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HomeMy WebLinkAboutMiscellaneous - 72 SUNSET ROCK ROAD 4/30/2018Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner lo/ Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: James A. Twomey JV_ Property address: 72 Sunset. -Road Rd. North Andover, MA 01845 Policy #: 2541107 Loss of: 2015/12/02 File or Claim No. AD 1949 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, _ Ch. _139_Sec. _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. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. Cc�G 12-07-15 Signature and date KA MASSACHUSETTS UNIFORM APPLICATION FOR PERMITTO DO GASFITTING (Print or Type) Building Z� w(�nse f 126L AT: Location ✓UUr�� /'y'1'1L�a��r Date/ 2061, Permit # N 0 Owner's --��^ Name C-TQMP4 l buoyn-eq Type of Occupancy: P9�`dp2Y,'ul New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No (Print or Type) Check One: Certificate Installing Company Name Uptack Plumbing & Heating, Inc [3 COrp. 1415 Address 32 Rochambault Street ❑ Partnership Haverhill, MA 01832 ❑ Firm/ Company Business Telephone 978 372-8503 Name of Licensed Plumber or Gasfitter Leonard A. Hall I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signaturc of Owner/ Agcnt I have a current liability insurance policy to include completed operations coverage. By Title City/Town APPROVED (OFFICE USE ONLY) TYPE LIC] ❑ Plumber ❑ Gasfitter ❑ Master 0 Journeyman Signature'of Licensed Plumber or Gasfitter License Number i . ........................... (Print or Type) Check One: Certificate Installing Company Name Uptack Plumbing & Heating, Inc [3 COrp. 1415 Address 32 Rochambault Street ❑ Partnership Haverhill, MA 01832 ❑ Firm/ Company Business Telephone 978 372-8503 Name of Licensed Plumber or Gasfitter Leonard A. Hall I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signaturc of Owner/ Agcnt I have a current liability insurance policy to include completed operations coverage. By Title City/Town APPROVED (OFFICE USE ONLY) TYPE LIC] ❑ Plumber ❑ Gasfitter ❑ Master 0 Journeyman Signature'of Licensed Plumber or Gasfitter License Number Date /CJ.�%.`?�D ."/ ..... TOWN OF NORTH ANDOVE "'PERMIT FOR GAS INSTALLATION l This certifies that.. .... �/ ................ . has permission for gas installation . LA, ,/-/..................... in the buildings of fir ........................ at 0 .. • • . • ... • , North Andover, Mass. Fee. No. �. .. �s ........ AS INSPECTOR r Check # /Gj,, 5760 771ECVA MONWE4L7H0FMASS4CHU.'SE77S Office Use only DEPARTMENTOMBLICS4= Permit No. 341 (Q/j1 BOARDOFFMPREVEMONRBGUTA770M527CMR 12'Oi0 ' Occupancy &Fees Checked APPLICATION FOR PE'RAff TO PERFORMEZEC"IRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 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) 7,4 e C. Owner or Tenant ,!f GIN e Owner's Address .S Is this permit in conjunction with a building permit: Yes No o (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service AmpsVolts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity "ALocation and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA grpund El ground 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 LocalMunicipal Other No. of Dryers Heating Devices KW Connections a ,,No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER htstM=C.aa� Pursu3t1othetagtt=atsdMwmdxmMC>amz1Lam lha%eaa=tLiabldyhmiat mPbbcyirt&&gCmvide C',omageerass *,%aie t YES NO Iha%e&hniwdvdidpafofsamebtvOTm YES r7 if} uha%edxdwdYFS,pl mn&*thet)'peofwmaFbYdedatgthe IIv�URANCE BOND OTHER (Pl =Spe fy) nl) Estim*dVaiueofBmftical Work $ �Ov6) WodCbStxt h>;pedmD*Ra*xsted Rough FmW Signed unirTr Rmities cfpa*.. FIRM NAME/f / LioelseNa Lioa>.see /�< Grf � ��Cf�I CyC� � I�� �G9�✓� . Busit=Td.Na Aja -513,2 7a� ^ ,, /U! � O ?o dp AkTdM OWNER WANER,Iamm%wedxttheLi=�nutt gtheit==wvmwor9ssw0%ekitasra#WbyMwmd&f asGenaalL -4s ands un ysig�cntzpamaappficmm%%Bf�md r. m* nem \ (Please check one) Owner Agent a Telephone No. PERMIT FEE $ 3(S CCCIII N22234 AORTIi 0 Date..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that......4..* .............................................................................. has permission to perform ...... . QJ wiring in the building of ......... T t ).ow;iis..\/ ........................................... .r .n r ,p at ....... . ....... � . ��.�.t. ... .�C.1�...... , North Andoveri-Mass. Fee.. ���U.... Lic. No.... .......17.a....... ELECTRICAL INSPECTOR /005 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF11 TING (Print or Type) /;U 1? , Mass. Date cW — A000 Permit # Building Location__ 7A . ,9-r "0C 7)j) . is Name 0 y' .. Type of Occupancy O u7-SjjX New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .68,7--:1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy D( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sagent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and acc u%e to the best of my knowledge and that all plumbing work and Installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (� i Tg of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 8697 Glty/Town Journeyman O FIC SE ONLY Y • tst�Mim1 .. ■MENEENNNEENNINEN9 ..000 MEN IN MEN •• ■�������������������ron son ONOMENEMENNOMM ONE OMNI NMI monsoons 0 Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .68,7--:1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy D( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sagent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and acc u%e to the best of my knowledge and that all plumbing work and Installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (� i Tg of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 8697 Glty/Town Journeyman O FIC SE ONLY Z� O F- U W CL (n Z N N W 0. 0 O cca N) W X: U w W X N i� W Z 1I a z k Oi 11 w t -- z Q W c a a F o ca w a a z P H LL N Q J C) 0 O O W N o � W U � k • � LL O W o z a a ¢ 0 0 LL LL 3 z G O W a In U J a CL a w W LL N) W X: U w W X N i� W Z 1I a z k Oi 11 w t -- z Q W c a a F o ca w a 3463 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ;/- . :�/Gx��... ( . r ........... has permission for gas installation ... f. q.q 4 ...!"./ ............ in the buildings of ..... . ..................... . at ...,? .rte.. �/. ?.fr.. , North Andover, Mass. Fee'..-- ... Lic. No..:.. ti .:..•...% ra ., ,/'GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TOWN OF NORTH ANDOVER - BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING y. • ,`_ ,-... -;_ _+ .--: wa97��#Ir$$]r;�7a r c�--^ `row,v''� '�'r r*:7n BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building CommissioneE r of wl ' gs Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �a Sans,2� d?VL Ck � /0 /a Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1 1.7 Water Supply M.G.LC.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ ZOIle Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) for Service: p�Address Signature UTelephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ a tum ilCjuA Licensl� nstruction Supervisor: (��S( to r>rl fin. License Number Address 6"10 SJUriloa S-�- k0_(z Expiration Date (kXL&_2 i`'t A L K V 3, Signature Telephone 6 Ct 3.2 Registered Home Improvement Contractor Not Applicable 0 . 9 Company Name tnt r1t1 Registration Number" lYIt1R 3 20Q(l �j f Address Expiration Date r 13UILt..fllllu W—t"KtY i tvtt_ — Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other VSpecify Brief Description of Proposed Work: { ,'IK ctr\ inPttnc, TbJ\A4� d SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to beOFFICIAL Completed by permit applicant : USE ONLY < . 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction /�®® 3 Plumbing Building Permit fee (a) X (b) ®®®. —we 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 d00 . Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, c.J , as Owner/Authorized Agent of subject property Hereby authorize to act on My be, , in all mattew Tdative to rk authorized by this building permit application. . I �,, _ 3�) a�a Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date I NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMHERS 1 2 ND 3 RD SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Location--' �kG f No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ �'�s'••'•'<�' Building/Frame Permit Fee $ s^CHUSE Foundation Permit Fee $ Other Permit Fee TOTAL Check # 6�,T U 13758 Building Inspector/�,�(,& 3)— FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION***************** APPLICANT . _5 tu.t n f V36ryl PHONE 63y- y F -7- LOCATION: LOCATION: Assessor's Map Number PARCEL�X SUBDIVISION LOT (S)_ R-1 STREET 2a (5tkA64&_ RLKL ST. NUMBER N2— *** **OFFICIAL USE ONLY**"`*'` RErPMIVJENDAT)ONSAF TOWN AGENTS: COftERVATION COMMENTS TOW PLANNER COMMENTS NISTRATOR DATE APPROVED t l(d0 DATE REJECTED too DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH o d� SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWER/WATER CONNECTIONS 'I MAR 3 1 2000 r� DRIVEWAY PERMIT— ut�r�isa►�� !V1ENT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm DATE SEPTIC SYSTEM AS BUILT CERTIFIED PLOT PLAN LOCATED IN NO.ANDOVER, MA. W SCALER"=50' DATE:10/26/95 REV. 11/20/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. L = SUNSET ROCK ROAD p _ 9502935 --Q =100.00' y R = 60.00 a LOT 13 ip 1521 �0qk \ LOT 15 ,m 1a a TABLE OF ELEVATIONS L INV_ OUT OF HSE.=148.70 40,OOb F_ IN TANK =148.12 " OUT TANK=147.97 a IN D. BOX=147.86 ca+• OUT D.BOX =147.70 /2 END=PIPE =147.39 116C;` " =147.35 2 vent I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE11� THE OFFSETS OF THE BUILDING INSPECTOR ONLY s SHOWN COMPLY AND SUCH USE IS FOR THE .• WITH THE ZONING DETERMINATION OF ZONING 13972 BY LAWS OF�'�fC/gTE NO.ANDOVER. MA. CONFORNTY'OR NON -CONFORMITY , SAL LAND S WHEN BUILT WHEN CONSTRUCTED. lb/26195 _REV. 11/20/95 03/29/2000 15:24 19789753987 LANDMARKINS PAGE 02 /���p/� "� r A4 ORD.?'♦ r h�S-- �} iq SR s 14+1. F1 OATS(IAMIDD/YYi f aViA Sibl4d:1• 03/29/00 pRODIJR TIFICATE IS ISSUED AS A MATTER OF INFORMATION CONFERS NO RIGHTS UPON THE CERTIFICATE Landmark Insurance Agency, Inc THIS CERTIFICATE DOES NOT AMEND, EXTEND OR EALTEIR 190 Massachusetts Avenue E COVERAGE AFFORDED BY THE POLICIES BELOW, North Andover XX 01945-4190 COMPANIES AFFORDING COVERAGE Lawrence R. Michaud, CIC COMPANY A Preferred Mutual Insurances, Co. 979-690-§829 Fame 978-975-;987 INSURED COMPANY B safety Insurance Co. COMPANY Swimming pool Center. Inc. Roy Charlond C Eastern Casualty Ins, Co. COMPANY 670 So. Union St. Lawrence MA 01843 D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANOINGi 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 CLAM, CO TYPE OF INSURANCE POLICY NUMBER LTR POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MM OPM DATE (MM/OD" GENERAL LIABILITY GENERAL AGGREGATE $ 2000000 A X COMMERCIAL GENERAL LMILITY CPP 0140520316 03/01/00 03/01/01 PRODUCTS -coMP10PAOG z2000000 CLAIMS MADE [j] OCCUR PERSONAL a ADV INJURY 11000000 SACNOCCURRENCE $ 1000000 OWNER'S BCONTRACTOR'S PROT FIRE DAMAGE (Any one tin) $ EsOluded MED OAP (Any one pMtan $ Esoluded AUTOMOBILE LIABLRY H ANY AUTO 1022438 03/22/00 03/22/01 COMBINED SINGLE UMR i 1000000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Par Penen) $ X HIRED AUTOS 6 X NON -OWNED AUTOS Per (Per Irovdrrll0 PROPERTY DAMAGE I GARAGE LIABILITY AUTO ONLY • EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY, EACH ACCIDENT 6 AGGREGATE 6 11 EXCESS LIAOWL RY EACH OCCURRENCE 6 A $ UMBRELLA FORM UC0100540211 03/01/99 03/01/00 _ AGGREGATE 51000000 OTHER THAN UMBRELLA FORM 03/01/00 03/01/01 6 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY... r EL EACH ACCIDENT $ 500000 C THEPROPRIETOR! PARTHERSf6XECUTNE INS =WC9847002,5 02/28/00 02/28/01 ELDISEASE•POLICYLIMTT $500000 OFFICERS ARE: EXCL EL DISEASE. EA EMPLOYEE $ 500000 OTHER A Comasrcial Applioa CPP 0140520316 03/01/00 03/01/01 DESCRIPTION OF OPERATIONS/LOCATIDNBJYE}ZLEWSPECUIL ITEMS Swimming Pool Installation/Service/Repwir !Gfiii IFRTIa HOi,i3Eii : G . CELI.ATIOIu. SAMPLE1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAL 54u ple Cert -1-0— GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEfT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMP Y, RB AGENTS OR REPRESENTATIVES. ..-...,..:....<,.:.��,<..:::._.::..........:..,_ ....... AUTHORIZED REPWSENTA Lawrence R. Company name: Address Phone '-- insurance Co. Polio Y Failure to secure overage as reauired under Section 25A or iVIGL 152 can lead to the imp sitien era cnmir.al penalties era a tine up to s1,5co.c0 anc/cr one sears' imorscnment as'Neil as c:vii ,penalties in the f.crm cf a STCF WCRK ORCE? and a Fine cf (5100.00) a day against me. I understand that a copy m 'his statement may be for.varced to the Office cf Invesrcaticns cf :he CIA for coverage ve.riiicaticn. do heretly cenry u .der the gains and ge Ities or perjury that .he information provided aceve is .'rue and correct. Sicnature Print name WPhone = Official useanly do not wrm a in. this area to be ccmpieted by c:iy cr town c7lCaf City or Tcvn Permit/Ucensina ❑Check ,r immediate resgcnse is required Conrad Berson: ❑ Bulldtna Cept The Commonwealth of Massachusetts c Department of IndustnaUcCidentS Office of Investigations C Boston, Mass. 02111 Workers' Compensation Insurance Affdavrt ❑ Name Please Print Name: a e :1zr&PiSA- Lcc2ticn: coo /n Cii~/ I J - J ") �. Phone (—j I am a homeowner performing all work myself. I am a sole proprietor and have no one Working in any capacity CI an an employer providing workers' compensation for my employees working on this job. Comoanv name: SL�l�/'s? �f>l�r o oz— RE Address SavT/7 l%r©A/ S� Citv L��i�¢ �'� /"<i� Phone T /17f —6/r Insurance Co ` SjC��u /T G%�f� Polio/ m &)C / 0 7 70006 �a Company name: Address Phone '-- insurance Co. Polio Y Failure to secure overage as reauired under Section 25A or iVIGL 152 can lead to the imp sitien era cnmir.al penalties era a tine up to s1,5co.c0 anc/cr one sears' imorscnment as'Neil as c:vii ,penalties in the f.crm cf a STCF WCRK ORCE? and a Fine cf (5100.00) a day against me. I understand that a copy m 'his statement may be for.varced to the Office cf Invesrcaticns cf :he CIA for coverage ve.riiicaticn. do heretly cenry u .der the gains and ge Ities or perjury that .he information provided aceve is .'rue and correct. Sicnature Print name WPhone = Official useanly do not wrm a in. this area to be ccmpieted by c:iy cr town c7lCaf City or Tcvn Permit/Ucensina ❑Check ,r immediate resgcnse is required Conrad Berson: ❑ Bulldtna Cept Licensing Board Se!ectman's Of Ice C Health Department ❑ Other %N I � z o c Q ¢Z ora ►- O O Z O d C UO r. « " W � O O U Z (") c17 w U -j O U Z at O W M: ¢ J Q N O W C O J c Z Q a M ..-, C7 U Z W •.. 1 Z I ... til - CP C r � � d 3 � O 0 x> J 3 Z d' � W t/f OC ¢ J I I Q cc ' Z t Q tl N Z �g L Tj C y f = (TJ Q � C(- 4-) .t-3 0 H r% OD a1 Ld r— 1 al m E n: " (Y) 00 0 (n (n C C 0 +.; U !01` U -N CJ +� a .-( Cl F -M -c U Z p -i U Q Z o �1a (Z Of x H C ( Z (n H C a F -VCRs Li Ld Z N Z Q F �- LU • -( 1- a -C Z r? J a w L:; z C U D > 0 e*, z ►- ! C (A - U l a -i (f) 0 a C (n Ln C C a o (-TUl oaZ z4- a;M Z^ aCO7 t -I C c 1: r WS o ,`Uz'if — W LL Q Z C U Z :— > 0 > H � C C•4H Zr- U1 L1 Sp L Z a -0 Z r 3C u J.i 1 Ln a _ ' a %N MAR 29 'tea 11:54AM IMPERIAL POOLS h T N Q . ce c*� m P.2 zt!j ru h zo .-1 co Z Lo 03/28/00 10:47 '0518 786 0954 IMPERIAL POOLS -o4- H VS VILLI 1SUU6/UUJ G E'd S -100d -ldI83dWI WUGS:IZ 00, 6E adW 03/29/00 10:47 9 518 786 0954 b'd IMPERIAL POOLSNY 444 $AVE Vl1-—__,,,_ Wduualuua %D m m ¢ v 5-1OOd -IUI83dWI WdSS:IZ 00, 62 ddW s.� xz A a Ou as ^J N O z z O ° C w° v U m x a o U O a0' m w a 0 W u U W 7 a�' cn ie w p U z O iq w w A w m O z cin Q v O cn c� 0 Qc CD Cz is C� r^ i _a d O ; `O C/) N . m C 1 coO O A C C N CCU O W N E O r ev E8 QV i m cm = C IS�= c O O m 0 O caa 'y g Z o M c c c CD CDc = CD'moo N� i F- o vi os~ m • COD c ea W O �l .y at o C z y LU �E E � 0 y C W L V O._ of a� � W3 VD a m -0zipO � J qk N Cl &- y = O 1 ,.- I- G r m ` Co O E CO m O Z O C3 H Co AgE CD CL CD 0 co V m WE LLI C U) U) CC W crw LLJ VJ. ]❑ I O I< I- I- 1- I> I- I z O O LL z U) z 0 F V D H N z W Z 0 LL 0 _ �l t f oN o o� s M V Z W e } O m m m U- G 0 (A o � i CL C LJJ J LLJ w (7Q � 7� C O J_ LL IL LL 0 N IL W 0 O F W F � rc M L 0 0 U N N Z Z 0 O W m 0 u u t W W N N f W N � F F w> > 0 0 0 R W K < JJ J J m F LL LL 0N V W z x W Z 0 LL 0 _ �l t f oN o o� M V Z W LL - L -C, 0= O m m U- G LLJ (A o � CL C LJJ J LLJ w (7Q � 7� C O J_ LL > W m t LL 0 N W 0 O F N F � rc M 0 Z Z 0 0 U N N Z Z 0 O W m 0 u u F W W N N f W N � F F w> > 0 0 0 R W K < JJ J J F l7 � F LL LL 0N V W z x m W W W l7 a d a U < W F w U) < W Z 0 LL 0 _ �l �nn M V 0 0 c D z Jn 1 D01 0-{N N NrN Zm MMO DO Nzz v°c �rn XN DLq Lq 010 N°� p3m m -1zD loo tna-1 �z_ m03 'DOm �„z mW0 Lo N 0r 00 Zn Brno I.... r • -+ ?�z =v �N 0.4 mD nz 20 mm N� 00 DO 3 � II N OO O A D O v D N izzn O Amv0D NNOA A D O m W m A O O DC C3 NZ DO 0 O x> Tm n�nn"iDOvm Dm D Nxnnm ��D p 000000^0 L0 3 O00 m 3 m 1 z D N 3 `" O `. 0. x < Z N z Z A z z 0 0 0 N x 2 A O 3 W A m v Z D 3 0 AQ°¢ m N w zm Glz r N �.% p 0 3L)A3Z>ZZ-^vZZ� ADZDD 3 O 30� D Z 00 D > Z O n c N <{ a a O 'T O rn0 n D 3 N 3 x NmDo Q TZJO m O N A30 0 N r 3 m v y 0 N z10 o { { N ~ { D x { Z . 0 I111'I Z O O r DN ZyT A D DO_ m3 0HG< vr On< 3Ati D Ax yrF za w D 0y D C v c D D n O x Dn D O W O z „D z zO cZvA`D vA i y NN nH xTZ nA AT= O xD n 3AZ OD _ m ti Z O D m zNz y AOD O D p SO m ZD vYm 31 ' NO mD � 0 Om{ nam zv r)OA vD<xC 0M ? :' O X w3Ate n N m D p Z N~ O Oz<Al m D z m ~ZI G) 7C N yx C c D m D p I �jw I I I Iw OA ATOO TA Z O O Z II II��II II I" 0 0 c D z Jn 1 D01 0-{N N NrN Zm MMO DO Nzz v°c �rn XN DLq Lq 010 N°� p3m m -1zD loo tna-1 �z_ m03 'DOm �„z mW0 Lo N 0r 00 Zn Brno I.... r • -+ ?�z =v �N 0.4 mD nz 20 mm N� 00 DO 3 � II Location Z- CU�i&0 20CAC PZ) No. Date ci 11'" TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ 0 — �ss�c„�SEt Foundation Permit Fee $ Other Permit Fee' $ Sewer Connection Fee $ Water Connection Fee $ 2—( 30— 0Building TOTAL $ Building Inspector 10/30/% 14:50 ' '% 7 8747 21130. oo Pain ` Div. Public Works Location 72 (13 4SE-T ex -16Z 'i<p No. Date H°"'" TOWN OF NORTH ANDOVER 3?0.t�.n I•,MO� p Certificate of Occupancy $ �IV! 41 • Building/Frame Permit Fee $ ";Cw„SE<� Foundation Permit Fee CQ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 150.00 PAID ry (46 Div. Public Works Location 7Z Stene K ocL No. 41S Date v -Z 3-95 TOWN OF NORTH ANDOVER A Certificate of Occupancy $ �` • : Building/Frame Permit Fee $ Ss�CHusE Foundation Permit Fee $ Other Permit Fee $ �1 -• Sewer Connection Fee .b • Qom? Wat6r Connection Fee $ _ /077, TOTAL il ' VInscto.©�y5.01 1,077.f a �, 8 9 24 Di -v' Vublic Works cz w W om c w- :o C � '. R W -cc u. m �- C=, sa � H • O m O c r4 Q� •mc ca �a N CC m z m Q' y ea p o U acs ':m ' '' UJ M cm W c C c -a w vi o C v ;Z o mCT)-s: 'a m c CD c = : p.+' C3;: N o y N LLI eat c Go CL=" 5 Z E v: y O yC3 a m� c� g _ a ` H � o Gco F z A m 0 0 v v. 4 w r O � 0 O E CO i � O z °' Q CD cm cz O y D � ca C .E in m C33 03 co O i Co O i CC 00. y O +�-' C �C O _.) J 'C .Q O D C z co O CL V C O !C y J Q. z LL I PO" mit J Q z_ J � Q Z LLJ F— C3 z � z pq LLJ Q w CL U) a� x O o F U CG 2 w w w O w z z o cg z a � � p 04 Q. •'�.. ` L4 W.7 fC C4y v O O LL v In O V LL U F. � C w p 1:4 a C cn G ,s• u (n cn W om c w- :o C � '. R W -cc u. m �- C=, sa � H • O m O c r4 Q� •mc ca �a N CC m z m Q' y ea p o U acs ':m ' '' UJ M cm W c C c -a w vi o C v ;Z o mCT)-s: 'a m c CD c = : p.+' C3;: N o y N LLI eat c Go CL=" 5 Z E v: y O yC3 a m� c� g _ a ` H � o Gco F z A m 0 0 v v. 4 w r O � 0 O E CO i � O z °' Q CD cm cz O y D � ca C .E in m C33 03 co O i Co O i CC 00. y O +�-' C �C O _.) J 'C .Q O D C z co O CL V C O !C y J Q. z LL I PO" mit J Q z_ J � Q Z LLJ F— C3 z � z pq LLJ Q w CL U) FORM U - LOT RELEASE FORM INSTRUCTIONS:' This form is used to verify that all necessary . approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor's Map Number Parcel Subdivision / / Lot(s) Street _ L "JL. St. Number 7 Z ************************Official Use Only************************ RECO DATIO S OF TOWN 'GENTS: l Date Approved PP I Conservation Administrator Date Rejected Comments �- Date Approved Town Planner Date Rejected Comments Food Inspector -Health Date Approved Date Rejected 4, Date Approved 7 ZQ4 -- Septic Inspector --Health Date Rejected Comments Public Works - sewer/water connections 73 - driveway permit -2 Zo �5 Fire- Depant Received by Building InMspector -Date M23'C:; } Town of North Andover, Massachusetts Form "O.2 1401ITiq BOARD OF HEALTH • •-- DESIGN APPROVAL FOR CHUS`�� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. : Site Location �-t �^��` * l2c-4) Cic— Reference Plans and Specs.-4�`"'L • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed • in accordance with regulations of Board, of Health. CHAIRMAN, BOARD OF HEALTH Fee C) Site System Permit No., 96 The Commonwealth of Afassachuse= Deparmiew of Industrial Accidents 111�nI►t1� 600 Washington Street k Bosron,Ma= 03111 Workers' Compensation Insumace AMdavit locyaon_ /%�/O�I I /�^�� l�5�jh�/VLA-,G/'/i'i r/J�/)� /Q �L//`� C'C/ Aj, __J"7IV lY(Lf✓_�� 111 _ _ tl IP' L'. J ^ROne ,Failure to secure coversge as required under Section lead co. are imposition of cnmioal penalties of a tine up to SI.500.00 and/or one vears' imprisonment as well as civil penalties in the form of* STOP WORK ORDER and a fine ofSi.00,00 a day against me.' I understand that a copy of this statement may be forwarded to the OtTice of Investigations of the D U for coverage verification I do herebv terrify under the pains and penalties of pQj rho; the infor"sadon provided above is nue and rreM Signature - — Date Print name Phone .4 S -Z —23 2 otllcial use only do not write in this area to be compitted by city oe to- *Mcial city or town:pest-aivucease x 7.Boiidiog Department C:Uccaaing Board . C check if immediate response is required "„ CScleetmen's OITice CHeaith Deparnocat contact person: phone se; _ r'Other (fa sd tri ►JA) A TI, . V�ijkg,.' -e5 , CERTIFIED PLOT PLAN LOCATED IN NO.ANDOVER, MA. SCALE:1 "=50' DATE:10/26/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. SUNSET ROCK ROAD D ^ 95°2935° � 00.00 LOT 15 I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE h WITH THE ZONING. 3ft DETERMINATION OF ZONING BY LAWS OF CONFORMITY OR NON -CONFORMITY) LAi�a NO.ANDOVER, MA. WHEN BUILT WHEN CONSTRUCTED. 10!26/95 9 -D KAREN H.P. NELSON �•'• - � Tow_ n of --.... °""`f o, ' NORTH ANDOVER BUILDING K CONSERVATION DWWO1 OF HEALTH PLANNINGPLANNING & COIBIUNITY DEVELOPMENT CHIMNEY APPLICATION AND PERMIT DATE 7 LOCATION Z- 4' OSvNER' S NAME BUILDER'S NrAIME /5, /J J MASON'S NAME1.�7( MASON'S ADDRESS-//"Z/�fe(l MASON I S TELEPHONE MATERIAL OF CHI`S?NF.1 INTERIOR C:-1IMNEY 120 Main Street. 01845 (508) 682-6483 L,T # J/ / EXTERIOR CHI'MNEY r>� NLi�,ER AdD SIZE OF rTrdre TH7CF :ESS OF HEARTH__T W 11 chimney Or f:' e�lc�.e %..�� reCL'irements Oi tie Code ai.' have rules a d recu_at;crs wee-: received: ' DATE. SIGNA—J URE OF MASONl i CONTR. LIC. % EST . CONSTRUCTION COSI/'Cr):: , RAC– EST. :RICE PERi•1IT GRANTED ROBERT NICETTA, B- ^R iidSPECTED REMARKS SC ID ..R!C{ REQUIRED THIS PERIMIT i?US T BE DISPLAYED ON THE PREi$ISES Location a No. 4 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee /� $ Other Permit F `e P" $ Sewer Connection Fee $ Water Connection Fee $ TOTAL (A 8 2t S- 11/27/953, 3 50.00 PAID iw' $ Building Inspector Div. Public Works CIO MOM, ~ ui• •� O IA z U :V I C CR Z O rr•�� ;ice-•�. � O - Z U � ca e� C m G ma. d � • Y Uk ♦�• N � o o` o Ca• r•-� N t7 V O 0 H 3 O �_ O V CZ 7 aCIO O .w _ . ^ I Z W � G O C Q cn O C m � t ev Z _ y W C O m � Cdr�� LA_ �. C ♦. W 12 V U Q v sg a ci m .— c�oC m } = E•� l0 L CD N ♦0.. :ZL.r m r � ..... ��.. �./ � I ii. •to � � �+.. .i.J (• � ^ate CIO MOM, ~ ui• •� O IA z U :V I C CR Z W -A I z_ •� O z U :V I C CR Z O rr•�� ;ice-•�. � O - Z U � ca e� C m G ma. d � • Y Uk ♦�• N � o o` o Ca• r•-� N t7 V O 0 H 3 O �_ V CZ 7 d O .w _ . ^ I Z W � G O C Q cn O C m � t ev Z _ y W C O m � Cdr�� LA_ �. C ♦. W 12 V U Q v sg a ci m .— c�oC m } = E•� l0 L CD N ♦0.. :ZL.r m W -A 1 J Q I z_ o z :V I Com°_ }f. -J Z O rr•�� ;ice-•�. � O - Z U � � � • Y � o Ca• r•-� V O 0 W cc O �_ CZ d O .w ^ I Z W � 0 LD Q cn O C cc _ C :C N 1 J Q I z_ I Com°_ }f. -J z : U � � t O FM4 0 z 1 o- `:, L,E Q F -- C* W H W C.3 y MQ a 0 i y CO m �w� Rk w x u f C G °` ° C W ° ' c = N Q o CD z Q G ° w° Ci) U w w C/) C/) L,E Q F -- C* W H W C.3 y MQ CD 0 0 Z O p y co .y coi CD c 0 CD V _cc m y O v .y c 0 .0 m a VA ��� J Q z S � o Uj QrL y } co � Z � C W oALUa Cp •� W z> �O o �D CD p o O fl. fl. o� Q c cJ Q I 'rg Z 0.2 W LL Q Q CD .9 z•. acr c T = 1• �m cc W C-13 Z � z W j LU a_ C/) a 0 i y CO m v/ w m ' c = N Q o CD ga m �+ HCD cc " m gym= •= O m C. e O N Cc Cc"a Net ve v, "E az = E � S = CC1 � O :0 Qo � a p N •= O N a� m CD 0 0 Z O p y co .y coi CD c 0 CD V _cc m y O v .y c 0 .0 m a VA ��� J Q z S � o Uj QrL y } co � Z � C W oALUa Cp •� W z> �O o �D CD p o O fl. fl. o� Q c cJ Q I 'rg Z 0.2 W LL Q Q CD .9 z•. acr c T = 1• �m cc W C-13 Z � z W j LU a_ C/) C ERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number /–/j Date -?— ( THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS w IN ACCORDANCE WITH THE PROVISIONSOF THE AS MAY MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS s..NOATN ho CERTIFICATE ISSUED TO �El- FOR D `� t�--z"-'r ,.., h? •` •• Lp ADDRESS ZL- s1AC.HUS ' ddc g Inspector 1 '