HomeMy WebLinkAboutMiscellaneous - 71 FOXWOOD DRIVE 4/30/20186/14/2016
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20541
This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20541
OF NORTh qti
5
��SSA C HUSE��
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that Glenn B Williams
has permission to perform Installing new shower new vanities and new toilet
plumbing in the buildings of WIRTZ, MARY ELISE
at 71 FOXWOOD DRIVE, North Andover, Mass.
Lic. No. 11144
Date: June 14, 2016
Im
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
POWNER
TYPE OR
PRINT
CLEARLY
CITY �, 6 1, s t� c. MA. DATE 45" e PERMIT #
JOBSITE ADDRESS �� / " O �1.7.4 <3/ Y)MWNER'S NAME
ADDRESS TEL FAX
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: ❑ RENOVATION: �" REPLACEMENT: � PLANS SUBMITTED: YES ❑ NO
FIXTURES Z FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOILISAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes ❑ No ❑
IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the
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 o General Laws.
PLUMBER NAME �1
LIC # ��M P JP ❑ CORPORATION [:1# PARTNERSHIP E]# O LLC ❑ #
COMPANY NAME YY t _/J Zq a�J� S ` `/- ADDRESS:
CITY / K �-�X✓%�%� TATZlye —zip ��-.�MAiL
TEL r7 CELL FAX
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06/07/2016 10:22 9783733360 KITTREDGE INS PAGE 01/01
coR CERTIFICATE OF LIABILITY INSURANCE
6/7/16
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 BYE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOF_$ NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),�
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. �AUTHOIRIZED
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(es) must be endorse D, subject to
the terms and conditions of the policy, certain polleles may require an endorsement. A statement on this certificate does not con r rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
Barry J. Kittredge Iris Agency
$1 South Main Street
PO SOX 5206
Bradford, MA 01835
CONTACT
NAME: Dana Mood
PHONE FAX
N - (9781 374--8400 Noe (� 8) 373-3360
ac
DDRESS: dana@kittredgainsu;cance.com
INSURE 5 AFFORDING COVERAGE NAr.*
INSURERA: COMMOrce 11118uran,Ge
INSURED
I NSU RER B
Williams Plumbing t. Heating, Z
INSURERC;
Glenn Williams
70 Maple Street
West Newbury., MA 01985
INSURER D :
INSURER E: I
1NSURERF:
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 DE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO THE TERMS,
ILL
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR
TYPE OF INSURANCE
amL
su D
POLICY NUMBER
MWfY
MMIDLYYYPvccm YYYY
LIMITS
py
CENERALLIABIUTY
BDQZTP
1/8/15
7/8/16
EACHOCCURRENCI $ 1 OOO QOO
}� COMMERCIALGENERALLUIBILITY
DAMAGE TO RENTED a S I 100,000
CLAIMS -MADE FXI OCCUR
ME0 EXP (AryonQ pemam) $ 5 000
PERSONAL BADV INJURY $ 1 000 000
GENERALAGGREGATE $ 12',000,000
GEN1AGGREGATI LIMIT APP LIES PER
PRODUCTS •COMP/OP AGG $ 2O0O OOO
riPOLICY PRO LOC
$
AUTOMOBILE LIABIUW
•
8 BCCI OINGLELIMIT
$
BODILY INJURY (Pe rpelsan) S
ANYAUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Pereccident) S
NON -OWNED
HIRED AUTOS _ AUTOS
P e09rEcl DAMAGE S
gl
UMBRELLALIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE S
EXCESS LIAO
CLAIMS -MADS
DED RETENTION S
s
WORKERS COMPENSATION
WC STATU- 0TH -
AND EMPLOYERS' LIABILITY
ANY PROPRIEM41PARTNERIEXECUTNE Y f N
OFFICrwMEMBEREXCLLDED?
(Mandatory In NH)
NIA
'
E.L. EACH ACCs DEM $
E.L. DISEASE -EA EMPLOYEE E
Ilyya^ describcunder
DESCRIPTION OF OPERATIONS below
EL,. DISEASH .POLICY LIMIT S
I)ESCRIP,nONOFOPERAT10N5/L0(AT(ONSIVENICLES(AftwhACORD101,AAUItlormlRelrmftSchedule, Ifmares pmceisreguired)
Plumbing & Heating
CERTIFICATE HOLDER CANCELLATION
0 19,'-2010 ACOWD CORPORATION. All ri lits reserved.
ACORD 25 (2010105) The AC ORD .name and logo are registered marks of ACORD
Phone: Fax: E -Mail:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEDBEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE bEUVERED IN
Town of North Andover
ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood street
AUTHORZEDREPRESENTATN
/—
No. Andover, 1 -IN 01845
N. Dana Moody M _j
0 19,'-2010 ACOWD CORPORATION. All ri lits reserved.
ACORD 25 (2010105) The AC ORD .name and logo are registered marks of ACORD
Phone: Fax: E -Mail:
March 24, 2015
Building Commissioner/Inspection Services
1600 Osgood Street
Building 20, Suite 2035
North Andover, MA 01845
.UTIO'N'S
NOTICE OF CASUALTY LOSS UNDER MASSACHUSETTS
GENERAL LAWS, CHAPTER 139, SECTION 313
RE: Insured:
Claim No.:
Policy No.:
Date of Loss:
Property Location:
Type of Loss:
Ladies and Gentlemen:
Silveira, Jose
HC208050
H012261206
2/21/2015
71 Foxwood Dr
North Andover, MA 01845
Ice Dam
The above insured has filed a claim involving loss, damage or destruction of the above -captioned
property which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,
Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139,
Section 313 is appropriate, please direct it to the attention of the undersigned and include a
reference to the captioned insured, locations, policy number, date of loss and claim or file number.
Thank you for your cooperation.
Sincerely,
Scott Faehnrich
VERMONT MUTUAL INSURANCE COMPANY - NORTHERN SECURITY INSURANCE COMPANY, INC.
GRANITE MUTUAL INSURANCE COMPANY
U
Date ....?J'�„
i-'
TOWN OF NORTH ANDOVERP''
PERMIT FOR WIRING
This certifies that ........v/�. t4— . &c� ��'
/7
has permission to perform ................. t �2.. .
wiring in the building of . Wf 2�
at .... 7.1, . 0 . (.{l aC� .. JQ6 ... Aorth Andover, Mass.
Fee`s.�...... Lic. No`s. f ........ .
ELECTRICAL INSPECTOR }
Check #
1.12b6�
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c.143, §, 3L, the
t application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed'
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. 01 c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of -ongoing construction. activity, and maybe.deemed_bytheTnspector-of_Wires abandoned_and.invalidaf_he—.
apr she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
plication, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the. permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers Us
purpose by establishing an automatic four-year extension to certaispermits-and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008_and extending through August 15, 2012.
Rede 8—Permit/Date Closed:
_-• _ �� ote: R'eapply for new perm?
❑ Permit Extension Act — Permit/Date Closed: / " \
Cone nonwea�i o/ Ma3dae1ucse91
lug
.Ueparfi>:arsf or. -,, serviced
BOARD OF FIRE PREVENTION REGULATIONS
O--7
fficiial UUse Only
Permit No.
Occupancy and Fee Checked
(Rev. 1/07] (leave blanl:
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 MR 12.00
(PLF.�4SE PRINT IN INK OR nT IIyF g,� ION
f / f ) Date: Z ! Z
City or Town of: Not / p W—e i < To the Inspector of fres;
By this application the undersigned gives notice of his or her in tion to perform th
Location (Street & Number) e electrical work described below.
/ I k6 ��`����
Owner or Tenant
Owner's Address
Is this permit in conjunction with . build' permitly Yes ❑
Purpose of Building /}'✓I �, 1c,
E
Telephone No.
No W (Check Appropriate Boz)
Utility Authorization No.
xuhng Service Amps / Volts Overhead
❑ Undgrd ❑
New Service Amps / Volts Overhead
❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Com lesion ojthe ol/orvin table of be waived b the ins cror of Ip-,,res.No. of Recessed Luminaires No, of Ceil.-Sus .
p (Paddle) Fans T°• ° _ Tota
No, of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No.EDryerso.KW
rs
No. Hydromassage Bathtubs
OTHER:
No. of Hot Tubs
SwimmingPool Above In-
Ernd ❑ t
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. ,.,ata
Space/Area Beating KW
Heating Appliances KW
No. of No, of
Signs Ballasts
Yo. of Motors Total HP
■❑
KVA
KVA
ALARMS INo. of Zones
o.
Initiating Devices
No, of Alerting Devices
No. Of e - nntnina
❑trlunrcipai F1 Other
Connectins
No. of 1�evices
Data Wiring:
No. of Devieec
or
Attach additional derail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 0_ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the Iicensee provides proof of liability, 'nsurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cov ge is in force, and has exhibited proof of s e to the pe it issuing o ce.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)/�
I certify, under the airs a td pen t' of erjnry, tl t lite in rnratio on tis ap Ifcntlb,! is true oif,2 J� ,
FIRM NAME: v P tl on eta
��
LIC. NO.:/gJ %
Licensee* le- ki �/ �b Signature
(Ifapplicoble, est "erem r"in the License number 1' '� LIC. NO.:
Address: r Bus. Tel. No.: o
*Per M.G.L. c. 147, s. 57-61, security w requires Dep ent of Public Safety "S" License: Alt.Lic, No..:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner
Owner/Ageat ❑ owner's agent
Signature Telephone No. PERMIT FEE. S
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
h
This certifies that..
has permission for gas installation.... Pf`- .............
in the buildings
1
at .... `.. ';? ihJ dl...- ...... .. , North Andover, Mass.
Fee .... Lic. No.. t"� ... M �.................... .. .
GASINSPECTOR
Check #
8471
-`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY -� � _ p' { MA DATE {� � PERMIT #
- - -
OBSITE ADDRESS c_.. - OWNER'S NAME
OWNER ADDRESS% [,uTEL_ FAX I_
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL FJ- EDUCATIONAL RESIDENTIAL a
CLEARLY
NEW:,. RENOVATION: El REPLACEMENT: ni PLANS SUBMITTED: YES _[_-I NO
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _. I . _J
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER'
ROOM / SPACE HEATER
ROOF TOP UNIT --
TEST ---
UNIT HEATER
NVENTED ROOM HEATER
WATER HEATER _
Q THER F-
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES ZNO[�]_(
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E BOND J
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 �j__I AGENT - J
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 bes f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i 1 Pe 'in e vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME 4� �/='LICENSE # �f _ _{ SIGNATARE
MP f91 MGF 0 JP ( JGF LPGI 01CORPORATION F]# L , ... _ 1I PARTNERSHIP 0#=LLC .._'#=
COMPANY NAME: ^��� ADDRESS
CITY� ---�
� !`Cr�'?C/� _.. STATE ZIP _� /Q, ]TEL'
FAXCELL%. _..... EMAIL .-
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rpt The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington. Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Z�n Z �� trit/1 �f GL'
Address: � % A_ L A/Z l
City/State/Zip:
Phone #: 70 :2 / Z T
Are�.0 an employer? Check the appropriate box:
1
I Jn I am a employer with
4. ElI 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. ❑ I 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 required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.;4PIumbing 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
i am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /L4�-%-c K
?olicy # or Self -ins. Lic. #: m,i ,�. k4g��;L �. Expiration Date:_ f �� , � 3
ob Site Address: 1�fA City/State/Zip:
_ lDc�L=
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
T 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.
do hereby certify uncle the a`ns and p alties ofper that the information provided above is true and correct.
/ /l (
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
I
ti
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 submitmultiple 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
COMMONWEALTH OF MASSACHUS - T :S
�P.UU:M'OWBERS AgND �GALSFITyT�EF rS '
{ LICENSED qS AMASTER PL`xUMBER`_ .�
ISSUES THE ABOVE LICENSE TO
l
EDWARD. A KELLEY
3fn_I
} 57 MARhL'Y,N RD
4 ANpDVE:R -MA 01 X9
81D3`
9,429 05/01/14 183146
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,COMMONWEALTH OF MASSACHUSETTS
.�
P�LU,MBERS AND GASFITTERS'
LICENSED
E. EN'
t ENS t
ISSUES E B
KELLEY D
zm:
-51, 'MAR UY.N R
�MA 0115 0 293'
kN-I)OVE10'
�94�29 05/01/14 183146
GENERATOR
DATE:
LOCATION: A-b � v\j YA
OWNERS NAME:
I I V em 1, --
GENERATOR kw_�
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR: Ed T�Q �LV,6/
PHONE NUMBER:
ELECTRICAL
t
tRESIDENTIA�)
GAS
COMMERCIAL
LOCATION OF GENERATOR:
*ZONING DISTRICT:
*CONSERVATION APPROVA
TEMPORARY
Location
No. /art j Date L`' f 1'7
0.4 TOWN OF NORTH ANDOVER
A -
Certificate of Occupancy $
cMus
�7S'•CH E<�' Building/Frame Permit Fee $
s�
Foundation Permit Fee $
Other Permit Fee $
.41
TOTAL $ 4< , �v
Check
l 1
4 8/ " —---
r� % Building Inspector'
FA,
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE. OR TWO FAMILY DWELLING
SIGNATURE:
Building CommissionerflLi�tor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
a .230
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
0 o 0
Zoning Distfict Proposed Use
Lot Areas Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required I Provide RecFred Provided
red Provided
136�L
:2-
1.5. Flood7. eInfonnation:
1.7 Water Supply M.G.L.C.40. 54)
Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
municipal On Site Disposal System 0
19 1 1
Public Private 0
-j
SECTION 2 - PROPERTY OWNERSEE[P/AUTHORIZED AGENT
2.1 Owner of Record
/Name(Print) Address for Service
§T;gnat. 7j aelephone
Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Cons tion Supervisor:
Not Applicable 0
Licensed Construction Superviar:
S 0
License Number
SIT-, QJ
-s-9 aS--,t= 2Z—'a,
Address
q9 g
Expiratiorr,"Date.
Signature oy Telephone
3.2 Re �dTpe I ove Conl$V!
A
Not Applicable 0
y
6
Company Name
Registration Number
5> Ld
Address
'9 gel 8
Expiration Date
�7g,6 F—lLt/
Signature Tele hone
N, E
a�
C
Ob
SECTION 4 - WORXERS COMPENSATION (MG.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application.' Failure to provide this affidavit will re— sults
in the denial of the issuance of the building rmit. rr 1
Signed affidavit Attached Yes .......0 No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction 0 Existing Building ❑ Repair(s) El Alterations(s) Addition 0
' 4
Accessory Bldg. 0 Demolition 0 ..Other 0 Specify
Brief Description of Proposed Work:
is
c'
N
d
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS i
Item
Estimated Cost (Dollar) to be
Com leted by pertrdt applicant
(a) Building Permit Fee
Multiplier
1. Building
/e:), O C) O ...--
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
/a op . —
Check Number
bEU11U14 /a UWAJVXAU1nU1UZA11UA IUBE UUMPLEIED WHEN
OWNERS AGE CONTRACTOR APPLIES FOR BUH DING PERMIT
I, as Owner/Authorized Agent of subject property
r
Hereby authorize to act on
�allmattersrelat�ivetqork i orized by this building pen -nit application. 12—(01 ZtO
Si er Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
property
Herebv declare that the statements and information on the
and belief
as Owner/Authorized Agent of subject
application are true and accurate, to the best of my knowledge
FORM - U - LOT RELEASE FORM
INSTRUCTIONS- This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
.rr;......■■rr.rrr...■rrrrr/r�rrrrrr/rrrrrrrr...•■........r.r....r..........r■
APPLICANT �%N 4 4/ i C� d w e Gple PHONE %% �` � �I' ��10
ASSESSORS MAP NUMBER
19082001
SUBDIwSION fW �CLV vo C LOT NUMBER
STREET STREET NUMBER
OFFICIAL USE ONLY
RON ...............■................................................
RECOMNIENDAT'IONS OF TOWN AGENTS
,.... �..... .. T
`... rr. ■...1 ............./ i.. r.. .. ...... ..
DATE APPROVED....... .... r.■... ■.
^ i� J Y` G 4
/CO SERVATION ADM %fISTRATOR
DATE REJECTED
COh*&NTS N d (;d
DATE APPROVED
TOWN PLANNER
DATE REJECTED
CONIIvIENTS
- --- --- --- ---- _ - ------------------ -----DATE APPROVED--- --------- - ---
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR - HEALTH
COMMENTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
COMMENTS
RECEIVED BY BUILDING INSPECTOR
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
�eq—���
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A.t/DOYE.� /y1.4S,S,4lf�l/SETTS O/8/O
�'t�®�Z13
Name:
Location:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
F-1
I am an employer providing workers' compensation for my employees working on this job.
Comany name: C=;te=4 ,r -e_ .t.0 X.ktP=C:5� e
Address
g;�.4q�8'
I
Company. name: -
Address
City Phone #:
-•-- -• -•--------- -----
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certiry under the pains 'and penalties of perjury that the information provided above is true and correct
tf-/3-0
Print name /1 o in 9 k -T D'9 I c- z- Phone # 9 7 !9 6 S.;-
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
❑Check if immediate response is required Licensing Board
El Selectman's Office
Contact person: phone #: E Health Department
Other
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1
Location 1 7/ fo
No Date
°"T" TOWN OF NORTH ANDOVE
4,
r W
p Certificate of Occupancy $
Building/Frame /Frame Permit Fee
t 9 $
_
�A MUS ��L :Foundation Permit Fee
• ; s Other Permit Fee
Ad. Sewer Connection Fee $
'
Water Connection Fee $
AQ 7 7•
TOTAL
ildi
S ��
Ins ect0
fls� Div. ,u
9c Works
Location
No.
2
Date 4 J—
TOWN OF NORTH ANDOVER
'Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
r)th,zr Permit
U
iliaJ.
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
Building Inspector
06/27/95 13:52 150.00 PAID
8657
Div. Public Works
o f CXXA rX �... -.
_Location-
4 No. Date
TOWN OF NORTH ANDOVER
Certificate of, Occupancy $i
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ 3
Sewer Connection Fee $
Water Connection Fee $ 1
I TOTAL $ -
4' .
1(0(0 Building Inspector
07I11/95 14e56 1,382.00 PAID
I Ta 8656 Div. Public Works
PER -MIT NO. 4 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
0
PAGE 1
MAP 4-40.
LOT NO.2
I5
RECORD OF OWNERSHIP IDATE
BOOK
:PAGE
ZOiVE
DI L T
o t
Lf1 F
—
LOCATIOPURPOSE
OF BUILDINGr of ^'`
OWNER'S NAMENO.
OF STORIES - /L. IZE
�•A �'
*JWNER'S ADDRES
(d
BASEMENT OR SLAB733
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST /J , 2ND
j
j��� 3RD
,•l
BUILDER'S NAME T I (_,, 1
/ y "
SPAN %
DISTANCE TO NEAREST BUILDING
/
-
DIMENSIONS OF SILLS
DISTANCE FROM STREET
'" POSTS
DISTANCE FROM LOT LINES -SIDES
REAR o
[`t V
GIRDERS
a'
AREA OF LOT !� rl
FRONTAGE
HEIGHT OF FOUNDATION C7'II THICKNESS
-V
IS BUILDING NEW i' ® S
1 /L
SIZE OF FOOTING /` x
•P
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Ye
IS BUILDING CONNECTED TO TOWN WATERS
BOARD OF APPEALS ACTION. IF ANY -
If/ d
`V rJ
IS BUILDING CONNECTED TO TOWN SEWER
.dt
ce/S'
IS BUILDING CONNECTED TO NATURAL GAS LINE
-:-INSTRUCTIONS
E BOTH BIDES PERMIT FOR FOUNDATION ONLY
\ REGULATED BY PARA, 114.8-S. B.C.
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12 -
- DATE FEE PAID Ibn,_
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
vL/
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATURE OF OWNER OR AUTF*49IZED
FEE
PERMIT GRANTED 0 PERMIT FOR FRAMUBUILDING
Im ATE; FEE .PAID::
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. fir.
4 APPROVED BY
OWNER TEL. J! � 2—ir 0 �^
CONTR. TEL. #
CONTR. LIC. N 0 `/ 3�P,
H.I.C. #
• �' 1995 On Dow (0�� Zoo Id
BUILDING RECORD
1 OCCUPANCY 12
:
SINGLE FAMILY
STORIES
MULTI. FAMILY '" .
OFFICES
APARTMENTS
r CONSTRUCTION , +
2 FOUNDATION
I
S INTERIOR FINISH
CONCRETE
PINE
a
1
2
I3
CONCRETE BL K.
BRICK OR STONE
HARDW'D
X_
_
PIERS
PLASTER S.,
DRY WALL
_
UNFIN
3 BASEMENT
AREA FULLS
V, +/, 1/1
FIN. B'M'T' AREA
FIN. ATTIC AREA Q -
NO B M'T
FIRE PLACES .
HEAD ROOM
_
MODERN KITCHEN
4_
4 WALLS I
9 FLOORS
CLAPBOARDS
CONCRETE
EARTH
B
1
2
3
_
_
_
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
HARDW'D
COMIACN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
I '
CONC. OR CINDER BLK.
WIRING
STONE OWMASONRY
STONE ON FRAME ' `
SUPERIOR I� POOR
ADEQUATE NONE
5 ROOF
GABLE HIP
10 PLUMBING
BATH 13 FIX.)
GAMBREL
MANSARD
SHED
TOILET RM. 12 FIX.)
WATER CLOSET
_
FLAT -17
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
'TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
1
TILE DADO
U \- -
`
6 FRAMING I
WOOD JOIST:
11 HEATING
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER.BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OI L
3,d
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
SLOT LINES AND EXACT, DIMENSIONS' OF BUILDINGS: WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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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 thistion*****/***t*�********
APPLICANT: x Co/
O pl '°P v c,.ei Phone
LOCATION: As=essor's Map Number Parcel
Subdivision 4-0 ia1 0e) Lot(s)
Street ± o x tA_?ae Dr / Vim- St. Numher 71
************************OfflClal Use Only*******************xx***
r
RECOMMENDATIONS F T WN GENTS:
Date ADnroved
Cons er-:ation Ad.;.inistratcr Date Rejected.
Cc-, e*
Date Approved
Town Planner Date Rejectad
Coro; e- zs
Date Approve:
Food ;nstecto_ - ealt:z Date Re-iected
Date Apprcved
Sed�_c 1nsnec"._-Hea_t:. Date Rejec:=_
PuAcrks - sewer/water connections
- dr_ve:aa.• pernit 77�<) e� A�---95
eidFirs Depar=e^t c
Rece=ved-by Building Inspector Date
,0221995
` Location f
No. Date
OO; TOWN OF NORTH ANDOVER
Certificate of Occupancy $
# Y CLI
Building/Frame Permit Fee $
,SSACMUSE� o -Foundation Fee $
Perms( Fee $ 2.,!
CD
Sewer Connection Fee $
Water Connection Fee $ CU
TOTAL $
Building Inspector
8791 Div. Public Works
KAREN H.P. NELSON
Dirmor
BUILDING
CONSERVATION
HEALTH
PLANNING
DATE
'•
120 Main Street, Olf�
.. _
NORTH ANDOVER t5oa) ssz•s4ss
r
' ...► DIMON OF
PLANNING & COi BIUNITY DEVELOPMENT
LOCATION
OWNER'S NAME
BUILDER'S NA:
MASON'S NAME
MASON'S ADDR
CHIMNEY APPLICATION AND PERMIT
r
PERMIT +
m
MASON'S TELEPHONE
G1
Lf
MATERIAL OF CHIMi7EY Y1� L-
II {
INTERIOR CHIMNEY EXTERIOR CHILIMNEY
NUMBER A1,10 SIZE OF CTT EC
THTCKi`7ESS OF HEARTH �<3
Will chimney or firec__ce ccn-f0= --o require7ents of the code and
have rules an recu�at_c:,s 'een received:
T�
DAL >
SIGNATURE OF MASON , CONTR. LIC.
rcT CONSTRUCTION CCST. CC.: RzC'= PRICE
r c
PERFEE
i1IT GRANTED S
ROBERT NICETTA, BU_.:D_•.� __�• -':VR
INSPECTED
REMARKS
REQUIRED
THIS PERMIT MUST BE DISPLAYED ON THE PREMISES
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12/08/1995 09:aB; 5086858069
c
COLLOPY
65 AYER STREET
FRANCIS H. COLLOPY
REO, PROFESSIONAL E140INEER
COLLOPY E1,51 IEERTAG
ENGINEERING CONSULTANTS
METHUEN, MA 01 8"
Mr. Dick Tobin
Foxwood Realty Corp.
733 Turnpike Street
Suite 311 MA 01.@45
No. Andover,
PAGE 02
qS_�
a.a1o•w« (508) 896.7969
01floc +5091886 9'J69
Fax
December 8, 1885
pear Mr. Tobin:
relative to the existing garage foundation at Lot 5
Z am writing I visited the site on
MA. the two cracks
on Foxcrood Road in No. Ando
oge of inspecting
DecemberVitfoun for thell- They are ]orated as »hown below in
in the garage
the sketch.
N"J6L
One crack is located the regi htlhandefcenter;
sidewallaboutand
4 foot
othreaer crack
m$ddlelocated
Jil the Ofthe wall. g
aired filling them with a
These cracks can be properlY reSikadur
xResin, which is
structural epoxy prod ctknownn Ase on tot #6 The Sikadur
wkiat I had indicatedY products for this kind of
company manufactures a number of P'
repair where you want. h rbelieve is best �suited ifor gyour repair
wall. The product which I bel This is a high -modulus, low -
work is "Sikacdur 35, Hi -Mod IAV" with a sealing & binder
viscosity, high strength epoxy grouting. cracks
adhesive. This material iO pressurean�e�eatfullndepth erepair.
in
a sYetematic fashion BO as to guar
DEC - 8 Jr.,
•
12.6-JR/1995 09:49 5066 58069 C:CILLCIP,: 161.1IE-NIIlia F'44: --IE 03
w
I know of two such companiee which specialize in this work, and
with this product line, namely*
Jager Construction Wayne Fortier
P.U. Box 325 Crack -X
Amherst, N.H. 03031 So. Natick, MA
1-800--722-0768 1-800-548-3378
1-617-235-2388
Upon inspection of the actual crack to be repaired, the Sikadur
contractor may recommend another similar epoxy product. It is my
understanding that each. of these companies stand by their work
with a guarantee.
If you have any questions concerning this matter, please do not
hesitate to call this office.
Sincerely,
COLLOPY ENGINEERING CONSULTANTS
Francis H. Collopy, P.E.
Structural Engineer
FG 8 )-'
NEW ENGLAND CLAIMS SERVICE, INC.
Incorporated 1985
���z
❑ Reply To r : Reply To ❑
P.O. B0X 345 - ' 100 CONIFER.HILL DRIVE, SUITE 308
MANSFIELD> MA 02048 N .�NV DAN�rERS, MA Ol 923
IIUN
INSSDEPENDENT DLIN,
' H .
TEL. (508) 337-8058 hoes ERS TEL. (978) 777-9900
FAX (508) 339-5835 �lWvr FAX (978) 774-9296
wrandall@newenglandclaiins. coin
RECEIVED
Form of Notice of Casualty Loss to Build in APR 1 8 2007
Under MASS. GEN. LAWS, Ch. 139, Sec. 3
LQHTe
EALTN DEPARTMENT F NORTH OF NORTH t,,NDOv'ER
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
O ,UI,A1 4 4u-, -S� ti►
RE: Insured:
Property Address
Policy Number:' 46 aD(�
Date/Cause of Loss: 67 aNws7e)4M
File or Claim Number: 13,5!k-7 !k-7
Claim has been made involving loss, damage or destruction of the above- captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
On this date, I caused copies of this notice to be sent to the persons named above at the
addresses indicated above by first class mail.
aims Adjuster Date