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HomeMy WebLinkAboutMiscellaneous - 75 BARKER STREET 4/30/2018Date .........6.......!... `d .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING \ 6c� ,S3•�CMU56 G t This certifies that ........ , (n►Q C`iL 1C-P%P p 2 li has permission to perform ......�..:tr' "'J Q .2 a. ............................ wiring in the b9ding of. at .,..,....,, ...... ,>lyrth Andover Mass. ,F�e.....'.... `..w......... Lic. No.1...Z 1 �) ►�T" ............................................ ELECTRICAL INSPECTOR Check # 1�1 t Official Use 0n1 • Commonwealth of Massachusetts �7 Permit No. t" Department of Fire Services - .� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. l/07] aeaveblank e APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: - ci -t4 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. q-16 - 68 2. - Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [g (Check Appropriate Box) Purpose of Building BPnt_— Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: It" Completion of the_following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA r No. of Luminaires Swimming Pool Above ❑ In- E]o. rnd. rnd. o mergency Lighting Satter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .* "" Tons "' """'"""""'..""'".... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems-* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: ` ., t doo Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Jjjg(When required by municipal policy.) Work to Start: 1 t+ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:. iq( LIC. NO.: Iq 1:5629 Licensee: Signature LIC. NO.: 42kL6`'j (If applicable, ente `exempt" in the licens number line.) Bus. Tel. No.: bad: f - Address: '� ��,� l !. S� _ S I il% l4 ©� 0-7'7 y Alt. Tel. No.: b ®2 . �2 137 - 1 q-1 I *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: 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 ❑ owne .'s agent. Owner/Agent PERMIT FEE: $ Signature _ _ Telephone No. `Je,.jarz _ ?e Piz ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the { i permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an Q 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. v Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, 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 this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Id Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass IM Failed Re- Inspection Required ($.) ❑ Inspectors Co ents: 727 Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com i ,The Commonwealth of ll2'assachusetts - Department of Industrial Accidents Office ofInvestigations 600 Washington. Sheet Boston, MA 02111 www.mass gov1d1a Wgrkexrs' Compensation Insurance Affidavit: Builders/Contractors/ER Appi:cant Information Name (Business/Organizationlindividual): � 1 0 i a, t 4 Address: City/State/Zip: Ij,�- r AAA- Phone #� (u� 9 -gt �2- `+!5_ Are you an employer? Check the appropriate box: Type of project (required): 1, I am a employer with 2,— 4• ❑ I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* 2. ❑ I am a sole proprietor or partner have hired the sub -contractors listed on the attached sheet. 7• ❑Remodeling ship and`have no employees These sub -contractors have 8. E] Demolition worldng forme in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised.their 10.[] Electrical repairs or additions 3.01 am a homeowner doing all work right of exemption per MGL II.[] Plumbing, repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.❑ Roofrepairs �ired. a insurancere ► employees. [No workers' 13.❑Other comp. insurance required.] 'Uny applicautthat checks box#1 must also filloutthe section below showingtheir workers' compensation policy information. i'Homeowners who submitihis affidavit indicatingthey tie doing all work and then hire outside contractors must submit anew 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' corptpensation insurance for my employees Below is thepoliey and jab site information. _ Insurance Company Name: Auc Policy # or Self ills. Lie. #: a - y- 3 2J Expiration Date: 7 - 1P, Job Site Address: City/state/Zip: �J- Attach a copy of the workers' compensation -p olley declaration page (showing the policy number and expiration date). Failure to secure coverage as requ1 dunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a %�e up to $1,500.00 and/or 'one year imprisonment, as well .as civil penalties in the form of a STOP fin WORK ORDER and a e 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. X do Hereby cert' ndier tZzqNlns and penalties ofperjury that the information provided above is true and correct. Signature: Date: to -4-/Y - Phone#: GC�� - Gf2 Official use onfy..Do not write in this area, to be completed by city or town official. City or Town, PermitiLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions `r Massachusetts General Laws chapter 152 requires all. employers to provide workers' compensation for their employees. Pursuaat to ibis statute, an eYawkee is defined as "....every person in the service of another under any contract of hire, express Orimplied, oral or written." An employee is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the Foregoing engaged in a j oint enterprise, and including the legal repxesentatives of x 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 notmore 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 employes." MGL chapter 152, §25C(6) also states that "every state or local lie-ensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildiugs iu the commonwealth fox any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required:' Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedta the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other thafr the members or partners, are not required to carry workers' compensation insurance. If au LL C or LLP does have employees, a policy is required. Be advised tat tbisafffdavit maybe submitted tothe Department of Industrial , Accidents for confnmation 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 he. City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill, outin the event the Office of Investigations has to contact you regarding the applicant: Please be sure to fill into permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write ,all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may b e provided to the applicant as proof that a valid of idavit is on file for future permits or licenses. Anew affidavit must be filled out each Year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox your cooperation and should you have any questions, please do not hesitate to give us a Bali. The Department's address, telephone aird fax number: The Commoumaith of Mo JDepaiftelat of Jadm5ftial Araddenta Office offAvestigatima 6.00 Was,gtmree Boston, MA0.2111 `1`el. # 617-7.27,4900 e�,t 406 or.1-87--7, :�i sm Revised 5-26-05 Fax # 617-727'7749 vaww.xaa�s,gov�d�a • �` �' �. • DATE: lo i I LOCATION: -16 �'u_rz_ -ter� OWNERS NAME: 4 I�e,2; GENERATOR kw u w NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR. �kl V, f,- , �1,-p-. , , PHONE NUMBER: ELECTRICAL RESIDENTIAL Q GASMERCIAL TEMPORARY LOCATION OF GENERATOR: Q i 44 J.�- V *ZONING DISTRICT: P-2, *PLANNING APPROVAL (IF IN WATERSHED) �j�� *CONSERVATION APPROVAL North Andover MIMAP October 9, 2014 035.0-0100 035.0-0001 034.0-0012 /-;035.0-0105 87 BARKER ST �6 Z 75 BARKER ST 035.0-0106 / Qb 1 035.0-0107 63 BARKER ST 035.0-0002 10 OLD FARM RD 91' Rail Line ..`« Wetlands InterIstates — CJ Exempt Lands — SR O Busine s 3 District Roads Busine s 4 District C, Easements Genera Business District ❑ MVPC Boundary 13 Planne I Commercial De' C3 Municipal Boundary C:: Corrido Development Dist Zoning Overlay 13 Corrido Development Dist 0 Adult Entertainment G Corrido Development Dist 0 Downtown Overlay District Industri I 1 District ©Historic District Industri 12 District ® Water Protection O Industri 3 District F3 Parcels O Industri S District t; Hydrographic Features Reside ce 1 Distdct I Reside ce 2 District C Ride ce 3 District 1 de ce4 District { A.de ce 5 District T de ce 6 District �a a esidential District — Streams 1" = 102 ft 035.0-0056 30 OLD FARM RD 284' /hp 1 111 BARKER ST 035.0-0103 035.0-0102 035.0-0104 95 BARKER ST 035.0-0063 60 OLD FARM RD Old,Farm'ROad Zoning '. Busine s 1 District 13 Busine s 2 District O Busine s 3 District Busine s 4 District NORTry Genera Business District f r q 13 Planne I Commercial De' C:: Corrido Development Dist 13 Corrido Development Dist G Corrido Development Dist C- ., Industri I 1 District Industri 12 District O Industri 3 District O Industri S District 1q wa.?i. +p� Reside ce 1 Distdct I Reside ce 2 District C Ride ce 3 District 1 de ce4 District { A.de ce 5 District T de ce 6 District �a a esidential District �1 r10 r.�'t.�• ,SSACNl�SE 328' �r_J 035.0-0068 035.0-0067 Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Date ... ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 4' 7L�q.�-�A .................................. .................. has permission for gas installation -4-t- ..................................... in the buildings of .... A ... ................................................. at .........15 ........ 1�� .... ....................... , North Andover, t — Fee ... Lic. Nod'.)9.L-'2 ........ Pr ............... ...... ... ......................... GASINSPECTOR Check Aq2- i0 eel eel Mass. V �' 7 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY rJ�f� MA DATEPERMIT # `� I JOBSITE ADDRESS OWNER'S NAME k OWNER ADDRESS TEFAX OCCUPANCY YPE COMMERCIAL EDUCATIONAL NEW: RENOVATION: E] REPLACEMENT: 13 APPLIANCES Z FLOORS - BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 7 RESIDENTIAL/ PLANS SUBMITTED: YES [__Jj NO 01 �N WIN WN W INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JO [ �]_I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT M SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provisiorkof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r/ PLUMBER-GASFITTER NAME LICENSE #� SIGNATURE MP 0 MGF Ejl JP ® JGF . LPGI © CORPORATION ©# PARTNERSHIP [ #� -� LLC D# COMPANY NAME: yt��,�TC j%� _ADDRESS CITY _I STATE ZIP G�TEL FAX _ CELL J EMAIL p r J `' i H Z O H U W a � A W zo El a O Nr-1 W } cc � ~ W O w O H a f Z U w pW., iz- � W 5 cc a WLLI a W w u w C a o U J F,, a a a � D 6i s w I-- LL rA H O z 0 H V a Vj `' i The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations qV 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation )Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): City/State/Zip: ZnAMC,�Mf✓ Phone #: `U3 Rf 03 A,rree,y an employer? Chec the appropriate box: ( 1.11Q I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' coma. insurance reauired.l 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. ❑ Roof repairs 13. ❑ Other !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they a're 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. , , A, t , Insurance Company Name Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 77.5 City/State/Zip:,(1sA2 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certtfy under the pains and nalties ofperjury that the information provided above is true and correct. Signature: ?*,401 Date: /0-//7—/ 3 -rY J - oP1 o Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person Phone #: s' 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Gommonwalth of MMassachuse is Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www-mass,gov1dia Y This certifies that . \j.. a..Af*�*". has permission for gas installation P -IG in the buildings o ...j T. at ...... ��� r . • . ,North Andover, Mass. Fee��.. Lic. No..�i13 GAS INSPECTOR Check # � l�� �0 �� ��� 8501 a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM CCAS FITTING WORK CITY R n Vi i MA DATE 2 ` / 3' / L PERMIT # JOBSITE ADDRESS -- - OWNER'S NAME G OWNER ADDRESS TYPE OR PRW OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL CLEARLY NEW. E-1 RENOVATION: D REPLACEMENT: ® PLANS SUBMITTED: YES 0 NOD APPLIANCES l_ FLOORS^► BSM 1 1 2 1 3 1 4 5 6 7 8 1 9 1 10 1 11 1 12 1 13 1 14 BOOSTER INFRARED ROOM 11,10wrVN14VG HV Vrr.A\7G I have a current lJobIlily nsurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO Q 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [ BOND OWNER'S INSURANCE WAIVER: l am aware that the licenses 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. OWNER CHECK ONE ONLY: OWNER E] AGENT 11-vuY F-Fuly u►ar an of 'no oeunis arm uttormauon 1 have sUbmitted or entered regarding this application are true and to to the best o my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In oomplia ot PerinBn�nt p on She Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �✓ PLUMBER-GASFITTER NAME 5qm mcGrc,.-,,-h - LICENSE # //3/ S NATURE MP 0 MGF [ 3 JP El JGF [j LPGI ® CORPORATION Ej � PARTNERSHIP [j# LLC COMPANY NAME: i R Cr - �a4 it'S - V%C • ADDRESS— CITY C -Q fse, Imo, _ STATE[jE]ZIP TEL 6r� 88y- �BdS FAX17 9° 'st3 CELL ' �+ 'S� MAIL ,n'+. 12-1 1 2A IZ I -Y Gt-kf-�k�,U - I -LQ ON IFA Location -K .4,-7-4r— No. .4i? 4r—No. Date it "QRT" TOWN OF NORTH ANDOVER f �,y R 9 Certificate of Occupancy $ s�CM Building/Frame Permit Fee $ y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #��Z-- �J 224 wilding Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:� Date Issued: & -(9 ANT: LOCATIO Date Received licant must complete all items on this page z � � Print MAP NO:L3-6--dPARCEL: ZONING DISTRICT: Historic District 2 Ch Machine Shoo Vil yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer Urw%.rur i 1UN Ur VVUKK 1 U hat PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: ���1 f� L _� ri� Phone:'�ib /61,3)6 Address: -7J / la rE/iF, ` 'z - CONTRACTOR Name -Z-7' �nPhone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. t Total Project Cost: $ FEE: $_ Check No.: Receipt No.: q 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund t/O A Signature of Agent/Own g _g Signature of contractor v' Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 `q� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 7 6✓ City/State/Zip:44.,e i ,1lN ,L hS� Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. : ship and have no employees 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 workers' comp. insurance. 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 required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other -:9ny a1Upi1Cani that Cl^1CCKS oox ;;1 Must also ilii out the section below showing their workers' compensation policy information. I 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day 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. pains ana penalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official, City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: m m m C m m y mm _v■ y C CD ■ � d CA Cl) ■v O C") Z y CLCOO �■ r CL = y aCC2 O o v CD CD o CD o CCD C CD y■ CD CZ O y to CD 1 S- CA O 'CD Z CD o CD 0 C CD z rn cn cn O l•� cn o� 0 cn 0 0 d0 S O .� y C O m C7 Cl) CA m _0 = M oil N CD CL CL = m —10ocot o N —i 3E ? !o m 2 = m co, O 0.� 1 ■O-► O ZS.c"-, O N Cl CD :` V a �,m CL o C O t CD 0 CD CL CD N r 03 CA fi cr CL CCD W C CA -t CD ACD . C oC.): moo: CD o ca o CD .O.r, C=,r32, / CD .T f�A CD d W. ate.: OR 1.5 c o o Mq, Cn C z b7 :IJw d ':7 .. PC aGc x c ro ny 71 w C/) o Ci7 w o tz O w x 0 w C) 'n n CA 0 a 0 O PTJ I z N w �y 0 0 CD ol CL 0 c NORTH TOWN OF NORTH ANDOVER bay° OFFICE OF ON BUILDING DEPARTMENT a " 1600 Osgood Street Building 20, Suite 2-36 yq� q,Te, ••icy North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print JOB LOCATION HOMEOWNER Number ame Home Phone 0 am(, awd Map/Lot 7b G8R /adv Work Phone PRESENT MAILING ADDRESS Rz_z—zf-�/ 5 - C;qx Town State Zip Cede The The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNA APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter. 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan Li Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 Arthur W Rose, P.E. PLLC Structural Engineer 33 South Commercial Street Manchester, NH 03101 (603) 622-6066 (603) 624-2244 Fax September 11, 2009 Building Department 1600 Osgood Street N. Andover, MA 01845 Re: Site Visit 219 Berry Street Lot #5 N. Andover, MA Gentlemen: Please be advised that I visited the above referenced building site this date. The purpose of my visit was to review the in place framing of the 30 ft. wide by 40 ft. long, two story single family residence with an attached two car garage. Based upon my visual observations and experience the wood framing and concrete foundation of the §tructure ha=ve with the approved framing plans. beer, `°ns`ructed in accordance Please do not hesitate to contact me should you have any questions or comments regarding this matter. Very truly yours, P �" t r ur W. Rose, P.E. AWR/zp Cc. ey Date -01 ::4 ... /1-1-1— TOWN OF NORTH ANDOVER PERMIT FOR WIRING -7,0& F -le d(I - i , - This certifies that ............................... 7 .......... C ....................... has permission to perform �" C--,/..................., 1-, 1 . .................... ...... ;K wiring in the building of ..... 14 (- 7/ iw-z- . . ................................................... ......... at ... jdlqr. Aleff'..A.'S� ..................... . North Andover, Mass. F -P- If....... ....... Lic. No. ........... A. .. I 'LEcrRicAL*INsP*E­ ­­* Check # 86,9 0 I o°Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �;�X e) BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07j nPa.,P,,,,..,., APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER By this application the undersigned gives.uptice of his or her intention to e perform the electrical wor dies abed below. Location (Street & Number) I ; )WW(: 9 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building E:dsting Service ,' Amps 'W 444&olts New Service Amps / Volts Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers Totals: _ ___.._ . _.._..... NEDishwashers NDryers No. of Water Heaters No. Hydromassage Bathtubs No. of Motors Total HP Ly Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd [0 --'--No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Com letion of the followin table may he waived by the Inspector of Wires. No. of Cell.-Susp. (Paddle) Fans PNof i Total KVA No. of Hot Tubs KVA Swimming Pool Above ❑ �_ y mg ng nd. rnd. ❑ No. of Oil Burners ?do. of ..:.nesNo. of Gas Burners andvices No. of Air Cond. Total Tons Alerting Devices 77__a Tr. _ Space/Area Heating KW Heating Appliances I� I� No. of No. of Si s Ballasts ❑ municipal Connecfinn ❑ Other No. of Devices or Data Wiring: No. of Devices or Telecommunications No. of Devices or Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Star (When required by municipal policy.) -%�-O " Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: - nless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify, p ❑ (Specify:) under the pains d penalties ofRerjury, that the information on this application is true and complete. FIRM NAME:-+�ii�✓ t'.� = t.2t c,¢.{ l l/l c. � Licensee: 1, LIC. NO.: % Signature �?/ IC. NO.: (If applicable, enter exempt in the license number line.) Address: j�[ �4ei�LD � fry ��v t� Bus. Tel. No.: ��- 4&`ro *Pdr M.G.L c. 147, s 57-61, security work requires D ©��� Alt. Tel. No.: OWNER'S INSURANCE WAVER: I am aware that the License does not Safehave ,the liability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner coverage normally Owner/Agent ❑owner's agent. Signature Telephone No. PERMIT FEE: $ I f` x i Aft{ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 JT-askington Street Boston, MA 02111 { ' www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 5131licant Tnfarma ;, n Nanne (Business/Organizadon/individual): Address: (I,( o(.&" 6c4zo:�,- (4 -pe City/State/Zip-_ M149O"(-- l'YV}{l`Oj q Phone #: ropriate box: Arc ytan employer? Ch=4, Ia employer ❑ with I am a general contractor and I employees (full and/or part-time).* 2.[] I am a:sole proprietor or have hired the sub -contractors listed partner- on the attached sheet x ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp. insurance workers, comp. insurance. 5. ❑ We are a corporation and its required:.] 3. ❑ 1 am a homeowner doing officers have exercised their all work 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..] YAnv an..I:....r,x Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. Q Demolition 9. ❑ Building addition 10.Q Electrical repairs or additions I I.Q Plumbing repairs or additions 12.❑ Roof -repairs I317 Other i.0 ouc me section below showing their workers' compensat t Homeowners who submit this affidavit indiion policy information 4t:ontractots that check this box cating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. musratraehed an additional sheet showing, the name of the sub -contractors and their wortrm..-' comp, policy is �z„tion l am an employer that is,providing:workers' compensation uzsurance for my employees: Below information. is the policy and job site Insurance Company Name: (49X --f,5 Policy # or Self -ins. Lic. #: _ rye Expiration Date: Job Site Address:_ l l? Gjj iC� p P, !� City/State/Zi 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 e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Officiat use only. Do not write in this area, to be completed by city or town o�ciaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Insp 6. Other ector 5. Plumbing Inspector Contact Person: Phone #: i 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 ficensing 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 evideuce.of compliance with the insurance 'coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' cornpensation 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 r be returned to the city or town that the application for the permit or license is being requested, notthe 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 numberlisted 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 per nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the '+ applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each a year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MA.SSAFE Fax # 617-727-7749 Revised 5-26-115 www.mass.govlois ' 6263 I) Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4 ............................... ... .......................... This certifies that .... e-2. —'� —, ll� has permission to perform ... wiring in the building of ................ .............................................................. at ............... . ...................... . North Andover, Mass. Fee ..................... Lic. No.......:...,. ..... ..... .......................... .. ...................... EcrmaL INSPECTOR if Check # b I Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC). 527 CMR 12.00 (PLEASE PRINT IN INK OR T pf ALL INF vL4T10/V) Date:__ City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of 11 or her intention to perform the electrical work described below. Location (Street S Number r Owner or Tenant 17— Owner's Address Is this permit in conjunction with a building permit? Purpose of Building. Telephone No j 0/7d. Yes ❑ No [ (Check Appropriate Box) Utility Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Albthorization No. Und ;rd❑ No. of Meters Undgrd ❑ No. of Meters /✓ 19L Completion ofthe following table may he waived by rhe tncnert— No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ In- ❑ Swimming Pool grnd. grnd. t o. o Emergency tg mg Battery Units No. of Receptacle Outlets No. of Oil Burners E ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and / InitiatingDevices [No. No. of Ranges No. of Air Cond. Total Tonsb of Alerting Devices No. of Waste Disposers HeatPump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances g PP KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: O (When required by municipal policy.) Work to Start: e— Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pahis and petialties of perjury, that the informatit application is trite acid complete. FIRM NAME: ADT Security Services, Inc. , LIC. NO.: 1533 C Licensee: S)�c,n Vefq,1rpt7,e r2.c"• Signatu (Ifapplicable, (Miter "exempt" in the license number line.) � ��� Bus. Tel. No.: 603-594-5900 Address: 18 Clinton Drive Hollis N.H. 03049 Alt. Tel. No.: 603-594-5930 *Security System Contractor License required for this work; if applicable, enter the license number here: J'S CC- 0, c, i 6-S 3 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ N Date ..... VORTp, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -t-ze_ . ............ This certifies that has permission to perform ....... .............. plumbing in the buildings of .... "Y".............................. w at ... l-) ,7�.'. . 4�......... . -;�?� ............... North Andover, Mass. ....... J"4 e A Fe ....... Lic. No ..... ... /CP... ......... PLIUM13-ING INSPECTOR Check # -117� 8005 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building k67rZ S i of New El Renovation Replacement - ", Vv m __ _ NSCL 7/C Date Permit # 'NG Amount Plans Submitted yesElNo ❑ Installing. Company Name__A'/TAi1!�'P?__ Check one: Certificate Address '—N��2 S 0aJ / 11Corp. Partner. usmess elephone S —6 ® Firm/Co. Name of Licensed Plumber. _f%P'Z19/"( 20"-� 2 Y/C 7 Insurance Coverase: Indicate the type of ms nability insurance policy urance coverage by checking the appropriate box: � Other type .of indecn� ty El Bond Q Insurance Waives I, the undersigned, have been made aware that the licensee of this application does not have anone of e insurance Y the above ignature❑ Owner Agent El hereby certify that all of the details and information I have submitted (or entered) inabove application are true and accurate to the best of my knowledge and that all plumbing work and insta tions compliance with all pertinent provisions of the Massachu tatePerformed under Percent Issued for this application will be in Plumbing Code d Chapter 142 By P of the General Laws, bignaWre Lac Ilse cu the Type o Plumb' 'cense City/Town G APPROVED co�ME USE ONLY Lccense vumoer meter ElJourneyman —x--" NORFOLK AND DEDHAM MUTUAL FIRE INSURANCE COMPANY t' SMALL CONTRACTORS POLICY RENEWAL CERTIFICATE Policy # R0210580 Named ABNER HOME IMPROVEMENT- Agent COUNTY INSURANCE AGENCY, INC. Insured PLUMBING & HEATING Phone ( 978) 774-2463 3 EMERSON LANE Agent # 20000-568 MIDDLETON MA 01949 FORM OF BUSINESS: ents I State Taxes I Total 1 $1,361 1 1 1 $1,361 1 1 Bldg./Location I I Address if Different Mortgagee Information Business Description POLICY DEDUCTIBLE PLUMBING & HEATING CONTRACTOR BUSINESS PERSONAL PROPERTY Limit T O T A L P R E M I U M P E R B U I L D I N G $250 $10,000 $1,361.00 EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE BUSINESS LIABILITY COVERAGE FORM. E... LIAB & MED EXP (OCCURRENCE/GEN AGG/PROD COMP OPS AGG) $1,000/ 000/ $2 , 000/ $2, 000 Included MEDICAL EXPENSES $5 Included DAMAGE TO PREMISES RENTED TO YOU $50 Included SEE ATTACHED PAGE BOP -2 (REV.04/05) Type of Payment: DIRECT BILL 4 PAY k C5� -/V- Date................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......f...p.....,............. ........................................................ has permission to perform ........ ....................... wiring in the building of ......... ...................................................... at..:....... .......................... . North Andover, Mass. .............. ............... Fee-..�S ............... Lic................. E- C -r' R"I 'C' A**L* N S � E C T 0 1 Check # 721 5 � Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked k [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 02-1 It- 02 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 7 j N99W OR2 Owner or Tenant /l5R Telephone No. Owner's Address Is this permit in conjunctioq with a building permit? Yes Er No ❑ (Check Appropriate Box) Purpose of Building AJ/,lOW14-(. Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -44-59©1-9 191<1-91 Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- rnd. ❑ rnd. ❑ o. o mergeney ig mg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons g No. of Alerting Devices No. of Waste Disposers Heat Totals:p Total Tons K o. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munic'pal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. o No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cra e is in force, and has exhibited proof of same to the permit issuing office. NCE ove CHECK ONE: INSURAOND ❑ OTHER [:](Specify:) I certify, under the pains an d p Wallies of pe ' , that the information on this application is true and complete. FIRM NAME: ✓ �'Ci��/taq LIC. NO.: I %Dlj Licensee: lifer Signature LIC. NO.: (!(applicable, enter "exempt")' he license num er line.) Bus. Tel. No. Address: Alt. Tel. No.:_,j!22 i -,_)?t *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent �L Signature Telephone No. PERMIT FEE..$_j 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): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infonnation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Sii4nature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.1 1'011J!h..binl . has permission to perform 4-p,/4 ... /�2eZ4 X �!! plumbing in the buildings of ........... at ...��.. , 4! ���., . 5.1 ......... , North Andover, Mass. Fee../.... Lic. No.. ........................��. . PLUMBING INSPECTOR Check # i 7277 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSET f$ Date 2 ._� —0.� Building Location 75 OFPKiL Owners Name N L7741T i Permit # Amount S //Ue�5 / r- Type of Occupancy New 0 Renovation 0 Replacement M Plans Submitted Yes No FIXTURES (Print or type) Check one: Installing Company Name P 13QU c (Z. rz-o tl 6l'u ,L Corp. Address Partner KIJ✓ !� ��� ' O/ 4 Business Telephone q -7e 7 s`o 4, 0 0'�— U Firm/Co. Name of Licensed Plumber. 4W -TQ0 J2JC? ` 1C 70 7:7/ 20 -7 / Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy © Other type of indemnity ❑ 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 threeinsurance Signature Owner 0 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 w*igno tions performed under Permit Issued for this application will be in compliance with all pertinent provisions of the State P u ing Code d Chapter 142 of the General Laws. By: umbing Lice Title'"S `� 6 City/Town (cense um er�"� Master Joumeyman APPROVED (OFFICE USE ONLY I.I�J Location �5— &lr' No. oda Date 1-2 NORTH TOWN OF NORTH ANDOVER Certificate Occupancy $ of s ""'°''t�' s+cH Building/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ - I a Check # C? 19952 v� lk Building Inspector Permit NO: Date Issued:/ ^ TOWN OF NORTH ANDOVER �10RTly APPLICATION FOR PLAN EXAMINATION of tt�•o 0.;'tic A Date Received O' c.e..�w.a. IMPORTANT: Applicant must complete all items on this page LOCATION 7S &R66ZI ,mom_ Print �i PROPERTY OWNERS—�-1(� Print MAP NO.: A±'S U PARCEL: TYPE AND USE OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition CKAlteration ❑ One family 0 Two or more'family No. of units: 0 Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other 0 Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREF071 Identification Please Type or Print Clearly) OWNER: Name: 1" MAN1,; [-444Ti Address: CONTRACTOR N Address: .'� ><}/il% ln� i ,i7 7'2-P.s F (G L D 1qA Supervisor's Construction License: C�5 0 9 % -7 0 5— Exp. Date: 0.1 ~ / e ---V- 00 9 Home Improvement License: /1 73 2 Exp. Date: /0- i O -QC 10', ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ 3.2 -.2,x..2 FEES -32rf Check No.: "' Receipt No.: f 15 Page Iof4 TYPE OF SEWERAGE DISPOSAL anning/Massage/Body Art ❑ Swimming Pools El Public Sewer Well ElTobacco Sales ❑ Food Packaging/Sales ❑ F1 Permanent Permanent Dumpster on Site ElPrivate (septic tank, etc. Meter location to project •..... —gl.lg .vss.l Kl—K-lereu cun(racrors ao not have access to the guaranty fund Signature of Agent/Owner r~ ignature of contractor - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Q DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED FIRE DEPARTMENT - Temp Dumpster on site yes Fire Department signature/date COMMENTS LEI Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit ✓tieam�reoi:urealt% o�'✓ratac%use�� f BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 091705 t Birthdate: 02/18/1971 t Expires: 02/18/2009 Tr. no: 91705 Restricted: 00. MARIUSZ ZYSK Y 184 LOWELL ST t'J' PEABODY, MA 01960 _,.,,_ _ ., _:�_. ___ _..._-_______ • y Commissioner .rolvilqulwpd £9610 VW 'a131JSd01 'a2i MS3bONV 9I, >iw zsnibv.w. NOIlOn2i1SNOO >ISAZ.: Vqa :edA.L - '4 LMZ1• #Jl 900Z/Ovoi, wolpeildx3' 6£LZZI. :uoljwjsI6gM s -• 2101OV-diNO3 1N3MA02icim 3WOH spispus;S pus sum vinlag But P11ng;o paoq. y�ay'yr%ydpp��o ��mrouvuio�i a�� • _s j 04 oATEp+a.�DaY+�Yh ACORD . CERTIFICATE Of LIABILITY INSURANCE 01/30/2007 A �► oN rRDDuee+ O NLY AND CONFERS NO RKiFiTS UPON THE CCA TE Richard Bertolino Jr Insurance Agency EFL M CERTIFICATE DOES NOT AMEND, EXTM OR 1200 Salem St 9121 R THE COVERAGE AFFORDED BY THE POLICIES T -OW. yynnfield, MA 01940 NAICIS RS AFFORDING COVERAC,E A: Arbella Protection IRsuRED Zysk Construction e: )sass Norkers Comp Ratiag HnreanMario Zysk c:15 Andrews Road2e efield Mass 01983 E wrw+vcTHE POLICY Ft:MUU a...... _._..._ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V" RESPECT TO WHICH THIS CERTIflCATE MAY BE SUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS• EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMTS mEOFnaauncE POUCYIANeER DATE 11 I DATE "� R0 04/21/2006 04/27/2007 ++ $1,000,000 A I �h^Y 850000027807 sl 000,000 pgFAg5EslF�ocurn�oe) � X COMMMIRLGENERALUABLITY X X CLAIMS MAEj OCCUR GENL AGGREGATE UMTT AWLIES PM ANY At" ALL Ow)W AUTOS SC IM"D AUTOS HRGDAUTOS I NOr4-Ow1.IEO AUTOS GARAGE UMULTTY ANY AUTO EXCE95AMOREW LLABILRY 7 OCCUR 13 CLAIMSMAOE RETENTION $ B wORKERs 7 MAM `"WIFEM LOJULRY I�EX�� B Ym, aascNim oder SPECIAL pRCMS10NS 6aaly MEDOPW700Val) ) $1,000 PERSONAL a AEN INRIRY $1,000,000 GEIJERALAGGREGATE %1,000-000 PRODUCTS-COMP70PAGO $1,000,000 CoM S*JM MW.LE UW $ IEtxcl�el BODILY INIURY s (perpe-0 WDILY RcIURY$ pROPERTY DAMGE 4 ww amwwo) AUTO MYY-EAACCIDEW $ OTHER ITWN EA ACC i I` AUTO ONLY: AOG t EACH OCCURRENCE $ AGfiREGATE $ i S $ 01/30/2007 101/aV/zuu0 TORY UMITs i a EL. FhCH ACGDBLT s 100,000 EL.DISEA9E-EAFAPLOYEE $500,000 { E.LDISEASE- POUCYUNI $ too ,000 ip0lILT09 ILOCAV IVEHICM1ExaUSPOW �,.�.o. �...,.._-•___. _. _ Bureau has been ordered for holder from Lass Workers Coup Town of North AndoVer Attn Building Department L60o Osgood St Andover Mass 01845 _ 979-688-9542 I'd slloutD AW of TIE ABOVE OE=M POUCIEB . CANCT3Lt•+D —GRg TRE E*VATION GATE THEREOF. T16 NSLOM BL UNS was BCMVOR TO MAL. GAYS VMr" NOTICE To THE Cm""'TE HOLDS! mwm To TN6 LEFT. BUT F"JAE TO 00 So SNA1 %Now No OBuOATON on LABLM OF ANY xMTD UVON THE INSURES. rte AS MS OR pEpRESBiATIV�• Richard Bertoli.no BTLOTESBLS Nr outToivag pueyois eTO:OT LO OE uer ACORD CERTIFICATE OF LIABILITY INSURANCE TM ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR DATE/Yh 101/30/2007 PRODUCER Richard Bertolino Jr Insurance Agency 1200 Salem 8t #121 Lynnfield, MIL 01940 THIS WMCA11E IS ISSUED AS A MATTER ONLY AND CONFERS NO RIGHTS UPON HOLDER THIS CERTIFICATE DOES NOT ALTER THE COVERAGE AFFORDED BY OF [W TION THE CERTIFICATE AMEND, EXTEND OR TIME POUCIES BELOW INSURERS AFFORDING COVERAGE MAIC IIISURED 2yak donstruction Mario Eysk 15 Andrews Road Topsfield Mass 01993 INsuRENR k Arbella Protection LUATfs WMII®Re.)Idose Wprkere Comp Rating Bureau INSURER C: GEN—LIMIITY moo: _ 3u1xRLRE: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. LTR nsRO - TYPEOFUSURANOE POLICY � cyW m17e( Pour oPORAYION DATEITAAf0WYY1 LUATfs A GEN—LIMIITY 850000027807 04127/2006 04/27/2007 ' EACHOCCURRENCe $1,000,000 $1,000,000 X COMMERCIAL GENERALUANUry X X CLAiM$MADE D OCCUR -P-R-O-MSESM0-6"W") MEnslEil e*(AM —�pow) $1,000 PERSONAI. a ADV INJURY $1,000,000 C4a4GUL AGGREGATE $1,000,000 GEWLAGGREGATEUMITAMMSPM PRODUCTS -COMP/OPAGG :1,000,000 POUDY PPERTT' LAC AMMOGI E UABIRY ANY AUTO COMBINED 6"CLE U1Wr 1F. ■cdAwA) BOOILYINJURY (PDRpPrRDDI $ ALLOMWEDAUTO" 9C#IEDt1t.ED AVTT15 BOOILY INJURY �� $ HIRED AUTOS NO"V1NED AUTOSoer i ao-y°A"ucE s _ OARARKIMBAlTY AUTOONLY-FA ACCIDENT s OT E RTRMI --- EAACC S AWAM AWO ONLY, ACG $ ptCPR9NNBtaFJiALpBaITY I EACH OCCURRENCE S OCCUR ❑ CLAWS MADE AGGREGATE $ $ $ DEDUCTIBLE i RETENTION I TIO 8 INORIOWCOAPENSATIONAND WCV-234678908 01/30/2007 01/20/2008 TORY rrS eR, ELPJUCHACCIDENT $ioo,000 E NPLOYERS•LRABtm ANY PROPRCr0R,oARTNER0MCVRYE EL OI EASE - FA EMPLOYEE + $500,000 OFFIOERAA mm acLwroT If yea, desedbe, t oeN SPECIAL PROVISIONS D64W EL OISEASE- POLICY LMR $ 100 , 000 OTHER i IT' I DE9CRIPTIONOFOPFRATW►neLocATmmivENCLFSIQCLgiDH' Amway HiDOROBdENI'f4PECMLPROVI510P6 Separate cert has been ordered for holder from Mass Workers Comp Bureau CERTIFICATE HOLDER CANCELLATION Town of North Andover SHwLD ANY OF THE ABOVE DEBCRIBFD POUCMS BE CANCELLED MOM THE EKWATION Attn Building Departsent DATE IMEN . THE MSUING INSURER IAYIL ENDEAVOR TO MAL DAYS VNRRIELN 1600 Osgood St NOTICE TO THE MRWCATE NOIDE.R NATE TO THE LEFT, Off FAILUR[ TO 00 30 SHALL IMPOSE NO DBU"TIM OR UABLNTY OF ANY KIND UPON THE •USURER, In AGWITS OR North Andover lass 01845 R£PAt-SENTA11VF7. Pax - 978-688-9542 MRIIORMODREPREIIENRATNE Richard Bertolin0 ACORD 25 [2001108R ® AGORU GOIGIORA-HUN TSM T ' a B T LO T ES8L6 6r OU T T 04jag P.Je401 N e6S = 60 LO 06 Uer M, m x m mm v y d C � - - d cotCD o 5Z Z H C. O �� O C. = y aCc � o O CD v CD o Q "C m a CD o CCD WIM a. C O co) CL v CD CD I S v CACD O CD Z 0 CD CCD n O Cn �I `i W C C �� ? �_ ,o Ce ao S.m 1 y _mea mao � m Mm Z cl N oEF-0 N '� = o CL0-0 CL �m o y m comm o O =m m = N (� a S. m m of CirN _ CR CL m c = CD m m m'� A am O m H CCOD CL co Jt d '- `_+ _JE ce M CA 7 o� cc act �c CD o O y O m M Vim: CL's O: CA 0 c o �o NO 4 4Tas ZI I:0 � O D 7d � NO 4 4Tas ZI I:0 1 1 • 1 • s Y t ri :-.,aprr s y .' #. da zt i^' q, 'Ph.„s. :V9 _21. .k��o ZYSK CONSTRUCTION PINE PINISH CARPENTRY, TILE AND PAINTING 15 ANDREWS RD. �r TOPSPIELD, MA 01983 u L 978-836-6879 IHC#122739 GENERAL CONTRACTOR C58091705 PROPOSAL SUBMITTED TO: "PROPOSAL al= lc0 / SIT N0. DATES / WORK TO BE PERFORMED AT: ADDRESS 1.�� DATE OF PLANS ARCHITECT We herebyrpropose to furnish the�mat riais and perform the labor necessar for the coyrnpletion of LA LLJ O t r rte, fY Gii A 0,NW C04el l v CCLA i A� C --Gr- 6 D+/ IF All material is guaranteed to be as specified, and the above work to be performed in accordance with th rawi 9 d specifi- cattiions submitted for Bove work a completed in a substantial workmanlike manner for the sum of P lel 410 - Dollars with paym$nts to be made as follows., (.tpFay1 CIJ�G=r>`�f+11 (,G r,'Ll � sG7G� qo / �f`t.rsk �p 6��`Ilespectfully submitted ny alteration or deviation from above specifications involve extra costs ?E will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents, or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL 'The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date !Adams NC 3818-50 MADE IN USA Signature Signature 411 WT �t s00 r ii.^.='..Y��.'R71Bx?'� "a'y..`.. ..J^�#x+'yr': ,rr fi ,YC��• ZYSK CONSTRUCTION FINS FINISH CARPRNTR Y, TILS AND PAINTING 15 ANDREWS RD. �n TOPSPIELD, MA 01983 U L 978-8366879 mc;¢I22739 GENERAL CONTRACTOR CS0091705 PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: ADDRESS J DATE OF PLANS ARCHITECT Ll We hereby proposq to furnish the materiels an rform the abo cessary for the completion of �sav� m r P 44%g 2r �OAY It en r tVi 4'le 0_.:e e �M lcf st f'r/ S S i Qv I 17 All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings d specifi_ cations submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ 1 with payments to be made as follows. Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per 1 t vl over and above the estimate. All agreements contingent upon strikes, ac- cidents, or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date !Adams NC 3818-50 MADE IN USA Sig Signature Proposal The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations w ' d 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): ?— Y 51<' CQ 110_f?? T_( 0 ff. . PAM 0 2-'15 Address: -/,5 gl j'p k 6 CO_5 FR City/State/Zip: O 4:/ F Z� A# Q%T 'hone #: '% 8��= 6'87 Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 required.] Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. A e _ , _ Insurance Company Name: Policy # or Self -ins. Lic. #: ASC 7015,0_610lao f Expiration Date: Job Site Address: 76 R A PT n2 _<�.T City/State/Zip: n0 A17Pwa1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: T'- sE36-_ -C cSS ZI' use only. Do not write in this area, to City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: or town official Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employdrs to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have'any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The 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 Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia Building Setback (ft.) Front Yard Side Yard Rear Yard Re uired Provided Required- Provides Required Provided Dimension Number of Stories: - — • Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: i,Nv i En ana LA 1 A — (v or department use Page 3 of 4 SERV Created JMC. Jan.2006 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 Location No. Date ,.ORT#j TOWN OF NORTH ANDOVER f �,r 9 Certificate of Occupancy - $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r Building Inspector./ f NORTH F3 _e..,. .. A TOWN OF NORTH ANDOVER ;' ...° APPLICATION FOR PLAN EXAMINATION 9SSACHUS� Permit \,O: 45V,.,2— Date Issued: -/Q-61) Date Received: —1 nk UNIMM 1'ANT: Applicant must complete all items ()n j LOCATION ! PROPERTY OWNER— OIL-)-035-v0-010(.-000'0,0 WNEROIu-O3$7r0-0IV(.--(700'0,0 Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND I NF OF m m nIN(`- ■iiCTllT TYPE OF IMPROVEMENT aaav� Vail. V1t711[ll.. PROPOSED USE / IV LIN U Residential Non- Residential _. New Building Addition Alteration 1)C0ne family - Two or more family No. of units: _: Industrial X,Rcpair, replacement = Demolition - Assessor), Bldg _---- _ _- - Commercial ' Moving (relocation) Other Others: Foundation on IN, I i DESCRIPTION OF WORK T(YRF PRFFf-PxAPn OWNER: Name: Address: Identification PleaseT e or Print Clearl ) Signature CONTRACTOR Name: Phone: Address: Stipervisor's Construction License: Exp. Date: Ilomc lrnpi-mement License: Exp. Date: \RCIIITL C'F1,N(iIIN, FI: Name: Phone: Address: . No. FEE .SCHEDULE: BULDING PERMIT. 510.00 PER S1000.00 OF THE TOTAL EST1A14TED COST BASED OA $ I25. 00 PER S.F. Total Project Cost :$fit (�(�� ; ��-o. e -0x10.00 FEE:$ Check No.: Receipt No.:—&6-19/ TYPE OF SEW ARGE DISPOSAL I S"N'1111111111", Pools Tanning,'!'lassage Bode Art I Public Sewer i Tobacco Sales — I Food Packaging Sales Well Permanent Dempster on Sitc 1 Pri%•lte (septic tank etc. NOTE: Persons contracting with unreistered contractors du not h(we trews to the ruurtud), /und Si1,nature of'A"entiOwn _ _ ignature of Contractor— - Plans Submitted F Plans Waived U Certified Plot Plan L Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoniiv, Dv6sion,'reccipt submitted yes __ _ Plannine Board Decision: Conservation Decision: DATE REJECTED ❑Water Shed Special Permit '__l Site Plan Special Permit ❑ Other DATE. REJECTED DATE REJECTED F1 Continents Comments DATE APPROVED DATE APPROVED DATE APPROVED Water & Sewer connection signature &, date Temp Dempster on "ite es l no_ Fire Department si;nature'date — — -- ---- -- ---- Building Permit Approved and Issued by: J O �h V 6 z x cn 0 w w v U ca w 0 w co a w r2 ci w rx co u. w cn z cn cn E s N 0 cmN C O m Of 'O m O cm C C N CD Z w 0 Z O g CD F a CA JR 1 CD O CD _O V Z C. O y Q C I Ccm O•— H Q CD.� H O C FE anCD 0 CD m Z O.D 3.0 O OCL G i 0 CL �e � 9 V O. O ♦caD C O C. V C C _cc CO2 C LU uj W 0 LLIW CA c� O O N C C0O- C� �.1 CLC O O O C :L O ' p i Ea CD CF o - E c m • c2, .. • : 2 w m • c m m r3N m C � � � m N O N Inc a� N m � CM' O Q �• aCt m O � vyCc Z m d H y C H W C N 0jz-0= LL O •NF O .. C m '!.s C' .E 0 .0 N W .fl CO., v ' Cf y C. m. O.0 = A ` y _ H t ��M E s N 0 cmN C O m Of 'O m O cm C C N CD Z w 0 Z O g CD F a CA JR 1 CD O CD _O V Z C. O y Q C I Ccm O•— H Q CD.� H O C FE anCD 0 CD m Z O.D 3.0 O OCL G i 0 CL �e � 9 V O. O ♦caD C O C. V C C _cc CO2 C LU uj W 0 LLIW CA Gerald A. Brown Inspector of Buildings TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE: �" I I ' (� ( 0 c JOB LOCATION: Number Street Address Telephone (978) 688-9545 Fax (978)688-9542 Map/Lot HOMEOWNER-'���� �0 — I C) Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATUP APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Fonn Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688- 9535 Buildin(u, Setback (ft.) Front Yard i Side Yard Rear Yard RCOUIred r Provided L R (e (c Required ProN,ided DIMENSION Number of Stories: Total land area. sq. ft.: Total spare feet of floor area, based on Exterior dimensions. -- r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Debris Removal Form � orkers Comp Affidavit Photo Copy Of H.I.C. And,"Or C.S.L. Licenses Copy of Contract zi Floor Plan Or Proposed Interior•Work Addition Or Decks La Building Pen -nit Application Li Form U ❑ Surveyed Plot Plan • Debris Removal Form o Workers Comp Affidavit • Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) Building Permit Application Li Form U Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit ,Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) • Copy of Contract • Mass check Ener -,,Q Compliance Report In all cases if a I ariall cc or special Permit «-as required the To��n Clerksofl7ce must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and Proof' of recording must be submitted H ith the building application Dnc: INSPECTIONAL SER\ ICES 1 EVERT\1EvT:BrFOR\105 A Date....................... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING . .................................... This certifies that ... L ....... . has permission to perform Y: . .......... z ........................................................ wiring in the building of ... . ......... '7 4 .4 at � I- t ...... .............. . North-;G—diov-6, Mass. .................................. Fee........ ) ............ Lic. No./ 5 ......... . .......... ELECTRICAL INSP Check # 54L8 Commonwealth of Massachusetts Department of Fire Service BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT All work to be performed'- ccordance w'9 (PLEASE PRINT IN INK OR ALL FO f City or Town of: By this application the undersigned gives n ce ot or Location (Street & Numr) Owner or Tenant r\ --PA/) /0' 91— _bl e,,.1, Official Use O' my Permit No. J w( / Occupancy and Fee Checked _Zr_ [Rev. 11/99] (1Pnvr hlnnk) ATO PERFORM ELECTRICAL WORK i the Massachusetts Electrical Code (MEC), 527 CMR Z120 TION) Date:_ p ' °11 To the Inspecto of Wires: ier intenpion to perform the electrical work described below. Telephone Note--4Jrp? - Owner's Address Is this permit in conjunction with'a.11uilding permit? , _ ..: Yes..El „NoLY (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system ('­I,Hi nftho t 11-d- t.,hle , J,., 1,,, al,.. Jr.,.,.rcrr:...... No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above In- Swimming Pool rnd. ❑ rnd. ❑ 0.0Emergency Lighting Batte Units No. of Receptacie Outlets No. of Oil Burners FihE ALAR rrIS No. of Zones No. of Switches No. of Gas Burners No. ot Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting in Devices No. of Waste Disposers ..-.. Heat Pump Totals: Number Tons IKW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal EJ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or E uivalent No. of Water KW Heaters No. o No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail it desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of El ctrical W rk: �-- , (When required by municipal policy.) Work to Start: a # Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the(pai-ifs, an penalties of perjury, that the information on this application is true and complete. FIRM NAME:Security LIC. NO.: Licensee: John S. Bassett Signature LIC. NO.: 15330 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No..• 603 594 5928 Address Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li*see see does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ v