HomeMy WebLinkAboutMiscellaneous - 725 BOXFORD STREET 4/30/2018N
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Claims Processing - Arnica Scan Center
PO Box 9690
Providence, RI 02940-9690
AUTO HOME LIFE
Building Inspector
Town Hall/ Municipal Offices
North Andover, MA 01845
File Number:
60002160169
Date of Loss:
02/27/2015
Owner/ Insured:
Karrie Brenneman
Street:
725 Boxford St.
Town:
North Andover
Type of Loss:
Ice dam
To Whom This May Concern:
Toll Free: 1-888-53-AMICA
(1-888-532-6422)
Fax: 1-888-818-9591
June 8, 2015
Please be advised that we insure the above named individual (s). A claim has been made
for Damage to Real Property and as the insurer, we are presently in the process of adjusting the
loss.
We are mandated to comply with Massachusetts General Laws, Chapter 139 and as such,
if there are any present liens on the above property, please notify us within 10 days of receipt of
this letter. If we do not hear from you, we will be under no obligation to pay you any portion
of this claim.
Sincerely,
Patrick J. Corrigan CPCU
Claims Department
888-532-6422 x21012
PCORRIGAN@AMICA.COM
XMICA MUTUAL INSURANCE COMPANY AMICA LIFE INSURANCE COMPANY AMICA PROPERTY AND CASUALTY INSURANCE COMPANY
AMICA LLOYD'S OF TEXAS AMICA GENERAL AGENCY, LLC. WEB SITE: WWW.A IICA.COM
I,
Date.... ..0 / . X•!•• ...................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
e
This certifies that
........................................... fiC.t.n.t✓1r.....�
has permission for gas installation t,( A- .,
in the buildings of ......./ ^...^'....1^ ......................................................
at 77 ,... 9�- .... .....' North Andover, Mass.
Fee .
... .�..c�.............. Lic. No.Z/�..... '.'.................
. ..............................
GASINSPECTOR
Check # 6 Z 7
9563
MASSACHUSETTS UNIFORM APPLICATION FOR R PERMIT TO PERFORM GAS FITTING WORK
IMAle ---�
® / / AIR-1"`
CITY MA DATE�p�0' PERMIT # v) tP
JOBSITE ADDRESS 7X `�Gi 4ZD '571—Ael-e OWNER'S NAME , &-AAe'5174 )
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENTX PLANS SUBMITTED: YES NOX
APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOKSTOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER `
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ik NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY )< OTHER TYPE INDEMNITY BOND i
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 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a ur to to the best of owledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance it II Pertinent pr i ion oft e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE
MP )< MGF JP JGF LPGI CCRPORATIONlv�# 3631 C PARTNERSHIP #. LLC #
COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com J�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
} `VzOffice of Investigations
I Congress Street, Suite 100
q` Boston, MA 02114-2017
SJby
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibl
Name (Business/Organization/Individual):
Address:
/State/
03
Phone #:
AW,1am
oa employer with u an employer? Check the a propriate box:
1.
4. E]I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
?. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.1
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.1 1 Roof
13KI 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
informal
Insuranc
Policy #
Job Site Address: L5: A-i9x—pew J 4/h22 City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
perjury that the information provided abovg is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
aim
BOARII> F C,
PLUMBEIZ:S AN -19 GASF I'TTERS•
i ISSUES THE FOLLOWINt LICENSE)
L I CENS.`:W A<S A JOU.RN:EYMAN PLUMBER
's.
j PETER G VIENS
9 BLUEBdRD LANE
ATX 1 NSON AfH 03811-2302
216.35 05M. 0511-6.: 213586
Common ft of Mus=ht
DxpgrUnent of Pit Sil
Hoisting Engineer
License: HE -110323
PETER G VIENS= <w
9 BLUEBIRD LA1
ATKINSON NH 03811
t
�Jn t.r<`"
Expiration:
Commissioner 11/13/2015
State of NeW. Hampshire
GAS FITTER$;il bibE
f NAME: PETER V&NS
ENDORSEMENTS'!`Vf kP
DATE ISSUED: 10/15/2013
DATE EXPIRES: 11/30/2015
I
I LICENSE #:GFE0700587
cedity that I have examined
Io accordance with the Federal'MoTor Carrier Safety F]itjulalions (49 CIW7391-41-391.49) and with knowledge
of the driving duties, 1 find this person is qualified; and, A applicable, only when:
❑wearing corrective lenses ❑ driving within an exempt intracity zone (49 CFR 391.62)
C]wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Cedificale (SPE)
❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64
waiver/exemption
The information I have provided regarding this physical a*a-minalinn is true and complete. A complete examination
form with anv attachment embodies my fotdinos completely and correctly- and is on file in my office.
SIGNATURE OF MEDICAL EXAMINER
T EPN E
ft//
��vYM/Gi
DATE
(/
MEAL EXAMINER'S NAME (PRINT)
M
❑ MD ❑ Chiropractor
f—
`/d wet/ ✓Y 6ti 7EJ�
J
iw4-
❑ DO Advanced
Practice Nurse
MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO.
ISSUING STATE
/ ��� /—
rV'
��
❑ Physician ❑ Other
Assistant Practitioner
NATIONAL REGISTRY NO.
SIGNATUR OF IVER
INTRASTATE
CDL
ONLY
[]YES NO
❑ YES kwNO
DRIVER'S LICENSE NO
STATE
I
ADDRESS OF DRIVER
e ,
lir
MEDICAL CERTIFICATION EXPIRATION DAT
PLY i DRIVER PLY 2 MOTOR CARRIER
26520 (5113)
'f—i�J►'l� 11`n.��T4slit!]r�.�2►]L�l\/_15141�i�lPl���
BOAR Q f
PLUMBEPS AND GASFITTER-5
ISSUES THE FOLLOWING LICENS.
LItENSEID AS A MASTER PLUMBER
PE.TER G VIENS
CN
9 BLUE81'R'D LANE i
ATKINSON NH 03811-2362
1211b.;. 05/O1:/1b 213585
T Ifo of IN.�t>sszcfRt�tQg
ovi atilt of Pill Sady
Piperitter JOUrnel-man
License: PJ -028388
PETER G VIENS _ +�
9 BLUEBIRD LNC w E ' `
ATKINSON NH -,03811' 1
Off
-J2' q fl lit 1, `R
Expiration:
Commissioner 11/13/2015
STATE OF NEW HAMPSHIRE
BUREAU OF BUILDING SAFETY & CONSTRUCTION
PLUMBING SAFETY SECTION /f --
NAME. PETER G VIENS
LIC #: 3249 M
EXPIRES: 11/30/2014
1
_ a,-
i
{I Peter Viens
Cert # 1023121001-12
Expires: 10/23/2015
Certification
N.F.P.A. 99-2012 ed.
ASSE 6010 Installer 8 ASME IX Brazer
Om 600316337 �
4lS.'�a�e@rlt�oYYyi$�Or
�IiS1� '}�Ld�1 �1kT1SNH18N1
Peter -Viens
hxssu�si>sCpr�btetlza�fmuA�eat.SSYmtymltl Fi��h
3e�+��ttsa"m
r"
ocation}
yo. �—�^ _ Date
MpRrM TOWN OF NORTH ANDOVER
O? • - .. p�
.. p .Certificate of Occupancy . $
Building/Frame Permit Fee $
Foundation Permit Fee
-Gt-her Permit Fee $ S
Sewer Connection Fee $
Water Connection Fee
TOTAL $ /0.
� f
r
/03lBuilding Inspector
1, 330.00 RAID
Div. Public Works
NORTIy
O� .��o ,• ,ti0
t �O 9
,S3 CMUS�
Date
T�r
TOWN OF NORTH ANDOVER 'DOVER
PERMIT FOR PLUMBING
This certifies that ... ,1. !�. y.� �..??� C .....I °C� .... ...... .
has permission to perform ... . ..fr <.�. ...�..�.. ` t
plumbing in the buildings of .. e ......................
at ...-7 ...... .. r`.' .. `�.......... ,North Andover, Mass.
Fee..-... Lic. No: p�.? �f.� t . . � .... 11...... .
PLUMBING INSPECTOR
Check #�
54
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIlVG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
New n
a as
is ee;
)wners Name ,-y al - Date L /%
Permit
of Occupancy L Amount _ SOL
Renovation Replacement'
FIXTURES
Plans Submitted YesNo ❑
�t
(Print or type)
insalling Compan Name ,i�TG Check one:
Address �I/3�3 Corp
.
Certificate
Partner.
Business elephone
9 > F3 Sr S`� t,/� a '❑ Firm/Co.
Name of Licensed Plumber
Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy (,_ Other type .of indemrni ❑
Lam- n' Bond ❑
three insurance
Insurance Waiver L the undersigned, have been made aware that the licensee of this application does not have any one of the above
Sign re Owner ❑ F1Agent
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 plur�g Code and Chapter 142 of the General Laws.
Fy:le
ignaLure of ,cense u er
Type of Plumbing Licese
/ 54�a2roFMCEUSEONLY cense vumo r Master ❑
Journeyman
N2 1 J32
pORT►�
0
O 9
Date."� ...- ....-
TOWN OF NORTH ANDOVER M
PERMIT FOR WIRING
�
This certifies that ...,.... ........... .................,
has permission to perform .... S.• r .......... ......................`'
C%
wiringin the building o�.................................................................................
at .. 7a ..... .......... `............. !......................... , North Andover, Mass.
Fee—,b.. �...... Lic. No? lc� .......................... ..... ........ .................
ELECTRICALINspECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Office Use
Only
Permit No. (/
7WE dP07 71L0?2-614z?P 07 ?1lr4SSr4G kSS7')S c
Occupancy &Fee Checked
Vo-cw-t 44;V -*G: S44 _
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andove
The undersigned applies for a permit to perform the electrical work described below. y�
Loc.don (Street & Number V S— -r, Ec,ad S -L
Owner or Tenant
Omer's Address I) vvr P
Date St- %ZI ` '? ,J_
To the Inspector of Wires:
Is This permit in conjunction s! PhO�
•with a building permit Yes Eli -'No ❑ (Check Appropriate Box) y
Purpose of Building S C� /D Utility Authorization No. e00 ! o 7
asting Service Amps Voits Overhead [IUndgmd [INo. of Meters
New Service ab �t � Amps /4P P L/O Voit5 Overhead ❑ Undgmd Q/' No. of Meters
Number of Feeders and Ampacity /
Location and Nature of Proposed Electrical Work Sc' -F' !/r CP / W r /2 e FO UL
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE BOND = OTHER = (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$ -5--2 vice -
Work to start Inspection Date Resquested ✓7" M Rough Final
Signed under a attles of pe ury: _
FIRM NAME %�O F'CTt/L! K1 LIC. NO. %�
J'-. i 24 A. i 1 /a i2 A i),,'0 G Slanature C_/ i'v� ✓- /�-- LIC, NOF �S 09
Bus. Tel No. TS/ 5 Y ZC-' -QQb T
Address 0 L'!�VGy% 4 r S l��y, �'w /4 - at Tel. No.
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE
(Signature of of Owner or Agent)
Total
No. of Liqht8ng Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑
In ❑
No. of Lighting Fixtures
Swimminq Pool gmd ❑
gmd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Bunters
Battery Units
No. of Switch Outlets
No of Gas Bunters
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices .
Heat Total Total
No. of Diposal
No. Pumps
Tons
KW
No. of Sounding Devices
Nod of Self Contained
No. of Dishwashers
Space/Area Heating
KW
OetectionlSounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
I Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE BOND = OTHER = (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$ -5--2 vice -
Work to start Inspection Date Resquested ✓7" M Rough Final
Signed under a attles of pe ury: _
FIRM NAME %�O F'CTt/L! K1 LIC. NO. %�
J'-. i 24 A. i 1 /a i2 A i),,'0 G Slanature C_/ i'v� ✓- /�-- LIC, NOF �S 09
Bus. Tel No. TS/ 5 Y ZC-' -QQb T
Address 0 L'!�VGy% 4 r S l��y, �'w /4 - at Tel. No.
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE
(Signature of of Owner or Agent)
61
CERTIFICATE OF USE & OCCUP
Town of North Andover
Building Permit Number C 20
THIS CERTIFIES THAT
THE BUILDING LOCATED ON
MAYBE OCCUPIED AS
WITH THE PROVISIONS OF THIZASSACHUSETT
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE D
ANCY
Date /�- `/— 7 JP
IN ACCORDANCE
STATE BUILDING CODE AND
nutuaing inspector
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TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
October 23, 1998
This is to certify that
the individual subsurface disposal system
constructed ( x ) or repaired ( )
by North Andover Licensed Installer
Peter Breen
at
725 Boxford Street, North Andover, MA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Approval date of January 28, 1997.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
L
oard of Health Inspector
6
19
N2 37
Date� `�.'9 .....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
A 14US 9,
This certifies that .........................
has permission to perform.. ........................
... ....................
plumbing in the buildings V
at ... North Andover, Mass.
Fee.�- . ..............................
PLUMBING INSPECTOR
06/05/98 11:20 75.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
New E4
Renovation
Owner's Name
(Print or type) �/ /f / Check one:
Installing Company Name ,J�(!y / o� %f r��/�✓Y - Corp.
Address 2-7 F.s G iAfl9 /� U/ T !2!DU Partner
Business Telephone 60.3 0 Firm/Co.
Nae of Licensed Plumber: d /5- �G
Name
Insurance Insurance Coverage: Indicate thetype o insurance coverage by checking the appropriate box:
Lilhbility insurance policy ® Other type of indemnity 11 Bond
Certificate
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent rl
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 PerrnitAsued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and er 14 General Laws.
By: Signature ot Licensedum er
Title �
e of Plumbing License
� f
City/Town License Mumuer Master ❑ Journeyman
APPROVED (OFFICE USE ONLY LLLCCC!l1111
f
::. I
-------------------------
(Print or type) �/ /f / Check one:
Installing Company Name ,J�(!y / o� %f r��/�✓Y - Corp.
Address 2-7 F.s G iAfl9 /� U/ T !2!DU Partner
Business Telephone 60.3 0 Firm/Co.
Nae of Licensed Plumber: d /5- �G
Name
Insurance Insurance Coverage: Indicate thetype o insurance coverage by checking the appropriate box:
Lilhbility insurance policy ® Other type of indemnity 11 Bond
Certificate
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent rl
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 PerrnitAsued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and er 14 General Laws.
By: Signature ot Licensedum er
Title �
e of Plumbing License
� f
City/Town License Mumuer Master ❑ Journeyman
APPROVED (OFFICE USE ONLY LLLCCC!l1111
E-Ok
r
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
'ype or print)
NORTH ANDOVER, MASSACHUSETTS
Uuilding Locations _
Owner's Name
New 1:1 Renovation ri Replacement
FTX TI iR F.4
Plans Submitted n
Date
Permit #
Amount
(Print or type) Check one: Certificate
Installing Company Name 11 Corp.
Address n Partner.
Business Telephone El Firm/Co.
Name of Licensed Plumber:
a
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
ignature Owner ❑ Agent 11
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 Plumbing Code and Chapter 142, of the General Laws.
OVER (OFFICE USEQAft�r-^
The
igna ure or Licenset Plumber
Type of Plumbing License
License Numer , Master Journeyman ❑
�6l �
•
1
Will.,
.....................Now
-..-.-.-.�---......�..mom
11'
-m.-.-...m
...............
(Print or type) Check one: Certificate
Installing Company Name 11 Corp.
Address n Partner.
Business Telephone El Firm/Co.
Name of Licensed Plumber:
a
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
ignature Owner ❑ Agent 11
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 Plumbing Code and Chapter 142, of the General Laws.
OVER (OFFICE USEQAft�r-^
The
igna ure or Licenset Plumber
Type of Plumbing License
License Numer , Master Journeyman ❑
�6l �
4126
Date ......... ...lid..... .
N0R7M TOWN OF NORTH ANDOVER
,
pF ��,,a° ,"C
3r "� p` PERMIT FOR GAS INSTALLATION
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sS"c�uSE
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This certifies that. .. . ......... • • ..
has permission for gas -installation ........... • • • .. •
2
in the buildings of���.:®��-.J'.�...................... V
Q
at c 3. f�// yr .... • , North Andover, Mas@
Fee Lic. &0.12 ,� . .........................�6
W GASINSPECTOR
WHITE Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
or print) Date ,/ -Ll( 19 f&
tvvnlH ANDOVER, MASSACHUSETTS
Building Locations ___ � &;@ y 26
Permit #
Owner's Name
New 0 Renovation ❑ Replacement ❑
Amount $
r
Plans Submitted ❑
(Print or type) �� x- Ge!¢f *– Check one: Certificate Installing Company
Name F1Corp.
Address 2 % jr `S e" Lt M, u ; - -*z a ,y— ❑ Partner.
Business Telephone
Name of Licensed Plumber or Gas Fitter
A5
® Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: ❑
Signature of Owner or Owner's Agent Owner ❑ Agent
I herebl*ertify 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 Gasj26AAd CJaaprerA549of ttKGeneral Laws.
ity/Town
VED (OFFICE USE ONLY)
Signa9he of Li
PlunIber
❑
Gas Fitter
❑
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SUB-BASEM ENT
B A S E M ENT
IST. FLOOR
2ND. FLOOR
3RD. FLOOR
JT H. FLOOR
S T N. F L O O R
6T 11. FLOOR
7T 11. FLOOR
sill. FLOOR
(Print or type) �� x- Ge!¢f *– Check one: Certificate Installing Company
Name F1Corp.
Address 2 % jr `S e" Lt M, u ; - -*z a ,y— ❑ Partner.
Business Telephone
Name of Licensed Plumber or Gas Fitter
A5
® Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: ❑
Signature of Owner or Owner's Agent Owner ❑ Agent
I herebl*ertify 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 Gasj26AAd CJaaprerA549of ttKGeneral Laws.
ity/Town
VED (OFFICE USE ONLY)
sed Plumber Or Gas Fitter
,i �/Y7
lcense um b e
Signa9he of Li
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❑
Gas Fitter
❑
Master
Journeyman
sed Plumber Or Gas Fitter
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lcense um b e
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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.
****************Appli ant fills out this section*****************
APPLICANT:
APPLICANT: Phone
LOCATION: Assessor's Map Number
Subdivision
Street (,
Parcel
i.
St. Number 7)IT
************************Official Use Only************************
REC NDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
r
Town P anner��
Comments 1PY(M,�_,
Date Approved 17
Date Rejected
Date Approved air
Date Rejected
Date Approved
Food In�s/peejcttoor-Health Date Rejected
Date Approved
Septic Inspector -Health Date Rejected
Comments
Odic Works - sewer/water connections
- driveway permit
B,epa ment t�l� ►tLG.�, SM.acaxi
110 V
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.
NamPPlicant on Building Permit (below) Address of Property for Permit (below)
Map and Parcel: Purpose of Application (check below)
Pho/n 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 iq 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
existence 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.
VdThis application is for dwelling units for low and/or moderate income families or individuals, where all of the
itions of 8.7.6.cvare met and/or represents Dwelling units for senior residents, where occupancy of the units is
istricted to senior persons through a properly executed and recorded deed restriction running with the land. For
rposes of this Section "senior' shall mean persons over the age of 55.
V
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.
adjThis application represents a tract of land existing and not held by a Developer in common ownership with an
acent 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 groun for refusal by the Building Department to issue a Building Permit.
Signtur o wner or Authorized Agent who signed the Attached Building Permit Date
This form must be attached to the Building Permit upon application for such permit
Town of North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
(Please print)
DATE
JOB LOCATION
Number '-Street Address
'HOMEOWNER" � E z _
Name Home Phone
PRESENT MAILING ADDRESS r :?h7
-)ecEion of town
ork Phone
City Town State Lip code
lie current exemption for "homeowners" was extended to include owner
occupied dwellings of six units or less and to allow such homeowners to
,ngage an individual for hire who does not possess a license, provided
that the owner acts as supervisor. (State Building Code, Section 109.1.1)
)F.FINITION OF HOMEOWNER:
Llerson(s) who owns a parcel of land on which he/she resides or intends to
C(3side, on which there is, or is intended to be, a one to six family dwell-
'r.ngi, attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in atwo-year
��
period shall not be considered a homeowner. Such homeowner��shall submit
Lo the Building Official, on a form acceptable to the Bulding Official,
that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1..1)
The undersigned "homeowner" assumes responsibility for compliance with the
State Building Code and other applicable codes, by-laws, rules and
regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
North Andover'Building Department minimum inspection procedures and
requirements and that he/she will comply with said procedures and
i:equirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35,000 cubic feet, or larger, will be
required to comply with State Building Code Section 127.0, Construction
Control.
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