HomeMy WebLinkAboutMiscellaneous - 76 OLD VILLAGE LANE 4/30/2018IN
Cunningham Lindsey U.S., Inc.
P.O. Box 703689
Dallas, TX 75370-3689
Telephone (888) 738-8714
CLCAT@CL-NA.COM
April 01, 2015
Facsimile (214) 488-6766
TOWN BUILDING COMMISSIONER
1600 Osgood Street
Building 20, Suite 2035
North Andover, MA 01845
Claim Number:
A033569359
Policy Number:
21774400005
Company Name:
ARBELLA INSURANCE GROUP
Date of Loss:
02/25/2015
Insured:
MARK OLEARY
Cunnin fih�amtA Va
l�Lindsey
Property Location: 76 OLD VILLAGE LANE, NORTH ANDOVER, MA 01845
To Whom It May Concern:
Claim has been made involving loss, damage, or destruction of the above captioned property,
which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,
to be applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer. Kindly include a reference to the captioned insured,
location, date of loss and claim number.
This certifies that .. /. yo!t'UI��•-
... . ..........................
has permission to perform .... -c - -�-�: .................
plumbing in the buildings of. . .....................
at ...North Andover, ass.
/.. .
PLUMBINTECTOR
Check # � �ZS
^
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT# 1
JOBSITE ADDRESS OWNER'S NAME
POWNER
ADDRESS S .�, eI TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL Q RESIDENTIAL'
PRINT
CLEARLY
NEW: 0 RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES 0 NODI
FIXTURES 7 FLOOR- BSM 1 2
3 4 5 6 7
8 9 10
11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM--
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR IAREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK.,...-..._.._f-!--_.___-
LAVATORY - ._( J--.._..__.( _.:.._...i (_..._._..!( ....__.__.{ I
ROOF DRAIN
SHOWER STALL
SERVICE /MOP SINK..._-.-A --I
TOILET
URINAL1
...__,..._."• ______! __...._.I ._-.-......_.! _.___.-! ._...__. __---_-.-_! __........_._! ._._-_-._(
.._........__! .._____- _....-_._! ....-._1 ......_....`
WASHING MACHINE CONNECTION I _..__.-; .. E _. ...{-AE._ - !
WATER HEATER ALL TYPES ' I I
WATER PIPING _..
I
OTHER _ I _I .i.-.-._...I
I --I — E
i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ... NO 0
it
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
Z LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ..I
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER E-11 AGENT ( _
SIGNATURE OF OWNER OR AGENT
g 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 complia a with all Pertinent p ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME, f'�/,� ,/ i LICENSE # �y� i IGNATURE
MPO i JP —, CORPORATION , # _ PARTNERSHIP # LLC
COMPANY NAME 1=� ��� ��,� ± ADDRESS j i
CITY %Zid STATE j? ZIP TEL
FAX 3. - a_ `CELL-6_.:� MAIL �=
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The Commonwealth of Massachusetts
' Department of IndustrialAccldihts
Office of Investigations
VV 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/OrganizatiorAndividual): "e7 y /O � he'
City/State/Zip;
Phone
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
_,employees (full and/or part-time).*
have hired the sub -contractors
listed the sheet.
? E] Remodeling
2. am a sole proprietor or partner-
ship and'have no employees
on attached
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance � re q uired. t
employees. [No workers'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomtation.
i Homeowners who submit this affidavit indicating they ate 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
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 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.
I do hereby certto under he pains and penalties o rjury that the information provided above is true and correct.
Si afore: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitUcense #
Issuing Authority (circle ane):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact Person: Phone
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 employeiis 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. AIso 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office offnvestigations
600 WasWngton Street
Boston., MA 02111
TeX, # 61.7-727-4900 ext 406 or 1.-877rMASSAFI�,
Revised 5-26-05 Fax # 617-727-7749
WWv.mass,govfdza
0151
C4
Date..(! .......2- ......�/..
`'OWN OF NORTH ANDOVER
i PERMIT FOR WIRING
This certifies that ..... Ml (..:..G....................... < < v.so%... .................
has permission to perform ........, ..... c'...../.. ..........................
wiring in the building of ..... lWh................................
..1..at ......2l.41...�.....�...�.......... , North And
7
.. Lic. Noff.?A2 .
BLBL'I RiCAL MR
Check it
Commonwealth of massachusetts
Official Use Only
,. Department of Fire Services Permit No.
t; BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] (leave blank
.
APPLICATION FOR PERMIT" TO PERFORM E RICAL app
All work to be performed in accordance with the Massachusetts ElectricalCod MEC) �- 527 C R 12.00 y ® R
(PLEASE PP,8VTININK OR TYPE ALL INFORMATIO
Qty or Town of: NORTH ANDOVER
By this application the R To the Inspector of Wires:
�i Date:
undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) Q%
t•
Owner or Tenant '
r vTelephone No.
Owner's Address I f` G O�� Z
` Ti
Is this permit in conjunction with a building permit? yes
Purpose of Building NO (Check Appropriate Box)
Utility Authorization No,�� ���
Existing Service oo Amps f o / Volts
A OverheadE] 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:
�° Aoe v C e
Com letion of the followin table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No. of Ceil: Sus No. of
D. (Paddle) Fans Total
No. of Luminaire OutletsTransformers KVA
No, of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above❑ In_ o. merg
o ency lg
-- d, nd• ❑ Batter Units g
-. No. of Receptacle Outlets No. of Oil Burners
FIRE .�-LttRM
No. of Switches No. of ZonesNo. of Gas Burners No. of Detection and
No, of RangesInitiating Devices .
No. of Air Cond, Total
Tons No. of Alerting Devices
No. of Waste Disposers Heat PumpNumber Tons KW _ No. of Self Contained
No. of Dishwashers Detection/Alertin Devices
Space/Area Heating KW
Local ❑ Municipal
No. of Dryers Connection Other
Heating Appliances KW Security ty
Systems;
No. of Water No, of No. of Device
Heaters KW No. of Data Wis or E uivaIent
rin
Si s Ballasts, g'
�
No. Hydromassage Bathtubs No. of Motors Telecommunica ons wiring:
ent
Total HP
OTHER: No. of Devices or F,nnivai.»+
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires
Work to Start: 2,e m (When required by municipal policy.)
�?' Inspections to be requested in accordance with MEC Rule
INSURANCE COVERAGE: U 10, and upon completion.
'Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee.provides proof of liability insurance including L°Completedoperation"
coverage or its substantial undersigned certifies that such coverage 's in force, and has exhibit d prroof of same to the permit issu g officeuivalent The
CHECK ONE: INSURANCES ❑ OTHER
EI certify, p ❑ .(Specify:) .
under the alis and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME;
Licensee: c�a r�LIC. NO.:
GSignator
(If applicable, enter mpt ' in the license number line.) LIC.
Address: u -0 eBus. Tel. No.:
*Per M.G.L c. 147, s. 57-61, ecurity work re cues D ���
q epartment of public Safety "S" License: Alt, L c. No.'
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage n --
required by law. By my signature below, I hereby waive -this requirement. I am the (check one) ❑ owner
Owner/Agent y
Signature ❑ owner's
agent.
Telephone No. PERMIT FEE: $ d ✓. v
ELECTRICAL PERNHT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUGSMALL
"/ bl1TT!'TT T%TnT1 .
.�vvJ_L u11OXJPJ%,lAM1V
.r auea —
Inspectors' comments:
(ln�pectors' Signature -no
2. FINAL INSPECTION:
Passed — Failed — [ ]
Inspectors' comments: _
�t.... w u vA6l aLLkjc - RU"Jffl1T
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed — [ ]
Inspectors' comments:
(Inspectors' Signature - no initiE
4. INSPECTION—SERVICE: -
DATE CALLED NATIONAL GRID:
Passed — [ ] Failed — [ ]
Inspectors' comments:
(Inspectors' Signature - no initial:
5. INSPECTION - OTHER:
Passed — [ ] Failed — [ ]
Inspectors' comments:
(Inspectors' Signature -.no initials)
�. 5•
Date
ection required ($Sfl_Ml -
Date
Date
Date
Date
DOOR TAGS ARE TO BE FiGLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSpECTION OF $50.00 IS TO BE CHARGED.
i
, L.4
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.
- w� ••�• �.,.v , uiy unaer me pains and penalties of perjury that the information provided above is true and correct
>,a-- �� /- 's 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
6. Other Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person:
Phone #:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of rnvestigations
600 Washington Street
Boston, MA 02111
Workers' Compensation Insurance A fi avi Buflders/Contractors/Electricians
Applicant Information
/PI>ia�nbers
Please Print I,e ibl
Name (Business/Organizatiorvindividual):
s r
Address:
f—
City/State/Zip:__ %// o/mss e
Phone[Are
you an employer? Check the appropriate box:
1. ❑ I am a employer with
of project (required):'
4. ❑ I am a general contractor
;mployees (full and/or part tim )e .*
—part-time).*
have hired the sub -contractors New construction
and I P7.[]
2. I am a sole proprietor or partner-
ship and have no employees
listed on the attached sheet. $ Remodeling
working for me in any capacity.
These subcontractors have
workers' comp. insurance. 8' E] Demolition
[No workers' comp. insurance
5. ❑ We are a corporation and its 9. El Building addition
required.]
3. ❑ I am a homeowner doing
officers have exercised their 10. [Electrical repairs or additions
all work
myself [No workers' comp.
right of exemption per MGL 11. ❑Plumbing repairs or additions
C. 152, § 1(4), and we have
insurance required.]
q ] t
no
employees. (No N=porkers' 12.❑ Roof repairs
comp. insurance required.) 13.❑ Other
`may applicant that check$ box M must also fill out the section below snC.: �..,�
•'J�•.,''•' :hell' .`t'C3%CFS' compensation pCl1Cy :::.cirraiion.
t Homeowners who submit this affidavit indicating they doing
are 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 their
and workers' comp. policy information.
am an employer that is providing workers' compensation
information. insurance for my employees Below is the policy and job site
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.
- w� ••�• �.,.v , uiy unaer me pains and penalties of perjury that the information provided above is true and correct
>,a-- �� /- 's 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
6. Other Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person:
Phone #:
10093
t
c
NOR7F�
Ot .«" ' • 1'ti0
O p
�,SSACHUS�
................ . ��..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that... .. ... . ... ...... ........ .. ....... . ,,./ ......
U �.
has permission to perform ... l s fu l .......... !....`r ....... ,,/!fvrf
wiring in the building of..,l�zi..................................... ...............................
/b ®�" ...... ''J '�......... ....; . ,North And ver, M s
at ................... .......
......... Lic. No, Ts S. ....... .......
.... Vii... . �:.:... ..
Fee .......... ' ....... ......
.ELECTRICALI SP CTOR
Check /t ____
Commonwealth wealth of massa
chusetts Official Use Only
A. Department ®f dire Services PernutNo. %GG y 3
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] `---
® p leave blank
APPLICATION FOR PERMIT TO PERS`®RM ELECTRICAL WOR
All work to be performed in accordance with the Massachusetts Electrical Code �`
(PLEASE PRIWTM INK OR TYPEALL INFO �O� date. Q, 527 CMR 12.00
City or Town of:
1 By this application the undersi ed gives no ' e of his or her intention perform the electrical woTo the Inspector of rk
Location (Street & Number) k described below.
`\ Owner or Tenant. �� Q �! 4-2
\ Telephone No.
� Owner's Address �' Q�
Is this permit in conjunction with a building permit? Yes
Purpose of Building No LK BLDG PERMIT #
Utility Authorization No.
Existing Service mo Amps %ln /_�?y,_ Volts Overhead
❑ Undgrd ❑L � No, of Meters _
New Service Amps /Volts Overhead
El Number of Feeders and Ampacity Undgrd 0 No. of Meters
Location and Nature of Proposed Electrical Work:
h
No. of Recessed Luminaires
Completion of the following table may be waived by the Inspector of Vires.
No. of Ceil: Susp. (Paddle) Fans No. of Total.
( No. of Luminaire OutletsTransformers �rA,
No. of Hot Tubs Generators KVA
` No. of Luminaires Swimmin Pool Above In- o. o mer enc i t1n
No. of Receptacle Outlets g rnd. � rnd. � Bafte Units y g g
p No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches No. of Gas Burners No. of Detection and
No. of RangesInitiatin Devices
No. of Air Cond. Total
Tons No. of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained
S
' Totals: .................
No. of Dishwashers Detection/Alertin Devices
pace/Area Heating KW Local ❑Municipal
No, of Dryers Connection ❑Other
ry Heating Appliances �y Security Systems: *
No. of Nater No. of No. of Devices or Equivalent
Heaters IOW No. of Data Wiring:
Si s Ballasts No, of Devices or E uivalent
No. Hydromassage Bathtubs No. of Motors Telecommunications Wirin
Total HP � gg
OTHER. No. of Devices or E uivaIent
Attach additional detail if desired or as required by the Inspector of Wires.
_/moo , (W
Estimated Value of Electrical Work: hen xequired 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 p
undersigned certifies that such coveermit 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
CHE, d has exhibited proof of same to the permit issuing office.
CK ONE: INSURANCE r s in forceanBOND ❑ OTHER
I cert, under the pains and penalties o er u that the information on this application is true and com feta
FIRM NAME: fp J rJ', PP
.p
Licensee: ��e4LIC. NO.:
aq11 �lam, Signature
(If applicable, enter `ex pt" to the license number line.) LIC. NO.: '%t" �—
Address: d? e"uu�r�. �'�`– a,&eve` ", Bus. Tel. No.:
*Per M.G.L c.147, s.57-61, s cirri y work requires Department of Public Safety "S" Licen Alt LIC. p �j� SS%- J-102–
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. 13y my signature below, I hereby waive this requirement. I am the (check one) owner
Owner/Agent ❑ owner's agent.
Signature Telephone No.
P [P:ERMIT�FEJ
y
ELECTRICAL PERT NO. INSPECTION REPORT: t
ELECTRICAL INSPECTOR - DOUG SMALL
I. KUUUti.11V.N'Y.N:I WIN:
gassed —I I Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) Date
2. FINAL INS TION;
Passed — [ IK Failed — [ ]
Inspectors' comments:
(Inspectors' Signature - no initials
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed —I ]
Inspectors' comments:
Date .i
�mspectors- signature - no initials) Date
4. INSPECTION — SERVICE:
DATE CALLED NATIONAL GRID:
Passed — [ ] Failed — [ ]
Inspectors' comments:
NAME:
(inspectors, signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
30
The Commonwealth of !Massachusetts
Department offndusWal.Accidents
Office o f 1"nvestigations
600 Washington, Street
Boston, MA 02111
UV www.mass:gov1dia
Workers' Compensation Insuxanve Affidavit: Builders/Coniractoxs) Electricians/Plumbers
Applicant Information Please Print Legibly
NaM(3(B.usiness/Organization/Individual): V1 6
Address:
City/State/Zip: Zowe
S/—
ale
Ao Phone
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4• ❑ I am a general contractor and I
6. [] New construction
ployees (full and/or part time).*
2. I am a sole proprietor orparlxler-
have hired the sub -contractors
listed on the attached sheet. s
7. ❑ Remodeling .
ship and have no employees
These sub -contractors have
8. [] Demolition
working for me in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
g•r] Building addition
10Iecixical repairs or additions
required.]
officers have exercised their
.
3. ❑. I am a homeowner doing all work
right of exemption per MGL
I LE] Plumbing repairs or additions
myself [No workers' comp.
c. 152, §1(4), and we have no
12.[(Roof repairs
insurance required.] t
employees. [No workers'
13. [1 Other
comp, insurance required.]
'-11y appucant that checks box #1 must also fhl outthe section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. /
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employee that is providing workers' compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company
Policy # or Self -ins. Lic.
Expiration Date:
Sob 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
flue up to $1,500.00 and/or one-year imprisonment,. as well as civil penalties in the form of STOP WORK ORDER and a fine
ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby certify under the pa ns andpenalties ofperjury that the information provided above is true and corn ect.
Phone #: '9,>,r— - ` S o�
Official use on y Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
X. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C ontactrerson: hone #.
0 , -0
12
Office Use only
Tow_7
of ftsathustfts Penh No.
"t4
ItIniftelml d Public %fritV Occupancy A Fee Chocked
3MO
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Peeve blank)
APPLICATION FOR PERMIT TO, PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMA 12.-00
�'V
(PLEASE. PRINT IN INK OR TYPE ALL INFORMATION) oats � g
r* or lbwn of NORTH ANDOVER To the Inspect of
Wires:
The ulderslorlidd applies for a permit to perform the electrical work �de ribed below.
41 & Number)
Leicst on (street
dzL ")e
dlvm& or I'
briant
6wrlet's Address
t 4r is this permit In conjunction with ok building permit: Yes No C3 (Check Appropriate Box)
tou'rpose fBuilding
Utility Authorization No.
9xisting semde Amps'VOits Overhead ❑ Undgrnd ❑ No. of Motors
Now Service Amps Volts Overhead 0 Undgrnd 0 No. of Meters
Number of Feeders and Ampacity
Location and Nitdre'of Proposed Electrical Work
Alf. -
No' of Whorto outlets
No. of -Hot Tubs
No. of lVansfo;mors Total
KVA
No.. of U96no,mmures
Swimming Pool Above In.
grnd. ❑ grnd. ty
Generators KVA
of Aiciourcli dutlatill
No. of Oil Burners
No. of Emergency Lighting
Battery Units
of twitali 61.11116ts
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Sell Contained
Detection/Sounding Devices
Local ❑ Municipal Other
Connection ❑
No., ano"
Total
No. of Air Cond. tons
W& of 018*t, 8-610
No.of Heat Total Total
Pumps Tons KW
No. of 01shwaandre
Space/Area Heating KW'
N6, of lbtyiri
Heating Devices KW
N64 of Wst6k Hestort KIN
No. of No. of
signs Ballasts
Low Voltage
Wiring
No. Hydro Message Tubs
No. of Motors 7btal HP
6THEA;
INSURANCE COVE14AOE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability insurance Policy Including CompleZvOperations Coverage or Its substantial equivalent. YES ANO r-!1
hive submitted valid proof of same to the Office. YES e.."
NO = If you have chocked YES. please Indicate the type of coverage by
checking the top riate box. '?
INSURANCE A)
BOND C C (Please Specify)
OT!5p/,
(E idn Date)
tttll6stod Value of Electrical Work S /o 0 C>
Work to Start - Inspection Date Requested: Rough Final
1111466d under the Penalties of perjury:
FIRM NAME e42 qgrk 4 LIC. NO.
Lleeftio �f 67:7, 777C 0 0 L< SignaIurt<tf2/__' 14�_r __LIC. NO. ZMIZ�
Bus. Tel.
J41clMs leo(_ eg— Alt. Tel. No.
Owkeg'S INSURANCE WAIVER: I am aware that the Licinsee does not have the insurance coverage or Its substantial equivalent as re -
attired by Massachusetts General Laws° and that my signature on this permit application waives this requirement. Owner Agent
(Pleats check one?
Telephone No. PERMIT FEE S
(Signature of Owner or Agent) x 4565
J000
NORTI�
,•'�+
pL
m
O 9
41
�,SgACNUSEt
This certifies that ...... fi'`t' • :
has permission to perform ...
Date..4..-./...::L..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
G7
M
Q
.. .. . ...
wiring in the building of.r..../.. �!} .................
..................................
at ....�.b...... M.t!r. ... t la4.q..•.... , North Andover, Massa
• o
Fee..:.... �....r.,--L-tc. No.... ............... ........... ................ I .................
,..
ELECTRICALINSPECTOR
1
C/ 4
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Date �... � .... 0 . ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................... k��j.. 7 ............................
I
has permission to perform .... ............... .... de -:9
-77�-
, . —&,,e
wiring in the building of ........ / ......
.....................................................................
z --711
at.. Z.,11.... ......... No Ando er, Mass.
............................... fZ0
FvO ... e ....... Lic. N&�z . ...................
ELECTRICAL INSPECTOR
02/16/99 12:14 40-00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
7YW C0HV0NWE4LTHOFMASSACQICIS= Office Use only
DEPARTMENTOFPUBLIMFM Permit No. �c
BOARD OFMEPREYFM ONREGUL4ROA S -W CWR 12.-00 �9
. Occupancy &Fees Checked
APPLICATTONFOR PFRMITTO PERFORMLLE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, Si% CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Z
Town of North Andovei
The undersigned applies for a permit to perform the electrical work described below.
Location (Street 8
Owner or Tenant
To the inspector of Wires:
Owner's Address 5 a. M
r
if—
Is this permit in conjunction with a building permit: - Yes E'No a (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service / Uy Amps / Volts Overhead Underground No. of Meters
NewS� ervice Amps / Volts Overhead M Underground No. of Meters
Number of Feeders and Ampacity
LL�ation and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of H% Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA .
and
ground 17
No. of Receptacle outlets
45
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
LocalMunicipal
Other
_
NX of Dryers
Heating Devices KW
Q Connections
.
dJ of Water Heaters KW
No. of No. of ;
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
t
8
OTHER —
Workloslart lnspe(:firnDaieRe4xsted
Sigh trxieM RMbies afPff*..
FIRM NAME
E=2kdVahrdE1e1xW Work S
Rattgh Fstal
u=WN,a % / 1 5-4
Lica�seNo
BusQ�ess Tel Na
AkTrlNn if>�3'��r� Q,�
OWNER'S IIvEURANCEWAIVER, IamawatdAtheL==doesnotha�+etheitstratceeo�erageai5s r>tralergdvaiaias>agtm�by G�ealLaws
aoddarrys ht Testc'
(Please check one) Owner r7 AgentEl
Telephone No. PERMIT FEE
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STANDARD PANEL LAYOUT
USE BACKBRACE AT PANEL JOINTS
AS SHOWN (MARKED X)
b7/�7TAAJ
!_1_1�j
2'-11 3/4" -
T'-11"
2' -113/4 --
JSPI-5 1995 STANDARD
CODE 1993 Table 421.1 1(2)
allations to be in accordance
Pacific Ind. recommendations
-TIP OF BOARD
ABOVE POINT "A
POINT *X- WATERLINE
MINIMUM DEPTH
BELOW POINT "!i'
5'-6"
Perimeter
130'-0"
41
Pool
Pool
Type
Area
Capacity
Pool
816
26,570
Sq.Ft.
Gallons
II
ROCHURE IS FOR ILLUSTRATIVE PURPOSES
The manufacturer makes only those representations which are
stated in its written warranty. Any other representations,
statements, or contracts made by the dealer and/or the
contractor to the customer regarding any materials produced
by the manufacturer are attributable to the dealer and/or the
contractor only. The dealer or contractor who sells or installs
your pool is an independent contractor and not on agent or
employee of the manufacturer. The construction methods
illustrated ore suggestions and apply only to normal ground
conditions. There may be additional precautions and/or
methods of constructions. The responsibility is the contractors.
v
ONLY
3'-4"
MINIMUM SLOPE OF 1/2" PER FOOT,AWAY
FROM POO EDGE FOR A MINIMUM OF 10'
SLOPE MAY BE 1/4' PER FOOT WHEN
CONCRETE DECK IS INSTALLED rrrrr
BACKFILL
HAUNCH CONCRETE
THRU TOP OF EACH
BACKBRACE
CONCRETE
BOND BEAM !
ARl W 9
UNDISTURBED EARTH
12' 12' 12' 1'
rrdv1 6 1 %A/`%% -A Il_ 11IJU-L-%.o 1 1fV1V rL_H114
NORTHERN ASSOCIATES, INC. A
N. MAIN STREET ANDOVER MA 01810 TEL: (50B) 474-4410 FAX (508) 474-5067
JAMES F. B COLLEEN TATTAN III
75 OLD VILLASE LANE
NORTH ANDOVER MA
1105197
DEED REF. 1151 / 54
PLAN REF. PLO5291
SCALE: 1- 40,
J08 IF: 97/0005
ATO.• IPw4cH SA VINSS SANK
gage inspection was prepared
mortgage purposes only and
led upon as a land or property
ilding location and offsets
ically for zoning determination
be used to establish property
shown hereon is based on
mation noted and may be subjecil
gs and easements. Northern
accepts no responsibility for
q from said reliance by anyone
aid mortgagee and its assigns in
its proposed mortgage financing
OLD VILLAGE LANE
This mortgage inspection was prepared in accordance
with the Technical Standards for Mortgage I.oan
Inspections as adopted by Cho Nassachusetts
Board of
Registration of Professional Engineers and Land
()F Afq
Surveyors 250 CHR 605.
y
I further state that in my professional opinion that
the structures shown
CARMEN �
�1,i
�+
conform with
-
the local zoning horizontal dimensional setback
T
requirements at the time of construction or are
exempt under provisions of H.G.J.. CII. 40-A Sec. 7.
a�
�fCIS1ERE�
11.Property/House is not In a Flood hazard.
2•Property/house
Q��
g0
�ONAI
is iu a Flood hazard Area.
❑ ].Information is inuutficient to
i Np
determine
Flood llazard.
q7
Flood Hazard determined t'rom latest Fedurdl F'IuuJ
Insurance Rate
Hap panel��pp�g
Date -- - --- —�_- Z
FORM U - LOT RELEASE FORK
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: J iM E'C I a -:TT AJ
Phone 660 1
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street /� ��d (� [=l j; L�y4A/ St. Number
************************Official Use Only************************
RECO DATIONS OF WN AGENTS:
-,�Xt Ah P ih-, 14-4 " J?A;,,-
Conservation AdminEstrator
Comments
Town Planner
Comments
Date Approved ),f
h-1
Date Rejected
Date Approved
Date Rejected
Food Inspector -Health Date ApprovedDate Rejected
Date Approved '
Septic Inspector -Health Date Rejected
Comments
i
Public Works - sewer/water connections
driveway permit
Fire Department
Received by Building Inspector Date
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•_ Location (c� U j L( C�
No. / Date ?
12776
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ ACO.C)_y
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL 66)• Qk)
/Building Inspector
09/04/98 49:22 �/ff
iti. ub i orks
h Location '�"� + L lV °
No. 2Date
A i
MQRTIy TOWN OF NORTH ANDOVER
A Certificate of Occupancy $
41
Building/Frame Permit Fee $ ' ►, }
cHustt Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
f+
TOTAL $ r '
01
Building Inspector
. - 09/04/98 09:22
Div. Pu is Works
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CERTIFIED TO.• IPSWICH SA VINSe SANK
NOTE: This mortgage inspection was prepared
specifically for mortgage purposes only and
is not to be relied upon as a land or property
line survey. Building location and offsets
shown are specifically for zoning determination
only and not to be used to establish property
lines. The land shown hereon Is based on /
referenced information noted and may be subject
to further takings and easements. Northern
Associates, Inc. accepts no responsibility for
damages resulting from said reliance by anyone
other than the said mortgagee and its assigns in
cumnection with its proposed mortgage financing
to said mortgagor.
OLD VILLAGE LANE
This mortgage inspection was prepared in accordance
with the Technical Standards for Martgage Lnen
Inspections as adopted by the Massachusetts Ruard of
Registration of Professional Engineers and Land
Surveyors 250 CHR 605.
I further state that in my professional opinion that
the structures shown conform with
the local zoning horizontal dimensional setback
requirements at the time of construction or are
exempt under provisions of M.G.[,. CII. 40-A Sec. 7,
1I.Property/House is not in a Flood Ilazard.
2.Property/llouse is in a flood Hazard Area.
❑ ),Information is insufficient, to determine
Flood Hazard.
Flood Hazard determined from latest Federdl F'lu xl
Insurance Rate Map Panel;_2'L5_ �' 8 p�O�3G
Hate
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DEPARTMENT OF PUBLIC SAFETY
CONSTR(CI ON SUPERVISOR LICENSE
Numb r„ Expires: Birthdate:
C�
41,0248 -,,03/19/2800 03/19/1953
R>istr-icted To.' ' 08
HAVERHILL, NA 01830
0
371.
HOME IMPROVEMENT.CONTRACTOR
Registration 108004'
Type : INDIVIDUAL
'I
Expiration 08/11/98
' STEVEN C. MCGLEW
1063 Western Ave.
-'J averhiII MA 01832
ADMINISTRATOR
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*
✓,0. Yoo 803 - - 71001-0
APPLICANT I M�Xe -[Yk:-
t,/LOCATION: Assessor's Map Number.
PHONE
PARCEL
SUBDIVISION LOT (S)
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STREET 4 ST. NUMBER
.*,►***,t,*********************************OFFICIAL USE ONLY*******''
RECOMME)ODATIQVS OYTjbWN AGENTS: -
ONSERVATION
COMMENTS
TOWN PLANNER `
N�
COMMENTS
FOOD INSPECTOR -HEALTH
TOR
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRJVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
�)Pw
DATE
CHARLES. A. McGLEW & SONS, INC.
Building • Remodeling • Custom Cabinets • Interior Finishing • Sunspace Designing
Telephone 372-9744 — 372-3104
1063 Western Avenue, Haverhill, Ma 01830
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CHARLES A. McGLEW & SONS, .INC.
Building • Remodeling • Custom Cabinets • Interior Finishing • Sunspace Designing
Telephone 372-9744 — 372-3104
9° 1063 Western Avenue, Haverhill, Ma 01830
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CHARLES A.-MCGLEW & SONS, .INC. '.
Building • Remodeling • Custom Cabinets • Interior Finishing • Sunspace Designing
Telephone 372-9744 — 372-3104
1063 Western Avenue, Haverhill, Ma 01830
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` "' SSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Punt or Type)
NORTH ANDOVER, , Mass. Date
Buliding�� oL l G� / PermK
Location r �/� !✓�
Owner's f
Name
New 9-�' Renovation p Replacement ❑ Plans Submitted: Yea ❑ No. ❑
FIXTURE$ .........
Insfall4ig Company f
Address
F4u,1.-,ess Telephone--_ 6
Name of Ucensed Plumber
Check one: Certificate
❑ Partnership
❑ Firm/Co.
W'SURANCE a6V R/11�8: Mack one
I have a current liability Insurance policy or No substantial equlvalenL Yes ❑ No p
If you have checked y", please Indicate Ihe'type coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity O Bond O
OWNER'S INS611ANCE WAIVER: 1 am aware that the licenses does not have the Insurance coverage required by
Chapter 142 of the Maas. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
signatuts of Dknei of Owners Aqent
I hereby certify that aI of the detalls and inlamatlon I have sutxnitted for ontsredl IgNurnTm are true and aocwate to the best of my
Itnowled a and that all plumbing wait and Instalaltons performed under the permitication will be h lana With an
pertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 112 0l
fay
Title '—.f7��
Cttyfrown
Type of Pkxnbing License: Master ®�
Ar'pnowD (OFFICE USE ONLY) Journeyman ❑
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2NDPLOOR
884 FLOOR
4TH FLOOR
sTH FLOOR
§TN FLOOR,
YTHFLOOR
=ITHOOR
-
Insfall4ig Company f
Address
F4u,1.-,ess Telephone--_ 6
Name of Ucensed Plumber
Check one: Certificate
❑ Partnership
❑ Firm/Co.
W'SURANCE a6V R/11�8: Mack one
I have a current liability Insurance policy or No substantial equlvalenL Yes ❑ No p
If you have checked y", please Indicate Ihe'type coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity O Bond O
OWNER'S INS611ANCE WAIVER: 1 am aware that the licenses does not have the Insurance coverage required by
Chapter 142 of the Maas. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
signatuts of Dknei of Owners Aqent
I hereby certify that aI of the detalls and inlamatlon I have sutxnitted for ontsredl IgNurnTm are true and aocwate to the best of my
Itnowled a and that all plumbing wait and Instalaltons performed under the permitication will be h lana With an
pertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 112 0l
fay
Title '—.f7��
Cttyfrown
Type of Pkxnbing License: Master ®�
Ar'pnowD (OFFICE USE ONLY) Journeyman ❑
+G 6 01
Date. ,! .��r • >........ .
if A
NORTH TOWN OF NORTH ANDOVER
F�py! ��ro ,e 1hOOp �1
PERMIT FOR GAS INSTALLATION
ql + c ,�•� •(g M
9SUCNUSEt fL
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60
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This certifies that ..............
has permission for gas installation ..0 G. r�'' ��..... • . .
in the buildings of ...........................
at. i �z .. U �.. �! t �� `` ..... North Andover, Mass.
Fee .a? ),..'... Lic. No.. . .... ...... .
AS
WHITE: Applicant CANARY: Building De . PINK: Treasurer