,0211.1 Tea.#61.7-727-4900 ext 406 or 1-877,7MASSAk'B Revised 5-26-05 Fax#617-727-7749 wwwmass,govaa t.� a :.g'COMMONWEALTH OF MASSACtiISETT: 3 ° ® ° ° LE xCiAN rS s S T7 F0-0:0W I,N LIC1 SfE A5 e1 Lit } F F FiPq w_�'r N �rrABonY MA o� bo b13o x.54'30 i I Commonwealth of Massachusetts Official Use Only 4,01 Permit No, Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] Qayeblank) APPLICATIn- l" L All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CM7K-12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: TL. t,, llz,3pt.aur (&,Irect&Number) 0-"F net-Z'r—citaa f T E.Lp i t; ovviit9i AiLl;cbs pur.-osz of Existing Set-vice Amps I Volts Oveilhead Lj Undgrd i j No.of INIeters, A ry Tati, ,Nu.u;'.r iTransformers SVA A!1Cntl ir, i 11:10C I' en- 3L7 4_gti➢d. 45rrnd. lfgat�cry i.nits J 0 L4 iniiia es qtlj)'(� k.p.);',ames Nkv CC"Vk NO. J"Ct�i,i ces or Z t,,tj'F a i eat' N"n '�f of of :Dn"a"Y-6 g: a e lis aHyd,om 4,sa - 2'viht,0. lk . tit 'M tcr% L!r t -n Wc n q ""-,si3in, ffl U j?� cc fu Do- _7W 5 g- own er/Ap-ent i � 1 � � ` / �¢�/l��'N4. i Date.... . ....... ,4°RTp 3:00� TOWN OF NORTH ANDOVER hw # PERMIT FOR WIRING ACHusE� This certifies that .... .. / �. _..! s.. has permission to perform ..................... ....... ............................................ wiring in the building of. . c t: --- ............................................ atj � ,North Andover,Mass. Feer-�—c :. Lic.Not , ....... y^ Z` �. ELECrRICALINS'P** Ii Check # 9269 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked /1,• e,�� [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W All work to be performed in accordance with the Massachusetts Electrica4ode(M C),5 7 CMR 12.00 WORK (PLEASE PRINT W INK OR TYPE ALL WOR LI TIOA9 Dater pf City or Town of: NORTH ANDOVER To.thee , or of Wires: By this application the undersigned gives notice�of,his o/�her' tention to perfo a electrical work described below. Location (Street&Number) �� �3'7CS�-� ��� Owner or Tenant Telephone No Owner's Address ���- Is this permit in conjunc ' n wi a buil g p rmit? Yes Purpose of Building No 2-'(Check Appropriate Bog) Utility Authorization No. Existing ServiceZ�O Am / a Ps � �/ Volts Overhead 9/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: Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus No.of Total p.(Paddle}Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In o.o mergency g d d.' Battery Units No.of Receptacle Outlets No.of On Burners FI.R�.ALARMS iS No.of Zones No.of Switches No.of Gas Burners No..of Detection and No.of Ranges No.of Air Cond. Total Initiatin Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW P Totals: ""'�""' --- —- No.of Self-Contained Detection/Ale . Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection No.of Dryers HeatingKW Security S s e :* Ams El � Appliances y No.of WaterNo.of No.of Devices or E uivalent Heaters ' No.of Data Wiring: Si s Ballasts No.of Devices or Eq uivaIent No.Hydromassage Bathtubs jNo.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Estimated Value of a cal Work: f18 � Attach additional detail if desired,or as required by the Inspector of Wires. Work to Starts (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 cove ge . in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER I certify / ❑ .(Specify:) under thf pains at pen ties of perjury,t./t�th A formation on this application is true and complete FIRM NAME: c �, c A Licensee: LIC.NO.: Iq z / 7.4 a lic Signature LIC.NO.:-3 l W /= (If pp ' ale`enter-"exempt" 'n the l� n�>�je li ) Address: Bus.Tel.No.: *Per M.G. c. 147,s.57-61,security work requires Dep ent of Public Safety"S" icense: Alt.TelLic.No.:� —� �f OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ �. I � � � /�� e rz 3 z ,� The Commonwealth of Massachusetts f ! Department of industrial Accidents t � Office of Investigations 600 T Zayhington Street a Boston, MA 02111 r : www.nzassgov/dia . 'Workers' Compensation In kmnce Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ*bl Name (Business/Orgenird6orAndividual):c Address: vz.e City/State/Zip: one# �� �� Are you an employer?Check the appropriate box: t.13 I am a employer with 4. Type of Pro,[ect(requires: ❑ I am a general contractor end I ployem(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a:sole proprietor or pamcr- listed on the attached sheet.= 7• ❑Remodeling ship and have no employees These sul;-contractors have working for me.in an g Q Demolition . g . y capacity, workers'.comp.insurance. [No woricars'comp.insurance 5. ❑ Weare a corporation and its 9• ,,❑...,,,,BBuilding addition required.] officers have exercised their 1 o.l�(jglectrical repairs or additions 3.❑ lam s homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions rgyself. [No workers'comp. c, 152, §L(4),and we have no insurances 12• Roof required.]t .employees. [No workers' ❑ mpairs comp. insuraneesequired_] 13.❑Other *Any applicant that checks boat#l must also fill out the section below showing their workers'6orapensaiion policy information t Homeowners who submit this affidavit indicating they ate doing all work and then hie outside contractors must submit anew affidavit indi — 'Contractors that check this box mustatta4hed an additional sheet showing the manic of the sub.coerrgcto ,,, .t a rs.ei. T. �ha6 such }Policy information. I ant an employer that is proradtng:workerscompensation insurance for JM employees: Blow is the policy mrd job site infornwion. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: - Job Site Address: City/state/Zip: Attach a co of the workers,kers compensation 0 Pe n policy declarationshowin Page(showing the policy number and e Failure to s expiration date secure coverage as required under Section ZSA of M GL c. 152 cim lead to thinal Penalties of a fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the lotme of a STOP Wimposition of OR ORDER and a fine In a to tions 0 a day agfor i the insurance or. 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 cert under the pains"penalties o er fP lam' that the information provided Ye • Me and correct -!�• Phone Of}`Icial use only. 7nlethis area,to be completed by clay or town ociaL City or Towtr Permit/License# Issuing Authority 1. Board oTHealthepartment 3.City/Town Clerk 4.Electrical inspector S. Plumbing Inspector 6.Other Contact Person• Phone#; 40 �A Date.. © � ,t ..`....... r•. ,� t No DTM 1 3?�•`�`� -• "�o� TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING ,SSACMUS� 'This certifies that ............:5:� .........�.!`.....C............................................ �PVICW- ulo c e- ba\A has permission to perform ........................... .M........ ................I...... / c.{.�. t.v/E- wiring in the building of .. ........Tti ... . / .......................................... �v 8 l� at...............,....Gr'{ Pa-tic Rd........................................................... . ,North Andover,Mass: . j.. � � ELECTRICAL INSPECTOR *'iheck # 5535 TBE COMMONWTHOFMASSA9HUSETIS Office Use only DEPARTALENTOFPUBIIC59F Permit No. BOARD OFFIREPREVEMONRE'GUTA770NS527CW 12.M g Occupancy&Fees Checked s APPLICATTONFOR PERMIT TOP' RFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH TVMA ACHUSSTS ELECTRICAL CODE,527 CMR 12:00(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date `/Town of North Andover To the Spector of Wires: The undersigned applies for a permit to perform the electrical worribed below. Location(Street&Number) Owner or Tenant CQ cs�i A/V 140 t' ( ,� V7 R Owner's Address Soh�G Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box) J�,/���j Purpose of Building ^e,5,�yr c-'� Utility Authorization No./ `/¢� / Existing Service /'0 Amps i� cy ovolts Overhead Underground M No.of Meters New Service O Amps / Volts Overhead underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground No.of Receptacle Outlets /,v 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 Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained DetectiordSounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHIIR• x/9lr�� /�9,/7s' i hrsur*Covere.Pt>W&ttothetaquita Mc)fMamdmscMGMIWIaws Ihaveaamentliaj yh>srmwPblicyinckdTCmiple G' GDVerd eoritswbstntialegtrivalerit YES NO a Ihave siftni edvaliddproofofsametotheOffice.YES F)w haw duclodYES,plemiridicatethe type ofeovettageby checi gthe a boax. INSURANCE�OND r7 OIHER (Please Spwity) �� %i o y C %( W Dai EstQr>ilmdvahleofflearicalwork$ WodctoStart kgecfi nDateReWested Rao Final Signedunderle d FIRMNAME zm55 c �c® lir Liar>,seNo. � /e Liaee Si / �2 LiaeNo 7 Bus¢iessTel.No. y/�- F.;;27-7a 77 arl lmcc Alt Tel.No. OWNER:SINSURANCEWAIVER;IamawarethattheLiximdoesnothavetheinst mwooverg oritsarbsontialegrmlentasmgmedbyM&wdncetsGeneralLaws and that my signature cn this pemm appkat ion waives this regtuterna>t (Please clieck one) Owner Agent �- �� Telephone No. PERMIT FEE d signature or Owner or Agent ° Location f Pr/ No. �i�5 Date l�-'fir'. <3 NORTH TOWN OF NORTH ANDOVER Ofi„ao ,a,h•G � 9 a Certificate of Occupancy $ s i ��s' •EtA Building/Frame Permit Fee $ Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ :Z2 Check # 16 3 6 9 L 8 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATEOR DEMOLISH A ONE OR TWO FAMILY DWELLING �q BUILDING PERMIT NUMBER: �� DATE ISSUED: ic r 5 - - SIGNATURE Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION O 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 Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Fater 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 0 - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print' Address for Service: py�py�� 1�1 Signature Telephone 90 , SECTION 3-CONSTRUCTION SERVICES - 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0 3 J 0 License Number A,Idress 7 S f S z Cf Expiration Date ic Signature Telephone 3.2 Registered Home Improvement Contractor-- Not Applicable ❑ v Company Name 03 ILi Registration Number Address </ z 7 7 S 9Z3 (/ ,( 1� Z - Expiration Date /y Signature Tel hone' �l/ SECTION 4-WORKERS COMPENSATION(KG.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 rmit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be y CIA►i.USE ON Completed by permit a licant L Building (a) Building Permit Fee 1Vlulti lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical HVAC 5 Fire Protection 17 6' `Total 1+2+3+4+5 `7 ®a Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ID U S A,-V L-T'c,.y as Owner uthorized Agent of subject property Hereby authorize_ �.�.,,P l e IJ j__`� e33.c�� _ to act on My behalf,m all matters relative to work authorized by this building permit application. Al®v 13,03 Silrmture of Owner Date -SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, Z.��, �:6 -a-Lit as OwneAuthorizedAgen f subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print N63 e ` Si ature of Owne en Date r NO.OF STORIES - SIZE BASEMENT OR SLAB SIZE OF FLOOR T11VIBERS isr2ND 3 SPAN DMIENSIONS OF SILLS DWENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORTH Town of Andover . ......... 35SO C' = o lover, Mass., OS' Z�' •03 O LAKE COCHICHEWICK V 0'%A T E D RATED PP .(C BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT........ ......................... ... . ... ...... ............................... .. .................... """""..... """ Foundation • has permission to erect........................................ buildings on .....46.40/... .... ................ ...................... ........... Rough to be occupied as... ...................... Chimney ................................................................................................................... provided that the person accept! 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .......................41010 11 W.1... Service UILDING INSPECTOR Final Occupancy Permit. Required t0 Occupy Building GAS INSPECTOR Rough { Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of P ffimit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I �� -�om�n�o?�cveaCr! o����aaaac�u� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration' -100811 Expiratgn 6123/2004 Type ` Pfriivate Corporation LEN GIBELY CONTRACTING CO., Leonard Gibely 149 Main Street " ' Peabody, MA 01960' = Administrator s :•t ` �le �oa„vnauueal!! �o�✓ucrcaacliva�lla t BOARD O.F BU�1.p1Na REGy1�ATIGtNS LICenSip: CQNSTRUUotfSI�I�{?€RY, In 41.23 3 04:, Tr .nQ 2Q7,19 R tr(ct`V.' .0 :1 "':LEONARDIB .I AdmfnistfatPT .....::._....L... .. C. 0 OCU r- u.L, L).L 08-11-03 A Ak On P PRODUCER THIS CERTIFICATE IF=18 ���F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.SENNOTT INSURANCE It FL THIS CERTIFICATE DOES NOT AMEND EMND"'OR 16 MAIN ST ALTER THE COVERAGE AFFORDED BY THE POLICIR BELOW. PC BOX 457 TCPSPIELD MA 01993 COMPANIES AFFORDING COVERAGE COMPANY 2946N A ROYAL INSURANCE COMPANY OF AMERICA WGURED COMPANY LEN GIBLEY CONTRACTING COMPANY INC COMPANY C COMPANY D 4� THIS IS TO CERTIFY T��i THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 16SUE0 TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY IPFECTM POUOY wwTm LTIR TYPE Of INSURMCK POLICY NUMBER DATE W"M" DATE(M"M" UMrT5 GENERAL.1.1111111011LITY GENERAL AGGREGATE 5 COMMERCIAL GENERAA.LIABILITY PRODUCTS-COMP/OP AGG. CLAIMS MADE OCCUR, PERSONAL&AOV.WJURY z OWNER'S lkCONTMCTOFrB PROT. EACH OCCURRENCE FIRE DAMAGE(Any one fire) MED.Evmg(Any OAG parson) S AUTOMONLE tLAGUM OOMOINZO GIN= ANY AUTO umir ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Fwvom) HIRED AUT0$ BODILY INJURY NON-OWNED AUTOS (PN Aeddemil PROPERTY DAMAGE QmtAae umury AUTO ONLY-EA ACCIDENT 3 ANY AUTO OTHER THAN AUTO ONLY, rllL P EACH ACCIDENT AGGREGATE OLCM LIARKM EACH O=AA5NCE S UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM WORKEWS COMMISAY1110111111 AND A ENPLOVEFr2 LIABILITY (UE-754X134-7-03) 08-03-03 08-03-04 STATUTORY LIMITS THE PROPRIETOR/ EACH ACCIDENT 8 _5MODO PARrNERarEXECVTFVE DISEASE-POLICY OMIT 3 500,000 OFr-ICF_qS A9ro. EXCL 08FAGE-EACH EMPLOYEE g SOO1000 OTHER Memo"a 44�Ng' w Evidence of Insurance 81110" AW OF THE AllOVE CWSCRWO POLIC"BE CANCELLED BEFORE THE EVIRATION GATE THEREOF, THE WW*Q COMIPANYWtU EMNAVOR TO MALL 10 DAYS ww NOTICE TO THE CLMMCATE HOLD"MIMED TO THE UIPT, BUT PAIWAa TO MAIL SUL% NO-1111CIE SHAH IMPOSE *o onucATIoN OR LIAMUTY OF ANY HIND UPON THE COMPANY.ITS AGENTS OR REPRE81INTAWM& AUTHORIZED REPREGENTATIVIE .... ....... TOTAL P.01 AIL VKLJ,� l.ttK 1 If ltoA I C ur- LIAMILI 1 Y INOU KANI-ot 01/29/2003 PRODUCER (978)887-4900 FAX (978)887-2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0• Box 457 INSURERS AFFORDING COVERAGE Topsfield, MA 01983 INSURED Len Gibely Contracting Co. , Inc. INSURER A: Western World i INSURER B: INSURER C: INSURER 0 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER DATE MMlDDII Y DATE M1 L{MITS GENISRAL LIABILITY 577724 01/29/ZO03 01/29/2004 EACH OCCURRENCE S 1,00o, X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one(Ire) S SO 00 CLAIMS MADE a OCCUR MED EXP(Any"Darvon) $ 1,00 A PERSONAL 8 ADV INJURY $ 1,000,00C GENERAL AGGREGATE S 2 000 GO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00( POLICY PRO- LOC JECT AUTOIA004LE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea 90Gdenl) ALL OWNED AtfTOS BODILY INJURY $ SCHEDULED AUTOS (Per perapn) MIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Par aWdenl) , PROPERTY DAMAGE S (Per ec6owl) GARAGE LIABILRY AUTO ONLY-EA ACCIDENT 3 ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S - 3 DEDUCTIBLE S RETENTION S 3 WORKERS COMPENSATION AND TO L{MITS ER EMPLOYERS'UABILITY • E.L.EACH ACCIDENT S E.L.DISEASE•EA EMPLOYE S EL.DISEASE-POLICY LIMIT S OTHER DC&CRIPTION OF OPE.RATIONS/LOCATION SNEHICLE$/EXCLU$IONS ADDED BY ENOORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL.INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO TME CERTIFICATE HOL. Ft NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBL13ATION OR LIABIUTY OF ANY HIND UPON THE COMPANY,IT9 AOENT9 OR REPRESENTATIVES. EVIDENCE OF INSURANCE AUTHORIZED REPRESENTATIVE / Robert Se-nnott LA ACORD 25-$(7197) ®ACORD CORPORATION 1988 Date. .. ... .. 06.:.x1 NORTH TOWN OF NORTH ANDOVER • . PERMIT FOR GAS INSTALLATION 9v h �,SSACMUSES[ f f This certifies that .�!�. . . . . . . . . . . . . _ . . . . . . . . . . . has permission for gas installation . . .1� .. . . . . . . . . . . in the buildings,of6� . . .. • . Z ate! / . . . . . . . ., North Andover, Mass. •f�U Fee . . . . . . Lic. No...l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J / GAS INSPECTOR IS. Check # 4977 ---- ---- V -- - New p Renovation p Replac ent 0 Pians Submitted; :Yes p No p r x w ti , N 0 V z N N N ¢ O a r x N 2 O r N• W m r S r7 < m W < W F- N (� S Z h- N < W -W z g S rt 0 W ¢ W W r W W .N c7 C7 LU < W > cL W Y. < Cr '< O O W a 0 N Y tC Z O O Y U. a 3 D O .1 U Y o a� Iw- O SU'u—dSMT. r BASEMENT IST FLOOR 2ND FLOOR 3RDFLOOR 4TH FLOOR STH FLOOR.. 6TH;,FLOOR 7TH FLOOR 8TH FLO0R: Ihstalling Company NameAME _44—L RIctas' PROPANE CO INC Address 2,15 Boston Street' Check one: Certificate Topsfield Ma 01983 Corporation Business Telephone 978-887-2353 ❑ Partnership ' -Firm/ Name of Licensed Plumber or,Gas Fitter D INSURANCE COVERAGE; I have a current liability insurance policy or•its'substantial equivalent whic Yes fj No U h meets the requirements of MGL Ch, 142. it you have checked yes, please indicate the type coverage by checking the appropriate box. A liablllty •insurance policy,11 r Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I'am aware that the licensee does not have the Insurance coverage required b Chapter 142 of the Mass, General Laws, and that my signature on this permrt application waives this.requirement. y Check'one: Signature of Owner or Owner's Agent 7 • . Owner[] Agent 0 I hereby cerU}y that all of the details and information I have submitted(or entered)in above application are true and accurate l04 the best"of m •knowledge and th s of work and installation;performed under the permit issue6 for this ePplication will be in compliance with all peNnent provisions of the Massachusetts,State•Gas.Code and Chaplet:142 of-the General Laws. y a T of License: Title Plumber6+gnature o censed Plumber or Gas Filter Y; asfitter City/Town M stet license Number