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Miscellaneous - 76 CHADWICK STREET 4/30/2018
T -s SN PATRICK J. DONOVAN ASSOCIATES, INC. claim and Xoss Adjustments P. O. BOX 110 WAKEFIELD, MA 01880 (617) 245-5540 — FAX (617) 245-7016 May 11, 1998 Building Commissioner City or Town Hall No Andover, MA 01845 Insured Prope fty Address Insurer Policy Number Type of Loss Date of Loss Our File # : Solof, Jeffrey R & Marta : 76 Chadv►: ick St No. Andover, MA 01845 : Merrimack Mutual Ins Co : HP1810894 : Sewer Backup : May 8, 1998 : WAP28123 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. 1 ��, Vern Laws Adjuster VL/so OF INDEPENDENT INSURANCE ADJUSTERS of Massachusetts 1Ij W 0) L L o it Date .k ..�),I� .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING L L - Thiscertifies that .............. A V..I................................................................................................. has permission to perform ............Q �.%,..,, j........... .. wiring in the building of ....... N..f.01...................................................................................... at ..........( `1'� L(r ................. . North Andover, Mass. / Fee. '�(,� �..............L-` y? Lic. No .................. ......:.................-............................... .... 4LE6TRICAL INSPECT6R Check # � Commonwealth ealth of Massachusetts Offic'a} Use 0 1y V Department of Fire Services r0ccupancy t No. �j 3 BOARD OF FIRE PREVENTION REGULATIONS (Llease add zO codes & electa�lelan7s cell �g and Fee Checked 07] (leave blank) contract # & bld toormit # if g2p icable ) PPLIC/, TIOM FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEf1SE PRINT.ININK OR TYPL ALL INFORMf1T10A9 Date: 542&-) City or Town of: i/ A 0,00 le— To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. 1 Location (Street & Number) r] Gj C 1A A9Wi Ci< n^ Owner or Tenant �y t4t�Lc Telephone No.g79 96S'tpgc6 C.� Owner's address rs this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) I Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters NewNew Service Amps / Volts Overhead ❑ -find rd - .. . _ • __-- _ . _ .g No. of Meters a IyTuzn�ep of eeders and Arapacity ]Location and Nature of Proposed Electrical Work: .����`�c�•�l L� � c}2LfJ.i'L VJ � e 5 (ern Com letion of the, following table niay be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans IN0 °t 'Dotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators XVA, No. of Luminaires Swimming Pool Above ❑ In- ❑ o.. o mergency rg sting rnd. rnd. Batter 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. ons] No. of Alerting Devices No. of Waste Disposers HeatPump Number Tons IOW No. of Self -Contained * Totals: Detection/Alertino, Devices No. of Dishwashers Space/Area heating IOW Local.Municipal ❑ Connection Other No. of Dryers Heating Appliances XW Security Systems:* No. of 'Water No. of No. of Devices or 1J uivalent No. of Heaters I£W Data Wiring: Signs Ballasts No. of Devices or E quivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: OTHER: No. of Devices or PmAN uivalent • Attach additional detail if desired., or as required by the Inspector of If"ires. Estimated Value of Electrical Work: (� (When required by municipal policy.) Work to Start: f} 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 X (Specify:) Self Insured X certify, under the pains and penalties ofperjury, iliac elle irzfo..rz9zc�tior on this application is true and complete. FIRM NAME: ADT LLC DBA ADT Security LIC No.: C-172 Licensee: Thomas J. Lee// i' ignature ,_ ,� LIC. NO.: C-172 (If applicable. enter `=exempt" in the h ease number line,�, �! Address: _ (; �L i n' i e m ` - Bus. Tel. No.: (n �� c? t 1 - ,r� \ \iSr N l Y C7 �c��,rc� Alt. Tel. No.:_ ' *Security System Conrrac,tor License required for this work; if applicable, enter the license number here: 001779 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/Agent❑ owner's agent. Signature Telephone No. k' I XT' �� o $ 5�s, s� /97- 3,)657 01*� s2c'd �1 M+101 A- . Q00,9JIMONnlllEA I! H •w'O.�u' y117�� ' LECTR(C)ANS - -X,REGiSTEREO SYSTEM CONTRA CTO i -ISSUES.THEASOVELICENSE Td' '`•ADT L:LC• DBA ADT SECl1R-ITY,- `l'HOP1AS J LEE..`. 1D :UWIVERSITY AVE of �A GJESTWOOl7 MA D2090-2311 t UZ G 07/31/13 _ •20_193_ Fold, Then Uelach Atony N1 Padoiations a � •,�.\" � :y1s� . .� . w .m >�•� g � . � 20 n. •d < 2•� •y y7a:§' sgr a.\• q� - m / mm ± k; _ 2 r- -(n m >• )me[t m m r� i . :9.w e. > >cn c K > < m slid cm= Ze£� m { \� � G - :o @ \C3 gee -'< & a• • : 2• ©» ..� 3� � ®o ». /� § ���t� @J��. _ • `_� Address. 18 Clinton Drive 'hone Are you In., employer? lC:heA theappropriate box! 1.[N l a171 a entpai0yer With v 1000+ 4 [:1 .l ani at gencrai contractor and T cer�tiloyces ftillaudfurpf arq-tulle. bavehiredthe sub -contractors x . 11,:Mnit the he sucked sh"t. 2.11 I atn a ,;ole 3arop fetor c r paitner- :566 a and have .no employees Working for me in any capacity. o workem ,camp. insuranco r�:tltiire�9.� 3.; E 1 'am a 11omcok" er doing W) work u r cif n ",vorker �' comp.. iiis>ararro required,] Tl1avo ciiipiloyices and have Drier,", tromp. insurance.+ 5, We tie a corporation and its ol'f`Icer- have cruised heir right of exemption per ntalM c. § 1(4), and v�Pthave 110 t i15151i:Fyocs. [No MvkeW comb. irsurattce'reauired.l Typt of projtct (reqpired). . ❑ t ear carr, uetl n 7. Remeilcling ], 17 olillon 9,. C' building addid.tiln lll.0 IP,;l'r.ctrical rapairs oradd it:ions 11. ] p1jun repairsor aelslitiatis 12.[j Roofrepairs 1.9,[Z Other Low Voltage Security Svstem 4ArLy dpp1 is mt Mat d1-Kl,& b€ X # I FRVit al.sd rilluut tht-sectidn below cilrP517':plsalio-n "I iev i ntoraciblioL . t Homcowjen who submit this affidavit =doing all work wd then hire outside ono actors must submit, a r&w affidavit it dicoting melt IContrdcton that chink Ibis box mast si'tucbed ah additional. €hect showing the mote of the sub cont wtun ung! stuto whether or not tiuysc cnlitics have omplry: , l i'1hc sdb-contractors hs empioym, they MUST provi& d4cir Work -ems, cOPip- policy -RAMIcr. .lam an enttplRyer t'lurt tslar0r1d1ngPw0orkerS1 eontpensatign lnsurance.,ior ' o/npl()yea . I3 low is diepalley t7l[1 job s le insurance CoTnpanyNamr,;,-,_ Zurich American Insurance Co.____ Policy r i alis, Sze, ; WC5095897-OONVC5095898-00 'p!Mts`oa Late; 10/01/2013 Job site Address; � 1� �,,L - -- Itw I tate pa._ d� l r, __�_y_ .� tiueh n dcop y of the workers' compensation pulley declaration page (7,hv►vleg the policy utttsaber and expiration date). Fdd rre to serum cl coverage as. ruired wider Section 25A. of IsIGL. c. 152 caCt lead to the imposition ofa,ritrlim. p m 4t'ies ofa dine up to $1,500400 i3 dlor oneryear irnprisonmcnL -as Nvell as civil penalties in tie �foim ot'a STOP Wf,?.[ K �01t(31;R and a fins of lip to $250.00 a day avainast the V;.ONtcsr, 130 advised that a Copy of this statement niky be. forivarded to the Office of Inv": iga3.tionsoftho )SIA for insurance royeridge tlOTMOatIM Lila here*,;ee7Vii` ader l r ] r3inS a [��1T e11aftie-T r?�`'�7el� u.0t J'hat Ate ��rf,thrllfctdvn provid tr! ahovve�is ime and cr�MCI. Pi, neo, 603-594-5937 a ffltr{ai`mve llnly. Do not write in this area, to be c0owlefed by dly orito n offir at % etyar`pow'nr ist�cmfrEti�en+rc # tssiAng, A.ultlierity ('circle .tine): 1. Board of l-iealih Z, Building 10(partmeut 5. City/Town Clerk 4. Electrical Inspector 5. IPlumbiny Inspector 6.0ther Contact Pel o.n Fiytrrtc #: The oJfLlFFion ia.FFR:fth ofAf f.?J:aeh usettJ apar wnt yy ndn }ay3f cc }i'yp; Office of In yesligations r1ra,ty I 64►.0Wayhln,'��fs�.fi��L9�� Hosta€Jn MA 0 111 NVorkers" Compensation, lnsunince Affidavit-.BuildorslCentructors/Electr'icians/Plumber: p lieant 10oil'rnat on - _._ _ Please Print L! Mbiv r�+�,ador�note��r�s�i�6 ADT Security Services Address. 18 Clinton Drive 'hone Are you In., employer? lC:heA theappropriate box! 1.[N l a171 a entpai0yer With v 1000+ 4 [:1 .l ani at gencrai contractor and T cer�tiloyces ftillaudfurpf arq-tulle. bavehiredthe sub -contractors x . 11,:Mnit the he sucked sh"t. 2.11 I atn a ,;ole 3arop fetor c r paitner- :566 a and have .no employees Working for me in any capacity. o workem ,camp. insuranco r�:tltiire�9.� 3.; E 1 'am a 11omcok" er doing W) work u r cif n ",vorker �' comp.. iiis>ararro required,] Tl1avo ciiipiloyices and have Drier,", tromp. insurance.+ 5, We tie a corporation and its ol'f`Icer- have cruised heir right of exemption per ntalM c. § 1(4), and v�Pthave 110 t i15151i:Fyocs. [No MvkeW comb. irsurattce'reauired.l Typt of projtct (reqpired). . ❑ t ear carr, uetl n 7. Remeilcling ], 17 olillon 9,. C' building addid.tiln lll.0 IP,;l'r.ctrical rapairs oradd it:ions 11. ] p1jun repairsor aelslitiatis 12.[j Roofrepairs 1.9,[Z Other Low Voltage Security Svstem 4ArLy dpp1 is mt Mat d1-Kl,& b€ X # I FRVit al.sd rilluut tht-sectidn below cilrP517':plsalio-n "I iev i ntoraciblioL . t Homcowjen who submit this affidavit =doing all work wd then hire outside ono actors must submit, a r&w affidavit it dicoting melt IContrdcton that chink Ibis box mast si'tucbed ah additional. €hect showing the mote of the sub cont wtun ung! stuto whether or not tiuysc cnlitics have omplry: , l i'1hc sdb-contractors hs empioym, they MUST provi& d4cir Work -ems, cOPip- policy -RAMIcr. .lam an enttplRyer t'lurt tslar0r1d1ngPw0orkerS1 eontpensatign lnsurance.,ior ' o/npl()yea . I3 low is diepalley t7l[1 job s le insurance CoTnpanyNamr,;,-,_ Zurich American Insurance Co.____ Policy r i alis, Sze, ; WC5095897-OONVC5095898-00 'p!Mts`oa Late; 10/01/2013 Job site Address; � 1� �,,L - -- Itw I tate pa._ d� l r, __�_y_ .� tiueh n dcop y of the workers' compensation pulley declaration page (7,hv►vleg the policy utttsaber and expiration date). Fdd rre to serum cl coverage as. ruired wider Section 25A. of IsIGL. c. 152 caCt lead to the imposition ofa,ritrlim. p m 4t'ies ofa dine up to $1,500400 i3 dlor oneryear irnprisonmcnL -as Nvell as civil penalties in tie �foim ot'a STOP Wf,?.[ K �01t(31;R and a fins of lip to $250.00 a day avainast the V;.ONtcsr, 130 advised that a Copy of this statement niky be. forivarded to the Office of Inv": iga3.tionsoftho )SIA for insurance royeridge tlOTMOatIM Lila here*,;ee7Vii` ader l r ] r3inS a [��1T e11aftie-T r?�`'�7el� u.0t J'hat Ate ��rf,thrllfctdvn provid tr! ahovve�is ime and cr�MCI. Pi, neo, 603-594-5937 a ffltr{ai`mve llnly. Do not write in this area, to be c0owlefed by dly orito n offir at % etyar`pow'nr ist�cmfrEti�en+rc # tssiAng, A.ultlierity ('circle .tine): 1. Board of l-iealih Z, Building 10(partmeut 5. City/Town Clerk 4. Electrical Inspector 5. IPlumbiny Inspector 6.0ther Contact Pel o.n Fiytrrtc #: Date .../�/Xr,Z........ . ''` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I This certifies that .. CI ! �.!!�Q� n u has permission for gas installatii n in the buildings of , .. �'. �T.......o a,� at ...%l! . �i ac�!G/' G .........:.. North Andover, Mass. Fee.��°:Sv. Lic. No..93� ............ ��// GASINSPECTOR Check # W& 8005 J ^. b J FIYTI (RFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING b City/Town: lyL�dL /S6t•�,3�L MA. Date: / %� /'� Permit# Building Location: 7(Q Owners Name: _ i -t F/r- del w ec Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential W � New: jr, " Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No E -- FIYTI (RFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes eo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ®� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By tuber Title Gas Fitter ature of Licensed Plumber/Gas Fitter City/Town ourneyman License Number: %J7 Ll4 APPROVED (OFFICE USE ONLY► ❑ LP Installer b►, -4-. (n W � Lu 16— Y 2 ¢ � W O uj O Lu W Z F- Z 0 J >- Z O O w Z x U) O e: w W p FQQ- � � �J bV AA 0 N w > N W () w m 0 a W rn Q! O W to a O HQ o F 0 W X S U. W 2 W G W W Z O¢ W W co J i- H O Z -1 C7 W a> O Z u_ O Z Z I-- W Q v o o u_ W 0 0 x x -j O a� W W E- >>> IS - p SUB BSMT. f BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 IHFLOOR 5 FLOOR 6 1H FLOOR 7 1H FLOOR 81HFLOOR i�� Check One Only Certificate # Installing Company Name: , ❑ 1(� Corporation Address: ! l 1t-/1�ir!= CJ City/Town: State: ❑ Partnership Business Tel: 7 Fax: _ /J ElFirm/Company Name of Licensed Plumber/Gas f Fitter: ///ellI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes eo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ®� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By tuber Title Gas Fitter ature of Licensed Plumber/Gas Fitter City/Town ourneyman License Number: %J7 Ll4 APPROVED (OFFICE USE ONLY► ❑ LP Installer b►, -4-. Alp It, The Commonwealth of Massachusetts Deparhnent of fndustr ial Accidents Office of investigations ..600 Washington Street .Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizafion/Individual): Address: City/State/Zip:_ Qj� f35Phone #: f7, ��'ZO% 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).*' 2. ®�am have hired the sub -contractors a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub=contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. El We area corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Home ., __ —_ ... ,,, c:�V •u: VLLL eLe SeClZOII oe.o�i' 3.20!! Wb TWeff wor*:wo' coW ••sation goliCy information. T owners 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: 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 ofMGL 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 Signature: Data: Phone #: 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 #: 1 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 coinpliance 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 app liaauJn for the parr_-Ut 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 permittlicense 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 burnleaves 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 4406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wvm%mass..gov/dia 0 a COMMONWEALTH OF MASSACHUSETTS �!`�9iel•�.el'�J:�:U��.�-•yL��!��?I,f.���� :l:r �w il�`';�� PirtJNIBER ANu UASPITTERS 7.a LICENSED AS A JOURNEYMAN PLUMB ' ISSUES THE ABOVE LICENSE TO: RICHARD T BOWMAN !. 6 HORNE'STREET �. — BRADFORD MA 0.1835-802 25201 05/01/12 791753 • COMMONWEALTH QF MASSACHUSETTS e i e '''Xe !;?-ice mix1` f11}. i i?'•ei Te ml LIC -.N,,. ED AS A MASTER PLUMIXE ISSUES THE ABOVE LICENSE TO: R_I:CHARD T' BOWMAN 6•HBRNE STREET BRADFORD MA 01855-60.;!K .� ;r. 13496 05/01/-12 79951 I� ��T�`�7i� L�l;ll:�all•7�LL•�E ��.1�7t �e�� ,i HORTp � p SACHUS� Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... �.�.0........... has permission to perform .... ...... ....................... plumbing in the buildings of ... at .........Cl �!�...'.(................ North Andover, Mass. II I Fee. .10'. Lic. No.c:� X..... .... ...... ........ J PLUMBING INSPECTOR Check # C51 MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, Building Owner 50 /0 New ❑ Renovation 0— Replacement ❑ WVmrrn.-vo Date Permit y/ Amount Plans Submitted Yes ❑ No (fit or type) Installing Company Name Check one: ertificate orp. 1-3 Partner. ❑ Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: 1...1 Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of tins application does not have any one of the above three insurance Signature I Owner Agent ❑ I hereby certify that all of the details and information I have submi en ed) in bove application are true and accurate to the best of my knowledge and that all plumbing work and insta 'o under emiit Issued for this application will be in compliance with all pertinent provisions of the Massach S b' Code d Chapter 142 of the General Laws. Y —��. igna kens um ,APPROVED �o�cE usE ornx Title NO umbing License Cit icense Numoer Master Journeyman ❑ The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations kvi .600 Washington Street Boston, AM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): L"A Address: r-T�-- City/State/Zip m. ,•.. , — Phone #: 15 _4� 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. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t iA -1;-- 4 - 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 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other ciao tui out Inc section ?e!^H, 'heun etr worix= comptesation- policy mrormation. 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 as additi onal sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providingwor r ' compejecation insurance for my employees information Below is thepolicy and job site Insurance Company Name: fit" 'b 142! Policy # or Self -ins. Lie. #: 1 Expiration Date: / 7 — Job Site Address: I>f 1'1 Lc�' 0, 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 D)A for insurance coverage verification. �Iido hereby u der the ain andpen ties of perjry that the informationprovided above is true and correct atu e: Date: Phone #: 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 #: M 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 cojmpliance 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 hav%any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Departmen of Industrial Accidents Office of Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 vtrwvs,.mass _gov/dia Date TOWN OF 14ORTH ANDOVER PERMIT FOR PLUMBING This certifies that '........�...............t has permission to perform ...... ....... -r ,% : ....... plumbing in the buildings of .. `:.'.. ' `:. `..�................ . at. ...........' �.-- .% ....... ,North Andover, Mass. Fee y�..... Lic. No.. ........ ' - ,............... PLQMBING INSPECTOR Check # I/, = / Fy o/-/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) 0 w f)rd'`v0)z—_ , Mass. City, Town Building AT: Location_ L ��► ►� +yi New ❑ Renovation t' I Date -----,3 -- 1n o Permit # &W Owner's Name- P -i 1,� Jd o p i -N Type of Occupancy:`t Replacement ❑ FIXTURES Plans Submitted Yes ❑ No ❑ (Print or Type) Installing Company Name LA `"V Address qA' m+41r s4 i -V) 1. . Business Telephone �� bkA - b 4+ Check One: [2 -Corp. 13 7— ❑El Partnership ❑ Firm/Company _ Nie ql Licensid Plujpber or Gasfitter Certificate I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Caws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. By - Title City/ Town APPROVED (OFFICE USE ONLY) FORM 1240 HIW—) HOBBS g WARREN'" Signature of Licensed Plumber q43j Type of Plumbing . Ljcense License Number E �Master ❑ Journeyman L 71'�—, 0 I —0 name: address: City state• zin: phone # I am a homeowner performing all work myself. Project Type: ❑ New Construction I am&a sole proprietor and have no one workingman capaci Build m Addition Tarn an employer providing workers' compensation for my emvlovees workine on, this iob. � a ---- - - -- c' -r"-"'-) b"• ---w• ., .......��,, .,& numcuwuer kctrcte one) anti have lured the contractors listed below who have the following workers' compensation polices: gQmna_nv..name: _ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statemel may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cc er the ps and naldes of perjury that the information provided above is true and correct Signature t�'— -1 '�) Date Print name l.V rr �i ' �/� 7T Phone # -- official use only do not write in this area to be completed by city or town official city or town: permit/license # -[]Building Department ❑ check if Immediate response is required OLtcensing Board (]Selectmen's Office contact person: 13Health Department (wed sea X1) phone #; []Others_ Date.. .:. �1�....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that G.. has permission to perform .....4—i,77�/............................................. wiring in the building of ...................... .v �................................................. ,North Andover, Mass. at ...q..........�.................... Fee .... /...��.. Lic. No. &/ *� .�...... t ........... ELECTRICAL INSPECTOR Check # 3 3; 0 J0U commenwsaIg o` Maldac"tfa .UaPartnwnl o`5ire Serviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No, 0 Occupancy and Fee Checked Rev, 1/071 leave blank) —7 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be'performod in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z? to City or Town of: NaeAl To the Insp ctor 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� 6 jwlei< Owner or Tenant !r.06DF _ Telephone No. ' Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Yes ® No ❑ (Check Appropriate Box) 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 Worktou,{�,,," q. Completion otthe tnllnwino tnhln mnv ha —f-4 h,, A. l.,„.,e.., -r w:--. No, of Recessed Luminalresi! —X No. of Cell.-Susp. (Paddle) Fans o. o ota Transformers KVA No. of Luminalre Outlets Z,2 No. of Hot Tubs Generators KVA No. of Luminaires Swimmin Pool Above n- ii rnd. ❑ rnd, ❑ o. o Emergency Lighting Bate Units No, of Receptacle Outlets No. of Oil Burners No, of Cas Burners FIREALARMS No. of Zones ecti on an o, o e Initiating in Devices No, of Switches No. of Ranges No, of Air Cond, Total Tons No, of Alerting Devices No. of Waste Disposers l eat ump Totals: _1 „,fir„ „„,9na _„ o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Headng KW Local ❑ Municipal❑ Other Connection No. of Dryers Heating Appliances KW ecur ty Sstems: No. of Devices or Equivalent No. o KW Heaters o. o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommun cac onsr ne: No. of Devices or E uivalent 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: Z 0 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless Waived by the owner, no permit for the performance of electrical work may issue unless the 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 pains and penalties of perjury, that the Information on this ppUca to is true and complete, FIRM NAME: VAgty 6LEcT9tCAL Cot'4*AaTtjjG I—LC LIC.NO,: IN943A Licensee: 'D 4Vt D AA64AOt Signature LIC. NO.: (If applicable, enter "exempt" in the license number line,) Bus. Tel, No,: - 682- (v ?_ Address: 87 6E0noNf Sr NORTil AjiVOyt'R SMA 0I'(N Alt, Tel. No.: 1 - 3 - 57 '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) 0 owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE; $ ,p r,( f ffv, -)/C(- i i Tz 41 c,/ 4� t -f- � — to em G -/.-2I`/0 �&, i Date.... ��.w..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Via, •' . This certifies that ..........�......&L-�- c./ ........................................ has permission to perform fir`' �~ �. ....................... h.............................. wiring in the building of s . O /= .....................pp............................................................. i at.........o..!Q.!/�1%......l.�:..D................. ,-, North Andover, Mass. d J ;- ' Fee..........'...... Lic. No....y.............. '( Gr„/ ECTRICAL INSPECTOR Check # Comanoncuaaith o�aa�achu�al Official Use Only c� Permit No.)' % eUapartmanE o� �ia �arvica� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] 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: 5-11 ) O City or Town of. N 12gH A/--%DPJ—ey2— To the Inspector ofWires: 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 5O1 -0f= Telephone No. Owner's Address %(:;, QO Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity q Location and Nature of Proposed Electrical Work: a No. of Meters No. of Meters Completion of the following table may be waived by the Inspector o/ Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool grnd. Above ElIn-❑ rnd. cy ig ung BWo-.—oette Units No. of Receptacle Outlets '� No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 3 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Disposers p eat Pu Totals: umber Tons KW o. o elf- ontained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW No. of Det ices or Equivalent No. of Water KW No. o o. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [4 BOND ❑ OTHER ❑ (Specify:) / certify, under the pains and peva/ties of perjury, that the information on this application is true and complete: FIRM NAME: V I D EGT RI CAA- t4T e.TIH(aLLC LIC. NO.: / `� Iq (031q Licensee: D Ail 1 0 NA6, 6 A r2 Signature LIC. NO.: (Ifopplicable, enter "exempt" in the license number line) Bus. Tel. No.: x118 . Address: R-7 F3EI- MDuT 5i, NOR'TH /�ND4�I E� �� d i6N s Alt. Tel. No.:g 11-3-75-' 73`1 *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 11owner's a ent. ❑ Owner/Agent Signature Telephone No. PERMIT FEE: $ No r?v t,. V,,•\ 40 O Date .......j ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ' n has permission to perform ................................ wiring in the building of ........ ......... at ..... z::f....:.............:...:..:.:::...:..:................... ....... .North Andover, Mass. Fee- .................. Lic. No..—� ...... I; .........:.:,:r-:.: ....:..........:...:...,............... ELECTRICAL INSPECTOR 05/12/99 11:17 WHITE: Applicant 40.00 PAID CANARY: Building Dept. PINK: Treasurer T1E09 M01 WE4LTHOFM4MCHU5 77'S' O tce Use only Permit No. DEPARTNIDVIOFPUBLICSAFETY ��( BOARD OFFIREPREVE/VI'IONREGUTATIOACS527CMR12l00 Occupancy &Fees Checked U41PPLICATIONFOR PERMIT TO PERFORMELE(MICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Ins ecto of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) C (,�'� vt/f'L'7 j f Owner or Tenant Owner's Address L %t Is this permit in conjunction with a building permit: Yes No r7 (Check Appropriate Box) Purpose of Building �—I�1 `�� 64f Mail Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters .,New Service Amps / Volts Overhead Underground No. of Meters `umber of Feeders and Ampacity a iaation and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers L Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground _ round No. of Receptacle Outlets No. of Oil Burners _ No. of Emergency Lighting Battery Units _ No. of Switch Outlets No. of Gas Somers FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total _ Tons No. of Detection and No. of Disposals r No. of Heat —Total Tota` Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating K.W No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers — Heating Devices KW r7 Connections r7 ,.No. of Water Heaters KW No. of No. of Sins Bailasis No. Hydro Massage Tubs — No. of Motors dotal HP OTHER ln&rd xCo� Ptaax"1D1hetegt =neZdMasmdusZGeneralLaws Ih2NeaarertLiabkhstrarxePo yu&di>gCagieoe m Co-crg crzabstriaimo'valat YES a NO Ea Iha,,eabrwtedvandp=fofsa=iotheCffmYES n j �� Ifjeuha%ed�YES, pkasecldi=thetMmofeows byct�tgthe INSURANCE F-1BOND F -1O LLIERR F-1 .� :. .: I •i i 11:. • 11 •: Lim 4q wr— s ft8sesl ) Ct,WRX `�,N VAR doortdoo r 1y Vahe&Demid Wat $ RagI Final n AIL Tel Na OWNER'SINSURANCEWAIVER;IamawacetgdrLitxr>sedioes�themxal=wym ea-itsskswtdc4m-dlatasm4madbyMamxhLseusGa>eralLaws andflatmystgmuecnthispelmaWphcad nwainllasMWR s = (Please c�ne) Owner Agent Telephone No. PERMIT FEE S 110�� 815 775-" 67 1) w v Q a M low x 0 F U W G z u z 0 q � C � Qs o C, C , Q O o 0 CU 0 x (� z o � PLO J s z a o z o S v -3 F z Sz � w w a w F F O o h Z �- L w a • o �' �' Z a u u �Z z z z � • W z o 3 3 z 5 m m m 0 F U W G z u z 0 q 0 � C � Qs o C, C , Q 0 2 z 6 a F zLU n w a 1 0 Qs r� V � o 0 CU 0 x 2 z 6 a F zLU n w a 1 O F=4 O z cz i� x w A d s u tx C4 O� U � z z w° T v U id w w 0j W D. LG 04 W U ua W yS 1(n m w U w a. z a cz w E W w w a� z C/) o O 0 a :Ct5 O C CO) : O C A O Jtv V CL dw CL: Z O m 'iC s E D c 0: o +' 4t: m C c a 3 Co C � cm cc N 'LC N A E� a'CO2 :CEO N O c Q Q,ct �� V N O �• v '� Z coa0 � m N m C = m m`ao � O aoF- W 4;:s -wc = W .N m� coLLI cr d ci CD CD 4D O.0 H r - ar m z Q U C r-� CO) Co .y Co I— CL Q. CO c co CL O CO) O 0 V CO) O V O .0 CO) 5 LLJ _0 Cn U) Ir w Ir VJ l • N _ J O m i CCCT^` aaa t go to 10 O •� .'� CL � n c 0 V) .Z \N s +------------------------------------------------------------------------------------------------------+---------------------------+ C E RT I F I CAT E O F I N S U RA N C E I DATE 04-20-99 (MM/DD/YY)l +----------------------------------------------+-------------------------------------------------------+---------------------------+ PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INTERNET INSURANCE AGENCY INC+-----------------------------------------------------------------------------------+ 522CHICKERINGROAD I C 0 M P A N I ES AFFORD I NG COVERAGE +-----------------------------------------------------------------------------------+ NORTH ANDOVER MA 01845-2840 COMPANY A TRUST INSURANCE +---------------------------------------------------------------------- -- + +----------------------------------------------+ COMPANY INSURED I B LEGION INSURANCE +--------------------------------------------------------------------------- -+ DAVID GULEZIAN DBA COMPANY DAVID GULEZIAN CARPENTRY I C 428 PLEASANT STREET+----------------------------------------------------------------------- -- + NORTH ANDOVER MA 01845 COMPANY D +----------------------------------------------+---------------------------------------------------------------------- ----- ---+ COVERAGES THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. +---+---------------------------------+------------------+----------------+----- -+-----------------------------+ EFFECTIVEI (LTRI TYPE OF INSURANCE I POLICY NUMBER IPDATE Y(MM/DD/YY) PDATE Y(MM%DD//YYON LIMITS +---+---------------------------------+------------------+-----------------+-----------------+--------------------------+-----------+ GENERAL LIABILITY GENERAL AGGREGATE $600,000 A [X] COMMERCIAL GENERAL LIABILITY TMP 1010570 11-10-98 11-10-99 PRODUCTS-COMP/OP AGG $300,000 [ ] [ ] CLAIMS MADE [X] OCCUR PERSONAL & ADV INJURY $300,000 [ ] OWNER'S & CONT PROT EACH OCCURRENCE $300,000 C ] FIRE DAMAGE (Any one fire) $50,000 C ] MED EXP (Any one person) $5,000 +---+---------------------------------+------------------+----------------+-----------------+------------------+-----------+ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ [ ] ANY AUTO [ ] ALL OWNED AUTOS BODILY INJURY [ ] SCHEDULED AUTOS (Per person) $ [ ] HIRED AUTOS BODILY INJURY [ ] NON -OWNED AUTOS (Per accident) $ C] C ] PROPERTY DAMAGE $ +---+---------------------------------+------------------+----------------+-----------------+--------------------------+-----------+ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ [ ] ANY AUTO OTHER THAN AUTO ONLY: C ] EA ACCIDENT $ [ ] AGGREGATE $ +---+-----------------------------+-------------- +--------------+-----------------+--------------------------+--------+ ESS LIABILITY EACH I[EICUMBRELLA UMHAN BRELLA FORM I I AGGREGATERM OTHER RRENCE I$ +---+---------------------------------+----------------+-------------------------------------------------------------- WORKER'S -----------------+----------------+ WORKER'S COMPENSATION AND [ ] STATUTORY LIMITS B EMPLOYER'S LIABILITY WC4-0115728 08-15-98 08-15-99 EACH ACCIDENT $100,000 THE PROPRIETOR/PARTNERS/ [ ] INCL DISEASE -POLICY LIMIT $500,000 EXECUTIVE OFFICERS ARE: [ ] EXCL DISEASE -EACH EMPLOYEE $100,000 +---+---------------------------------+------------------+----------------+-----------------+--------------------------+-------- + OTHER +---+---------------------------- +---------------+---------------+---------------- +---------------------------- + DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS GENERAL CARPENTRY +--------------------------------------------------------------+------------------------------------------------------------------ + CERTIFICATE HOLDER I CANCELLATION +--------------------------------------------------------------+-------------------------------------------------------------------+ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TOWN OF NORTH ANDOVER, MA TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED 120 MAIN STREET TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO NORTH ANDOVER, MA 01845 OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. +-- -- - - - --- ------ ------ - ------------+ IAUTHORIZE TIV A Ar/h - +--------------------------------------------------------------+------------------- -------- j0dUfto---------------------- + +----------------------------------------------------------------------------------------------------------------------------------+ mm, li UN l 4 � � O � � 3 � � mm, li UN a 4 � � O � � mm, li UN S f Location /l No. O Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 U .) ! �,' � `� Yom- �C_.. /--,•-`_'� �� Building Inspect r/ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ctift far(?Jit°' ' �ctat Use ©JOY , BUILDING PERMIT NUMBER: DATE ISSUED: .d SIGNATURE: lfaW C Buildin Commissioner/I for of Buildin Date SECTION i- STTF. INFn11?MATrniv 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 7 C� CF < u, ; (-k DDf t7 v/ o- vF�k Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (st) Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RaqUired Provided Required_ Provided 1.7 Water Supply M.G.L.C.40. S4) Zone 1.5. Flood Zone information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record off- � � CI1G�G�►c k S' i Y"ec f, N e (Print) for Service {Address �74 6�f Z Signature Telephone 2.2 Owner of Record: 4 Name Print Address for Service: Signature Tel hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Signature Telephone Expiration Date 3.2 Registered Home Improvement Contractor. Not Applicable ❑ _DAVLP CA5TR_ )e,on)r= Company Name / x 1 �b_.9 u T0/) 9)7 S u t - TF 4,A4 Registration Number —� Ad Expiration Date Signature Tele hone M Z O D rn SECTION 4 - WORIKERS COMPENSATION (M.G.L C 152 S 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work checkall applicable New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b permit applicant- OFFICIAL USE ONLY I. Building Butlding 7 C 0 � a Permit Fee () Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X tbI 6� 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 ( CU Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I 4 V G 4 S rK L uA2 E as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief �} U c 2 CA s TI L CDnI F__ Pri Si nature of Owner/A entt � Date O NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGTTT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE APPLICANT INFORMATION T& Commonwealth of Wassachusetts Department ofhiduATialAccidents Office of Investigations 600 Washington Street Boston, WA 02111 Workers' Compensation Insurance Affidavit Name: Location: City' t11t�t T�-1 b� t'� Telephone P #:_ fLID G p ' t -*I I A L� M I am a homeowner performing all work myself. I am sole proprietor and have no one working in my capacity I am an employer providing workers' compensation for my employees working on this job Please PRINT Legibly,:. Company Name: 3AV 1b Q.«I.i co 0 k 120 0 F I Q 6. S fl I b 3 3 qab Address: 5TO N `•3��-� U T S U I�I�e. 2 Z �o City: fu?_T1k Aw T10 4 Gm Telephone #: 3 3 qab Insurance Company: AIM Policy#: V W C. toOO 146 Od 1 a00q O I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone #: Insurance Company: Company Name: Address: City: Insurance Company; Policy #: Telephone M Policy #: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under�4e pains and penalties of perjury that the information above is true and correct Print Name: Zl/y 11^('ASTY—t 0AL Official Use ONLY - Do not write in this area City or Town: Permit/License #: o Check if Immediate response is required Phone #'y) I t f 3 ?y L -d o Building Department ❑ Licensing Board o Selectmen's Office o Health Department ❑ Other INFORMATION & INSTRUCTIONS 4 Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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, par nership, .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 section 25 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, neither the commonwealth nor any ofits 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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 ase ca "law" or if you are required to obtain a workers' .compensation policy, please the Department at th listed below. e number City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. 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 Fax # (617) 727-7749 Telephone # (617) 727-4900 ext. 406, 409, or 375 JUN 15 2005 DAVID CASTRICONE ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS BY ---------------------- HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 7 HILLSIDE ROAD, BOXFORD, MA 01921 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premii�sees below described: Owner's Name....../.....L GCAp. ...... 5�IF �.................... .......... .................... Tel hone#i....Grz.��.:....f..�.A...7......... (f% Job Address.....ryt✓Cq....... t.J.Llb4 ..... ,e................... City../.V.t?.....A ............. State..M/.7.............. Specifications: ......................................................................................................�................................................................................................... VStrip existing shingles. i/Apply new drip edge to all edges. k)k,"� _ Apply feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane In valleys and bottom edges of any unheated areas of house. d,,,, t. ........................ ..A......... ............................................ ......cg `' ............................................................. ✓1l;pply felt paper under! ent. natall ridge vent tota ................................................................................................................................................................. VXeroof using shingles with a`year warranty. ................................ I ....... ................ ............................... o ounterflash chimney. taw vent pipe flashing. egal disposal of all debris. �,- ..a.. °.................. ..................................................................................,............................... Area(s) to be worked on:. ......................��T � s.........................a............................ . .1.......... w-.5-e-W...................�...I.......................L c� ................................. ............................................... R.�%�``........ ak .......................................................... �� f ,. ....... One Year WorkmanshipWar sferable) Manufacturer's Warra a cifled b mann r Materialsand Labor t ost $ .r],f' ... . able ............................. on ................................. Payable..... /o(F . Balance payable on completion of job Owner or Ownersam not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property, including pm -existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces, water stains when roofing shingles have not had adequate time to cure). Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates. The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There arc no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place Room 1301, Boston, MA 02108 Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -related permit or deals with unregistered contractors shall be excluded from access to the Guarantee Fund. Approximate starting date of work..................................................................... Completion date .............................................................. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner has three business days to cancel this contract and incur no penalty. IN WITNESS WHEREOF, the parties have hereunto signed their names this ........... ............ day of ................................. 20 .............. Accepted: Signed................................................................................... Owner G Signed....................................................................................... Owner Per....................................................................... Representative NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: SJ, /) `T Fire Department Sign off. Dumpster Permit (Location of Facility) Signature of Permit Applicant Date s 0 O z LU am C 0 o . AM a x C h C CJ V "ago CL C O to m C O Ea .0+ C w chi • _O w° rx U w a4 4. �0. � � �,? wo' w QQ cn U) LU am E �O A. C O cm ac C m CD 0 cm S C m 0 Z Cl g 0 In u O O v O v G3 Z C. O h D O co cm C C h O� m � 'E m m F— .0 Z one 3 .0 Ci CD L Cc o L C ZE Q CA c ev .v .3.0 CL 0 CD c Z0 CL m V h O C C COO 0 W W C9 W C 0 . AM C 0 O J C h C CJ V "ago CL C O to m C O Ea .0+ C • _O *+ C �0. o m CC+ HW ' m m o �' h � 45 3 m C C � .m W 'O CA W m :o ac.3 z r � O C Q ' dcf_O �Z o o0C o ` m C = o 3 r •N dt W C �:. °C E BIC� C* _ .0 ��aa4w WO E �O A. C O cm ac C m CD 0 cm S C m 0 Z Cl g 0 In u O O v O v G3 Z C. O h D O co cm C C h O� m � 'E m m F— .0 Z one 3 .0 Ci CD L Cc o L C ZE Q CA c ev .v .3.0 CL 0 CD c Z0 CL m V h O C C COO 0 W W C9 W Location 7� No. 'y1-1Date NORTol TOWN OF NORTH ANDOVER O: ��.ao ,•,ti0 _ • OL .. 9 a ;+ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ r Other Permit Fee $ _ TOTAL $ = Check # Building Inspector/ -0 v -o-0/y-006 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / � M SIGNATURE: Building Commissioner/I for of Build*Date SECTION 1- SITE INFORMATION 1.1 Property Address: -76 C h aS uv rc � &?-t 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning information: Zoning Dia;ic—t Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided R Provided 1.7 Water SupplyM.GLC.40. Public 0 Prim" ❑ 54) 1.5. Zone Flood Zone Information: Outside Flood Zone ❑ 1.9 Municipal Sewerage Disposal system: ❑ On Site Disposal System ❑ NEUI IUA 2 - FKUYEKTY OWNEKSHILF/AUTHORIZED AGENT 2.1 Owner of Record �djoF —7� Name (Print) { x Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ �C(V(6 6 JI-t9v10(q i Licensed Construction�o } upervisor: 5 t I /l 4JPu !� Q y� �— License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not App,p IUV�� 601--r(u-7 Company 1,6me Registration Number Address Expiration Date Signature 17 Tele hone r 6.4I Z cr z N OA E OD m cc p w v uca 0 w° � GL cn a w° 02 v U G x a O o; G X. a O UW w w w � x p z rs: co w w A a w co z cn Q 0 cn H CO2 W F— a� W G3 L4 ,mm OCD y c c � o ` C H O r C O CJ C.3 •a •O CL. � r=... O t o p•CZ 1 C° o CD C42 yam•+ O EQ CD r r c O CD.- •O y :r •E0 CD O. N O. � c .c a= m c$ 0 0 I=.— co re H CO2 W F— a� W G3 L4 E NJ y c O cm a°'c Q1 c m O CM c •c N m t 0 Z 0 J cm f O v v 4-1 .,A EM O O co O v Z aL CL O y � C O Om I O 0 � m m C fr t O.a 3.0 L CMQ ca O � C O ca C � CL� V h � C C C _O d y m U) Ir W w U) ,mm OCD y c C � _m y R :C y E m .o 0 0 :ave y O � r=... O cm c p•CZ 1 0 �C O ROOT � Z � d O N m c 0 CD r CL4- ~ y O yO„ •O y •� 0 c •E0 � •g, w O •— O. O- O -S .c a= m E NJ y c O cm a°'c Q1 c m O CM c •c N m t 0 Z 0 J cm f O v v 4-1 .,A EM O O co O v Z aL CL O y � C O Om I O 0 � m m C fr t O.a 3.0 L CMQ ca O � C O ca C � CL� V h � C C C _O d y m U) Ir W w U) ' Location—q/9 `�,,Jyj ( `c C `� No. 1-16:7 Date TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ s'MUs,<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I—I! Check # l Building Inspector 1.1 Property ddr 1.2 Assessors Map and Parcel 0oog Map Number dumber: _ Q, Parcel Number 6 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS M Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Public ❑ Private ❑ Zone Flood Zone Information: Outside Flood Zone ❑ log Municipal Sewerage Disposal System: ❑ Oa Site Disposal System 0 a1S1, 11vm'q L - rMUrr,icli I vwt'lr,xJnLC/AU inOK1Z. !) AGLr1VT L, C L Il.i L. I bJ -14 U 2.1 Owner of Record I(M- 7 Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: t Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Corkstruction Supe WE Not Applicable ❑ vt� -60o, Licen Construction Su rvisor. O (/ l License Number Address l Itl q����5 7 /U o a d5 Signature Telephone Expiration Date 3.2 Register ome ctor ImproveTent Con� , Applicable ❑ Not Cb mpany Name /e(e�,q K � �7 Registration Number Address Signature Telephone Expiration Date 00 rn M 3 z 0 J s NJ r Q 0 z M 90 0 D v r r MIMMIMIz G) c1 .rTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Workcheck all applicable) New Construction ❑ Existing Building 6),' Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify / BriefDes ion of Proposed Work: Id- a( (3(rdt�J� Wl0`�d1d-Lak- J7inI� w V I q100 r FC) ,� Ir Sia (2)h SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY I . Building 75 • (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbingBuilding Permit fee (a) X (b) —_ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 7 ?5, Check Number SECTION 7a OWNER AUTHORIZATI N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTIOK 7b OWNER/AUT' HORIZED AGENT DECLARATION 1, PqV14 V /4 I a-15 /,C/o As Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name'"( ���Si ature of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2' 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFIIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of i (Location of Facility) Sig ature of Permit Applicant 9 �y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: V4 6 Jv-eFaw Location: ? & chgi wir 6 �T City )y "bA--t kc— Phone # 7 7V S�-- I am a homeowner performing all work myself. FI am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company nam e:t���n 5 Address r7r ( V t e Y o Company name: Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment.as_weU.as_civil.penaltiesinthe fnrm of STOP WORK.ORDER-and..a fine.of ($10.0.00.).a bay against me. I understand that a copy of this statement pAy be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the S Print name of perjury that the information provided above is true and correct. Date t� I'LXUy Phone # Z >P3Y-6- 77, li4S Official use only do not write in this area to be completed by city or town official' City or Town PermitiLicensing Building Dept [-]Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other to OE� Na. ui am �50 czO • C O J O N C O ca 42 d C O a z a //O��:Om Ea �. 3= u w a ci w° a°' at U cu w Ow w°' w w°' u w C7 o aG G w CO K co z cn cn Na. ui am f t O� O 0 D 0 eov o a ZE ca o cccc C.3 O. O CD co o Z 15a V W O C cc h 0 LU U) 19 W W W W co �50 • C O J O N C O ca 42 d C CL :Z O 9:x'1: //O��:Om Ea �. 3= E z A Qrm C2 E o c•— CO K N N a _ y fto' co W O h CLf y m O OI C OI0Q 7 CO _ � �Z o0 CL O cm C F- = m . 6* 2 C a.o C s mss m h C O= • C r S .� ' t_ az_t°c .� O W E v O a � g CIO Fc - _4D CL f t O� O 0 D 0 eov o a ZE ca o cccc C.3 O. O CD co o Z 15a V W O C cc h 0 LU U) 19 W W W W co Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that...1........................................ has permission for gas installation .............................. in the buildings of .......................................... at .................................... North Andover, Mass. Fee......... Lic. No........... Check # .......................... GAS INSPECTOR G' ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING l o.— OVAt or Type) &W-AQ 46-ttt . Mass, Date' �, :es _ Permit # 3 2 Building Locator -7 � UA � ult�(L �l r Names ` Type of Occupanry I New, Renovation ❑ ReplaCement ❑ Plans Submitted: Yes❑ No ❑ Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET FE Corporation 103C MIDDLETON, MA 01949 0 Partnership Business Telephone 978-774-2760 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No ❑ if you have checked yes. please indicate the type coverage by checking the appropriate box A liability Insurance policy El Other type of indemnity 0 Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit &;pilcation waives this requirement. Check one: Signature of Omer or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above appicatim and accurate to; a best of my knowledge and that all plumbing work and installations performed under the permtn for fttis H in pHs with aH pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of theaws BY T of Ucense: Plumber gum r or titer Title I 3785 City/Town Joico r an Ucense Number c e� Y Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET FE Corporation 103C MIDDLETON, MA 01949 0 Partnership Business Telephone 978-774-2760 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No ❑ if you have checked yes. please indicate the type coverage by checking the appropriate box A liability Insurance policy El Other type of indemnity 0 Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit &;pilcation waives this requirement. Check one: Signature of Omer or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above appicatim and accurate to; a best of my knowledge and that all plumbing work and installations performed under the permtn for fttis H in pHs with aH pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of theaws BY T of Ucense: Plumber gum r or titer Title I 3785 City/Town Joico r an Ucense Number c e�