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HomeMy WebLinkAboutMiscellaneous - 7 FRENCH FARM ROAD 4/30/2018 (2) 7 FRENCH FARM ROAD 210/035.0-00 0000.0 /?/y / A t Date..- -../...,z:-...t HORT" TOWN OF NORTH ANDOVER - p PERMIT FOR WIRING SACMUSEt ,� Pic (\ T t C k412 7/t, This certifies that .............................................. .....................................C.... has permission to perform ........... �..5..... ... ...... ... / D.3 wiring in the building of.............. .".!.. ... .......................................... at................................�� .......................................... , orth Andover,Mass. am Fee..6 Lic.No...34.... ................... ELECTRICAL INSPECTO� 1` Check 7D `i 0764 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an ° electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be-deemed-by.the.Inspector_of-Wires abandoned_andlavalid.if he--. or she has determined that the authorized work has not comniei ned or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of wor?;shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was creaTed by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence'during the qualifying period beginning on August 15,2008 and extending"through August 15,2012. 10—Ule 8—Permit/Date Closed: / —� �- / ***Note:Reapply for new perRftf 0 Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0`7 _ BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked (Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 C 12. 0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: L /7 v1 City or Town of: NORTH ANDOVER To the Inspector ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 7 - Owner or Tenant Cf1/', ,S Telephone No. Owner's Address .5 4 m G Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building 5,.n 'G �cr+, // 041e//1n12 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:moi' otlsti f •h S/t h �� fG/,Ch Com letion o the ollowin table mav be waived by the Inspector o Wires. No.of Recessed Luminaires Z-c> No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers RVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 10 Swimming Pool Above ❑ In- ❑ o.o mergency ig mg rnd. rnd. Battery Units No.of Receptacle Outlets Z p No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches S No.of Gas Burners No.of If�Dtia Detection Dead vices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices No.of Waste Disposers l Heat Pump I Number..Tons KW.......... No.of Self-Contained Totals: Detection/Alerting Devices I No.of Dishwashers f Space/Area Heating KWLocal❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Sectio f Devim s or E uivalent No.of Water No.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No,of Devices or E uivalent Attach additional detail ifdesired,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 MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE © BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete FIRM NAME: 1 cc .'C LTC.NO.:Y O�-9 Licensee: �k:G k Q;Ccrdj Signature LIC.NO.:A 2, XID (Ifapplicable,enter`exempt"in the license number line.) Bus.Tel.No.- L 0 Address: 1`l Gsr y Sone (2.O Alt.Tel.No.: *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 Signature Telephone No. PERMIT FEE.$ _ luLECTMAir.CERLF'J_LT NO. WSPECIL.ROJ.'4 R_'u.CORT.- , _ ELEC'1[MAL INSPECTOR-, .ROCTG ,. PCTON ,. Pgssec -r +'ailed--[ ] Re-inspection requiuecf($50.00)•-X ] ?inspect s' e�tfs• 12 (Xttspecforsy Si tore_n °fiaTs) _ Pate 2.JH'aNAL X1�7S3PEC'.�'ION'; . ?gassed—[ ) Failed-[ ] ate-inspection required($50.00)--[ j Xnspectars'comments: (ffispectors'Signature•-no Wilals) Date 3.UMER GROUND WSPECTIO': X'assed—[ ] Mled--[ ) ?fie-inspection,required($60.00)-[ ] Inspectors'coxam.ents; (Inspectors'Signature-no initials) Pate 4.INSPECTION—SwirfC�`: � - DATE CA L X,P,D N•ATXONAL GRD: N'AMM:. 3'assed—[ ) X'ailed--[ ] Re-inspection xegWred($50.00)-[ ] Xnspecibrs'comments: (&Sp ectors'Signature•-io initials) Date S.INSPECTION--OMER:' Passed—r Xailed [ ]. Re-inspection required($50.00)•-[ 7 Inspectors'conoMents: '(Inspectors,Signature-no inizuals) Date D®OR TAGS ARE TO BE FILLED OUT•AND LEFT ON'SITE IF THE AREA TO 3E INSPECTED ISNOT ACCESSIBLE.AND.ARE WSPECTION OF$50.0 0 IS TO DE CHARGED. The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ` /i-ccrr'll E1Cc el-'L Address: /L/ GrcY�$�o�e D City/State/Zip: ti_S m A Phone Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with `/ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Com/'''erg S Policy#or Self-ins.Lic.#: Expiration Date: r rr Job Site Address: 7 /rch c A /'r� cu, RQ City/State/Zip: ort-4 4i CJpUt,,e_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under and penalties of perjury that the information provided above is true and correct. Signature:ature: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 producedacceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have + employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston}MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,govfdia 77 Date.. $. r. !°!-.\ a. .... .. HORTM 3? °` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION - h SSACNUSE�t This certifies that . 9 .. . . . . . . . . . . . . . . . . . has permission for gas installation .6.kl,.5. . .k?.,.p ti:t(; . . . . . . . . . . in the buildings of . . . . 1 t .c. �. . . . . . . . . . . . . . at . ..7. . ids A t . .. !1`�' l . . . . . .. North Andover, Mass. Fee.`?O .yJ. . Lic. No.!- ''.f.©?.?. . . . . . . . . . GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: AV 4nl4I~pr- /77-4- , MA. Date: �5-/� _ Permit# jj Building Location: F-1y Ick 1,-4,44 � Owners Name:���� XC,/j" Typeof Oc panty: Commercial F-1Educational E] Industrial El Institutional ❑ Residential New: Alteration: Q Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES N 6 Lu W c Z F- N U = m 2 LU w v W H O = W 0 w z1-- z w w w O F- n O Lu m 0 ~ w O a f' > CO MULZ h- Q w > U W Q ur J W Z N = co FO fn 2 Z W. Z U O O C7 O = = m > O z O w Z z W a H O a > > > O SUB BSMT. BASEMENT 1 FLOOR 2 NUFLOOR -3'FLOOR 4 FLOOR 51HFLOOR 6TH FLOOR 7Tr FLOOR 8 FLOOR Installing Company Name: Check a Only Certificate# S r' Corporation Address: Town: / , lC/ State:�/!� C4-'?-0 M C41 G1 ❑Partnership Business Tel:9'7tK- I Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: �i,«� 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 indi a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent E] By checking this box❑;1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑Plumber Title o� ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter ❑Master City/Town ElJourneyman License Number: APPROVED OFFICE USE ONLY 0 LP Installer Date.:-*/7/.. .. . . . ... .. WORTH OF 11'O TOWN OF NORTH ANDOVER O ...;. D • PERMIT FOR GAS INSTALLATION y,SSACMU5EtS r This certifies that . .f1cl. . .`O! '. . . . . 1 has permission for gas installation in the buildings of � 9 �. . . . /P�!C<f G'rl?s at . . . .� .�. . . .� . .�. . . :, N rth Andover, Mass. ` 1 f Fee S4.,.qq. . Lic. No. GAS INSPECTOR Check# oy 9097 ti T MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:.P- 144dat/-o✓ MA. Datej ` /' —r ?'-�Permit# Building Location:_ Fle n(A Aalvk Owners Name: G.. , mo Type of Oc upancy: Commercial El Educational[I Industrial El Institutional El Residential New: Alteration: ❑ Renovation: lacement• Re ❑ p .❑ Plans Submitted: Yes❑ No❑ FIXTURES - - - - - - - - - -W - z Lu Cd j. Lu o Z F OF 0 J >- W z U) Q W RW' � 4 o W COW g o I- = WW O a � W m o 0 W 1- Q W W W (n = W O W Z W Q.' Q' Z W W Z O J t- 1-- O z -j 0 u- = w l- w W mOZO W a FV � < E = Z Z 5 O a t- > > > O % SUB BSMT. BASEMENT 1'5'-FLOOR r 2Nu FLOOR 3 FLOOR 4 FLOOR 5 FLOOR j—FLOOR ' 7 FLOOR 8 FLOOR InstallingCompany Name: F'9' MCA,+rG,96 n fGhAV) 6C)) Check One Only Certificate# '1 -el A�� I` /20 / (�,.� � ) A Corporation Address:�t l City/Tow • / /U State: El Partnership Business Tel:�0� 7�� Tlso S Fax: pfee'm/Company Name of Licensed Plumber/Gas Fitter: 7INSURANCE COVERAGE: nt Iiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes�j Wo❑ecked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 Signature of Owner or Owner's A ent Owner El Agent El By checking this box❑;1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertin nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. B L _ .�Za Type of License: By Z- ❑Plumber Title ❑Gas Fitter ignature of Licensed Plumber/Gas Fitter ElMaster City/Town ourneyman License Number: APPROVED 0 1 E USE NLYP Installer , ±t2 C4 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, ALL 02m www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A rm licant Infoation � ' Please Print Le ibl Name(Business/Organization/Individual): - Address: City/State/Zip:f 1x r� DPhone#: Are you an employer?Check the appropriate box: [2. ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required):'e ployees(full and/or part-time).*' have hired the sub-contractors 6 ❑New construction 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. [No workers'comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions Myself [No workers'comp. c. 152,§IN,and we have no 12. Roof repairs insurance required.]t employdes- [No workers' comp.insurance required.] 13.❑Other *f-ny a_pficant tilt chh-e s bo.=.�1 must also fill ont the section b low sho i--. _. _ t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Conhactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce uthe in nd pe Ifies of perjury that the information provided above is true and correct Sienature: Date.: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitfLicense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone M 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 parson 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 houseor on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,'§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(S)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with.no employees other than the members or partners,,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should be returned to the city or town that the application- for the pe-- nr rc nse l emg a• t f p .�.:3it�--1' e_ i_.b . re y.rest;.a,nsz..ne I3=amen..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/liceme applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to burnleaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r 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 Invesfigat:iions 6.00 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-8.77 MA S.SAF'E Revised 5-26-05 Fax#617-72.7-7749 www.rmss..gov/dia 9 /J 4. Date.4A112-. . NORTM TOWN OF NORTH ANDOVER '• O PERMIT FOR PLUMBING ,SSACMUS� , This certifies that . . ././!C�`r /NQ� has permission to perform . . 5'h�r. .! .S / . !. . . . . . . . . . . plumbing in the buildings of . .!.?w(' �. . . . . . . . . . . . . . . . . . . . . . at . . .! . . . . . . . . . . . . . . . ... . . , Nptth Andover, Mass. Fee. �G.00.Lic. .. . �! ?'. . . . . . . . PLUMBING INSPECTOR Check # J400 ASSACHUSETTS UNIFORM APPLICATION FOR A PIERMIT TO PERIFORM PLUMBING WORK CITY n y AjV VG+lMA DATE 3 PERMIT# JOBSITEADDRESS 7 rrel^rh �u✓,�r�n � OWNER`SNAMEJ C„ /�yli$y OWNER ADDRESS{ F✓� ik I TEL IFAXI I TYPIC OR OCCUPANCY E COMMERCIAL , EDUCATIONAL I RESIDENTIAL 16 PRINT CLEARLY NEW;I RENOVATIQN:I I k0LACEMENT:I ( PLANS SUBMITTED: YES I I NO.I } FIXTURES-1 FLOOR- BSM 1 2 3 4 5 G 7 a 9 10- 11 12 13 14 BATHTUB _ .. .-. l CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM -I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM w. ......... DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSERFLOORIAi . — � REA DRAIN i INTERCEPTOR(INTERIOR) �� I KITCHEN SINK LAVATORY ROOF DRAIN , SHOWER STALL SERVICEIMOPSINi( TOILET — -- -— URINAL -- - ..__1....... WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING — -- —-- ..OTHER U v INSURANCE COVERAGE: _-- 1haveactirrOnt-liabilfty iisliralice policy.or its sulistantial equivalent which meets the regoirettients of MGL Cit.142. YES(t-r"N0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECi(ING THE APPIZOPRIATEBOX BELOW L!ABILITYINSURANCEPOUCYJ I OTHER TYPE OF INDEMNITY I ( BOND(• i OWNER'S INSURANCE:WAIVER;I am aware that the licensee.tloes not have iheTnsurance coverage required by Chapter142 of the Massachusetts GeneralLaws,and that my signature on this pertiiit application waives this regttireitient. CHECK-ONEONLY:. OWNER I ; AGENT- -I SIONA7URE bF OWNER OR AGENT 1 hereby certify that all of the details and information I have subinflled of entered regarding;lhis application ate true and accurate to the best of my knovrlddge and that all plumbing work and Installations perfomied under the permit issued for this application Will be in con lime vrilh ertin t p' vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I PLUMBER'S NAME iGhut'U �l '� LICENSE# c`�F>� i SIGNATURE MP( I JP I LI/ CORPORATION) III' 1PARTNERSHIP'l Jill' LLC I- In ! COMPANY NAME{ �� rk 1� J ADDRESS I)j rn M-4*1 a CITY SFS) STATE �7 ZIP 3�I`oS TEL( � 3 766 S� FAXCELLV/7335�31� EMAIL f i 7RO UCH..PLUINOINOINSPr,,CTION*NOTE,& nELOW FOR O . � CE, IUSL:ONLY TTNAL!NSPE,CTION NOTE,S Yafi No 3 Z� THIS APPLICATICK S cl` VES AS THE PER IT4 ra FEE: PERMIT 9 PLATvT -ZVMW,NOZICS T ' r i � r F t - 1'Ir�C'pJy?tl,{nij[Ue{f(lIl fi,�lYl`is�,tlCltlfstti�lls �., ,D�li�it'luteiifr►�`XtrtT rsfittrl.•�lccf�l+rirts ..rr � ic�'o,j`l�ilir�sfig�liarrs aII.�Yftsltlyglait�SYt��a! � I 1ps`lott;MA 02-U.1 �y:� �Ni(rllItrlfsrSoif(irt lkrcrl iitt,re 1![1C115fd(RtIII t� ttirnt cc 4 �itlil}'i� Kiri(itc slL"oti in to sly»le #►I'c�lt[s!'uili��}eli `pllliertiil�)fil€or-ittlititiit . .<. l�lttliei•:Ilrtsuucef<'Ur�►tR`i�itien/ltlitiridual}� d 11• ✓ (�I}•YI Y j ccliressc '" 4c�ts[icef �iw. - ���� �! itiuttg � 3 3 787•.•�J... 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' tL\v'rs;(ci;�liu[ctt:.•ttitfiuL+lartthl'daatt:$tn 11 LE�tilt0�1t S1ail5rta{CiO�lli niTill`r;flip$(ill-rt4[lOt�ltit;fY.EIt[at lCi+lr.ClS`[a>.Ya1 l!i�IiirtltfiaflliVid7G • !'tirrfarieuiplvi�c�rllc(rllrjfel!T(liugn�nrfc'rs'cniifrcrrrsnlinirlrtsrrrartcc r/tirr'ir fvl'ec�s.J3efou�trrlrclrvltci�nrt(fJ�Gslfe°u�`. li�arirtarlart. - I,nsltraltce:Cong?au���iuil�� ho]icj�lFtorS'eJfitrs Lie,Il:: _ >uxJiitilti►itt�i;te,: - . . _ I dpbSit��c�cTrc3s;• ... ��ir�ISlaEclZij)�, /litnetltlCo,llk_ro['(liatroiels'cou�ie►i5t[ioiiiib]i�t��icgtiun[olrltttgt=�sJtt?iLltt [Titstloi[cS�ttigitTtetitttJct�lllTiaicitt�Ce). T<zi[ttrc[�sas<ur.ldt'cillgeiistetlult(duni[elSect[oti251101Mt3i, ,l52crinLeadtoUteiitiposiiiallpPCrjiiiitiRtUcRRftie Ara hits ult[o:S1,SQp.ll4aitdfoioric}'eariulprisoninenl�listicl[[is ctrripetiail Les.iniliefortltoELLSTOP" @QRt OIEEIR[tzint afitl tiful3(05254.4pR'daS+t ,7�iisE(IiFvioCa(os. lactrdt<iscitIhafiwopyaF(hls.statemalit ivaybefondar&4to11mofficeof { —- Jureslig(l7ions,of DIA for itlsumt_iceCoverage►etification: - j XitTglrercrt,}:eer �trr lc rlreltn r. rrrtjre '.rFe? )rerJrtr[Iffialr!=iL(m�rtt�FoleprbrliTfrtniat lsli irticdr.��c! �le(IiittfrC;' �6 �� • afrit:tir`�crwacrt,Jho[mtlilir'r[:frrlirlsrrrc>rr,tobiscarrijitelcitQl•cl��or[ati�rrbjjtcTril. Ciry dI-To iijk.,: 1'et iiilf(L{c�iise tf ts�liirigliii(tiorif*t:(cit•�ieoilc}; ' 1.)3Uaraorf-joII6 2.R(tilt[ingDciEticfillwd 3.Gifj1frolviiCfe lc .Lr[gc(ttc(ilTusjlec(oi` -1'lttttlLfngins�ie foie �G.Qtllet� �iili�il:l�'ci•�u{t:: �'Jioli�IF: s fi�asSsteltuSEfts".Generr�Lltt><s pTiapfe:X52 3ecytiites ttlieu,p)agers�oalto�t�ideit'ur�et'�'cciit,�i�i,s�.toiy fo>`tlle3r ompTn��ees; Pcti"stia,tt fofnisstafilte_:an eri�roy��is ie�iledas.`;.,e'veiypersoitti><ille�ercica o€oi,.otltcrta$erpp�tcontragto£Itite-,, etuie�orit,iplied,.pmlpi�ttzitfeitk - : . �W:ctU�I03esistlti�ilte$as"�ginilivitiiE'eel,paitite,sliipy,a�s��lateoh;cpXp�r��ibnpoEher�}.e��tet�titygotranyittka�DZiiiorz - o.St�t�fo>�goingeugagetli„ia;�oinf et,feiptise,ai,:t�iu�licding�[be:Teg�i i�przscutatitres':bFa ileceasecTenipfo}�e,;orlTze •�eoeiztf;fort'ittste�afeuutcliF�idt,ai,1►art,tersLl�s,as�eciatibn:ol•outer:leg<'filen(i[y;�i>jpkoy,�u, ,cmpIQyees Hoi�eYexfHe oune�b1 tt�Itt�e)tii,g lioiise l,aviFtg uoti,ibrz tliau tlireapaifine,tls:aud SY)io rsiclesllierei»;:ol the occupant oftite tlisel(ivgltottseoEa'tioflier �Itoeinplop etsonsta.'tltr•,mbifanalice,coi.stiticti6ltof°�epair'KY01;:01iSUc7tCitie)liugIioifs ifpl,:tlt�grotnt(isoGnitdingl,pucienanttitereto<sfiallh,otUeeauSe+ofsuclt.eitiaioyntentbad a»tetl`tbbeuentplo}ger:'° Zt.GLclla cr152;° .5G 6 aisostntestI,al`•`esoi laf';i[esu oes,l�icensf»gngaitci�sSlaltiQitltiioltttltejssgiuteeor gitet?l al st.lfceals bl lir-rtuit to ope.>:atea Gtisiltesso Eo:constt iicE buildings in file r011111foitnealth lbi-sttty ;rlpplicailf -11 astiotprotlucedaccepfnbleevMd liceofeaniplin11MIUVitftthia'his tiitiuc pokci4�get:equlrecl' Additiolially,l�Gl:etl ]fed51:2;§256(7)states"1`]eitllerlitecomntotttYeaItllnarady�ofitspaliticalsubtliyision$s atl 400 ultb any contract dor titeperfomlattce ofpttbl fig iYorT;ilat)1 acceti[abTeeviilence ofgotnpliauce-tYiili t1iF insurance t:e.�itiretnenfs ofttis cl,apte�ltaYai�se,tpreszuteclto ttieeolitractingPutltor)ty;" Rleaseftl[otlf�ltyivotlt�r':eatll),eits3fiorr�Tfic1'et+itt6ni Ietolo p�E.bttecUttgi}te},a�estl,afa y � y�I •bllrSl;tiatl0111tT,if y ttecess�t� suppl}�stti,contraclor(s}�,glue(s),a8ttiess(es)ottdpltoltenulltbei'(s}along�t ith iheu cec#'iticaletrs�p'3' • instlraltcc-,Li»lited�iaUififyCotnpaitie's(IiT;C)orLimEfcdLiabi[itj!Pfttiiieisllips(LLP}i4ifltt,aetri�i#oyersotl,et#)i�,r:iite :life-titters oi•parhters;�lrettof xeouiredfo catiy!tiYorkess`co,l,pcnsation insurarice. Ifati•LLG or LLP does Jtat�e :einlitayeas,apolicyr is required.•8 .�'td►ised thai Phis iiffitlat�if uiay be siibn,itteti to the I?ep<�rfnient of Ind»strlal �ecidenfsforconfin„afiottofitlstttance ovePage. Isafiiesltrefosigtts,llcldntetlte;tftitlatjit< The riftidavitshoul_d beret”r(le(itotltacityOrtOWn,11,afthe appIfeaf o»for the pe,utifarlicenseisbeingrequested,not fheDepariniet!`saf 1'ndmlilvialAceidelifS. SliOitt(iyoUJI'on1w,queslibils11��1i1,;•t1f6I1iY60fy01iare reqniNdtwobfahintivorkcrs' ulIipeli ttionpulicy;pleasecall ti,ep i9attine i:ritt[tenu»tber isteclbelotF. 5G3f-Ilfsnroitwll,pztiies )touiclenferti,eir tieff-i,is»fancelicensenumberm tllenpptoprialeline Clf or Toltii dificiais - I'le(lseb s'ttretltattheattPiiat*it is conj�lef6Atuipri,ite legibly. '-Tfie p�tft,ieittl,asprottiaetla.;lizrpn tl,�Goitotit oEttie,2fticlavit foe}�ofe tti f t!brim tlt"wif theOflicobf flivestigations bas to coufnc[ynuregai-�in"ihe•applicaa, Please-besur@tofillinthepenniit!liceusirmnnberiYlticiltY)II.be.ttsedase-;refereuc aitutlber.Inadc#ilial,anstpp)ic��ut tClafmust:stlb,hittitilltipIe-pemllJticense hppl%catio,is'in any*giS�ei,year, tee;lona}`sttUn,it one affdaYlf iadicafingcu>rent �; }ialicyrinfon,,ation{if=necessary)zttt{rLtc�er".Tolisite-�ddrzss"titeapplicatit'shotti(l�vrite`!aiflocafionslu (ciEy�o1 j UI)I}!'A cppy o€lite afhdat'it thaCTiasbeen officialrys[an,pede-f n,alkett by the cityF o:fort uiay Ueprot idccl to the- aliplicanfasproaflbat:attaliclattidai�itisd,i rfCle:for�iE[urepermifsorlicenses.%}.rietY.tiftidatitmusFt,efille<toute,�eT� t ye4r Wiere•alioaleotYrlera cifize,tisobtaiii,nz;ttlicenseoi:perniitnotrelatetlfoanj�bus,tessorcoliimercialYentuce F (f:e_a<Tog.license or.'pern,itfa barn hates efc)sant gersottis I3QTrz(luirad to coniplefefllis aFfidl«t. , _ __ .... . -r;t*<C1' .tCeofItiSietEl$afionss�,'ot1Yi1]i�efo#1ta[[�`yottinfttltrancet'dey'otipdG��r�i�git�itcts#ioll`[ci5�ote.l,ai!i;�ii}o�tiestiotts, • �I�ilsedo.notltcsifafetagivatisttcpli: - . . �'itc Dgl,at#i;te,lt'saddress,tele,jtl,o,teatt('i fas ittintTiz� .. .. . .. { The,Conitxtttl} �fl>; �\ ss2�utse#s _ .D6ifarftiielit Offs iclltstii41 Awfldwits j Off-tee pffliv dg% ( ow 600-Wasliitigtbli Sffeot ,Bos€011,AIA.0111:1 1 'hex.0617 7274POU e8€. l(t6 0�'1-$77 I�IASSAI�� Fi191t 6N,727'47749 �tRt�Ic.i�tassgo��,`clio APR-18-2012 12 :56 PM LARRY OGDEN 978 352 2858 P. 01 -" XNCE H.OGDEN,F.E. z" EAST MAIN STREET GEORGETOWN,MM-% 978-34241318 fax 979 cell:978- 5921 April l b,2012 Mr.Kevin Murphy 169 Boxford Street North Andover,Ma 0 RE. Naim R i ,7 French Farm Rmd,N Andover,Ma. 01845 Dear Mr.Murphy Pis yon 1 I��= �x site to review the installation of the Engineered � .. —ate r-. ..!..- -r..t-- -t=- -- •--• Matefiek i�aE1°g Ar r[iq s.Blewi : [!Y shown on Il �,sr—. -a�sTs.so,. sF.l..;�:�iF�`� �;f i zt 1� �`£t.�q.►,�} t � xS:�4�i« 11/22/2011. As we discussed the LVL Bewmm d he--�� : oZv!n;E.-P-a s�owir of-Ott tet— - �. drSw�ttgs_Also thG,�tll�: •�:_. _;�--__H _t_ �* :rL ._ts x __'T�;I ,a,��!>.;a=•�•���; aw•n /�yq�u�y. M. gL Based on the above site visit and base_cm- wh- 1 c vise", see: pr vid: 't' LS .[�;glf Ittiv P xr�f5 tit: tat�_. iL_ L i i .3 ,.x :::..: i3t i)i 121y LILUWLU LIYG 1 LVID t*-„"` -�. -s� ?? p -;yza 3= 1 ;„-J?, �_ yasvir�3 on the drawings are{lns%W-r-� _#t{�lw�s R s€t 5�#€#��"'itimis t rth �I+ .=ln Stat AV o0w l” gv rpir=ts ofthe ejnw!W and oxL-,including but not limited to n%W-64tw;!f U+ ;o'er bWf ii "N104 € s fl mponsildity c--^1L SWd you have Imy questions please do not hesitate to call. Yours truly, f Date. .' / Z. ..... . HOFTM pf Sao ,e 1'YO f o ` O� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACMUSES R This certifies that . . . .. . . . ul� � has permission for gas installation . 1 �' . . �� . . . . . . . IAI in the buildings of ./ . a '� . . . . . . . . . . . . . . . . . . . . . . . . . ',/5Pv C' r rr� at Nort�lr/"Aver' ass. Fee 4�'4�. . Lic. No.Zo3.O`'. . i�.i v'. . !! ✓! .! . . . GAS INSPECTOR Check# - Z� X164 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ,�' _ MA DATEW S 1J PERMIT# JOBSITE ADDRESS �"�1��-� 4K OWNER'S NAME GOWNER ADDRESS TYPE OR OCCUPA%NOVATION: PE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: __. ❑J REPLACEMENT:El PLANS SUBMITTED: YES F-11 NO0 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVEI DIRECT VENT HEATER [ .( DRYER FIREPLACE �.--- FRYOLATOR I FURNACE _ GENERATOR (,—. J ! GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER F — -- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Vd0 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY E] 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 E-11 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compf cflrwit all P i e vis' n of t Massachusetts State Plumbing Code and Chapter�1-4-2.of the General Laws. PLUMBER-GASFITTER NAMLICENSE# SIGNATURE MPI MGF��I JP _..1 JGFQ LPGI 0( CORPORATION _(�_J# PARTNERSHIP # 1 LLC D# COMPANY NAME: ,`� 1 ADDRESS� �Y►���' GJ� � CITY 11 STATE ZIP ]TELLT� � ) FAX CELL .,/7j 3s/ MAIL p ��. %Z' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES No THIS APPLICATION SERVES AS THE PERMIT ❑ [� FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MM 02III kv www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibI Name(Business/Organization/Individual): - Address: City/State/Zip;f ��S)�L,� 1 )r phone M Are you an employer?Check the appropriate boxy 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required):' CD ogees(full and/orpart-time).V have hired the sub-contractors 6 ❑New construction am a sole proprietor or partner- listed on the attached sheet. 1[7. ❑Remodeling Vship and have no employees These sub_contractors have 8. ❑Demolition working for me in any capacity. workerscomp,insurance. [No workers'comp.insurance 5. 9. EJ Building addition p ❑ We area 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-El Roof repairs insurance required.]t employees. [No workers' comp.insurance required.) 13.❑Other EYuLican:that check-box im1 m+si also BEout fhe section b lots:ho:*, YR=;e b -ii wo j v coWyr sation pot;cy infom afica. Y Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this•statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ido hereby ce unFder t pains arf i ' oferiuty that the information provided above is true and correct Si re: Date: Phone#: ` � r�� ;/ 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express 6r implied,oral or written." An employer is defined as"'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 employers or the receiver or trustee of an individual,pazlnership,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 6r 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than time 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 thrt the ap p hca on fjr the p e: to_r'hcez�;r is being reques+ed,nut 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 ofInvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations wouldlike to thank you in advance f6r your cooperation and should you have any questions, please do nbt-hesitate to give us a call. The Department's address,telephone and fax number. The Commonw calth of Massachusetts Department Of Industrial Accidents Office of Inv'estibations 600 Washington Street Boston,MA.02111 Tel. #617-72.7-4900 ext 406 or 1-8.77-MASSA-FE Fax#6.17-72.7-7749 Revised 5-26-05 ,_, Date../���? /..��....... WORTH 3?Oya�..ao ,e•,SGL TOWN OF NORTH ANDOVER O •; F PERMIT FOR GAS INSTALLATION gnu.•�`th �,SSACNUSEt This certifies that . . . . . . . . . . . . . . . . ti has permission for gas installation ��.J. . . . . in the lbuildings of/ .. . . . at . . . ... . ./.�''�ry. /.`'!! . . . . . , Nort Andover, Mass. Fee. .�oV Lic. No./0/9 . . . . /ll,�L. /����: . . . . . GAS NSPECT0 Check# 4?113 7855 � R r ...d. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: MA. Date: Wz Permit# Building Location: �1' I Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: Alteration:❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES W W to M = O W w L) cn 0_ a) W (9 J ~ O W W Z z Z O W W O F- fA V W W O O W to O 2 U W Q 0 J W Z U) = W ~ Z W Z >- to =� Q Q m W O z 0 0 ~ > Z F. _ SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 6 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name- l U Check One Only Certificate# /,. ❑Corporation Address 1�� ✓/Town• State:A& r pp Business Tel: Fax: -92 El Partnership ��4—, '� ❑Firm/Company Name of Licensed Plumber/Gas Fitter: S/kAwbi INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes o❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy E� Other type of indemnity ElBond ❑ 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 Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the est of my Knowledge and that all plumbing work and installations ormed and he permit issue s application will be in comp'ance wit 11 Perti ent provision of the Massachusetts state PI Ing Cod an Chapter 1 2 r f the Gofieral aws. By L Type of License: ❑Plumber Title ❑Gas Fitter Signature of License um er/Gas Fitte ❑Master City/Town OJourneyman APPROVED OFFICE USE ONLY ❑LP Installer License Number:IAQ� COMMONWEALTH OF MASSACHUSETTS IN PLUMBERS AND GASFITTERS LICENSEps6A-ANLWNW INSTALLER DAVID R SIMARD � 54 SWEfTHILL ROAD PLA.ISTOW NH 03865-2352 • � j , ,.v y r COMMONWEALTH OF MASSACHUSETTS ' f • • i • • .,r-s'• IN PLUMBERS AND GASFITTERS LICENSEg -A F9 L�?NgA§ INSTALLER DAVID R SIMARD 54 SWEETHILL ROAD P.LAISTOW NH 03865-23.52 p 10/24/2011 11:30 19785212751 ANTHONY&MALCOLM INS PAGE 01/02 DATE(MMfut" YY) CERTIFICATE OF LIABILITY INSURANCE 10/24/2011 "OCR (978)373-S623 FAX (978)521-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HOMY & MALCOLM INSURANCE AGCY., INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 S0. CENTRAL ST, HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BRADFORD, MA 01835 INSURERS AFFORDING COVERAGE NAIL 4 INSURED Simard Furniture Inc d/b/a INSURER/, Penn-America Insurance Simard Gas & Oil INSURER R; 53 Florence Ave. INSURER C: Haverhill, MA 01832 INSURER D: 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 CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IHSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY PAC6913499 09/01/2011 09/01/2012 EACHOCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50.000 CLAIMS MADE [E l OCCUR MED EXP(Any ono pnrson) $ 51,000 A X PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $ 11000,000 POLICY PRO• 1.00 JE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea eccldenl) $ ALL OWNED AUTOS BODILY IN.IURY SCHEDULED AUTOS (Per Derson) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per ocddpnl) PROPERTY DAMAGE $ (Por o=ider l) OARApp LIABILITY AUTO ONLY.EA ACCIDENT S ANY AUTO OTHER THAN EA ACC a AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE OCCUR Q CLAIMS MADE AGGREGATE ._ $ a OEDUCTIAI.E $ RETENTION S S WORKERS COMPENSATION AND WC STALIMTU• OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIFXECUTIVE E.L.EACH ACCIDENT 5 OFFICERIMEMBER EXCLUAEO? E.L.DISEASE-EA EMPLOYEE $ If yes,desoribe under SPECIAL PROVISIONS bolow F,L,DISEASE•POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS SAS & PROPANE CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of No. Andover 10 DAYS WRITTEN NOTICETOTHE CERTIFICATE MOLDER NAMED TO THE LEFT, Attn. Rick BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1600 Osgood St. OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. No. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Frederick Malcolm ]r. 7A �. ACORD 25(2001!08) FAX: (978)688-9542 AACORD CORPORATION 1988 Date. .... .. NORTq Oft o� TOWN OF NORTH ANDOVER . � PERMIT FOR GAS INSTALLATION Io �,SSACHUSEt C This certifies that . �G�.1�. . .L)�. s . . . . . . . . . . . . . has permission for gas installation .4014. 1�. . . . . . . . . . . . . . in the buildin of . . . . . . . . . In.61A4,- .. . . . . . . . . . . . . . . . . . . at . . . . .fi !u. . . J ALIM . . ., North nd ver, Mass. Fee J� . . . . . Lic. No. ^./. . ,/ •F� ` . . GAS INSPECTQ0,11 Check# F� y NLASSACHliSEITS LINUORM APPLICATON FOR PERINIlT TO DO GAS FTMNG (Type or print) Date �j2 ;,2r)- NORTH ANDOVER,MASSACHUSETTS Buildinz Locations I rl-e/t Permit# knmunt$ Owner's Name New❑ Renovation ❑ Replacement 91 Plans Submitted ❑ U w H F,,, a z z 0 a a u O a a E~ H z H ¢ �� c W w H A F x aW a rA° z c z o H O .4 U a > A a H C SUB -BASEi�i ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4T II . FLOOR 5TH . FLOOR 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR (Print or t e � �r / Check one: Certi Name r' ficate Installing Company Corp. � Address f / Z Partner. Business Te ephone Firm/Co. Name of Licensed Plumber or Gas Fitters v INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No If you have checked Y(--,s,please' cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 1:3 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the :Mass. General Laws,and that my signature on this permit application waives this requirement. Check Signature of Owner or Owner's Agent Owne Agent I hereby certify that all of the details and information I havesubn, ("or cnt °d)in above application are true and accurate to the, hest of m� knowled-e and that all plumbing work and instal lati( ,hcrfnrn : anile(Permit Issued for this application will be in compliance with all pertinent provisions of the Nlassachusctt•, to Gas .ode and Cha iter 142 of the Gencral Laws. By; A ",nature of Licensed Plumber Or Oas Fitter Title Plumber City/Town ❑ Gas Fitter [cense N1.77'r �'Iaster APPROVED(OFFICE USE ONLY) 0 Journeyman .; The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 M 5. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: � ! Phone Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors t am a sole proprietor or partner- listed on the attached sheet. * 7. F] 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 1 l`Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must 6ubmit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy #or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A 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 a the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the A f insurance coverage verification. I do hereby cer I un r the pains and penalties of perjury that the information provided above is true and correct. Si nature: G 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#: rJ Date i °f No°T.�"c TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING a r a � • • o a ,SSACMUS� This certifies that . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . !(.. .ter . . . . . . . . . . . . . . . . . . plumbing in the buildings of . 'iff�� eiZ . . . . . . . . . . . . . . . . . . . . at . 7 . ,f-,iovh . Frv.! ✓ItI . . . . . . . . . ., North Andover, Mass. // PLUMBING I �PECTOR Check # 11S � 4 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Clty/Town: ;/� _V/0 /� 4� MA. DatePermit# Building Location: 1 &-Ikll yJj�2� Owners NameA Type of Occupancy. Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential 5< New.❑ Alteration:❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES a DEDICATED LU Z SYSTEMS W Z U z a rr z F- Q y U F w ❑ ❑ Q Q W ED O m y , a ,n F w H p z d d tr w ❑ LL Q ❑ Q Z z v'ni ° X N w F- O w p ❑ w w Z a ri z . Q Q W U ¢ _. a ou z a w N a a m m o o _ ~ o gEn 0 Z a a a z d a 'SUB BSMT. 0Qt� BASEMENT 1sT FLOOR 2ND FLOOR d 3RD FLOOR 4T"FLOOR 5T"FLOOR 6'FLOOR 7'FLOOR 8T"FLOOR la1Si ?Il'tii�r�jii <.11 r.3I71i?`G�!!7A/ ,c.0 C=rt3 Addresso- c", v� ElCorporation City/Town: h State: A/fQ Business Tel:97���� � El Partnership Fax: ❑ Name of Licensed Plumber: Firm/Company INSURANCE COVERAGE: I have a current lia- b�lity 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 below. A liability insurance policy Other type of indemnify ❑ 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 Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered Knowledge and that all pl��mbing ork and installations performed under the p ,it' suedf or tfiis application will be in compliance with all r Pero ent ovi ion of the ssa usetts State Plumbing Code and Chapter 2 0° he General Laws. accurate to the best o,my 3y Type of License: 'itle lumber ature of Licensed Plumber Ry/Town Master PPROVED(OFFICE USE ONLY) ❑Journeyman License Number: l b The Commonwealth ofMassachusetts Department of lndustrial Accidents Office of Investigationg 600 Washington Street s� Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors[Electricians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/Individual): Address: sl� City/State/Zip: Li6 - ���3� phone# ��G Erequired.] an employer?Check the appropriate box: a em to er with 4, Type of project(required): p Y ❑ Iam a general contractor and Iloyees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling and have no employees These sub-contractors haveing forme in any capacity, workers'comp.insurance. 8' ❑Demolition orkers'comp.insurance 5. ❑ We are a corporation and its9 ❑Building addition red.] .officers have exercised their 10.❑EIectrical repairs or additions a homeowner doing all work right of exemption per MGL 111 Plumbing repairs or additions lf. [No workers' comp. c. 152,§1(4),and we have no ance re uired. 12.[]Roofrepairs q ] t employees.[No workers comp,insurance required.] 13.❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 tlae policy and 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 required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to$25e��ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigationfor insurance coverage verification. 7doireby he ains and enalties o P P fperjury that the informationNovided above is true and correct. r Date: ?'hone#: 2 Offrcial 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 CIerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: ' Phone#: 4 • ` t 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 apartinents 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 nny 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 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),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy.;please call the Depaiiment at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been'officially stamped or marked by the city or town,may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 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 Can-unonmal1di oJ.Iqassachnsetts Deparbnent of ladustriall Accidents Office of Investigations _ 600 Washington Street Boston}.MA,02111 TO.#617-727-4900 ext 4406 or 1.-877-MA.SSAFE Revised 5-26-05 Fax# 617"727-7749 www.mass.gov0a G' Date.... .............. ......1.../..........G...... f 40RTH, 3?°.<e`` "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS�CHU This certifies that .......:.`.C `.. : ....................... .................................................... has permission to perform .... r/...: . l wiring in the building of... ..., . .............J '" r ...............................n............�........ at............................................................................... .North Andover,Mass. 01{ dee Lic.No. / i ELECTRICALINSPECTOR ' 7 Check # �� ,. IV DEPAR MSYTOPPUBUC94FEIT permit No. Ao' BAARD0FF/REPREVF11t11gNRBlZWM527(11R12v MPM ked Fees Chec APPUCAHONFOR PERMITTO PERFORM CTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS CODE,527 CMA 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street 3 Number) rpl ly? Owner or Tenant 1y7/G Owner's Address .�i ^—e. is this permit in conjunction with a building permit: Yes[:I No a (Check Appropriate Bos) Purpose of Building 35 za Z rpt g /���o C,A�P II7��,� ��?� iyi� S'ei,•t Yo a r•^ Utility Authorizatioo n No. Existing Service ?-0. � Amps o/Z Volts Overhead Underground © No.of Meters New Service Amps Volts Overhead M Underground C3 No.of Meters Number of Feeders and Ampecity Location and Nature of Proposed Electrical Work Na of Lighting Outlets Na of Hot Tube No.Of Tmuibnners Total KVA Na Of Ughtby Fixtures /Cl? Swimndng Pool. Above Below Genershn KVA BMW 171 r I No.of Receptacle Outlets No.of Oil Buenas No.of Emergency Lighting Bsitery Units Na of Switch Outlets No.of On Burners No.of Ranges Na of Air Conti. Told FBtE ALARMS No.of Zones Tons No.of Disposals Na of Hast Total TOW No.of Dabcdoo anti Panys Torts KW InitiMias Dem No.of Dishwahars Spsrx Area Hesting Kw Na of Sounding Devices Na Of Self Cgasined No.of Dryon Heating Devices KW DeroctiarJ3aonding Locel Mmicipel � Ott connections s Waw No.of Heston Kw Na d Na of sizo@ ailssis f, No.Hydro Maasge Tube No.of Moun Total HP CYi'HER• IrntrarneCbMW Plm®metbbemac}irnremkafMe�dsmaell.Ga®1Ltmws IhMaamWLi*ftJiii=vF WiFAft ormbs�rnilequiva>ermt 1+fi4 NO IhsrezhA&dv&pmoafofstmerobean YM ayuulntedmeaedYMpkwi1' *gme%rcfwmwVby Er =4D O am 0 rgm** WakcbStat �S D k� D*Rq RaoE' dVal>cafHectdcslWaidr$ 9SWundir Pbleftc(p*W FitMM?Al LiaeeNa tigress ��nom/ �e,4!/i?�f S'gf,dise LiatmfeeNo eg 24�9D 7 AtT11% C1WI�R'SIIVSCJRAI�XEWANFR;Ia�nswaeilatlhel�ireh�Qteiraaaneoo�aag~ar�stibe0aridacliivalar{aamecpiedbl'Mas�clrms�GmaalLaute arddtetrrrysiBtelseondiepertitappfc�imwait�sligraquimat (Please check one) Owner � Agent Telephone No, PERM FEE S DEAInMFM'OMMESAFM 60 10 BOARDOFF2EPREVFN/I�ODVRFXiUl.4Til0U 5M7(11�e a* �"'�c No. • �paM 3 Fees Checked nummummmmmaw APIOUCA71ONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK To BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRDff IN INK OR TYPE ALL INFORMATION) Date 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) Owner or Tenant /97/C- Ile- Owner's Address is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box) 35 41/1z- Purpose of Building /��?�c� A�P., /27��?1/ ��' Lyr rp �'��n 1'c v� Utility Authorization No. Existing Serviceo2 c�� Amp' a/2 -t Volts Overhead Underground Im No.of Meters New Service Amps olts Overhead Underground C3 No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worst Na of Lighting Oatlets Na of Hot Tubs No.of Tlrushamars Tont KVA Na of Lighting Rxtmn 10 Swimming Pool' Above Below Clenrerstow KVA nd rl yound ri No.of Recepncis Outlets /7C No.of Oil Burners Na of Emergesoy Lighting Battery Units Na of Switch Outlet No.of On Bornrs No.of Ranges Na of Air Cond. Told FIRE ALARMS No.of Zones Taos \ Na of Dispowb Na of Hast TotalNa and of Dabcdon a Ponys Ton Kw No.of Dishwashers Spate Mea Hating KW No. DevicesSoastdlag DeMoss Na of Self coommml P No.of Dryer Heating Device KW t�°"�0°Od"t Devices 0 Other�� iNo.of Won Heaters KW Na of Na of O Comrecdons AE Bsibsb No.Hydro Mawage Ibbs No.of Motors Total HP OTHER' nvatneeo Pu�aacbbera�}ie msativfaedi 00mo hers. Itmeact=tLi*fthasxsFbLyirditCm#*r Ey C Lhemarbabb"WAN YES IhsveahrAbdvddpadc( mebhOlA=YM )fyeuhnedrededY>?s,phts hkaletbetypeef enirby WSUItAI� Bl�� UlfFlt � �� 13gi�ionDsb -;, EstrraddVak>CdHect WWa&S -r WodclDSbist le's IrapecdcrrD*Ra}resbd Rwo FkW ,Sgredurrdr Psvftafpajiiy. fRtMNAME tkiterra lhrritm !r' 11V' L_441 ' CY*WSMJRAI� awWAMRl= &dieLiaens Qre'' a rddonylaratreandils., IappI d- '�arfto *c ar�sir�ieiiaquvalntmAlt'IMNa Ctn Nq*zdbyMstssdwwW aws (Please cbeck one) Owner a Agent Telephone No, FEB s Sagnamm or Owner or Apm ..Pam mriaaAt,t7uJt I I, u[vtt-UKM Art-LICATION FOR PERMIT TO DO GASFITTING o (Print or Type) Mass. Oat /� 19 r Permit# C)f Building Location_ , Z /Q�� jj�� �fif K Owner's Name GleOl5zl- Type of Occupancy Acs New Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ Ncc Y W N1-- W U z Cr. N 0 cc 0 tl J N W U !I] r S A z o c.1 Q ¢ tC o M O 1,. W Q m rn F- :u O o r W a N tl U w = z f' � O > w W ul CO x Q s � a W a Cr. r w t- s z a m J a c ~ tW- W tl o > U. r W J N W Q W > cc W. : z. Q ¢ Q m z O Z a p ¢ 'x o t� U. 7 a tl aj (� C > a a Fes- o SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR [I 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate Address 55 MARSTON STREET XJ Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 508-68Y-- 1105 Fir o. Name of Licensed Plumber or Gas Fitter Y � V" INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy K Other type of indemnity❑ Bond ❑ OWNER'S 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: Signature of Owner or Owner's Agent Owner❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and aocu�te to the best of my knowledge and that all plumbing work and installations performed under the permit issu4' s. is application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Geneug- (j �y T e of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 8697 City��T--TCO--F—FIC—�E—USE Journeyman APPSONLI� Date.�f. � . . .. .... is t� � NORTH TOWN OF NORTH ANDOVER pF i«ao ,s,'t'O �, PERMIT FOR GAS INSTALLATION2' , o,r' qy C. �,SSACeHUSES -� nl This certifies that . . . ��. has permission for gas installationy. .. . ?. .�, y. . . . . .O M. in the buildings of . .C 1j v S s. . . . . . . . . . . . . . . . . . . . . . . . . . . . a at . . ."7. F. �.�. . .�!`���t., ./. r�., North Andover, Mks. Fee Lic. No.. S✓�.�.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File Location No. Date „OR*M TOWN OF NORTH ANDOVER 0�� .ao ,a,ti0 9 41 + ; ; Certificate of Occupancy $ sACMUs t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # Building Inspectdf TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. ! a DATE ISSUED. O . �S SIGNATURE: ,/L� C ic Building Commissionerfl for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Aodoye,( i A , Map Number Parcel Number J� 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 11 Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 0 1.7 Water Supply M.G.L.C. Nft 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ -• Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record ?a-"r i C u M ./lila l�,c v)c I "Fa r m Name(Print) Address for Service: ` a 61aAA-281- 0281 Signature Telephone o� 2.2 Owner of Record: N Name Print Address for Service: O Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable M Licensed Construction Supervisor: O License Number 11 Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name m Registration Number r Address r Z Expiration Date ^ Signature Telephone Y, SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......E1' SECTION 5 Description of Proposed Work(check all applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ,❑ Addition ❑ Accessory Bldg. Demolition ❑ Other _❑ Specify Brief Description of Proposed Work: I SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building ©© (a) Building Permit Fee Multiplier 2 Electrical J (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 ''- Yereby'authorize as Owne uthorized Agent of subject property to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date ' SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date 2. 1 Emil NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I LI;1GFIT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Uf K4R7/� • Town of North Andover ? ,.��,- ,+ Building Department = # A • 27 Charles Street � F Y North Andover, MA. 01845 -•=- �' D. Robert Nicetta Building Commissioner (978) 688-9545 . (978) 688-9542 Fax HOMEOWNER UCENSE EXEMPTION Please print DATE C Ce00� JOB LOCATION x l �Ir0—V)64 . T�C(/V1 2cj �n f (� ©•_ AO��f Number Street Address � `✓,C�` Map/lot "HOMEOWNER 'e Name Home Phone Work Phone PRESENT MAILING ADDRESS S u-t City Town State TTP Code The current exemption for"homeowners"was extended to include owner-0ccupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Budding Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL 4• FORM U - LOT RELEASE FORM MSTRUCTIONS: 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 SECTION*********************** APPLICANT PHONE LOCATION: Assessor's Map Number 3 PARCEL SUBDIVISION LOT (S) STREET tree Oc- VA IP-M ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** REC MMENDATIONS OFT WN AGENTS: CO SERVATION ADMINISTR OR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS V FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm Me RTGAGE IN& 'E'r'T/ON PLAN 7 FE/V6'l, r"AR-A4 ROAD �4 NORTH AADOVER ILIA. ESSEX REGISTRi" CF DEEDS.-W. / 797 PG 45 �'ER PLAN .' NO. X3/8 TIF/ED TO.' GREAT 1�/E TERN MORTGAGT CORPORA T 10N i .,;CAL E.' /"= 60' DATE; JULY/7,19 95 1700 o a slr. o ocb � fRMs; i DWL. rz, 0T3, A 3°3'93 APPOolf LocA 4i vN v'y NOTES.' I,% DO NOT USE OFFSETS TO ESTABL I PROPERTY Y LINES / Y;; J N OR TO ERECT ANY STRUCTURE. A � . 2JPROPERTY LINES ARE DETERMINE,; FROM COMP/LED #35773„ INFORMATION TO BE USED FOR MORT6AGE PURPOSES ONLY. � ,SS,o�P CERTIFICATIONS.* BASED ON MY KNOWLEDGE, INFORMA7/0N AND SEL/EF, / HEREBY CERT/FY THAT THE PERMAAEAIT STRUCTURES INDICATED ARE LOCATED ON THE GROUND APPRO:'IMATELY AS SHOWN AND ARE CONFORMING TO THE ZONING SETBAC;` RE01/REMENTS OF THE MUNIC/PA.I.IT Y OF NOANDD✓ER WHEN CONSTRUCTED AN,., THAT THE STRUCTURE SHOW111IS NOT LOCATED IN A f"L 00D HAZARD ZON7 AS PER F. E.M.A. .MAP, COMMUN/1"Y .NO. 250098 EFEECi %✓E DATE'06-02-93 ZONE*)( f JOHN ABAGIS B ASSOCIATES, PROFESSIONAL LAND SURVEYORS I 137 CHANDLER ROAD, A NL'O✓E R) MA. (508J 688- 4699 APPLICANT:'CRO.SS NO. P2,373 NORTH Town of Andover �o o� LA E o �dower, Mass., — " COCHICHEWICK RATED P9�" CJ S � BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System Av � BUILDING INSPECTOR THIS CERTIFIES THAT....... ,. .���. a.......... .4.......A.. ..................................... .............................: ............ Foundation has permission to erect.... .'y..x� �..., buildings on .... .... .F... .irN�..�......FA�01...... ...... Rough to be occupied as...SIf0.r'. ... . ......S�.t 4.... ....�`. .r .....y...A....R.&I...................................... chimney provided that the person acceptin�this permit shall in every respect conform to he terms of the application on file in Final this office, and to the provisions of the Codes and B Buildings in the Town of North Andover. - ws relating to the Inspection, Alteration and Construction of PLUMBING INSPECTOR 3 g` �30*� VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 61161 11 Les ............Sw A.... JWA^0000' 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. V 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG (Print or Type) 7JBuiNontA 4ndoven , Mass. Date yan 1998 Permit #-a24- Building lding Location_ 7 f a en c A f a a m ?d. Owner's Name M a A e.n Type of Occupancy •Well i_n! 17 New Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ N Y W N U3 N K O O N = F- WW CC O U F- O J N Wr- x a F- .c >- = •*X' .o F- w < cc O O ¢ m rn H sr W OUJ V3 a C rtr }- OW ,Waw, C W 2 < S a W W W t- _ W W O O H U. F- W d W J W C !- 4! m = O = O S > CC W O O W 6: t O F ct '= O LL r G O J U C Y SUB—BSMT. BASEMENT ISTFLOOR 2ND FLOOR 3RD FLOOR I 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Demers Plbg. & Htg. , Inc. heck one: Certificate 7 Address P.O . Box 88 5/corporation _2144C Methuen, Ma 01844 ❑ Partnership Business Telephone ( 9 7 8 ) 683-9755 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Donald Demers INSURANCE CO ERAGE: 1 have a current abliify insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142: Yes No ❑ If you have checked,yes, pleas indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity❑ Bond ❑ OWNER'S 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: Signature of Owner or Owners Agent Owner❑ Agent ❑ I hereby certify that all of the details and Information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of eneral LZws. T e Ucense: Title U-Muber Si a ure o ce a um r or Gas rrl.'*"�',tter r Ucense Number 9442 City/Town neymanAJ n0W-.D0 •C Date./.... ....... ........ r / A HORTM TOWN OF NORTH ANDOVER 9 0 ' `p PERMIT FOR GAS INSTALLATION 8 SACHUSESS r 0 This certifies that . . . . . . . . . . . :: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�, a~ has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . w in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . !. . . . . . . . . . .ti. . , North Andover, Mass. Fee. ./. . . . . . . Lic. No.. . ..'. .. .? . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer LT , MASSACHUSETTS UNIFaRM•APPLICATION FOR PERMIT TO DO PLUMBING �-\ (Print or Type) Nvnth 4ndvven -. Mass. Date Yan• 8 19 ,98 Permit# Building Location 7 f-n en c h f a rc m Rd. Owner's Name Mahe n Type of Occupancy /�w e L L n g New I/ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ • B.P .# SEWER# FIXTURESSEPTIC# z Q 1141 N Z Y v W Y J N Q (_ N O N bl N Z N Q a Cr 2 Z O Z d O W 1-� W N Y. 2 .. % v X U Z D m N W Uj >- F- N 2 C 4 0 < E d Q £ 44 Z O Q a W ¢ a W a a to Z a a � , N W ►- !- W N D . J (n C J G � O LL C� I W 2 d = tis O z x Y a Q Y W LL V- X < H > H O vii N ~ z o a �n z x, W o Q < a x a a o a J ., �c .J m w o c J 3 = r cn U. C7 :1121 a Q 3 x m q o SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR EH . Installing Company Name_ D em e n a %,L 6 a. & / t Q. , Inc. heck one: Certificate # Address P.O. 80X 88 /Corporation2/44 Methuen, Ma 0/844 ❑ Partnership Business Telephone19J') 68 3-9� ❑ Firm/Co. �- Name of Licensed Plumber 1)vnal d INSURANCE COVERAGE: I have a currenYllability 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 coverage by checking the appropriate box. A liability Insurance policy IN Other type of indemnity ❑ Bond ❑ OWNER'S 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 permitapplication waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code a apter 1 he General Laws. Signature of Licensed Plumber Title Type of License: Master Journeyman ❑ City/Town APPROVED(OFFICE USE ONLY)- License Number 99442 HORTIy ?°;<,�•°.;�,',"o°� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ISA us (/ F This certifies that . ...i��!?!41�F. . . �.y. . . . . . . . . . . . . . . . . . . has permission to perform . . ./ `lti T. . /. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .1p./. ljeJ C?. . . . . . . . . . . . . . . . . . . . . at. . . �':� r :. �. . .l`f1!?!�r. .I'?�. . ., North Andover, Mass. Fee.0 .,. . Lic. No..-J 7!Y?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR 01/14/98 10:46 15.00 PAID "'HITE: Applicant CANARY: Building Dept. PINK:Treasurer Location No. Date �ORT� TOWN OF NORTH ANDOVER 3?Oi�,�•O 0 L 1 f 9 o , Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s�CHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ %� Check # r 6/ Building insp or TOWN OF NORTH ANDOVER r BUILDING DEPARTMENT APPLICATION TO CONSTRUCT!U_Al&RENOVAT& OR DEMOUSH A ONE OR TWO FAMILY DWELLING , Set"f ow BUMDING PERMIT NUMBER: DATE ISSUED: n s SIGNATURE: AW 2L� Building Commissioner/I or of Buildings Date SECTION I-SITE INFORMATION I Property Address: 1.2 Assessors Map and ParcelNumber ` Le,i Al ` L Map Number Parcel Number 144�0y�P r /Al/T 1.3 Zoning hlfbi ation: 1.4 Property Dimensions. Zoning Didrid Proposed Use I Lot Arae F it 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regaired. Provided Required Provided 1.7 W*w Supply M.G.L.C.40. 34) Zai"T.3. Flood Zone Info®atioi:`F1ood Zoaa ❑ 1.8 Saworapo Disposal Syslam: ' Public ❑ Private ❑ 0oftideMmkigt ❑ Ora Silo D'npowl System ❑ 11 SECTION 2-PROPERTY NERSHIP/AUTHORIZED AGENT jCtflCt: ; f o 2.1 Owner of/Record N� ` n D v. i /"GO q G1 G /c,4— Act e•r C �l Pyr /�'1 /pct Name(Print) Address for Service s'z/ 5' 3 C J Te Signature ephone f 1 2.2 Owner of Record: Name Print Address for Service: idr Si ature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor. Not Applicable ❑ M Ke�rsTG0.T�oYl l Zdl ON 4 Licensed Construction Supervisor: A 11 L 0-1'— Pg - A .5 T //c,v-ef h r�l� O/ License Number Address/ �e 7 r L T 7-3�3 Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ . rE Company Name n Registration Number r Address r Expiration Date ♦♦� Signature Telephone V SECTION 4-WORKERS COMPENSATION(M.G.L C 152 f 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 it. • Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check d avokabb New Construction ❑ Existing Building 0 Repair(s) j2" Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Cowleted by permit applicant 1. Building / (a) Building Permit Fee 3 C v. � 0 Multi lien 2 Electrical (b) Estimated Total Cost of Construction 3 Plumb' Building Permit fee(a)x(b) 4 Mechanical HVAC 5 Fire Protection t 6 Total 1+2+3+4+5 4- da Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ll� if f/-- ,as r Authorized Agent o ubject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit applic` ation. /L AG— S> >ature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ture of Owner/Agent Date NO. STORIES SIZE BASEMENT OR SLAA SIZE OF FLOOR TIMBERS I 2• 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH ovm of _ _ over d ., COC MIC ME WICK over, MassV �d AOA, RATED O'?�,`�5 7 H BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ............... ... .... ... ........................... ...................................... ................... Foundation has permission to erect........................................ buildings ......on.. ........... .... . .... ...f Trough to be occupied a Chimney provided that the person a pting this permit sh in every respect conform to the terms of the application on file in Final this office, and to the provi ons of the Codes an 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. trough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR ough ..................................................................IL........................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. N. The Commonwealth of Massachusetts d Department of Industrial Accidents Mice of Investigations Boston, Mass. 02911 - Wofkers'Compensation Insurance Affidavit Name Please Print Name: Location: 2 City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity Ef�I am an employer providing workers'compensation for my employees working on this job. Company name: S G rt e <0 'Roo Address Citv / �-� r6 r �I.rT d l S 3 Phone* g 7g Insurance Co. Policy# Company name: Address City: Phone# Insurance Co. Policv# Failure to secure coverage as required under section 25A or MGL 152 can lead to the imposition of criminal penalties d,a fine up to$1,500.00 andlor one years'imprisonment_aS well_as_civil,penanlesin.lhefmnda.STOP WOWORDER.aid_a fine of.(S1oo.0o)_day againat.me, I understand that a copy of this statement may be forwarded to the Office of Investlgations of the DiA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permif/Licensi ❑ []Check it immediate response is required Building Dept ❑ Licensing Board E] Selectman's Office person: Phone#. ❑ Health Department ❑ Other �C ��" All 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: 0.7 (Location of Facility) ignature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Board of Bnilding R�alatio�a0.d • r C 6 - KOME IMPROVEMENT CONTRACTOR Registration: 143201 ExPira'ti°n' 017212006 TYps DBA SAG SIDDING+ROOFING' KEVIN MORGARbO 25 PARK ST 01830 Ador HAVERHILL, `` KEVIN B. S.A.G. Siding & Roofing MORGARDO D.B.A. 25 Park Street Estimate 2nd Floor Date Haverhill, MA 01830 5n0/2005 Custermer Name/Address Job Name/Location Patricia Maher Patricia Maher 7 French Farm Rd. 7 French Farm Rd. North Andover,MA 01 845 North Andover, MA 01845 Item Description Qty Rate Total Roof Installation-A Installation of Architectural shingles, per sq 26 265.00 6,890.00 Promotionall Dis... 2 free squares of roof installation -530.00 -530.00 S.A.G. is responsible for installing 8" white aluminum drip edge, will also install and seal all necessary roof vents, pipe boots and all necessary step, roll, and lead flashing. S.A.G. reserves the right to land a dumpster on or around 7 French Farm Rd. North Andover , MA 01845 and the right to post a lftx2ft company sign on the above mentioned property. Total time expected to complete project is 3-5 work days. S.A.G. will hold a five*ear warranty on all work completed. Payment made as follows: 1/3 of estamate price due at the start of job, 1/3 Subtotal $6,360.00 of estamate price due paid at half way point and the total balence is due upon completion. o FIRST PAYMENTS ,� �j D0 SECOND PAYMENT$ /�O.00 Sales Tax (5.0%) $0.00 All labor is guaranteed to be as specified.All work to be completed in a substantial workmanlike Total $6,360.00 manner to specifications submitted,per standard practice.Any alterations or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.all agreement contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,torn do and other necessary insurance. Date / Signature Website Cell#/Home# E-mail www.sagroofing.com (C)978-476-1042/(H)978-521-9363 sagrooftng@netzero.com TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVA OR DEMOLISH A ONE OR TWO FAMILY DWELLING .) - ' n BUILDING PERMIT NUMBER: DATE ISSUED: r = SIGNATURE: 44iw Building Cotnmissioner/Inspector of Buildings- Date a. SECTION 1-SITE INFORMATION r� 1.1 Property Address: 1.2 Assessors Map and Parcel Number C A/ 7��.�•r Q.�oL Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dmenaicoa: Zoning Diaxid Proposed Use Lot Area Frady 8 1.6 BUILDING SETBACKS tt Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Rtguired Provided I.S. blood Zoee tnfmmdioa:"-- �. 1.8 sawenp Digwasl system: pab4e al water supply Mo L.C.4o. ser) zone od"blood Taub ❑ t� ❑ t�mivate 11Mroicipal o Oa Site Diapoaal Sydam ❑ � SECTION 2-PROPERTY NERS13IP1AUTHORIZED AGENT .10 t' 2.1 Owner oof/Record LV,ii All r G r Z---�-7 Fre K c L, k e-4-7 Name(Print) Address for Service 57z / 5 3C 13 Signature Te hone 2.2 Owner of Record: Name Print Address for Service: C r Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor Not Applicable 0 r. d Licensed Construction Supervisor. Z 1-- /'4 )G Address / License Number Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 4d Company Name n Registration Number r Address r Expiration Daft r2 Signature Telephone Y SECTION 4-WORKERS COMPENSATION(M.G.L C 152 125 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description o Proposed Wont checknmacahk New Construction ❑ Existing Building ❑ Repair(s) JY Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: L /� n e r C t S7/ kzC /LUc7 f SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building / (a) Building Permit Fee t;/ 3 C U. O Multi Tier 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 0' od Check Number SECTION 7s OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT l fz � Ke v `O�q �"'� ,asr Authorized Agent o object property Hereby authorize to act on 4My behalf,in all natters relati a to work authorized by this building permit applic`atiioon. /L/0S i iature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBFRS lSM SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOO'L'ING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE `Location No. rDate .Vr"Qir NORTH TOWN OF NORTH ANDOVER f 9 Certificate of Occupancy $ ;�a Eta Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 /< Building Inspe'cFdr TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Jul BUILDING PERMIT NUMBER. ( DATE ISSUED ) Q D M ic SIGNATURE: <« Building Commissioner/I for of Buildings Date z SECTION I-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: t,,-- "7 X66(h riym `Rd, 036.0 o � 355 G4i A4ae v M A 0 f! ` Map Number Parcel Number rj y 1.3 Zoning Information: 1.4 Property Dimensions: C 9 150, 00 Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R iredProvided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public n Private p Zone outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No M 2.1 Ow-*r of Record I --tk6,�+bOer 'k4rlkev, '7 t2w, ame(Print) FAddress for Service Signature Telephone Q 2.2 Owner of Record: Name Print Address for Service: M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number 0" Address Expiration Date ic Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name M Registration Number r ro Address z Expiration Date A Signature Telephone �1/ SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ScCYP-en ror*-'n Rt ( � Ktrv►n e rS i�cCh (,Oro G ra.1 n.d�'� n �oo►� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 4 5 Fire Protection 6 Total 1+2+3+4+5 Check Number , SECTION 7a OWNER AUTHO IZAT ON TO BE COMPLETED WHEN r OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,as Owner/ thorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. 'Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that ents and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent MA IWWDate f. R._ .. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IS7 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS FIEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Y 1--as- 'Ff utwe es FORM U - LOT RELEASE FORM 36 9 4 3Q, s�ts�N 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 SECTION*********************** APPLICANT 1. ( S4cpt .tr S r4k4 ti& �(�c�4y PHONE Q7 1-0-12l 035,0 LOCATION: Assessor's Map Number PARCEL-� SUBDIVISION ( I,CLOT (S) STREET (PYIr rCtyvp Kd- ST. NUMBER ********************tet*******************OFFICIAL USE R MME O F NOWN A TS: CONS NATION ADMINISTRATOR DATE APPROVED 2 s DATE REJECTED COMMENTSWflat�s, l TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm CITY,STATE: N ANDOVSA MA JOB#: 9707893 DATE: //-26—97 SCALE: 2�• t w LOr 36 A 0 LOT- 35 A ,yc 5 58 SF, t a� Lo-r 94 A �► 0 a► If N�00. �rOPOTeI PrCA N 2 sry. wD. "' 'o 0 95 FRENCH FARM RD. CERTIFIED TO: AMDOVER 8414K 11OTC: This mortgage inspection was prepared ►►AA,. 'Phis mortgage inspection was ptupased in accordance specifically for mortgage purposes only and ► with the '1'echniedl slandnrds tut Ilotlynyn I.oun is not to be relied upon as a land or property ►� 44 Inspections as ndouted I,v the hast:nchusottn itnwrn nr t pORTM TOWN OF NORTH ANDOVER OFFICE OF A BUILDING DEPARTMENT > 400 Osgood Street +s AA7.v- North Andover, Massachusetts 01845 sAcaust D. Robert Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: /,35A, Number Street Address MO/Lot HOMEOWNER__fia4hCrG q(�Qr �� -ipi 11-0721 Name Hunte Phone Work Phone PRESENT MAILING ADDRESS 1 f(� r)& _r(A(` I 2�, &41 And gev AAA- 014`-15 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE / APPROVAL OF BUILDING OFFICIAL BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 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 at: 'rl fQr,& J�rm Q.Ajar-( ,Ajr ads that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: TE(eun Ck Mt-m 2d. AL[� AnL&r- 11AA (Location of Facility) G Signature of Permit Applicant Fire Department Sign off: Dumpster Permit a /0j- bate I 5 1 1 I I 1 I oQ,Q Y � N • � 1 ® l e C 1I P`k7 s4'1 ►2 _ Y$ !CQy E or zx 6 x ''`f ► - — — — _r-1 _ 2tte Ce,Lr.� �pr ST(G��O•C . Lori l i 1 1 -- cP,a��C S _ Vico lCyx y As7I? lc +,. aliow = 1711, Savv'r j R c LAO r 6 )zsrP6 11 I� _ �� - :. . �Z�� ��� �' ��S - � ��z _ �--I �C y Jn�� ls/ s � �� ���� - �� � � S S _____._- ---- -- _.____._____ —______ -___ _ _ '��fi ���r2 „ °_" �j �o� G� 2 �7�it�ds/ �//�'�' �racGc 3G-0 I " `�1� 1� rS 3 P x � I t I v i M i I I i � 4 rii /A 7- L/ e,+r*ek- 73 z7r J., k ywo i i I z 3 a Z.�So4rTP�' i I 1 �8 JorsTiY.y e�Z. �r o�✓t`— JasT.N.ryzr,•. Z x p pr S DSS`r /6,�0. • �-" 0 Ar R earl /Z' SonJAY'SE-S W'7;t�P MCRA. L-0 Z 5715 - ------ -----�- - NORTH Town of over No. _ * •e) O© Soft& v — �, z__ _A dover, Mass., 8 ISO COCHIC.EMCK y� ORATED O'P� �5 BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D . 400#0 *AA41ICl/� BUILDING INSPECTOR THISCERTIFIES THAT...Cktik....... .................................................................Aukoom........................................ Foundation pp• �r,3` • '7 F� 0..** �'AR rh Rough haspermission to erect.Q.................................. buildings on.................................. ... ............................................. g t0 be Occupied 8s A MRr►1► � %f3A S �� �!��y Chimney .F ....F...''............s....�.rcG......................................................5........... ................. ...... y 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. 3 5- 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 AC ................................. . .. 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.