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HomeMy WebLinkAboutMiscellaneous - 70 HUCKLEBERRY LANE 4/30/2018Date . bx� tt.rp 7�6 TOWN OFNORTH ANDOVER PERMIT FOl GAS INSTALLATION �CAd-L This certifies that ................ t°.c�............. . 1 ► p eA cam- S P . has permission for ga�s�'nstallation .....¢.. � •�! • • • �.� ivl y J1.� in the buildings of. U i ( ... . ..................... e. . at ..... � .. ! �- ��! 2 k? ? N rth Andover Mass. Feel ... Lie. No. ��...�..... ... GASINSPECTOR Check #o_ 8454 1N.— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / , DATE /��� 21 2v t 'z MA � �� PERMIT # JOBSITE ADDRESSiD uL a. wru OWNER'S NAME -- - GOWNERADDRESS TEL FAX� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL= RESIDENTIAL CLEARLY NEWT] RENOVATION:E] REPLACEMENT: __. 6-1 _ �(��� —� PLANS SUBMITTED: YESF-- N0 el— APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTERy� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER nl FIREPLACE F YOLA TOR FURNACE GENERATOR 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 INSURANCE COVERAGE have a current liab_ ility insurance policy or its substantial equivale ich meets the requirements of MGL. Ch. 142 YES . __ NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY EA BOND L] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are 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. PLUM BER-GASFITTER NAME Cir tL h I i44r—Nt,--4 d LICENSE #L � SIGNATURE MP _ MGF [�i JPJGF LPGI CORPORATION 3j 6 6..__ J PARTNERSHIP ��IJ# LLC# COMPANY NAME: ADDRESS CITY /�1 (.c Cc,•_ STATE iW"=-=.ZIP G/5 y ]TEL FAX CELL y7b' �3 _ EMAIL \N ._. The Commonwealth of Massachusetts IL a 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): /"- 47-�, Xz -" Address: 3-7 s i City/State/Zip: phone #: rj Y �T G Are you an employer? Check the appropriate box: 1.1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance reauired.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. kContractors 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. , e Insurance Company Name jj(iA �_ ?olicy # or Self -ins. Lic. #: �Expiration Date:_ 3 za -r 41 3 ob Site Address: �� 1��2(�LCL-E City/State/Zip: lttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby cert#yunder the p n n penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitALicense fit./ � zo Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia r tj -n o Cl T n 7; ing ro (n MR In >M c: I > In cnM En (n M -4 �:r IM > G 0 CP -a ar rn u Go M 0 rnft IN ;u cl Z> T -M > rn rn M LI) U) XN C3 In CD fs 49 70cn NtinM 17� T:; ii' -4 N > > rii-0 ZE ZE tj::. re N. -M3 C/7C r> cn n C ;u . ;; ::1M Ui Eng z —1 0 Z M rn W M;o Ln. w rn o 0 w —M -n > ril .7Z W, 01 N o 00 AN N z =NN r— M < n C= w Ln. M 0 1-1< C:) Fn > 1AC, cn Ro to V) > E: -n V3; z Mtn U) CJDis M C -)U) N Ul W Mr rn vcf. CD ln on CP 7 6 v Date..? /(....... NOR " TOWN OF NORTH ANDOVER �o PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation in the buildings of .... !��!!`'`�........................... . at ���..... ��4k�e�??r ........ , JNorth ndo er, l�Iass. Fel. ? : ? . Lic. No.. / �, ...... ... ��k� . �.� GAS INSPECTOR Check # of G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) �(}( /Z ,Mass. Date 20 // Permit # � N o U Building Location 70- 1)v/�/-/Owner's Name �VU I?RA (� T Owner Tel# Type of Occupancy ,�?�,/ New ❑ Renovation 0 Replacement 9-- Plan Submitted: Yes ❑ No 13 FIXTURES Installing Company Name cALLAA a -c✓ c-- i- d:i`"(, Check one: Certificate Address 9/ &a D& S7—((// 4Ttorporationqo P- At ob � � N/V 6-1 � T � ❑ Partnership Business Telephone # ?-.) d 6 �9 qd--��3 / 11Firm/Co. Name of Licensed Plumber or Gas Fitter � -Fp f v%/v 1J INSURANCE COVERAGE: 1 have a curve ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Ms, please 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: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that ail of the details and information I have submitted (or entered) in above applic tion are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for hi 4pVication will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Genera By Type of License: um SignaituPjc#e4&kwber or Gas Fitter Title • dtRa tic l4umber City/Town • Journeyman APPROVED (OFFICE USE ONLY) mm MR. Installing Company Name cALLAA a -c✓ c-- i- d:i`"(, Check one: Certificate Address 9/ &a D& S7—((// 4Ttorporationqo P- At ob � � N/V 6-1 � T � ❑ Partnership Business Telephone # ?-.) d 6 �9 qd--��3 / 11Firm/Co. Name of Licensed Plumber or Gas Fitter � -Fp f v%/v 1J INSURANCE COVERAGE: 1 have a curve ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Ms, please 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: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that ail of the details and information I have submitted (or entered) in above applic tion are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for hi 4pVication will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Genera By Type of License: um SignaituPjc#e4&kwber or Gas Fitter Title • dtRa tic l4umber City/Town • Journeyman APPROVED (OFFICE USE ONLY) The Commonwealth of Massachusetts 1 �: Department oflndustrialAccidents Office of Investigations t'" U 600 Washington Street Boston, MA 02111 ~=y'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluxmbers Applicant Information . / Please Prinf Legibly Name (Business/Organization/Individual): �-�1 C L%�► �/ L Address: City/State/Zip:,/��,17U(/�12 j`7 O/�ifPhone /#: ap employer? Check the appropriate box: Type of project (required): gou 1. am a employer with 4. ❑ I am a general contractor end I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors ❑Remodeling 2. EJI ain, a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9 ❑Building addition [No workers' comp. required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL - 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. F1 Roof repairs - insurance required.] t employees. [No workers' 1300ther Rcviba La/_z IsL� comp. insurance required.] *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Job Site Expiration Date: 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 Sedtion 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 maybe forwarded to the Office of Investigations of the DIA for insurance•coverage verification. I do hereby ce if der the pains and penalties ofpeijury that the information provided abov is frt3k and coxrect Si ature: / Date: 6gin. J^ l cl l Phone #: % �-q g/ in. . 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. PIumbing 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 thi dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling housd onon 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) naine(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 cavy 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 confinnation 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 pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any. questions regarding the law or ifyou 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 penriitllieense number which will be used as a reference number. In addition, an applicant that must submit inultiple-pennitllicense 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 pen -nits 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 n 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 foryour 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 7)c,PaA=.Ut of Industrial Accidents (Office of Tnvestiptions 600 Washington Street Boston, MA 02,111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAF.F Revised 5-26-05 Fax # 617-727-7749- www.mass.gov/dia q The Commonwealth of Massachusetts 1 % I Department oflndustrialAccidents Office of Investigations ' 600 Washington Street ate','°fie Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,�ff % Please Prinf y_ f,egibt N !O ization/Individual)' CA �./; A 1L J f"hC_ f / ! t-% ame (Business rgan Address: '?/ l3�1 I1)A;T S� City/State/Zip:,/ t�NI�Ui/�12 %%/� 0&y�7hone #: !�2> � Are an employer? Check the appropriate box: 1. I a with �2 r 4. ❑ I am a general contractor and I LI am employer employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.00ther 9 Gfi *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 thep 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 acid their workers' comp. pol icy information. Iam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy andjob 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 fonn 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. .I do hereby cder the pains antipenalties ofpefjury that the information provided abov p tY and correct 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 rnnfar+ P,rann- 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, o'r 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 thi dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling housd or_on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation 'affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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 confinnation 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 ifyou 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 pennit/lieense 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 pen -nit 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 1' gWment of Industrial Accidents Office of Investigations 600 Washington street Boston, MA 02111 Tel. # 617-727-4900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORDr CERTIFICATE OF LIABILITY INSURANCE FDATE (MMDD"YY) TT IM 011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY INC. M.J. FOSTER INSURANCE SERVICES PHONE 978) 686-2266 (978) 686-6410 ADDRESS: cfernandez@nafins.com 163 MAIN STREET PRODUCER Callahan Air Conditioning& Heating CUSTOMER ID N. NORTH ANDOVER MA 01845-2508 INSURER(S) AFFORDING COVERAGE NAIC# INSURED Calla tan Air Conditioning & Heating INSURER A :PEERLESS INS CO INSURER B :TRAVELERS (PHOENIX) 91 Belmont Street INSURER C INSURER D MED EXP (Any one person) $ 5,000 North Andover MA 01845— INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF (N POLICY Y EF POLICY EXP ( POLI Y Y'YY) LIMITS A GENERAL LIABILITY CBP4016154 9/25/2010 9/25/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR / / / / / / / / DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 X CONTRACTUAL / / / / PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 / / / / POLICY X JEC LOC / / / / NOWND $ A AUTOMOBILE LIABILITY ANY AUTO BA4544035 9/25/2010 / / 9/25/2011 / / COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X X SCHEDULEDAUTOS HIRED AUTOS / / / / PROPERTY DAMAGE (Per accident) $ X NON-OWNIEDAUTOS / / / / $ X COMP.$1000 DED COLL.$1000 DED / / / / $ A X UMBRELLA LIAB X OCCUR 08809334 9/25/2010 9/25/2011 EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAIMS -MADE / / / / AGGREGATE $ DEDUCTIBLE $ / / / / RETENTION $ / / / / $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNEPJEXECUTIVE OFF EMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A BUB789BY60-7 9/25/2010 / / / / 9/25/2011 / / / / WC STATU- OTH- I TQRY LETS I ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEd $ 500,000 E.L. DISEASE -POLICY LIMIT I $ 500 000 A INLAND MARINE BP4016154 9/25/2010 9/25/2011 LIMIT 50,000 EQUIPMENT / / / / DEDUCTIBLE 1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) �tr(Ilrtcvtt MULutK CANCELLATION (978) 688-9500 (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 120 MAIN STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- " ?5 12009/091 n �011>z_�nn0 emanon rnoononTln ua re. ?/. q. 6 C TOWN OF NORTH ANDOVER PERMIT FOR PLD A This certifies that haspermiss, -/-4 ...... Plumbing in 'On to perform• • .......... the buildings of .... at..... 7o .................... FA. .�!-?Y N Andov OrSh /.e Lic. Mass. Check # PLUMRIFUr.' City/Town.., MSA. Date., I Permit# Building Location: 7���C/it.L L�(� i� d� Owners IName:U��2 f� PType of Occupancy:. Commemial ❑ Educational ❑ industrial ❑ Institutional ❑ Residential �— New: r] Alteration: I I Renovation: FIXTURES Plans Submitted: Yes I 1 No rn��►ng Eziplppny f���e C/-{ GG/-� /�� _� ��1—� --- Wress: !?/a E-lit'7wit J / City/hewn: P . State: b&. Business Tel: ! X a- I ! )--� 3 Fax: � Name of Licensed Plumber: -% U these lane manly ��QrPQ►1�ll4n Partnership ❑ FirMCompany 6eruncaze a INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes [?No ❑ If you have eked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ 0WhIEFJM lluSURANCE ti'itk WEk t am aware UW #W IWWMW does not have the msufance wmirage cequtred by Chaipter W of the Massachusetts Oenerai Laws, and that my signature an this permit application waives this requirement Check One Only Owner f-1 Agent f-1Sionature of Owner or Owner's Aaent t hereby eertity that aH of the details and information t 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 1i$ gfjthe General Laws. I By Type of License: Title a -AU flier OftyaM mQ dc�j"'�' ume n APPROVFrl /f1FFIRF I ICF Argyll X1 �--- Plumber Lfwnse Nurrsbw: Z_511,I) DEDICATED SYSTEMS rn��►ng Eziplppny f���e C/-{ GG/-� /�� _� ��1—� --- Wress: !?/a E-lit'7wit J / City/hewn: P . State: b&. Business Tel: ! X a- I ! )--� 3 Fax: � Name of Licensed Plumber: -% U these lane manly ��QrPQ►1�ll4n Partnership ❑ FirMCompany 6eruncaze a INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes [?No ❑ If you have eked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ 0WhIEFJM lluSURANCE ti'itk WEk t am aware UW #W IWWMW does not have the msufance wmirage cequtred by Chaipter W of the Massachusetts Oenerai Laws, and that my signature an this permit application waives this requirement Check One Only Owner f-1 Agent f-1Sionature of Owner or Owner's Aaent t hereby eertity that aH of the details and information t 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 1i$ gfjthe General Laws. I By Type of License: Title a -AU flier OftyaM mQ dc�j"'�' ume n APPROVFrl /f1FFIRF I ICF Argyll X1 �--- Plumber Lfwnse Nurrsbw: Z_511,I) '�H ANDOVER BUILDING DEPAR'I'MEN NOR 400 Osgood Street �SUCMV`'� Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLER% DATE: e 2. 3 Z o a S- 4e 66 NAME, J oSC�°f� l�un ADDRESS. 70 �uc������2s� LAuc si ZONING DISTRICT: ScAj4 c. C pCXSO �u GvtiSuoT,4U7- TYPE OF BUSINESS: t /� � ' eok g D �'�1 C E No T t b NO BUILDING LAYOUT PROVIDED: YES wd C L Q Ear v 2 GccJ i�kl t r r5 AVAILABLE PARKING SPACES.. YES NO ZONING BY LAW USAGE: G� BALDING INSPECTOR SIG 11.5.04 BUS(�iPSS FORMFORTOWI9 CCK Date .. N° �VER OF NORTH ANDD NORTH ,, TOWN WIRING °° PERMIT FOR O 9 F ` a��O+ten• .�V � � ...........` ......... This certifies that ................ ................ ............. ............. fission to perform K.� •.—' ............... has perm , .� :. .... wiring in the building of ........... .. , North Andover, Mass. �r at.......... INs ESR �= Fee;• ......... ....... Lic. No................ •• $LSCC l;.rv� / 35.00 PAID ✓_''��U`1 �- !/ 03/02/9810:01 PINK: Treasurer CANARY: Building Dept. e CA�1)l]�Or��1 WHITE: APPlicant OAR OF Fl�� pDApanm�7r o/ f'r 1Vl`?SSMC' f)U APp�//,j�� /br7r• S•.7/nry S�ffS f, l�ti �EVENr(UN Ff-G(1C,1T10 � O/rin ATI r �2i A,r ti 0 (PlF'1`f f `l/t/r O� I�n��) P �; M� t2:pp mirlro� / � -",-•_ I N IPII{ worm ro s. �+. F? MArty, r11e Clty or 1• On TYp� �1 prrrnrn„y rn "oc� w �'� !/�if ,.✓90 �Y Foy ch,ch L vnder7irpr ,d applie�a:�7 _ l 1Nf-ORMA-rloN ""n • w•n, nr• Ar�.r��r�� ` �1 J ` 1 (nevi blgnF,t \,,`� °Gar(M °n 1)"t �A perrnitf�� 4 ZOO ral nOr or ^,rant J/°r_ gam, m flry ectriJ__ n r C'�l'"• IJ miner J Adhre `�7C(���j ��C,���/�I Nork d,°sCnb d bvlo���. Cate1�" this pert R/ -CEJ- nit in U CGr �/- PoJean/Uon with `S �,C _�� Of 8Wl a bu cli - —�J, f� TO the (nJ r3tt E*i�tln9 S //%{�,l9 p(°r►nit J'�---�C�J ��,Q <Q%� ° or o/ �ytre /J urvrGB 1J'C -�+Y " ".^+L'•�l./1��i )•nJ /"t ro o ice --A ' 'SCS. l/vrnber of F 4rnps�_ _J ^UtilirY .loth (Ch Lor °gderJ and Am '_~�`�r^pT� _ Volr, ori2ado,. Plv k Apor°nri7 and rJar p ___ - _ r✓olls C,^rhA7d IJ ° oP 11 of Propos„d J Un !�r N ht/n pativrS Elvrtncal d9rd LJ of Ll htln ext �._ ( Undsrd (� tl°• °I IJo urgJ Nn olt �ecvotacle putlar_ N",_ o^=o' tabs `-�J �-r! ,4��,•yti, _�..,__ Jlo Of Metnr.. NO No No. Of DIS %.°tp er; No. of Water NO. oP N dro h O rNEA: ° of S - --irng _.,..' of oundh, OarFY S If CO^9 Dov re.s >>� ✓Sopndl^9 Manic; P-� I haOV 0��,tjaeb -'�`°tat i1P N✓ln�V°/ra9e ConnvG;' vOr ,_ Il alld proinllAG�; f'vrsva �� _� V_ Lliou hsam 4' InJvr nt to _ T� �L / -� ave ch a to thi ance p the r r -�_- - °ck9 s orRc opc e9�rre 1NSURgNCfi �d B�IV plgasa Indc,p ND �Uln9 Cornpie� 33-d C,Ir u-- - Genn1 ,_ Or711 Valve of EI D Q O rl iEr? I elf Iv of °verege by checkin Co/9f a9e or its SvhJr'n signed to Sta ectrfca/ Work S ase sp�_r�t 9 the aper°priafe bo hal 9quive1vnt• N der the pen Me aV 'ubrniltnd 0, ,.. ee J °f par/vri: tnJPect/on 7 harry AdUreT, � � �l�'� � •'rav°sled; —� t o RF '9h_e- MIS IV -C 04 jr rhvs°ns Gena 1 laws�FR �� �= f�/ r�,_�, P__ and r 'lware Q'/ _S•-e� 1- � n, �ZGi hat m that Ur '� '_r fSi°nerurp Y slgnattrre Cicv,rSn r ^��n �� I /C Itol- r> .. on ' . J �_ N c/ irlo,Nai, 77 BMs lo-, n 9uJ• ter• Plv // O, ' n� PI, 7(,Irgrr'9nl ver.,�e All C'Nnrrror its s"jbsr -- A9onr anl(i In l'�it•q —� _ - - --'4q rhn�raJ rn,1'iirn� h ------- rnn) Y I i Locauon v v Not Date "01t7" TOWN OF NORTH ANDOVER p Certificate of Occupancy $ bz Building/Frame ,,, ... , ,,• , g/Frame Permit Fee $ o Ss„C,,,,SEt Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL v 04/29/97 15:17 Building Inspector 150.00 PAID Div. Public Works Location I ,�. � � � r Date l8 4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ -- Building/Frame Permit Fee $ ., Foundation Permit Fee Other Permit Fee • Sewer Connection Fee Water Connection Fee TOTAL C �uildi Inspector Div.. ubi c Works PER31rr NO. l APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K -4O. LOT NO. -7 2 RECORD OF OWNE HIP IDATE BOOK PAGE : ZONE SUB DIV. LOT NO. �I LOCATIOW PURPOSE OF BUILD NO. OF STORIES SIZE OWNER'S NAME20A rmAg OWNER'S ADDRESSA , BASEMENT OR SLAB ARCHITECT'S NAME y�� BUILDER'S NAME „9 SIZE OF FLOOR TIMBERS 1ST ..yS� am 2ND `^1�i Io 3RD SPAN S�f DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET / --- i DISTANCE FROM LOT LINES - SIDES �.` REAR �V GIRDERS v �� AREA OF LOT / �_ FRONTAGE -7 'cv`-7 9-1 HEIGHT OF FOUNDATION �i/THICKNESS �� y IS IS BUILDING NEW b J SIZE OF FOOTING X V IS BUILDING ADDITI N i n1 MATERIAL OF CHIMNEY IS BUILDING ALTERATION MD IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEJ%S, / IS BUILDING CONNECTED TO TOWN WATER 1 b BOARD OF APPEALS ACTION. IF ANY J /� IS BUILDING CONNECTED TO TOWN SEWER t/� IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED T// %1l / AA SIGNATURE OF OWNER OR AUTHORIZQ'b AGENT FEE PERMIT GRANTED SLUM , e � I cep FDA � 64�.IV 1 il �i..-a�K+�'7 DUE FRRME �; ,qZ 3 PROPERTY INFORMATION LAND COSTJ0 K- i.-/ EST. BLDG. COST, EST. BLDG. COST PER SQ. FT. {.., EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. k CONTR. TEL. k 4 177Q CONTR. LIC. /! SO—ZR09 H.I.C. X BUILDING RECORD 1 OCCUPANCY_ _ 12 SINGLE FAMILY _ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES, ETC. SUPERIMPOSED. THISR EPLACESPLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ B 1 2 ,I3 , CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ _ DRY VJALI _ UNFIN. 3 BASEMENT •�' w ` AREA FULL it F2N. B'M'TAREA 1/1 1/I '/1 FIN. ATTIC AREA NO B M FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 11-19 FLOORS CLAPBOARDS B I 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D _ ASBESTOS SIDING COMI.AC:N ✓ I_ VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR— I� POOR _ ADEQUATE NONE 5 ROOF O PLUMBING GABLEIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED ATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER 6 FRAMING 11 11 HEATING =731 � Is R WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ CONDITIONING _1�1'-AIR RADIANT H'T'G UNIT HEATERS GOAL 7 NO. OF ROOMS B'M'T / 2nd ELECTRIC 1st ( 3rd I NO HEATING Pin/ u/0 42 /`?d A p /"/PID�'a.yE'O .'/C7UJGc LO�A�'if.�N ANO llc�[ G0 T IA'G 14n/ IAI OF s�v�tw, . 'O.�•I/Ir.V FO.P �E. �u0is : ;: � �vE.4G /QG��'-n/ /77.4.✓.4 GE/�'7E��/T ,. / "t lie ' C~4- -r7d- wo-r avPI i!', .04jrXooeWrdrrx 4/I/A A ON .-a 4 rW oP W C4 c � C ` y O C VV G. c C � C 0 o c`c • °�i A 0 Cd w° x a°G U w a w w a W aG ,r�:: w COL n4 ii � A ° z � A G� cn rW oP W c � C ` y O C VV G. c C � C 0 o c`c • H � EQ u ..O �• � ci O0 ,r�:: COL �r c � QO : G� �: 4( :mcm CLom y ' v O c` N O 0 3 o.3 ;o c y O aL-) O H O O C C yQ dCt O O HE A Z � • � O C O C p S m CL._ V1 W 4- A =a m W E ���� =3 Al c� K `8' S2 N s N 7 2 sam N Z H cm C 7 m S c" C m O cm C CD qC N Z O Z 0 8 O Cn O 0 0 z O U pQG tzl lid 4 0 O as • V Z °L CL O y � C CM O CO) 0 CA MO MMO Fco CD W W CL. .0 O•a O � i �a CMQ ca C C C Cc ■ CD C ' z 0 CL C3 CO) c C ■ C _cc 0. CO) D FORM U - VERIFICATION FORM INSTRUCTIONS: This form.is used to verify that all necessary •approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT:oI 'Thain Phone b3�77 LOCATION: Assessor's Map Number Parcel T, Subdivision PA-Ae. L,, l Lot(s) Streetl�l'lP,t.J� lg1V�,�j St. Number ************************Official Use Only************************ REg=fENDATIONS OF TOWN AGENTS: Date Approved -+ Co servation Administrator Date Rejected .Comments C a Date Approved �- ._4 Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected Date -Approved Septic Inspector -Health Date Rejected Comments A Public Works - sewer/water connections 4 Llsb7- - driveway permit LTJ �1) 4IlA/�2 '!9 Fire Departure t 64nt� JIY_4� Received by Building Inspector Date Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) JLA k -le Map and Parcel : urpose o implication (check below) Phone Number of Applicant: � Single Family _ Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in e�xisten as of the effective date of this by-law, provided that no additional residential unit is created. lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent Te—duction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adyacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building penmits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit iE allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information,_.or the checking off of an above item which does not comply, whether done to my knowled .ngrounds f refusal by t Building Department to issue a Build* g Permit. Signature of Owner or Auth rize ent who signed a Attached Building Permit ate This form must be attached t e Building Perm upon application for such permit. 4 x CERTIFICATE OF USE & OCCUPANCY y. Town of North Andover Building Permit Number 176 Date1�rI9 THIS CERTIFIES THAT THE BUILDING LOCATED ON- 7 O Wr,,t 0'44e feieA y i� A MAY BE OCCUPIED AS ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO ADDRESS f w fl LM iw v v ,;Zv V, i"� Cd �N fale r z � E ~ 0 C2 v v ,;Zv V, i"� rA� w O O H 6 z c o CD c � o LS e c � O C at: J'wV G� :a= ,10 Ca •m m o o a E c ��o m y cw U) CO r-1 "4t; C" :� • O c E �Hr o m O 3 N (a \' t r.+ cwt � C .0 m O a m E� 0 p ao � � m y0m CC CO N o m = 3 c 'S o' 3 c s CL . o W � C .� ui .� L.s a O W gli p Ciam 0 F 8 �m a G C 09 I'O v u 0 z 0 U Cn 0 I CCm O•— N3 'fl O y O O m CO CD 0 CD COL Q 0 CK CMQ Q � •v c cc di c Z 0 CL V H O C cc COCL 0 GG ,7I xW •0 w NGOPQ a w O w Ow w a chi a g C w° 04 � U "� w a Ow o°G w w w w o°G w w� z cn .� cn w O O H 6 z c o CD c � o LS e c � O C at: J'wV G� :a= ,10 Ca •m m o o a E c ��o m y cw U) CO r-1 "4t; C" :� • O c E �Hr o m O 3 N (a \' t r.+ cwt � C .0 m O a m E� 0 p ao � � m y0m CC CO N o m = 3 c 'S o' 3 c s CL . o W � C .� ui .� L.s a O W gli p Ciam 0 F 8 �m a G C 09 I'O v u 0 z 0 U Cn 0 I CCm O•— N3 'fl O y O O m CO CD 0 CD COL Q 0 CK CMQ Q � •v c cc di c Z 0 CL V H O C cc COCL 0 ,7I xW •0 NGOPQ w O O H 6 z c o CD c � o LS e c � O C at: J'wV G� :a= ,10 Ca •m m o o a E c ��o m y cw U) CO r-1 "4t; C" :� • O c E �Hr o m O 3 N (a \' t r.+ cwt � C .0 m O a m E� 0 p ao � � m y0m CC CO N o m = 3 c 'S o' 3 c s CL . o W � C .� ui .� L.s a O W gli p Ciam 0 F 8 �m a G C 09 I'O v u 0 z 0 U Cn 0 I CCm O•— N3 'fl O y O O m CO CD 0 CD COL Q 0 CK CMQ Q � •v c cc di c Z 0 CL V H O C cc COCL 0 / w z 0 I c�I 2a �.o ' QE» C C Q 1 r I I L�-c I I ( I c/i �j � alow rh Z f' C13 M bo / � � f- `�,•'�''� " �; 1 +off F / w z 0 I c�I 2a �.o ' QE» C C Q 1 r I I I I ( I . a rh Z f' C13 M bo / � � f- `�,•'�''� " �; 1 +off F T•� T y h h♦ i h ik ! c Z t • - '�. '� 'tis •� '���r �,�G, .' � �° . *+�?�• ;'. ,%+�1a.......e�.`^��r ps I I c�I 2a �.o I N 'I. QE» C C 1 r I I I I ( I . a omv `y q �•i • • 1.1 • ,•:• : •s • 1• + i j•�: 1 • 1 • t J r V uC_Y,ve vj" v � a° _ocation Date 353 No. TOWN OF NORTH ANDOVER �-� Certificate oj Occupancy $ Building/Frame Permit Fee ---� Foundation Permit Fee Other Permit Fee TOTAL Check #(=_ f Building Inspec�or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 39,3 DATE ISSUED: a Q _/y 3 SIGNATURE: Building Commissioner/IREMtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 // Assessors Map and Parcel Number: Number Parcel Number OMap 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �- utkl G�Otvr l rrusf �se 1, �. urrw 1%r.�-vusfee- 7U �uC1-i f�C�e�err L �iHe, �o �M�ovP�1 A48 Name (Print) Address for Service : 7zS- 6 6 3- SignalUr Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construc.ion Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Ma M Z 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 ❑ Snecifv Brief Description of Proposed Work: V' i a i- - x. I L' -�--J ,p C- I SRCTTON 6 - FSTIMATF.D CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 nJ� 7 3 Plumbing Building Permit fee (a) x (b) — 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ISECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Herby authorize 'i `./ to act on My ehalf, t alLniatteTs relative toork authorized by this building permit application. IZ241a3 Si i ture of Owner Date SE TION 7b OWNER/AUT14OkIZED AGENT DECLARATION Se k E . a r r4 V / r. 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 oSee C . AAKrrgK� of /Z 11°3 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TFvIBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IIEIGHT OF FOUNDATION THICKNESS S V E OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM • • , �1 �, 1 INSTRUCTIONS: This form is used to verify that all necessary Boards and Departments having jurisdiction have been obtained. This does not from the applicant and/or landowner from compliance with any applicable or requirements.qnot relieve HirirLIt;ANT FILLS OUT APPLICANT '\1 a J C PN LOCATION: Assessor's Map Number_ �o S XPHONE(g7 ) 72 664x3 PARCEL a 1:2, SUBDIVISION LOT (S) STREET�66e n ST. NUMBER 9'C) OFFICIAL USE ONLY*********************************** iritC MENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIST f TOR DATE APPROVED Q TJCT DATE REJECTED COMMENTS- -F i'Y�oE�e,-1-11M � .� 0.1 unJ d1" f�i t(r�c� ¢ 1. :I'pSrC>n Con�{'r0�s S�C !(�� -iroM ai j aloe -A, 5,_ TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH 1"OP-M: I UH -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT Ie RECEIVED BY BUILDING INSPECTOR Revised 9\97 im DATE ;IV E. f/mow 17 KC KCEf3Ex,Qy L, A NE .. .----�,'�<�� 1, �Q. .•4�/OO 1/x',4 /Y7 �9 , STEPrl�'�ti Ae-4 -A E ,e4..5 OgrE 4 , A.VOdYf� ,ftAS.£IC.�li..f"E�TT,.f' O/6'/D SWOOHNf1S SNOSV3S ?11103 30 S32ifLLOV3f1NV14 QNV suaRbIS3Q itLI T 'XHOk M3N 'S002IH10H 0 co Za xx M kV&HDIH 7V12I0143IN SNV2i3Z3A SODS •ax03;siOnQoZIa HVIOS SNOSVHs Hnod .00 O ,t/I 9 w o� 0 o d m 0 co Za xx Sm w mW U O In Ln xIm a� 1 F I Cl G (4 N 2 5„ DEE4 N C.... 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SPACING BW HEIGHT GG HEIGHT XH HEIGHT ROOF LIVE LOAD (psf MAXIMUM WIND SPEED ROOF LIVE LOAD (psO MAXIMUM WIND SPEED ROOF EXPOSURE LIVE B C D LOAD (Mph) (mph) (Mph) (ps MAXIMUM WIND SPEED EXPOSURE EXPOSURE B C D (mph) (mph) (mph) B C D (mph) (mph) (mph) WCLT 3 ':: 3 318'.' 2 -T314"" > ,::2401 190 < : a45. ,:: '<i30' .;':240 :'i 185r .;140) t'- 125k 240k . _: a55..:.:,,.120, ­l. 405, WCLT-5 3 3/8" 2'-7 3/4" 105 170 130 115 100 160 125 110: 97 130 100 90 WCLT-8 3 3.18.. =2 7,3/4: r .>554 155 ;>:i20 .. ,a: :105: ° >:52s 145,` a 1�Q `;100./ ,49 : f' a 155 ., 90 :;80... WCLT•10 3 3/8" 2'-73/4- 2-7, 3/4 30 72 140 105 95 ;.. i40` :105 , i,95?.,.<68 28 130 100 90 26 :130„ , ":100> „b 9Q, 65 100 80 70 8100 ; : 80 70< WCLT-13 3 3/8' 5 T-7 3/4 16 130 100 90 130 700 80 16 A2G 125 95 85 16 ` s:,125�T 95/ti '1 +4� 40; 100 80 70 `` 100?a x:` 80. 70> WCCT3. 33/8:". :'3 13/4:. "200; ? "-175 1 :.,135. �,cE20tx t;; 200* � ":170.. r "t30 ?; 1A5x; . _200;..;'.' 145 , 110?;; .100,.' WCLT-5 3 318" X-1 3/4" 95 160 125 110 92 155 120 105 80 130 100 90 WCLT-8::: 3378' 3'43/47:,+:,, 45=s }''140, :. 105 .. :95 r ..43,...:140x, WCLT-10 3 3/8" 5"' ' . T-1 314" ' ,... X-1 3/4 . 25 60.4 , 130 100 90 r`:°'131. i00 <.:;' 90 .� 23 58 130 100 90 21 _.. 130 100..t4`53,: . 100 80 70 70 WCLT-13 3 3/8" 5": ` T-1 3/4 3 1 3/4 14 36)` 115 90 80 1251 95 / i.:;85i 14 u` 35 115 90 80 13 1251 ."95 '85i x=33 100 80 70 ( 400. ' `, 80? 70"' EXPOSURE B - RESIDENTIAL AREAS, EXPOSURE C - OPEN TERRAIN AREAS, EXPOSURE D -AREAS WITHIN 1500' OF OCEAN 0... _ u?:%"� �.nncuu 15 rarroFlEllu rc,alE. ncE>rcn ALABAMA ARIZONA ARKANSAS ~ILLINOIS IOWA KANSAS ni'i-A MISSISSIPPI MISSOURI MONTANA tvCE FIS rll�l \" Lt ffhA` e :f 5 c ?'p `�'1'CINtEQ� •-re..L`.: ��o- �'ii�� NORTH DAKOTA OHIO OKLAHOMA tom- ., �-: 7. �/•r•�• +M.c/" "�'rlT'^ SEF'" SOUTH CAROLINA SOUTH DAKOTA TENNESSEE r watt vu''. r• VIRGINIA WASHINGTON WEST VIRGINIA CALIFORNIA COLORADO CONNECTICUT 111111//r w w 3 ,�� 1.E 11,,, KENTUCKY LOUISIANA MAINE -esJ°�fE�`A•i ��r�"i VI. '�7 uw.ace z pkv - nwfea earn � Q CMI\ ' �"'hvxE�� M.� NEBRASKA NEVADA UTAH VERMONT �.+o° s� M! 1 [Ir dfi ;t �v � y OREGON PENNSYLVANIA idw+d�we_n y5 70219 m...y��tii TEXAS mss. WISCONSIN �.Iw w+� . [RJ61 NEW HAMPSHIRE tNCF l�S� � 1 IA.14r1 L PUERTO RICO u 0 UTAH VERMONT �.+o° s� M! 1 [Ir dfi ;t �v � y F`'faf,En°+P �'EorFEo WYOMING n r �Kll,� O R C -� 4� z 7dr�W�� DELAWARE FLORIDA GEORGIAIDAHO '-.+��RT1'f•• •F �1'..•'�.�.4� Iv.w..vr wn.:. v:. ..-.... 111x.\C,� Vii.. i f\"' .L.. rtO� r. i'�•3 MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA nsof n[tx. gnpnP •10E�15� NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINE NOTES: 1) BEAM MATERIAL LAMINATED NORTHERN PINE. 2) DEAD LOAD OF ROOF SYSTEM IS 7 PSF 3) CONNECTIONS TO, AND ABILITY OF EXISTING STRUCTURETO SUPPORT SUNROOM MUST BE EVALUATED SER4RATELYI 4) ENGINEERS CERTIFICATION: I LAWRENCE FISCHER CERTIFYTHAT THESE ENGINEERING SPECIFICATIONS HAVE BEEN PREPARED UNDER MY DIRECT SUPERVISION AND THATI AM A REGISTERED PROFESSIONALENGINEER IN THE STATES SHOWN. =r.- -- The Commonwealth of Massachusetts ' � .ss•r. Department of Industrial Accidents ON= 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affldavit ::tore ocinon �tjv phone e O I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity �9taatt�a ® I am an employer providing workers' compensation for my employees working on this job. comniny nnme• Maw marmime address: Nmdm.. &.�.& rWnewT, UMMACHUSETM 01M cif T@L ('riM =.6399 fit f9781ge phone a insurance co. Travelers Cyd, 6KUB 957X8951 jg I am a sole proprietor genets contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: Severini & Associates address: 80 Westech Drive city: Tyngsboro, MA 01879 'bhonee (978) 649-2889 .nsurence Co. Travelers ICE -.UB -762D646-6-02 �74+��st+aaase�atatz:an iL—SY Company name: address: one years' imprisonment as well as ei4il penalties is the o m ofa STOP WORK ORDER end s flat tion otS100 0 a dayagainst Of a flue 1 understand to 00 rr hat 11 copy of this statement may be forwarded to the Office of lavestigatioas of tha DIA for coverage verification. l (to h ereby certify under the pains and penalties of perjury that the Information provided above Is true and correct. ,�{{�� Signature . CA)IVC �lt�hr � �NCOrdAr� r/I (/� 1Late Print name E. A. Klemm hone M (97 8) 535-5399 off cial use only do not write in this area to be completed by city or town official city or town: permittlicenseN nBuilding Department p check if immediate response is required OLicensing Board Oselectmen's ofrice Oklealth Department contact person: hone N• P pother —L ) fie c H -tet Ld t ` VJ D1 w Y � to y r ch o ,¢ LAI w _1 V7 p Q W fie c H swooaNns sxosv3s ano3 ao saafilovdnNvw axv suallots3a TUTT 'AHOA 113N 'x00HEnOH .IV,QHOM 7VIHOw3w SNVH3laA SODS •aZIoD sianQoxa HVIOS SNOSVHs WIOA N �.1 ]z Y > T r 2 I. Of u m w I z 0 7 ozW Y Z U W U N O d N Y > T r 2 'n L>7 W ^ •O o. fi '� * 2Q� . • •p .G . n Y \ \ .\! . Qm Y • . ¢T \ \ M M > \ \ 1� P¢D NIn. n ti\ V Q SZ p¢q 1! W r W q ^ K = N M M ,N, �, • .r o 0 r \ NNN \ NN \ vv rr v ^^ N M X X X M M M* M OI f\•1 %% X x In M O W� x x %X l�W m w N ^ • •D i t ^ 1 •• 00 n f` I •0 ^ V1 ^ N-• ;u 1\0 \ < N m \\ mK M- \\ �� 00 X X N N-• \\\ J Li Li q Z T \1�1n r J ... 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V) [L H a :co w :a O O 0 a :w 2 � z J : O H : A 7 c 0 v c3 � C7 a ac w ..0 fd s : m o _G A7 : p 1 ii N 7 mCS O h: z ; s*C' m c�r VJ lC m m m CL L; C �: H '_ O � : 3 \ pG CO O vJ z , o O �Em W U m o � ♦ H m m � r^ N k o oQ W W cc m t' IS ?z o C O` G cm Q r.+ CID, CL y m C C S m :m�3 O N oo �- m m W OCO) Mz m •.� C y.., O �. CO) d L C ow. m•H Z O LU V p m C VD C a m� ��25 OM = Q H a w O a � z A � a w ..0 fd O _G CD 0 E CDO O C.) Z o Q CD O t/! C C I Ccm V! G :2 CD i O GD CLCD ~ O CD O L �C O d 2-L vs Q N! C O O V J 'C 'a o a? c Z CD v CO) C� cc CL is v O E 0 U) C/) Ir w w Irw 0, 1 ... .... ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING T'h �s certifies that . I ..... t 1 ......... -f,- � *** .........., - ................. 4S.Pernlission to perform.... ..................................... "ring in the building of ........ ............................................... .............. .. ....... . ........................................... ................. ...... ms. .e ..................... Lic. p4p ...... I North Andover, A4,us. 'Ck jY -7 .... ... :............ THE COMMONWE 4L"I H OFAMSACHUSEM Office Use only DEPAR7111VT0FPUX1CSA= Permit No. BOARDOFFMPREVF.IV 70NREGUTANONSR7OMl2: O Occupancy & Fees Checked APPLICATIONFOR PERMITFTO PERFORMELECFRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 c//� JO (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date J / 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) / f� �IJG �l to Q ��� Z 4 o -e Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) 3 g•3 Purpose of Building ,J)U/e //t✓Jg Utility Authorization No. Existing Service Amps / Volts Overhead M Underground No. of Meters New Service Amps / Volts Overhead r1 Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work W 1V -e T eu/ o c7i tLern.4/4 • —/yfrT %riffP No. of Lighting Outlets No. of Hot Tubs No_ of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round and No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No.. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal _ Othe No. of Dryers Heating Devices KW I E3 Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- hmtranceCovsage. Putsuanttothem4mmie dNla%adiseusGe rrAl-aws IhawaaaaatLiaW maaroePblicyi duJWc xrpice ageoritsst>b&cfia1o#vabt YES F1 NO Ihav,tsLimA dvafdptoofo(sametntheOffoe. YES L2 j—lah F)mha%edniodMN,ple�eitl� drtyMOfcov�by ox �J cliedd�?:the b�LJJ N&UN �Nm FFr BOND OTHQZ (PleaseSpet fy) c ExptrdhortDra� Estffn*d Value ofE7edrical Wcdc $ 60 0 WodcoStit htspecfimDa1eReqtrsted Rough Final i' mw\Tel 1% • tl U' I I' I a I - •: • • t:. • . I .i c •• • . a.•ar.: I. :• I :• n:• • %.: sett and that my sigww on this pe m ut application waives this Iewmanent ,Please check one) Owner Agent ape Telephone No. PERMIT FEE $ `� ionn nrp n' xxlnpr nr A opn Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance. Co. Policv # Company name: Address City: Phone #. t Insurance Co. Policv Farkue to segue coverage as required. under Section 25A or MGL 152 can lead to the imposition of airninal penalties of.a fine up to $1,500.00 and/or one years' impmommntas_metLas_and.penarim-olbeimn-faBTQPV1DWDRDERand_aliine-fA$lJDD-00)-a day againstmm 1 understand that a copy of this statement may be forwarded to the Office of Ions of the DIA for coverage verification. / do hereby cerfory under the pains and penalties of pegiffy that the information provided above is true and cwD& Signature Print name Official use only do not write in this area to be completed by city or town officiar City or Town PernAfticensincl E] Building Dept E)Check if immediate response is required .0 Licensing Board E] Selectman's Office Contact person: Phone #.• 0 Health Department n Other 'Ode Er apo Code Start :P84S OPOC Staple GidejS Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 DEP File Number: i0cor, 949.47:, rrovlaea oy ucr- A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the computer, use Dalton & Finegold, LLP attn: Katie Rando only the tab key Name to move your 34 Essex Street cursor - do not use the return Mailing Address key. Andover MA 01810 City/Town State Zip Code t� 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Wilmac Realty Trust RAM Name September 20, 1989 242-475 Dated DEP File Number 3. The project site is located at: 79 Huckleberry Lane (Lot 10) North Andover Street Address City/Town Map 65 Parcel 216 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner (if different) Essex Northern 3024 208 County Book Page Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 1/12/16 Date wpafrm8b.doc • rev. 5/29/14 wPA Form 86, Certificate of Compliance • Page 1 of 3 L11Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands I orinfi� L DEP File Number: WPA Form 8B — Certificate of Compliance '°cow' Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 242-475 Provided by DEP B. Certification Check all that apply: ❑ Complete Certification: It is hereby certified that the work regulated by the above -referenced Order of Conditions has been satisfactorily completed. ® Partial Certification: It is hereby certified that only the following portions of work regulated by the above -referenced Order of Conditions have been satisfactorily completed. The project areas or work subject to this partial certification that have been completed and are released from this Order are: PCOC for 79 Huckleberry Lane (Lot 10) only. ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above -referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring that should continue for a longer period). Condition Numbers 53 C. Authorization Issued by: North Andover Conservation Commission This Certificate must be signed by a majority of the C copy sent to the applicant and appropriate DEP Regii re ional-office-for- o -cit - r-town.html . Signatures: qss�:olD e ofonce )rvation Commission and a Office (See wpafrm8b.doc - rev. 5/29/14 WPA Form 8B, Certificate of Compliance • Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands r;`L DEP File Number: WPA Form 8B — Certificate of Compliance 1'CC) C' 242-475 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP L i - D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. -------------------------------------------------------------------------------------------------- To: North Andover Conservation Commission Please be advised that the Certificate of Compliance for the project at: 79 Huckleberry Lane (Lot 10) 242-475 Project Location DEP File Number Has been recorded at the Registry of Deeds of: Essex Northern County for: Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant wpafrm8b.doc • rev. 5129114 WPA Form 8B, Certificate of Compliance • Page 3 of 3 Date .7��//k ............ - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that X C .14� J/.. lel. 0. 4 � � ..... ... has permission to perform ...... 141 ..... v/W�*—" ... ........................... wiring in the building of ..... at 7 North A nd ov er, Ma s s ................................................................... ...... ........ . . No 35 Fee.../.� .......... Lic. No . .................................................................................... ELECTRICAL INSPECTOR Check# r �.BOARD OF FIRE PREVENTIONREGULATIONS urnclal use vmy Permit No. _ F�6% Z' l Occupancy and Fee Checked [Rev. 1/071 (leave blank) - APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: January 18, 2016 City or Town of: North Andover, MA To the Inspector of Wires: 3y this application the undersigned gives notice of his or her intention to perform the electrical work described below. : ocation (Street &Number) 79 Huckleberry Ln owner or Tenant David Bender Telephone No. (610) 304-8085 owner's Address 79 Huckleberry Ln Is this permit in conjuncti9p with a building permit? Yes L] No 'u!' (Check Appropriate Box) ?urpose of Building_ 5�. / Utility Authorization No. Existing Service Amps / Volts Overhead ! i III Service Amps / Volts Overhead ' --f number of Feeders and Ampacity : ocation and Nature of Proposed Electrical Work: Undgrd[-, No. of Meters Undgrd L J' No. of Meters Installation of a low -voltage, wireless burglar alarms stem. Completion of the following table may be waived by the Inspector of Wire 1o. ARecessed Luminaires No. of Ceil: Susp. (Paddle) Fans o. of Total Transformers KVA 1o. of Luminaire Outlets No. of Hot Tubs Generators KVA 10. of Luminaires Swimming Pool Above D In- (� nd. grnd. o. of Emergency Lighting Battery Units 1o. of Receptacle Outlets No. of Oil Burners FIRE ALARMS o. of Zones 1o. of Switches No. of Gas Burners o. of Detection and Initiating Devices 1o. of Ranges No. of Air Cond. Total Tons o. of Alerting Devices g io. of Waste Disposers Heat Pump _Totals: umber onso. rw of Self -Contained Detection/Alerting Devices 1o. of Dishwashers Space/Area Heating KW Local Li Municipal ( ; Other Connection 1o. of Dryers Heating Appliances KW Security systems:* No. of Devices or E uivalent To. of Water KW Heaters o. of No. of Signs Ballasts ata Wiring: No. of Devices or Equivalent 1o. Hydromassage Bathtubs o. of Motors Total HP elecommunications Wiring: No. of Devices or Equivalent )THER: Attach additional detail if desired, or as required by the Inspector of Wire. ;stimated Value of Electrical Work: $850.00 (When required by municipal policy.) Vork to Start: January 18, 2016 Inspections to be requested in accordance with MEC Rule 10, and upon completion. NSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless ie licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The ndersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. ,HECK ONE: INSURANCE ! BOND OTHER + (Specify:) certify, under the pains and penalties ofperjury, that the information o his a plication.'s true and complete. 'IRM NAME: Defender SecurityCom an LIC. NO.: C 1355 ,ic,ensee: `W Signatur . NO.: D 434 If applicable, enter "exempt" in the license number line.)_ {' Bus. Tel. No.: 800-689-9554 ►ddress: 3750 Priority Way S Drive, Suite 200, IndiangRolis, IN 46240 Alt. Tel. No.: 866-502-3559 Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SSCO-001258 )WNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally -quired by law. By my signature below, I hereby waive this requirement. I am the (check one) owner owner's agent. )wner/Agent Telephone ignature No. [PERMIT FEE: $ 1:143 146 4X-av 6 <t, / The Commonwealth of Massachusetts 4. 0 1 am a general contractor and I Department of Industrial Accidents have hired the sub -contractors Office of Investigations 600 Washington Street listed on the attached sheet. Boston, MA 02111 >f` wwx.maSS.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Defenders, Inc. dba Protect Your Home Address: 3750 Priority Way S Drive, Suite 200 Indianapolis, IN 46240 Phone #: Are you an employer? Check the appropriate box: I. N I am a employer with 3 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capaci employees and have workers' [No workers' comp, insurance comp. insurance.1 required.] 5.E] We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [ Demolition 10.1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 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 submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: IVl J Insurance Polity # or Self -ins. Lic. ##: TCJ UjB 1116 LO3015 Expiration Date: 07/01/2016 Job Site Address: 7I G l City/State/Zip: _/ U?L15 Attach a copy of the workers' compensate 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 the and penalties of pe jury, that information provided above is true and correct Si ature: Date: 1/8 Phone #: q66 _ 5c a _ 3h s9 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 i COMMONWEALTH 0 -avtinu v - .E L E CTR I C-1 ANS ISSUES THE. FOLLOWING LICENSE A A. REG.I;STERED SYSTEtl CONTRACTOR, , DEFENDER SECURITY CO / PROTECT Y 0 STEPHEN C. EHRL-JCH Z' y 3750 PRIORITY WAY SOUTH'. STE.,.200� IND IANAPOLIS IN 46240-3815 1355_C 07/31/16 38220, il�i._';1:J�T._j�"u�_�w •:,`.3 �:,'`.'..4tl vJi._ ,2,i:�d��::s" BOARD OF EIECTR I GI ANS ISSUES., THE FOLLOWING LICENSE A REGISTERED SYSTEM TECHNICIAW. STEPHEN C EHRLI.CH ew to 369 CENTRAL STREET z UN I.T . 9 =OXBOROUGH: MA 02035-2637 434 D- 07/31/;1:6 45560 SSCO-001258 STEPHEN, C EHRLICH' 3750 PRIORITY WY S DR #200 { INDIANAPOLIS IN 46240 12/03/2016 CONTROL # IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at mass.gov/dpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on 'your person or posted as required by law and/or regulations. CONTROL # t 3 �' !� ;3 Z,, b, , IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at mass.gov/dpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. Employer: DEFENDER SECURITY COMPANY For DPS Licensing information visit: www.Mass.Gov/DPS NOTICE OF COMPLETION OF ELECTRICAL WORK Pursuant to M.G.L. c. 143, § 3L, Stephen Ehrlich hereby provides written notice to the inspector of wires that the electrical work outlined in the preceding permit application has been completed. Po BOX 55098 Boston, MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall N ANDOVER, MA 01845 N ANDOVER, MA 01845 RE: Insured: DOUGLAS MAY and JOANNE CUSATO-MAY Property Address: 79 HUCKLEBERRY LANE, N ANDOVER, MA Policy Number: HMA 0144815 Claim Number: BOS00061912 Date of Loss: 2/14/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lindsey Hodgens Claim Examiner 6/10/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3418 Fax: (617) 603-4914 Email: LindseyHodgens@Safetylnsurance.com BUILDING DEPARTMENT (ommunity Development Division Mr. & Mrs. Douglas May 79 Huckleberry Lane North Andover, MA O 1845 RE: 79 Huckelberry Dear Mr. & Mrs. May:. August 24, 2009 Please be advised that the shed on your property was installed without proper permit and is in violation of a side yard setback. Please be advised that the Town of North Andover Zoning Bylaw Section 10 (10.13) Penalty for Violation states " Whoever continues to violate the provisions of this bylaw after written notice from the Building Inspector demanding an abatement of a zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Each day that such violation continues shall be considered a separate offense. Please be advised that you have 30 days to obtain a permit and move the shed within the \proper setback. Please contact me upon receipt of this letter so that the process to remedy this situation may be addressed. Respectfully, Gerald Brown Inspector of Buildings 1600 Osgood Street, Suite 2-36 North Andover, Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com I .44 f September 15, 2009 Town of North Andover Attn: Gerald Brown Inspector of Buildings 1600 Osgood Street Suite 2-36 North Andover, MA 01845 Dear Mr. Brown, 1 would like to give you an update regarding the 8x10 shed in our yard becoming compliant. As soon as it is in compliance I will apply for a permit. Per our discussion, we will move the shed closer to our house, 9.7 feet from our/ the Traverso's property line. Our house is 9.7 feet from the property line, therefore, you determined we have special dispensation regarding the footage our shed needs to be from that property line. We expect the shed to be moved the week of Sept 21St, 2009 or the following week at the latest. Please note the attached pictures where we measured 21 feet from the Traverso's house and 9.7 feet from our house to determine the property line. Thank you for your cooperation and patience in this matter. It has b n a challenge to have it moved due to the water flow off our backyard hill and the fact that machinery c not get to the shed to move it. Thus, we have decided to move it closer to the house to meet the tow s requirements. moved. Please let me know if there is any other information I should be aware of prior to the shed being Kindly, L:::ne us 79 Huck eberry Lane o 1 1845 C- so $-ay69-z/g1s' F r U) Q w O a z a F- 0 z D J_ m H H w CL Fz 0 LL z O a V J CL M 0 z w CL z O Q O LL z H a W 0 M CwCL ti O U O O U J p m z U) g w F- F- b U) w a F- U O U O 0 J m F- m W 2 0 O cr w w a F- m O U 0 J m F- U W fn Z w (N - z O '? •1A � z U U F Z z l O 0 - F- )_ ` O u z W w p J W j U) to Z i Q U w wa 1&5 a 0 0 0 J_ J_ C = F- LL LL L 0 — N Co w w < Q Q w f U) a a < ^2 Q w V Z J (� w of W U) Q a ") 1 z pLLI Q t� Z>iU)< —i gzzElf 0 3 (/ ~, w 0OZ J mW N X� xLL000 z� BMW zo` T- oow w �" m O F- s 10 p a Co g� �0LK o� 0zzz U U U p m U�1- a(7 z zzz lL O w l X 0 X 0 p 0 O (.)9000 LL 0 0 0 U Co z zLL O U Z O LL O 0 O Z Z Z Z a LL LLD Z, , = 0 x o 0 0 0 (Y -Ow ZOQNa-w�oa W (7wwpppp cncncn<n CL z m to u) 0 = 2 _ CL 2 W Z P 0 4� LL w O �Q Z 0 w irw w N - 414 O\ U Z< C) C) O Z Z F- OJ mew a z O U >_ )WZ WXF- ZF- O Q Z p tn� QNOJ �W F- OJ m w < (Z c w Z i w o x- w z¢¢ 0-j a cn ZQ w< zF---0 0 o o a Q (o (n U)www --JZZz'ZLL 0 O Z ��F" W w W U Zzz0JJJ U U LL p p 0 F -a IL w Z w Z U_ Q p � � w m m m z U Q Q QtA�U000 O3:x=) z O Q O LL z H a W 0 M CwCL ti O U O O U J p m z U) g w F- F- b U) w a F- U O U O 0 J m F- m W 2 0 O cr w w a F- m O U 0 J m F- U W fn Z w (N - z O '? •1A � z U U F Z z l O 0 - F- )_ ` O u z W w p J W j U) to Z i Q U w wa 1&5 a 0 0 0 J_ J_ C = F- LL LL L 0 — N Co w w < Q Q w f U) a a < V Z w Q wa) •1A � z l � O (� ) if O p ) LL 0 W H Q p J W j < Ur LLF- w Z i Q U w 0 1&5 a Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property ffoir Permit (below) 71 Map and Parcel: Purpose of AWlicatlon (check below) Phon,e,Nue7 �f Applicant: Single Family — Two Family 1 the undersi3igned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the'requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existent as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. Signat re of Owner or Authorize nt who signed a Attached Building Permit Date This form must be attached to the Building Pe it upon application for such permit. 09/19/1997 11:05 508-4751448 MERRIMACKENGINEERING PAGE 02 r; t ti�0 �d �0 � 0 7- o.sosz 79 s we RICO p. 34 5, -vi o_ G_>,00 s fai.ve Wgp,p o O zs.29', ,qA/ ,N _. wtNF U.,s,� J� --•,•_� /Vp, JEFFREY ~„ O,�A/✓�t/ FO,Q S. •,. HOFMANN 36�� *v /d GL f'gR.t' .srW-4f7- .I.vvOrE.c, ,y,�s.�vcv�serrrs orsiv FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applic nt fills out this section******************* APPLICANT: Phone qJI- ZI LOCATION: Assessor's Map Number Subdivision T/ Street Parcel Lots) 10 St. Number 79 *********** ** Official Use Only************************ 7RECOMU7 DATION OF -e AGENTS: ✓ Date Approved Conservation Adminis`r or. Date Rejected Comments {y� (Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved - Da.te Rejected Date Approved Date Rejected Date -Approved Date Rejected Public Works - sewer/water connections ����i ( 7✓3 - driveway permit_ -` I �J� int f `% 3 `� 7 A 0/,k 0-761 / Fire Department Received by Building Inspector Date A �!7eornmonrr�n�,/ii a�✓„jr,�•�rrdt'ds HOME IMPROVEMENT CONTRACTOR Registration 105931 Type - INDIVIDUAL• Expiration 07/21/98 HURLEY CONSTRUCTION Thom s M. Hurley alem St ADMINISTRATOR N Reading MA 01864 f OEpARiMENi OF ?UP,LTC iAFE?'i (IN'TRU' TI' "N; ',!I"ER9!So E ;: ENSF Nu�ber. Yntr..: Bir?.hdaW nc?3O 01!14/1999 01/14/1966 P'est r icted io r. THOMAS M 'dUPLEi �I '-T �� �,�/✓ 5 Alt.. :�r,E, N RE11OINi�. i"A 01864 a cn n 0 VJ =r_ O �• N O Q SO Sm aoSo y d0 O m a� m CD CD T CD nod CL O y O -40 0 N p N O m a = > > -0 0 co a p O v 1 O �Zyn t� C13 =r_CA ' CL..-+. �o o CD m CD CL ;w LY O d N N d d j. 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C N m ? m N y 0 C m � �H G to 0"` co o G 0: :7 CD Q "b 0 o s (- rn p a =-1- m Q o Cr:d: ='OC ��. r Co .� C:rJrJ ZOO CD2m CD O = y 0 9 �7 h� �J I Z ►TJ p o {� T ro r n z Q * 3n z �7 h� �J I Z ►TJ p � 7 T ro r n z Q r O z n r w C� n S �7 h� �J I `L OR 1.7 CHECK NO.. 4299 E , ©RTH ANDOVERS Pp MEMO: �,0'� 10 EW E� iR�':C ev 4# r 1 t 194 CHECK TO,,**'* . -��_� a' ,+ 1-1 5 CERTIFICATE OF USE &OCCUPANCY Town of North Andover Building Permit Number_—�/— Date THIS CERTIFIES THAT THE BUILDING LOCATED ON_G(�C MAY BE OCCUPIED AS � IN AC ORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE SUCH OTHER REGULATIONS AS MAY APPLY. AND NORTq °.��•'° •'ti° CERTIFICATE ISSUED TO P� P ADDRESS AighgInsp=ector i 11 I'r It • O r;� 0 ui am O H O oc � O Q �a ct [--+ CD 1p cm LL co - C oo Cd a Qo V '.a w ,rO O z u LL.c9i w° U ii O Ea �� 7 ID, CF CD E m V) U) ui am O ai • �• L O V Z CD 0. 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W � o (9= U z w� 0 2 �a E ~ t3 J Q 0 o v 3 O 1 N ~ _� C: c 0 O J z > in 0 0 2 oLun > .p . -0-0 J p N o G W > > > ° > z 4- WO � ti w� ° d -d- wcii-�c J ° ° o v m U) ti J J d' W gUi ui W O II2 w IZ> � " aY www ►r0�w o ►- r- r o W CIO ��J��� U pW�U wz�w ��, 9 ....... N2 1 ,, 11 6) TOWN OF NORTH ANDOVER ISp PERMIT FOR WIRING This certifies that ............................ all ..................................... I ............................ has permission to perform ....... .......................................... wiring in the building of..... at ..... / . ....... ........................................................ North**--** * 'A' *n- Andover v**e*r",' *Mass.***** **'' 711 Fee.,. ................ Lic. No . ......... . . ........... . . .... . ..... . ....... ................. ELECTRICAL INSPECTOR Jf /9 6, 03/02/98 lo:ol WHITE: Applicant CANARY: Building Ndrt. Pn'PINK: Treasurer The Cohillionwe[ilth r.,i �1assac! �usetts j Department of i''f.lf)!ic Safra(y �EBOARD OF FiRE PREVENTION REGULATIONS 527 CmR 12:00 APPLICATION Olftce Use Ontv Permit flo._— / -- OerupRncy t Fag Checked �1?0 (1eeve blenk) FOR PI=.:RMIT TO PERFORM ELECTRIC AI" work TO bra prrfarm^d In tcclmsnr• with rhe MR,CAU14tU Elscrncal apt s. 521 CMR 12 Qp (PLEASE. r'cTittT IN I'll, TfPE ALL INFORMATION City or To. of The underrinned applies Location ('" h eel Num Owner or "9nflnt a perrnit to perform the electriczlworkdq$Crld b� -� below. Date_�� WORK To the Insp9ctor of Wires: C*A,ner's Arldre. Is this permit in conjunction with a building permit„ Purpose of Building ) (Ch --.-k Appropriate 130x) _-Utility Authorization No. E., istlna Snrvi • New Service -- AmI1s'-----�-------Volls -----_J1mps----/-----_'1olt5 Number of Feeders and Ampacity (:N'erhead IJ Undgrd ❑ --- ------ No, of M9tnro Cverhead ❑ Undgrd U ---- rlo. of ocation and Nal ­ of Proposed Elertricai %vork___ -- No. of Ilahtina Outlets ^-_- - - - - -------.-...- -- ----- -- __ ------ -- - __-__-, tJa, of Nct Tubs --- -`-- NO. o_ t L--ighting FiXt -----------.—_IN0. of Transfarmors _-_- Swimrninq Poor r�hove�� jn- t�0. of Receptacle Outlots No. of Switch Outlets No. of Ranaes No. of Disposals No. of Dishwashers No. 0f Dryers Generators ran. of Cil 13urrer5 i1o. of Emr`- -----_ KVA --- Battery g” 1 Lighting Units Na. of Gas BU�'n9r9 N -._' as Burn rs------ ----'"—`---- No. of Air Conditioners iaTAL FIRE ALARMS NO. of GCnn1 Pro. of Detection ---- HEAT-T0T.1L' TONS TUTAL and Initiating D.e vir_ng NO. of Pumps TOMS - KW ilo. of Sounding Dovices No. -- -- of Self Conrainr+d Space/Area Hearinq !L -----L____ KW Kw Delection/Sohnding D9vices (Hea_tirl pr_vices -v No. o_ f Water Heaters KW * Sof No, of -�_ S1 na,- Ballasts No. of Hydro Mas -ape Tubs --'-^---" _ -_ No.�of Motors Total HP OTHER: - - _--- L^cal LJ 1 1 Municipal low Connection Voltage Other INSURANCE COVERAGE; Pursuant to lite requirements of Massachusetts r;eneral Laws 5- I have a current Liability Insurance Policy including Co It" of rd Operations Covera r. —_—_ v91id proof of same to this office. YES p NO ❑ g- or its substantial equivalent. YES ❑ NO ❑ 1 hnave submitted If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑� BOND El rHER [J(Please Spr*:ify)_--�- Estimated Value of Electrical Work E______A-- (Expiration Dete.) Work to Start_ Signed under the penaitles of er u -r Inspection Datn '' quested; P 1 ry� Ror.tgh_ Final_ I•I^'4 NAME IJ, 'ee `S LY --- — // 1.- pO• LJ .'�—,—�— Sign:rturri},.�_ Address{- 611 r �__� lJ�t sC /�, -----'ts-dl�-- LIC. NO._Q_�l_- f; flit M�°J'rE . �r ' _ /'k - Ai f-- - `J_. - -------__E3w. tat. No.Sf'�' c; vii O',�1.<rn - ER'S INSURANCE General WAIVER: I at aware that the license e:l ,rs not heve r.t,'"'•chusens General Laws, and that my signature on this ar• I'�• Aft. Tnl• Ihe in^rrranrn cpvera171 or Its substanflal 1quivalent as rr,�rirnd by r �tlon Naives.thia rT`ntuirem;fnt. Owner Agnnt (Ple"ge check rnet pORTy\ O!��ec Ar. BUILDING DEPARTMENT Community Development Division Mr. & Mrs. Douglas May 79 Huckleberry Lane North Andover, MA 01845 RE: 79 Huckelberry Dear Mr. & Mrs. May: August 24, 2009 Please be advised that the shed on your property was installed without proper permit and is in violation of a side yard setback. Please be advised that the Town of North Andover Zoning Bylaw Section 10 (10.13) Penalty for Violation states " Whoever continues to violate the provisions of this bylaw after written notice from the Building Inspector demanding an abatement of a zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Each day that such violation continues shall be considered a separate offense. Please be advised that you have 30 days to obtain a permit and move the shed within the proper setback. Please contact me upon receipt of this letter so that the process to remedy this situation may be addressed. Respectfully, Gerald Brown Inspector of Buildings 1600 Osgood Street, Suite 2-36 North Andover, Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com 0 � BUILDING DEPARTMENT Community Development Division Mr. & Mrs. Douglas May 79 Huckleberry Lane North Andover, MA 01845 RE: 79 Huckelberry Dear Mr. & Mrs. May: August 24, 2009 Please be advised that the shed on your property was installed without proper permit and is in violation of a side yard setback. Please be advised that the Town of North Andover Zoning Bylaw Section 10 (10.13) Penalty for Violation states " Whoever continues to violate the provisions of this bylaw after written notice from the Building Inspector demanding an abatement of a zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Each day that such violation continues shall be considered a separate offense. Please be advised that you have 30 days to obtain a permit and move the shed within the proper setback. Please contact me upon receipt of this letter so that the process to remedy this situation may be addressed. Respectfully, Gerald Brown Inspector of Buildings 1600 Osgood Street, Suite 2-36 North Andover, Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com Date....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING sT This certifies that ...:.. 1�..c... ........... r...................�?�....................... has permission to perform ....... J....................../.......................................... wiring in the building of .......` ry / i/:.. Y ................................................ 7 % rT r.%fF ;/ �.1 North Andover Mass. Fee ....lc...:� Lic. No..f.�..:J�........... ..�..:.f^...... ��.......`. �n ELECTRICAL INSPECTOR Check # � 439 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 5 7 CMR 12.00 (PLEASE PRINT W INK OR ALL/j,17VFO ATION) Date: Q City or Town of: ly/Ii�� To the Inspect4 of Wires: By this application the undersigned rues n ticeo hi or per intention torform the electrical work described below. Location (Street & Number) 7 /(a�J)d I_/v I -- Owner or Tenant - Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system Yes ❑ No [V (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters _ Overhead ❑ Undgrd ❑ No. of Meters f'mmnlotinn nftho fnllnwino tnhlo mnv ho wnivoil by tho t—n—mr nr W; — No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In -170-.-01 rnd. rnd. ❑ mergencyiging Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number TonsKW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent nt OTHER: s/ Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Ele_ctrica Work: ,f (When required by municipal policy.) Work to Start: 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under th pains ndpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: 153,30 Licensee: John S. Bassett Signature LIC. NO.: 15330 (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 603 594 5928 Address: Alt. Tel. No.: required by law Owner/Agent Signature _ JRANCE WAIVER: I am aware that the Li see does not have the liability insurance coverage normally By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Telephone No. PERMIT FEE: $ --