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Miscellaneous - 8 GIBSON COURT 4/30/2018
1: (#*.5pe c: rl u/1 p: 3° d-03-�--- r B,4RKAN Stephanie Berlo, AMS®KA° Senior Portfolio Manager Barkan Management Company, Inc. 24 Farnsworth Street Boston, Massachusetts 02210 barkanco.com T 617.532.8671 F 617.532.9671 I sberlo@barkanco.com .. I QWOWMD I unawww % North Andover Health Department Community and Economic Development Division LETTER OF COMPLIANCE DATE: 8/30/16 Woodridge Homes 1 Gibson Court North Andover, MA 01845 Attn: Kristy Prince PROPERTY LOCATION: 8 Gibson Court I A complaint was submitted to the Health Department on 7/26/16. Violations were found of the State Sanitary Code, 105 CMR 410.000, Minimum Standards of Fitness for Human Habitation. A re- inspection of the property, completed on 8/16/16, has found that all of the violations have been corrected. S c rely, Michele Grant Health Inspector Xc: File Page 1 of 1 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 ci CD 0 -i N O_ O v m Cl) r m c m' ci Cl U) O 55 O 0 N n o co es � � n) o 0 0 o w T � i CD p n A { w 7 O C O a n .. CD i� s C A _H 9 'N■ i' "S (gyp O ►S Y�y /(pv (D y -J.�_ w � i n A { a CD m i� 00 ro H N N ' ' N G7 N �' w Q- �• O� � � CD �. CD G+. ` • w c rn n i rn CD m i� It ALYSSA CONLEY 8 GIBSON COURT NORTH ANDOVER, MA 01845 1675 North Commerce Parkway, Weston, FL 33326 (954) 3844446 Certificate of Mold Analysis Prepared for: Phone Number: Fax Number: Project Name: Test Location: Chain of Custody #: Received Date: Report Date: ( r Erika Piechowski, Technical Manager ALYSSA CONLEY (978) 360-1288 ALYSSA CONLEY 8 GIBSON COURT NORTH ANDOVER, MA 01845 964245 July 14, 2016 July 20, 2016 621;> '9 21n, E.Ek4 Carlos Ochoa, Quality Control Manager Currently there are no Federal regulations for evaluating potential health effects of fungal contamination - and remediation. This information is subject to change as more information regarding fungal ® AHA ���' ��� contaminants becomes available. For more information visit hftp://www.epa.gov/mold or www.nyc.gov/html/doh/htmi/epi/mold.shtml. This document was designed to follow currently known industry guidelines for the interpretation of microbial sampling, analysis, and remediation. Since interpretation of mold analysis reports is a scientific work in progress, it may as such be changed at any ACCREDITED LABORATORY time without notice. The client is solely responsible for the use or interpretation. PRO-LAB/SSPTM Inc. ENNRONMENTALMICROBROGY makes no express or implied warranties as to health of a property from only the samples sent to their ISNEC17025:2005 laboratory for analysis. The Client is hereby notified that due to the subjective nature of fungal analysis and the mold growth process, laboratory samples can and do change over time relative to the originally sampled material. PRO-LAB/SSPTM Inc. reserves the right to properly dispose of all samples after the WWWAIMMIUMDUSM testing of such samples are sufficiently completed or after a 7 day period, whichever is greater. LAB 6163230 For more information please contact PRO -LAB at (954) 3844446 or email info@prolabinc.com Page 1 of 8 PRO -LAB® Prepared for: ALYSSA CONLEY 1675 North Commerce Parkway, Weston, FL 33326 (954) 384-4446 Test Address : ALYSSA CONLEY 8 GIBSON COURT NORTH ANDOVER, MA 01845 ANALYSIS METHOD Direct Microscopic Exam INTENTIONALLY BLANK INTENTIONALLY BLANK INTENTIONALLY BLANK LOCATION BATHROOM DOORFRAME/FLOOR COC / LINE # 964245-1 SAMPLE TYPE & VOLUME BULK SERIAL NUMBER None supplied COLLECTION DATE Jul 11, 2016 ANALYSIS DATE Jul 19, 2016 CONCLUSION UNUSUAL IDENTIFICATION Mold Present Raw Count Spores er m Percent of Total Raw Spore? Count er m Percent of Total Raw Count Spore per m Percent of Total Chaetomium X TOTAL SPORES NA MINIMUM DETECTION LIMIT NA BACKGROUND DEBRIS Not Applicable OBSERVATIONS & COMMENTS Presence of current or former growth observed. Background debris qualitatively estimates the amount of particles that are not pollen or spores and directly affects the accuracy of the spore counts. The categories of Light, Moderate, Heavy and Too Heavy for Accurate Count, are used to indicate the amount of deposited debris. Increasing amounts of debris will obscure small spores and can prevent spores from impacting onto the slide. The actual number of spores present in the sample is likely higher than reported if the debris estimate is 'Heavy' or'Too Heavy for Accurate Count'. All calculations are rounded to two significant figures and therefore, the total percentage of spore numbers may not equal 100%. • Minimum Detection Limit. Based on the volume of air sampled, this is the lowest number of spores that can be detected and is an estimate of the lowest concentration of spores that can be read in the sample. NA = Not Applicable. Spores that were observed from the samples submitted are listed on this report. If a spore is not listed on this report it was not observed in the samples submitted. Interpretation Guidelines: A determination is added to the report to help users interpret the mold analysis results. A mold report is only one aspect of an indoor air quality investigation. The most important aspect of mold growth in a living space is the availability of water. Without a source of water, mold generally will not become a problem in buildings. These determinations are in no way meant to imply any health outcomes or financial decisions based solely on this report. For questions relating to medical conditions you should consult an occupational or environmental health physician or professional. CONTROL is a baseline sample showing what the spore count and diversity is at the time of sampling. The control sample(s) is usually collected outside of the structure being tested and used to determine if this sample(s) is similar in diversity and abundance to the inside sample(s). ELEVATED means that the amount and/or diversity of spores, as compared to the control sample(s), and other samples in our database, are higher than expected. This can indicate that fungi have grown because of a water leak or water intrusion. Fungi that are considered to be indicators of water damage include, but are not limited to: Chaetomium, Fusarium, Memnoniella, Stachyhotrys, Scopulariopsis, Ulocladium. NOT ELEVATED means that the amount and/or the diversity of spores, as compared to the control sample and other samples in our database, are lower than expected and may indicate no problematic fungal growth. UNUSUAL means that the presence of current or former growth was observed in the analyzed sample. An abundance of spores are present, and/or growth structures including hyphae and/orfruiting bodies are present and associated with one or more of the types of mold/fungi identified in the analyzed sample. NORMAL means that no presence of current or former growth was observed in the analyzed sample. If spores are recorded they are normally what is in the air and have settled on the surface(s) tested. Page 2 of 8 7/27/2016 Town of North Andover Mail - Bathroom water damage and mold 0i�l, OVER Brian LaGrasse <blagrasse@northandoverma.gov> .Massachust?tts Bathroom water damage and mold 1 message Alyssa Conley <lyssphot0@gmail.com> Tue, Jul 26, 2016 at 12:48 PM To: SBerlo@barkanco.com Cc: blagrasse@northandoverma.gov, Jcollins@mass.housing.com July 25, 2016 To Whom It May Concern: I would like to make you aware of an ongoing issue of water damage and mold that I have been asking management to resolve for over two years now. I began calling in work orders with concern of a leak in the upstairs bathroom. It began with the recognition of water stains that appeared on the laundry room ceiling, which is directly below. the bathroom. Maintenance came in and sprayed the ceiling, assuring there was no leak and placed blame on my children, -"they are splashing water from the tub". This may be true if they took baths, but unfortunately they were not to blame, as they shower in the downstairs bathroom. At this time, I was also dealing with the issue of the ceiling in the bathroom growing mold, bubbling, and peeling. The Ceiling fan was "repaired" and the ceiling was scraped, sprayed with bleach, puttied and painted. These steps have been repeated three or four times. As time went on the water stains in the laundry room grew, the bathroom ceiling began to grow mold again and bubble/peel. I also noticed white powdery looking debris on the bathroom floor, lining the tub and the doorframe. Every time I would clean this, it would come back within the day. I also noticed the rotting wood of the door and doorframe. The wood would be wet along with the surrounding carpet. As my bedroom is wall to wall with the bathroom, I believe this is the cause of the musty wet smell that I have been fighting to mask for years. I had to buy an air purifier that helps but will not solve the issue. While Woodridge Homes began the process of the renovations and "upgrades" in February 2016, 1 finally caught the ear of the right person, so I thought. I voiced my thoughts and concerns and pleaded for them to please fix the issue. They ordered the bathtub to be replaced, and turned out there was a leaky pipe that also needed to be replaced. (or so they say..) Since replacing the pipe and the bathtub, no new water damage has been done to the laundry room ceiling and the bathroom ceiling has not grown any mold, bubbled, or peeled. Although they have resolved the issue of the leak, they have not repaired the damages that have been done to the floor, doorframes, and carpet. I have asked multiple times when the NEW floor would be fixed and also if they could do something about the rotting doorframes. I have had no luck, until I mentioned my recent attempt of having a mold analysis done, which has come back positive. I am asking for the issues to be resolved correctly as I worry about the long term health issues that my children and I could potentially suffer from. I have attached pictures documenting before and after as well as a copy of the mold analysis. I have requested documentations of work orders that I have called in regarding this issue as well and I have been denied access. Alyssa Conley 8 Gibson Court North Andover, MA 01845 (978)360-1288 hftps:Hm ai l .google.com/mail/ca/u/0/?ui=2&i k=2c94973612&view=pt&search=i nbox&th=156281 bbfe5f225G&si m 1=156281 bbfe5f225c 1 /1 co M v co N M M M J LL C w W R Y R CL, m m E E 0 v L 0 2 r m w ° O O N a y c O` @ U E 0c E r- E o 6 i -°Na)N QI 01 7 w C O C O °p_ N - U U N v O1E m� o -o c°o C t C L r ML ET U C 00--o N N f0 O a7 C.L.. N U 7 °" w Oi a) N U a3 Co ;a w N rr N my m N N N a7 N N U L y o 7 N E L ns d Dw = E a) a c E E O N O O U C L E Z N ZLw a)aI O L U L aL 0 °.L (o C) 0mNNN3 Rc +� ° d m m C E a L U3 v� o a cc L- da w cl d Occ T a) y o Z m 'm n. 0 CL ° �ca T O O ._ O 3 (3) O1-6 d "O c EL a) o ° :3 3 m a `m o'.o N-2 N N-0 Z 2 .0 co N U Z '° L f6 C M N p E L_ S 0 ° ° ° N f6 7 c »�0°��3 = m m oa m c o U 3z c E� rn N N a3 d c+ m cts (D L OC 0 m C 3 O �O- O c 0 w o c a� M U PRO -LAB® 1675 North Commerce Parkway, Weston, FL 33326 (954) 384-4446 Prepared for: ALYSSA CONLEY Test Address: ALYSSA CONLEY 8 GIBSON COURT NORTH ANDOVER, MA 01845 Indoor Air Quality Testing Introduction The fungi are a large group of organisms that include mold. In nature, the fungi and mold help breakdown and recycle nutrients in the environment. Mold are the most common type of fungi that grow indoors. Mold are microscopic organisms that live on plants, in the soil, and on animals, in fact almost anywhere food and moisture are available. Mold is everywhere present in the outdoor and normal indoor environments. It is in the air and on surfaces as settled dust. Exposure to mold is inevitable in everyday life. Thus, exposure to mold is considered part of a normal activity for most people. Only environments for which extraordinary preparations have been taken don't have mold present in the air or on surfaces. Understanding Mold Under the right conditions (moisture, a food source, and time) mold will grow, multiply and produce spores. Mold grows throughout nature as well as the built environment. Mold reproduces by microscopic cells called "spores" that can be spread easily through the air. Mold spores are always present in the indoor and outdoor air. There are mold that can grow on any organic substrate including wood, paper, carpet, food, ceiling tiles, dried fish, carpet, or any surface where dust has accumulated. When excessive moisture or water accumulates indoors, mold growth will often occur, particularly if the moisture problem remains undiscovered or un -addressed. There is no practical way to eliminate all mold spores in the indoor environment. The way to control indoor mold growth is to control the amount of moisture available to the mold. Mold growth can become a problem in your home or office where there is sufficient moisture and the right foodstuff is available. The key to preventing mold growth is to prevent all moisture problems. Of course, hidden mold can grow when there is water available behind walls, sinks, floors, etc. Indications of hidden moisture problems are discoloration of ceiling or walls, warped floors or condensation on the windows or walls. Controlling Moisture The most critical step in solving a mold problem is to accurately identify and fix the source(s) of moisture that allowed the growth to occur. In order to prevent mold from growing, it is important that water damaged areas be dried within a 24-48 hour period. If a small amount of mold is present in the home, the mold can be cleaned up with a mild detergent and the excess water or moisture removed. It is not necessary to try and kill the mold or its spores. You can carefully remove the moldy materials if necessary. There are many common sources of excess moisture that can contribute to indoor mold growth. Some of the primary means of moisture entry into homes and buildings are water leakage (such as roof or plumbing leaks), vapor migration, capillary movement, air infiltration, humidifier use, and inadequate venting of kitchen and bath humidity. The key to controlling moisture is to generally reduce indoor humidity within 35% - 60% (depending what climate you live in) and fix all leaks whatever their cause. Mold Growth Sources If the source of moisture is not easily detected or you have a hidden water leak, mold testing can be helpful. Often a roof leak or a plumbing leak can be identified as the source. The difficulty arises when there is an odor present or when an occupant shows signs of mold exposure but no visible mold can be seen. Excess water intrusion can also lead to dry rot of lumber and cause a serious structural defect in buildings. Health Related Risks Based on the Institute of Medicine and the National Academy of Sciences, dampness and mold in homes is associated with increases in several adverse health effects including cough, upper respiratory symptoms, wheeze, and exacerbation of asthma. Mold and fungi contain many known allergens and toxins that can adversely affect your health. Scientific evidence suggests that the disease of asthma may be more prevalent in damp affected buildings. Dampness and mold in homes, office buildings and schools represent a public health problem. The Institute of Medicine concluded, 'When microbial contamination is found, it should be eliminated by means that not only limit the possibility of recurrence but also limit exposure of occupants and persons conducting the remediation". Page 4 of 8 PRO -LAB® 1675 North Commerce Parkway, Weston, FL 33326 (954) 384-4446 Mold Sampling Methods The goal of sampling is to learn about the levels of mold growth and amplification in buildings. There are no EPA or OSHA standards for levels of fungi and mold in indoor environments. There are also no standard collection methods. However, several generally accepted collection methods are available to inspectors to study mold (and bacteria) in indoor environments. Comparison with reference samples can be a useful approach. Reference samples are usually taken outdoors and sometimes samples can be taken from "non -complaint' areas. In general, indoor fungal concentrations should be similar to or lower than outdoor levels. High levels of mold only found inside buildings often suggest indoor amplification of the fungi. Furthermore, the detection of water -indicating fungi, even at low levels, may require further evaluation. There are several types of testing methods that can detect the presence of mold. They can be used to find mold spores that are suspended in air, in settled dust, or mold growing on surfaces of building materials and furnishings. There are different methods that can identify types of live mold and dead mold in a sampled environment. Mold spores can be allergenic and toxic even when dead. All sampled material obtained in the laboratory is analyzed using modem microscopic methods, standard and innovative mycological techniques, analyzed at 630 —1,000 times magnification. Testing for mold with an accredited laboratory is the best way to determine if you have mold and what type of mold it is. Surface Sampling Methods Surface sampling can be useful for differentiating between mold growth and stains of various kinds. This type of sampling is used to identify the type of mold growth that may be present and help investigate water intrusion. Surface sampling can help the interpretation of building inspections when used correctly. The following are the different types of surface samples that are commonly used to perform a direct examination of a specific location. Spore counts per area are not normally useful. Tape (or tape -lift) These samples are collected using clear adhesive tape or adhesive slide for microscopic examination of suspect stains, settled dust and spores. Tape lifts are an excellent, non-destructive method of sampling. The laboratory is usually able to determine if the there is current of former mold growth or if only normally settled spores were sampled. Bulk This is a destructive test of materials (e.g., settled dust, sections of wallboard, pieces of duct lining, carpet segments, return -air filters, etc.) to determine if they contain or show mold growth. Bulk sampling collects a portion of material small enough to be transported conveniently and handled easily in the laboratory while still representing the material being sampled. A representative sample is taken from the bulk sample and can be cultured for species identification or analyzed using direct microscopy for genus identification. The laboratory is usually able to determine if the there is current of former mold growth or if only normally settled spores were sampled. Swab A sterile cotton or synthetic fiber -tipped swab is used to test an area of suspected mold growth. Samples obtained using this method can be cultured for species identification or analyzed using direct microscopy for genus identification. The laboratory is usually able to determine if there is current of former mold growth or if only normally settled spores were sampled. Identified spores are generally reported as "present/absent". Carpet (filter -type) Cassette A carpet cassette is used with a portable air pump (flow rate usually doesn't matter) to collect mold, pollen and other particulates. Samples obtained using this method can be cultured for species identification or analyzed using direct microscopy for genus identification. This method is usually used to determine a presence or absence of water -indicating mold in a carpet. The laboratory is usually able to determine if the there is current of former mold growth or if only normally settled spores were sampled. Page 5 of 8 PRO-LAB® 1675 North Commerce Parkway, Weston, FL 33326 954 384-4446 y c► Air Sampling Methods Air samples are possibly the most common type of environmental sample that investigators collect to study bioaerosols (mold, pollen, particulates). The physics of removing particles from the air and the general principles of good sample collection apply to all airborne materials, whether biological or other origin. Therefore, many of the basic principles investigators use to identify and quantify other airborne particulate matter can be adapted to bioaerosol sampling. Common to all aerosol samplers is consideration of collection efficiency. The following are the two most common forms of air sampling methods. "Non -Viable Methods" (The Laboratory results are reported in "spores per cubic meter (sp/m3) Z5 Cassette The Z5 spore trap is used with a portable air pump (5 liters/minute for 1 to 5 minutes) to rapidly collect airborne aerosols including mold, pollen and other airborne particulates. Air is drawn through a small slit at the top of the cassette and spores are trapped on a sticky surface on a small glass slide inside the cassette. They are efficient at collecting spores as small as 1 Nm. Micro5 Cassette The Micro5 Microcell spore trap cassette is used with a portable air pump (5 liters/minute for 1 to 5 minutes) to collect airborne aerosols including mold, pollen and other airborne particulates. Air is drawn through a small circular hole at the top of the cassette and spores are trapped on a sticky coated glass slide inside the cassette. They are efficient at collecting spores as small as 0.8pm. Air -O -Cell Cassette The Air -O -Cell spore trap cassette is used with a portable air pump (15 liters/minute for 1 to 10 minutes) to collect airborne aerosols including mold, pollen and other airborne particulates. Air is drawn through a small opening at the top of the cassette and spores are trapped on a sticky coated glass slide inside the cassette. These cassettes are efficient at collecting spores as small as 2.6pm. Allergenco-D Cassette The Allergenco-D spore trap cassette is used with a portable air pump (15 liters/minute for 1 to 10 minutes) to collect airborne aerosols including mold, pollen and other airborne particulates. Air is drawn through a small opening at the top of the cassette and spores are trapped on a sticky coated glass slide inside the cassette. These cassettes are efficient at collecting spores as small as 1.7pm. "Viable Methods" (The Laboratory results are reported in "colony forming units per cubic meter (CFU/m3) Agar Impaction Plates The agar impaction plates are used with a portable air pump (28.3 liters/minute for 1 to 3 minutes) to collect airborne mold. This is called "viable sampling" because it only grows what is alive at the time of testing. Air is drawn through a 200400 holes at the top of the impactor and spores are trapped in the agar media. The agar plate should be shipped to the laboratory immediately or kept cool until it can be shipped. These cassettes are 90% efficient at collecting spores as small as 0.7pm. The laboratory results are reported in "colony forming units per cubic meter (CFU/m3)". Page 6 of 8 PRO -LAB® 1675N oth Commerce Parkway, Weston, FL 33326 (954) 384-4446 Data Interpretation Information (data) on mold in buildings can consist of the simple observation of fungal growth on a wall, analytical measurements from hundreds of environmental samples, or the results of a survey of building occupants with and without particular building -related conditions. Data interpretation is the process whereby investigators make decisions on (a) the relevance to human exposure of environmental observations and measurements, (b) the strength of associations between exposure and health status, and (c) the probability of current or future risks. These interpretation steps are followed by decisions on what measures can be taken to interrupt exposure and prevent future problems. Remediation of Mold Prevention of mold growth indoors is only possible if the factors that allow it to grow are identified and controlled. When prevention has failed and visible growth has occurred in a home or building, remediation and/or restoration may be required. The extent of the mold growth will determine the scope of the remediation required. The goal of remediation is to remove or clean mold -damaged material using work practices that protect occupants by controlling the dispersion of mold from.the work area and protect the workers from exposure to mold. You should consult a professional when contemplating fixing a large area of mold growth. Generally, remediation requires (a) removal of porous materials showing extensive microbial growth, (b) physical removal of surface microbial growth on non -porous materials to typical background levels, and (c) reduction of moisture to levels that do not support microbial growth. Identification of the conditions that contributed to microbial proliferation in a home or building is the most important step in remediation. No effective control strategy can be implemented without a clear understanding of the events or building dynamics responsible for microbial growth. Following the completion of the remediation process, mold testing should be performed to obtain clearance. Symptoms of Mold Exposure The most common symptoms of mold exposure are runny nose, eye irritation, cough, congestion, and aggravation of asthma. Individuals with persistent health problems that appear to be related to mold or other types of air quality contaminant exposure should see their physicians for a referral to specialists who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Decisions about removing individuals from an affected area must be based on the results of such medical evaluation. Mold is naturally present in outdoor environments and we share the same air between the indoor and outdoor, it is impossible to eliminate all mold spores indoors. Ten Things You Should Know About Mold 1) Potential health effects and symptoms associated with mold exposures include allergic reactions, asthma, and other respiratory problems. 2) There is no practical way to completely eliminate mold and mold spores in the indoor environment. The way to control indoor mold growth is to control moisture. 3) If mold is a problem in your home or building, you must clean up the mold and eliminate sources of moisture. 4) To prevent mold growth any source of a water problem or leak must be repaired. 5) Indoor humidity must be reduced (generally below 60%) to reduce the chances of mold growth by: adequately venting bathrooms, dryers, and other moisture -generating sources to the outside; using air conditioners and de -humidifiers; increasing ventilation; and using exhaust fans whenever cooking, dishwashing and cleaning. 6) Clean and dry any damp or wet building materials and furnishings within 24-48 hours to prevent mold growth. 7) Clean mold off of hard surfaces with water and detergent and dry completely. 8) Prevent condensation: reduce the potential for condensation on cold surfaces (e.g., windows, piping, exterior walls, roof, or floors) by adding insulation. 9) In areas where there is a perpetual moisture problem on the floor, do not install carpeting 10) Mold can be found almost anywhere. Mold can grow on wood, paper, carpet, foods; almost anything can support . some mold growth provided there is moisture, time to grow and food to eat. Page 7 of 8 PRO -LAB® 1675 North Commerce Parkway, Weston, FL 33326 (954) 384-4446 References & Resources Bioaerosols: Assessment and Control, Janet Macher, Sc.D., M.P.H., Editor. 1999. ACGIH, 1330 Kemper Meadow Drive, Cincinnati, OH 45240-1634. Health Implications of Fungi in Indoor Environments, Edited by R.A. Samson. 1994. Elsevier Science, P.O. Box 945, Madison Square Station, New York, NY 10159-0945. Damp Indoor Spaces and Health, Institute of Medicine of the National Academies, Washington, DC, 2004 Field Guide for the Determination of Biological Contaminants in Environmental Samples, 2nd Edition, Edited by L -L. Hung, et al. AIHA, Fairfax, VA, 2005. Recognition, Evaluation, and Control of Indoor Mold, Edited by B. Prezant, et al. AIHA, Fairfax, VA, 2008. Useful Websites www.aegih.org/resources/Iinks.htm American Conference of Governmental Industrial Hygienists - information on Indoor Air Quality and useful links www.cal-iaq.org California Indoor Air Quality Program - California Indoor Air Quality resources and useful links www.health.state.ny.us/environmental/indoors/air/mold.htm New York State Department of Health - New York state recommendations for IAQ, indoor mold inspections, remediation, and prevention hftp://www.nyc.gov/html/doh/htmi/epi/moldrptl.shtml Guidelines for Assessment and Remediation of Fungi in Indoor Environments — a good reference for mold clean up and removal orf.od. n i h. gov/PoliciesAndGu ideli nes/ORFPol icies/Mold PrevPolicy. htm National Institutes of Health - information mold prevention and remediation http://www.niehs.nih.gov/health/topics/agents/mold/index.cfm National Institute of Environmental Health Sciences - information on mold www.epa.gov/mold/ United States Environmental Protection Agency website on mold and moisture www.aaaal.org/nab/index.cfm?p=faq American Academy of Allergy, Asthma, and Immunology — information on mold and allergies and outdoor allergens hftp://www.aanma.org/?s=mold Allergy & Asthma Network — information for homes about allergies and asthma http://www.homeenergyresourcemn.org Minnesota Department of Commerce Energy Information Center— good information on moisture control in homes http://eetd.lbi.gov/ie/ Governmental Indoor Environment Department — good information on indoor health, comfort and energy efficiency in buildings http://www.osha.gov/dts/shib/shibl01003.htm I Occupational US Department of Labor (OSHA) - A Brief Guide to Mold in the Workplace Page 8 of 8 FA Date ...... e. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...................'`� ` ' ' /`�� ....... has permission to perform ....61- .... 61- ................................ .. ......... .......... ................................ plumbing in t e buildings of X .... . . . ............. ........ .................. . /P.- at .......... ............................................................. North Andover, Mass. Fee �V Lic. No.,&ZS�3 ............ -- ........... ............................................................. -A PLUMBING INSPECTOR Check W ,,3 /,3 - W1,23 1, _ - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' POWNER TYPE OR PRINT CLEARLY CITY MA —D -ATE JOBSITE ADDRESS 1 ` C�S.L G` it 0 NSR' ADDRESS OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [31 NEW: RENOVATION: ® REPLACEMENT: 0'—. PERMIT # _ G NAME % y/ i�r _�.. 11 TEL___JIFAX RESIDENTIAL PLANS SUBMITTED: YES ® NO FIXTURES'l 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 GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I E-11 (_ v_ _ _ _ _ I I —_III DEDICATED WATER RECYCLE SYSTEM _( [ DISHWASHER I �. & J ._._ J _---__ _.. _-- I ----IIF-- --IF j _._. -j -- I ---IF- A_,._-- M I _-_.-_ ___. J _ I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .-.—I -to 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2--' OTHER TYPE OF INDEMNITY Ej BOND D 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc a the best of my edg and that all plumbing work and installations performed under the permit issued for this application will be in complia a aent pr isi the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ LICENSE # SIGNATURE MP 2 ---JP Q CORPORATION n#PARTNERSHIPD#®LLC COMPANY NAMES- 11ADDRESS I CITY _.__.._.. � STATE ZIP TEL f at FAX CELLEMAIL o rl z W Ix w LU LL Fr' Is. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA- 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIVIITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: 1 Phone #: 9 6 L« Are you an employer? Check the appropriaie box: Type of project (required): IT -11a a employer with employees (full and/or part-time).* 7. F1New construction 2: I am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp. irisurance required.] t 10 ❑ Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ 13. ❑ Roof repairs These sub -contractors have employees and have workers' comp. insurance. 6. ❑ We are a corporation and its officers have exercised their right of bxemption per MGL c. 14. ❑Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] rt *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-cor&act6s' have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name-4�r A) 5 Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Y G'il 65;6 V_ o ff, r % 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 MGL c. 152, §25A is a criminal violation punishable by 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. A cop of th' ent may be forwarded t Office of Investigations of the DIA for insurance coverage verification. I do hereby certify VoWs—and provided aboo is truA and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical 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 employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia LUMBCPS t4fdD G"�J.�IT�`�RS ISSIif?5. TflC FOLCOWfh1G LILENS 1 Lie 3L! 4 'V Date .Au.. 2.-CA(.,5 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ............ ...................................... .. ....... ........... . .. .... ....... . ... .............. has permission to perform ...L- 1 ,I— " . ...................................................... plumbing in the buildings of **"*****'**"*'*'*****'*"* . ........................ ......................... at .......la........................... t1i .......................................................... , North Andover, Mass. Fee....-^k6 .. . .... Lic. No. .. ................................................................................. PLUMBING INSPECTOR Check R 2-042 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY(PERMIT # 119N ----MA--DATE JOBSITE ADDRESS' _ C�_vl T, II OWNER'S NAME POWNER ADDRESS !/V ac /', ` TEL[::-_FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL �---- PRINT CLEARLY NEW: f] RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ® NO FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _= DEDICATED GRAY WATER SYSTEM ! ._ _ _- _,_. I ___ S DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL _I .____ ! ___-_! __T. ____ ► ___ .! __ �.( __ ___ J __ I �___ k ! SERVICE / MOP SINK TOILET URINAL ---_-__f WASHING MACHINE CONNECTION f f _._......� _- __.__I .__..._ _! .___..__! ! _ __ _._._ J __.__.J ._._.. WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .B'1TO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY Q BOND D 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 EJ AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acura est of my kn e and that all plumbing work and installations performed under the permit issued for this application will be in compliant V MIP in rovi io e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ LICENSE # SIGNATURE IMP E I JP �I CORPORATION # ( PARTNERSHIP P# ; LLC —�J COMPANY NAME 12!yycy�pl ADDRESS CITY .----=STATE ® ZIP �j� J TEL FAXCELL _.__ __d,_ __ ..., EMAIL-------------...._----.-------_..---_...__._.__.__...._....__..._._.__...._---------_.._...- MEL N ❑ W CL w w LL r, c M 1'he Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 �t www mass.gov/dia T d�M sy1 V`q Workers° Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE MED WITH THE PERMITTING AUTHORITY. Name (Business/Oigabization&dividual): Address: City/State/Zip: Are YOU an employer? Check the appropriate box: Phone 4: 1.❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp, insurance required.] 3.[] I am a homeowner doing all work myself [No workers' comp. insurance required] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and we have no empldydes. [No workers' comp. insurance required.] Type of project (required): 7. ❑ N6Vd6nstr6etion 8. 0 kemodel hg 9. ❑ Demolition 10 ❑ Building addition 11.0Electrical repaixs or additions 12. Pliunbing repairs or additions 13•. [] Roof repaixs 14.Other *Any applicant that checks box1 must also fill out the section below showing their workers' compensation policy information. Homeowners who subn ii.this aMT ,vit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such 't Homeown,tors that o subheck his box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have ,...,.-.,....e>. Tf+hr. c„b-contractors have employees, they must provide their workers' comp. policy number. - lam an employer that is providingworkers, compensation insurance for my employees. information. Insurance Company Policy # or Self -ins. Lic. #: Below is the policy and job site Expiration Date:. City/State/Zip: fob Site Address:the policy number and expiration date). he Attach a copy of tworkers' compensation policy declaration page (showing p Y Failure to secure the coverage as required under MGL c.152, §25A is a criminal violation punishable by a foie up to $1,500.00 penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. £do hereby certify under thepains and penalties of perjury that the information provided above is true and correct. Date: Signature: Official use only. Do not write in this area, to be completed by city or town offaciaL 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 Phone #: Contact Person: 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 We, 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 receivet'or, trustdd 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 certificates) 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 liue. - 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date....... .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................................................................................................................. has permission for gas installation ..`'`� c-- �'` .......................................... in the buildings of .....uu� c-`�`{ v%.< ........................................................................................... at ..... 1...�.1....................................... North Andover, Mass. ........................ Fee. 2............ Lic. No. ....... Check # j�+� �� ` _ / GAS INSPECTOR 10 2 3 i (gyp-' } MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 CITY MA DATE PERMIT # JOBSITE ADDRESS 7�v SCJ 1� C�II.OWNER'S AME F/����^''_ G, OWNER ADDRESS =TE FAX�� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL -B -" CLEARLY NEW: RENOVATION: REPLACEMENT: Lj--' PLANS SUBMITTED: YES N APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE -! A. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR G- ._ �_ _—J �- FURNACE j _I GENERATOR GRILLE --- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER _ _ _. I _ __ _ �- _ _ RQOF TOP UNIT - TEST UNIT HEATER j C44VENTED ROOM HEATER�- WATER HEATER OTHER INSURANCE COVERAGE have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES Bm- IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT Ejf SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and cura o e best of my ledge and that all plumbing work and installations performed under the permit issued for this application will be in complian i IIP p s1 he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME T �..1'' LICENSE # SIGN URE MP GF [j JP EI JG D, LPGI [1 CORPORATION ©# PARTNERSHIP ©#= LLC ®# -FF COMPANY NAME: -_- _� ADDRESS _ ---- - - — CITY � STATE ZIP TEL FAX CELL AIL _ _ - on z N El} W a ci i w LL 4 The Commonwealth of Massachusetts F Department of Industrial Accidents ICongress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers Compensation insurance Affidavits Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY- Name (Business/Oigariization/Individual): Address: City/State/Zip:_ Are you an employer? Check the appropriate box: al Phone #: 3 6 5'-�) '/G 'Y-� 1.[] I am a em yer with employees (full and/or pari time),* 2. n a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required,] 3. I am a homeowner doing all work myself: [No workers' comp. insurance required.] t 4,❑ I am a homeowner and will be, hiring contractors to conduct all work on my property. I will ensure that all contrac;ors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6. C] We are a corporatioii and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and We have rio employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ Nevv'constriiction 8. R.emodel.irig 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additiolis 12T[f Plumbing repairs or additions 13-. [] Ro6f repairs 14. [] Other *Any applicant that check's box #1 must also fill. out the section below showing their workers' compensation policy information: At Homeowners who submii,this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those, entities, have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providingworke rs' j ompen yyon insurance for° my employees. Below is the policy and job site information. Insurance Company Name:, Expiration Date: Policy # or Self -ins. Lic. #: . Job Site Address: City/State/Zip: Attach a copy of the workers' comp . ion policy declaration page (showing the policy number and expiratiou date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby cert under tliepains andpenalties of perjury that the information provided above is true and correct. Date: Signature: Phone #: official use only. Do not write in this area, to he 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 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 enferprise, and including the legal representatives of a deceased employer, or the receiv6for 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 requited." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance ofpublic 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 numbers) along with their certificates) 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. B e 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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASS.AFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia l Date . 77//..`. �'<� •� :�"o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING s o s SACMUS� This certifies that ... ° �r `� r!� 44 , . , , , , , , , , • , has permission to perform .... ................ plumbing in the buildings of ... �'�" v a `l !' '.. �.�-............. at. 1. �.. 3 ... (! . C � .'...`.. �.......... , North Andover, Mass. Fee.1......Lic. No. �.? �.�. �...1 - ....... PLUMBING INSPECTOR Check # Y) 7098 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Civ/kners Nan Date l� i i Termit # Amount Type of Occupancy New 0 Renovation Replacement [3-- Plans Submitted Yes ❑ No 13 FIXTURES (Print or type) Check one: Certificate Installing Company Name a /�QP6111 Corp. Address o l2v C'(r e- ` Partner Business Telephone Firm/Co. Name of Licensed Plumber: = C, k' Insurance Coverage: Indicate the type of in rance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity E-1 Bond 0 Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent I hereby certify that all of the details and information I have submitted (or entered) in best of my knowledge and that all plumbing work and installations perfornleux compliance with all pertinent provisions of the Massachusetts State P in e By igna 'MiLicensearlumoer Type of Plumbing License Title .� City/Town License ' um er Master APPROVED (OFFICE USE ONLY application are true and ggeumte to the Issued for thiappl' i will be in )t`e Laws. Journeyman 0— ail �� --I • � � . = .a - — .. — a ,1 (Print or type) Check one: Certificate Installing Company Name a /�QP6111 Corp. Address o l2v C'(r e- ` Partner Business Telephone Firm/Co. Name of Licensed Plumber: = C, k' Insurance Coverage: Indicate the type of in rance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity E-1 Bond 0 Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent I hereby certify that all of the details and information I have submitted (or entered) in best of my knowledge and that all plumbing work and installations perfornleux compliance with all pertinent provisions of the Massachusetts State P in e By igna 'MiLicensearlumoer Type of Plumbing License Title .� City/Town License ' um er Master APPROVED (OFFICE USE ONLY application are true and ggeumte to the Issued for thiappl' i will be in )t`e Laws. Journeyman 0— Date. C/-O. �/'/- /.- .0 / TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .................. has permission to perform .... C. %A r.- . . . . . . . . . . . plumbing in the buildings of .. U— r,. e.-. t1. ..... at ................... North Andover, Mass. Fee. .... Lu. No.) 4 .t . ...... k PLUMBING IN ECTOR Check # 7097 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date G Building Location f ers Name APermit # I Q 17 Amount L f Type of Occupancy New 0 Renovation 1:1 Replacement ©� Plans Submitted Yes No FIXTURES (Print or type) .Check one: Certificate Installing Company Name ./ZlCorp. Address G Partner. Business Telephone EkFirriVCo. Name of Licensed Plumber: Insurance Coverage: Indicatethe type ' urance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are tTA and accurate to the best of my knowledge and that all plumbing work and installations performed de it Issued for th' pgl cation will be in compliance with all pertinent provisions of the Massachusetts State Plumb' C d?MZJ�the,deneral Laws. By Signature oT Licenseaum er Type of Plumbing License Title 9G )r;7 City/Town Li-cense=lQu=moer Master � - Journeyman APPROVED (OFFICE USE ONLY 8# Date. /G..C. TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING This certifies that .... Lit'L . �..t. ... "Y 5 ................... has permission to perform ..... ?O. rG"/...4 .............. plumbing in the buildings of .. t, �. x: P. 'J. r". l .. ............. . at ...,......... , North Andover, Mass. Fee. L.... Lic. No/41 c� .. .... Q-... PLUMBING INSPECTOR Check # 6765 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location / 3 Ga � 56, Q - I* Date�"� Permit# Amount 2-:M of New Renovation Replacement Plans Submitted Yes No FIXTURES (Print or type) t Check one: Certificate j Installing Company Name Corp. d Address yitPartner. Business Telephone49 Finn/Co. Lie - Name of Licensed Plumber: � _JC-Glij^n1 �) D [A "" � �9 Z -� Insurance Coverage: Indicate t e ype of insurancdicoverage by checking the appropriate box: Liability insurance policyT Other type of indemnity 11Bond 0 Insurance Waiver: I, the un ersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent 0 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 per ed nder Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat ode a d Cha ter 142 of the General Laws. By: MgnaWot LIcenseaum e e of Plumbing License Title City/Town i ense um 2 'qMaster Journeyman APPROVED (OFFICE USE ONLY { . f: WOLF AUMBI1Ir6 d NEA TING INVOICE NUMBER: 8126 INVOICE DATE: 7 -SEP -05 P. 0. BOX # 2229 SALEM, N.H. 03079 RANDOLP'11 H, .IOLF TEL: 603-898-6505 MA. MASTER PLUMBER BER 12299 FAX:SAME CALL AHEAD CUSTOMER: WOOD RIDGE HOMES CO-OP TELEPHONE: ADDRESS: 10 WOODRIDGE DR.. PAX: CITY, STATE, POSTAL CODE: NO. ANDOVER, MA. 01$45 PO NUMBER: 13 OIBSON CT ORDER DATE GARY: PIXMRER."HELPER START DDATE i ;itANDY 3.00 $90.00 B -SEP - 270.00 0.00 $0.00 TOTAL ACMTY COST: $170.00 MATERIA IS j , �. 1 1)%y/2CMA. INSTALL TUB/SHOWER 1.00 2) 1/2 C 90 VALVE 1.00 21 1/2C.MIL BANGER FOR NEW TUB 3.00 2`) 1/2 COP TUBE 2.00 1) SYMONS RE OD PLATE .CP 35.00 0.00 0.00 0.00 0.00 0.00 TOTAL MATERIALS COST: N£T. 10 DAYS THANK YOU TOTAL BILLING: $31.8.00 Invoice Date.. 1...... O- o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ` SACHUSEtth This certifies that ... ).�) ...l.l.=.'f.�� �!'.1�x has permission for gas installation .,/: ............... in the buildings of ...:....................................... at ....... ............ . North Andover, Mass. r Fee...?.:... Lic.No..:�....? Check # ( y J :-)......... . GASINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print a Type) G .A/% . 7 til 144 (,P0 ,^ , Mass. Date - J �'. �2- _A1 2c2/, '� _ _ Permit # Building Location J eQ.. 6 f' S tM f : Owners Name V,-6.,_-14,jP?j , P -- be Al. Ao-744;&z. )UGT Type of Occupancy-,Bj�� N T, rQ i— New p Renovation p Replacement 2- PlansSubmitted: Yesp No p Installing Company Name 'A(-jA= g T "t . �5AM MA TrA r2O Check one: Certificate Address 30 CrDA [ H I" A ry i—ti(, ❑ Corporation M E T H U E n1 r11 rl 0 l k y ❑ Partnership Business Telephone 6g! - 9 9 -7 f -2-Firm/Co. Name of Licensed Plumber or Gas Fitter -'�ojBEleT A• SAMMiI A r� INSURANCE COVERAGE: I have a current �I ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2' No ❑ If you have checked Ye, please indicate the type coverage by checking the appropriate box 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I 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 the pe r ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of her Laws. BY T of License: C� Plumber n ure of cen u or itter r►ue tter 8333 9er License Number City/Town 0 IC Journeyman mom ill .. - .....■.■..�■..�....�..��.� Installing Company Name 'A(-jA= g T "t . �5AM MA TrA r2O Check one: Certificate Address 30 CrDA [ H I" A ry i—ti(, ❑ Corporation M E T H U E n1 r11 rl 0 l k y ❑ Partnership Business Telephone 6g! - 9 9 -7 f -2-Firm/Co. Name of Licensed Plumber or Gas Fitter -'�ojBEleT A• SAMMiI A r� INSURANCE COVERAGE: I have a current �I ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2' No ❑ If you have checked Ye, please indicate the type coverage by checking the appropriate box 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I 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 the pe r ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of her Laws. BY T of License: C� Plumber n ure of cen u or itter r►ue tter 8333 9er License Number City/Town 0 IC Journeyman z 0 P u W a N Z N N w cr C7 O Ix 0. LL 4. o i d Z' H r W N N J o z df o 0 c W 1 0 U � Ous O Z 0. Q O W W 3 Z G 0 W m a v J 0. d W W W LL 4. o i :i W d N _Z df a v 1 i Date . - !. - 07 . . r' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that "." .. ........ ........ . has permission to per orm ..�LC?�!.. �` ......... . plumbing in the buildings of ..°"° at ./o? . ��-! �,Sv n ...................... North Andover, Mass. b Fee.Lic. No.. -.��<3 ............ ............ . PL ING INSPECTOR Check ,H /S—D 8134 f� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS `` Date Building Location % oZ G 1 ,� O"1'` Owners Name Lilac. a A i s`14 d Permit # 01 ^ Amount Type of Occupancy t�J W t New 1:3 Renovation F1 Replacement c- Plans Submitted Yes 1:1 No (Print or type) S j Check one: Certificate Installing Company Name [� 42 P Co rp. Address 5—O a 0 t ❑ Partner. Business Telep one Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner ❑ Agent n 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 ' tall ions pe ormed under Pe it Issued for this application will be in compliance with all pertinent provisions of the Mas ch is State u bin de and hapter 142 of General Laws. By: igna ure ol LIFFF—seuum of Plumbing License Ty e Title b City/Town icense INumBer Master (OFFICE 1:1APPROVED toCE USE ONLY i i • 14 (Print or type) S j Check one: Certificate Installing Company Name [� 42 P Co rp. Address 5—O a 0 t ❑ Partner. Business Telep one Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner ❑ Agent n 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 ' tall ions pe ormed under Pe it Issued for this application will be in compliance with all pertinent provisions of the Mas ch is State u bin de and hapter 142 of General Laws. By: igna ure ol LIFFF—seuum of Plumbing License Ty e Title b City/Town icense INumBer Master (OFFICE 1:1APPROVED toCE USE ONLY r I .JIM � t rut Thee Commonwealth of Massachusetts Department of ljoustr al Accidents Office of Inveskgatio►rs 600 Washington Street Boston, MA 02111 www-nmsgov/dia . �F'orkers' Compensation Insitranee Affidavit. Builders/Contractors/Electricians/Plumbers aiL't_ant Informafinn Nazne Address: CitylState/Zip; Phone #: . Are you an employer? Cheek.the appropriate box: i. ❑ it am a employer with 4. ❑ I am a general contractor and I employees (fun and/or part-time).* 2. ❑ I am .a.sole proprietor. or have hired the sub -contractors listed partner_ ship and have no employees on the attached sheet, $ These sub -contractors have working far me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ .We are a corporation and its required.] 3. ❑ I ain a homeowner doing officers have exercised their all work right of exemption per MOL myself. [No•wor6rs' comp, c. 152, § 1(4), and we have no insurance required.l.t employces. [No workers' comp, insurance uired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demoiition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof mpairs I317.Other •Any a{Owncim who checks botC a I must also Fitt our the section below showing their workers' compensatiae policy mformation. I r Homeowners who submit this affidavit Indic afing they ars dMing all work and then hire outside contractors Must submit a new affidavit indicating succi. _ ;Coattactors that check this box roustatt elmd an addt'tional sheet showitgg Ehe ttemc of the suh-con tractors and their wotkars' cen. oatier inf l....A14 . , an employer that is provi&n :workers' cornpensadon insrerancefor erg' eirrP[oYees: Below is the o • - _._... information. p hcY and job site . Insurance Company Name: Policy .# or Self -ins. Lic. #: Expiration Date: Job Site Address: workerCity/State/Zip: Attach a copy of the s' coaepensaiion policy declarati Failon page (showing the policy number and expiration date ure 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 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office WpRK ORDERnd a fine l a Investigations of the DIA for insurance coverage verification.of I do hereby certify under the panes andpenalties ofperjury that the information provided above is true and rorreet O, fj`tew ase only. Do not write in this area, to be completed by city or town o rxa( City or Tower: Permit/License # Issuing Authority (circle one): I. Board of Health Z Building Department 3. City/Tovvu -Clerk 4. Electrical Inspector 5.. Plumbing IIwna..f... 6.Otbe'r Contact Person: Phone #: Information a. end Instructions Massachusetts General Laws chapter 152 requires all emp I oyers 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, mcn diatian, corporation or other legal entity, or any two or more of the'fomgoing engaged in a joint enterprise, and includirn the legal representatives of a de;=ased 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 license or permit to operate a baseness or to construct buildings in the commonwealth for any applicant who has not produced acceptable evideuce.of compliance with the insurance coveragge required." Additionally, MOL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pmformsnee of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presmftd to the cantracting 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), aund 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 UP 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, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are requited to obtain a workers' oompensation policy, please call the Department at the numberlisted below. $elf in -scared oornpaniess should enrt the self-insuranoe license number on &e* appropriate dine. 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 appiicant that must submit multiple permit/iicanse 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•tbe affidavit that has been officially stamped or marked by the city ar 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 flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as 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, IviA 02111 TeL # 617-727-4900 ext 406 or 1-9.77-MASSAFE Fax # 617-727-7749 Revised 5-26-45 www.raass.gov/dia Date ... O / .... . WORTIy o F TOWN OF'NORTH ANDOVER p • PERMIT FOR GAS INSTALLATION T This certifies h� that . ! `. - !... � !'�L�? e........ ... . has permission for gas installation L-- .t'.. . !� 4.r.4r-4 --... . 4/( in the buildings of . wl �^! �.�� .�... l �'^" .`. S .......... at .. ...� !r.7 ..... /.. n... , North Andover, Mass. Fee.. Lic. No.. (?. `� .. + :............ . G�CTOR Check # rD 6 b �-- MASSAMUSEIM UNIFORM APPUCATON FOR PUMU TO DO GAS Frrr'ING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date / �/ q Building Loqations owner's Name New Renovation Replacement rwwmwmn� [a (Print or type) Blame_ Address .5 U lJ h k Lev /L- L usm�eepe r, Name of.Licensed Plumber'or Gas Fitter Permit # . Amount $ Plans Submitted ❑ " w to U zz w v J w Q s 1-z z Q aWj e e z w w iU 0--BASEM ENT o z '' v IASEM ENT a a ST. FLOOR N D, FLOOR w q RD, FLOOR T . FLOOR cz Ww T . FLOOR TN. FLOOR TH. FLOOR FLOOR (Print or type) Blame_ Address .5 U lJ h k Lev /L- L usm�eepe r, Name of.Licensed Plumber'or Gas Fitter Permit # . Amount $ Plans Submitted ❑ " Check one: Certificate Installing Company Corp. . 11 Partner. 1_31irm/Co. E:=e NCE COVERAGE Check one: current liability Insurance, policy or it's substantial equivalent. ave checked es Yes please indicate the type coverage by checking the appropriate box.Gy No� insurance policy �� Other type of indemnity Bond13 insurance Waiver 1.amaware that the licensee does ndoes n---°�=e the Insurance coverage required by Cha ter 142neral Laws, and that my signature on this permit application waives this requirement.P of the of Owner or Owner's AgentCheck one: certify.that alI of the details and information 1 have submitted (or entered) in wner 0 applicatione best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application c compliance with all pertinent provisions of the Massac a Stat and accurate to the as Code d Ch er .142 of th eneral'Laws ill be in By: 19nature of Lice ed Plumber Or G Fitter Title Plumber City/Towrl; Gas Fitter (cense um er Q' Master APPROVED (OFFICE USE ONLY) Journeyman w to U � c o z t5o, a a w q cz Ww Check one: Certificate Installing Company Corp. . 11 Partner. 1_31irm/Co. E:=e NCE COVERAGE Check one: current liability Insurance, policy or it's substantial equivalent. ave checked es Yes please indicate the type coverage by checking the appropriate box.Gy No� insurance policy �� Other type of indemnity Bond13 insurance Waiver 1.amaware that the licensee does ndoes n---°�=e the Insurance coverage required by Cha ter 142neral Laws, and that my signature on this permit application waives this requirement.P of the of Owner or Owner's AgentCheck one: certify.that alI of the details and information 1 have submitted (or entered) in wner 0 applicatione best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application c compliance with all pertinent provisions of the Massac a Stat and accurate to the as Code d Ch er .142 of th eneral'Laws ill be in By: 19nature of Lice ed Plumber Or G Fitter Title Plumber City/Towrl; Gas Fitter (cense um er Q' Master APPROVED (OFFICE USE ONLY) Journeyman -'s 1 ne L'ommon" zith of Hassachusetts Department of Industrial 4cci�lents f1ce Of Irnvestigations 600 N'ashirzvon Street Boston, MA 02111 WorkersCompensation Ins sgov/c� Acant Inforuatioi nce€davit.Buiders /Conirac%rsE ectricians/Piambers NaIIle (Bu siness/Organiza ion/individual): Address: City/State/Zip: Are you an employer? Check the appropriate box• 1. ❑ I an. a employer with employees (fill and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. No workers', comp. insurance required.] 3. ❑ Iam a homeowner doing all work Myself [No. workers' comp. insurance required.] t *Any appliamt.that checks box # 1 .must also fill out th Phone #: 4.❑ lam arr—. I M-- era contractor and I have hired the sub -contractors Iisted oza the attached sheet t These sub -contractors have workers' comp. insurance. [] We area corporation and its ofncem have exercised. their right of exemption per MGL C. 152, § 1(4), and we have no employees, [No workers' camp• insurance required.] Type of project (required): 6•. ❑New construction . ❑ Remodeling . a. ❑ Demolition 9. ❑ Building addition 10:0. Electrical repairs or additions i 1.❑ Plumbing repairs'oraddhions 12,11 Roof repairs 13.❑ Other e section below showing th.-ir workers compensation ii r riomcownerF who submit •flus &ti�davtt inc" tltei art; Goiter a i ;,V- A. 1Conm=rs deal check this box. �-tcu tit Po mthrmatioa. must attached an additional sheet sho" m o ftl outstoe contraciurt muni subtnii a new atntiav � the rtasrte.of fl:e scb-c-- it indi.:sing o;;oh. I am rm. em.Plover M is providing Works -M t co ar� ��arectors and their workCty' comp, policy iniommtion. information °°�t%-�n Insurance for m3' e mP10Ye-s Below is the policy andjob site Insurance Company Name: Policy # or Self .ins. Lic. #: Expiration Date: Sob Site Address: Attach a copy of the workers' compensationtic City/State/Zip: p° y tiecEa ration page (showing the oil .Failure to secure coverage as required under Section 25A of Policy number and expiration date). fine up to 51,500.00 and/or one-year imprisonment; as well MGL c. 152 can I=' to the imposition of criminal penahies of a Of up to .S2S0.00 a da against as civil penalties in the form of a STOP WORK ORDER and a fine y a=arrest the violator. Be advised that a copy of this statement map be forwara d to the Office ER a Investigations of.the DIA for insurance coverage verification. f,"Lm% ana penalties o e u � p r! rJ th¢t the informa6 n provided above is True and correct Official USE only. Do not write inthis area, to be co►npleted by city or town off ccaL City or Town: Issuing Authority (circle one): Pernlit/License # 1. Board of [Jealth 2. Building Department 3. City/Tow,, Other Clerk 4. Electrical Ins pecto r 5. Plumbino b Inspector Contact Person: Phone 4- lniormanon and instl•uciions Massachusetts General Laws chapter 152 requires all empioyers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined. as ".. ever—y person in the service of another under any contract of hire, express or implied; oral or writton." An employer is donned as "an individual, partnership; association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and incluciir:g the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associate on or other legal entity, employing employees. However the owner of a dwelling house having not more than .three ap a-rtments and who resides therein, or the occupant of the dwelling house of another wh.o employs persons to do mintenance, 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 1525 §25C(6) also states that "every state o►r 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 worl< uurtal 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 compel-etely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) narne(s), address(es) and phone number(s) along with their czertificate(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 carryworkers' compensation insurance. ff an LLC or LLP does have , employees, a policy is required. Be advisedthat this affidavit may .be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also The sure to sign and date the. affidavit. Theaffidavitshould ba returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should vou.have. any questions re=�rdirg the law or. if you are required to obtain a workers' compensation policy, please call the Deparnnent at the nriirmber,listed below. Self insured companies should enter their self nsurance ficense number on the appropriate line. City or Town Officials Please be sure that the kfridavit .is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appii=L Please be sure to fill in the permifflicense number which will be used as a reference number. In addition, an applicant that must submit multiple pennittlicense applications in arty given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should writs "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 futurf-- permits or Iicenses. A new affidavit must be filled out each year. VA= a home owner or citi= is obtaining a licenses 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 M=achusetts Department of l industrial Accidents Office of Lnvestigati4ons 600 Washington Street Boston; MA 62111 Tel, 4 617-727-4900 Mrt 406 cr 1-877-MASSAFE Revised 5-26=05 Fax 4 61 7-72.7-7749 WWW-mass.Dov/dia Location = !". ,No. 22n Date f�-j NOItTIy TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ AMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL i Check # �,?9/6 `116 7 67 eBuilding Inspect r e The Colnlnonwealth of Massachusetts U,r'f 1.2 Assessors Map and Parcel Number: State Board of Building Regulations and . TOWN OF NORTH ANDOVER Standards 1.3 ZoWq Information: BUILDING DEPARTMENT Massachusetts State Building code Zoning D6trid Proposed Use 780 CMR Frodalge(ft) 1.6 Building Setback R APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number.. /� D J Data Issued: 3 o©.3 U' C Rear Yard Signature: Provided Building Commissioner for of Buildings Date RFf'I7nN 1 _ 31TF. rNFARMATInN 1.1I Addaa ,�j U,r'f 1.2 Assessors Map and Parcel Number: 7ohvn 1 Hq Map Number C;) 2 ParW Number c� 1.3 ZoWq Information: License Number 1.4 Pmpotty Duueosioos: Zoning D6trid Proposed Use Area (sq) Frodalge(ft) 1.6 Building Setback R j )5 Z� Frod Yard 5C�' co zc� Side Yard Signature Telephone q Lo IZY Rear Yard Required Provided Not Applicable Q Required Provides Required Provided Expiration Date SO `r to ZC7 Signature Telephone g' / 65, 107 WaterSupply9MO.LC.40.4 S4Z Public Private o 1.3. Flood Zoo Information: Zone � Outside Flood Zone Q 1.8 Sew I)upoad System: Municipd On Site Disposal System 2.1 Owner of Reoord W aOCt RLOCIe 1-6vne5 Coo 10 Name (Print) Address:. 10 (0cp0 ISY 1 d e Red e/ Signatura Telephone 97 (082 7093 2.2 Authorized Na.�q (3ar Name (Print Tv � aaffiAddress 3 w t -j / t r -q3 k 4 W tQ � AA Signature Telephone p CD Qw-rinN a ry%veTDTTf nf%V %zviD fmwe unu vunTQlTQ 1 4QQ TUAN M fWW%r1T4Tr1 VQVT nip vwry rW VT QDAfR 3.1 Licensed Construction Supervisor. Not Applicable Q 7ohvn 1 Hq Licensed Construction Supervisor: License Number (0-�3��3 `die if�(1 t Q wls red r<� Exptiori Date 3 j )5 Z� 5C�' co zc� Signature Telephone q Lo IZY 3.2 Registered Hoe ement Co tor A Q SS C� Not Applicable Q Company Name Registration Number I 0 Address_ tx-Ad (� `7 S' Expiration Date SO `r to ZC7 Signature Telephone g' / 65, Kcvlsem LYY/ JM(: X) f Q QS Ck i SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction Existing Building Repairs U Alterations Addition 13 Accessory Bldg. Q 1 Demolition I Other [3 Specify Brief Description of Proposed: ✓1 dbw g o �t- S . T 1 ✓1 s Iej 1,09 SECTION 7 - USE GROUP AND CONSTRUCTION TYPE Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT USE GROUP Check asapplicable) Signature of Owner Date CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA 1B Q 8 B Business 13 2A 2B 2C 13 E3 13 E Educational 0 F Facto 13 F-1 F-2 H MghHazard. 0 3A 3B 0 O I Institutional M I-1 I-2 I-3 M Mercantile 0 4 R Residential E3 R-1 R 2 R-3 5A 5B Q 13 S Storage E3 S-1 S-2 U Utility Specify: M Mixed Use Specify: S Special Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing ifapplicable)Pr Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , As Owner of subject property hereby authorize T -T Pi i Qn C_ to act on my behalf, in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION 10b - OWNER/AUTHORUED AGENT DECLARATION I, , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Sisnature of Owner/Aeent Date SECTION 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction from 6 �� 0 DOD 3. Plumbing Building Permit Fee (a)(b) 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number 64A? 9F 41`.RU4,�►TIONS r a lUCens9: CONSTRUCTION SUPERVISOR y I' NumbQR 033843 1 ` Tr. no: 19350 JOHN T HAFFE 1:X 3 WILL WAYLAND, MA 01� Admin(strator a k. <WO c - =D a(n O -n D CL .m{ O � y C V r c Q m cn A O O w V Oa 0 > bd 0 0 �� rpt cn O cn O cn m 00 W ,t v rA O NCO go � a 4 Co (D pO O UAi A O N O 7 oy0agr ° > d r•�s vC, � A 0 = E:.s oa � I c - 7J 20 T w T CA CA >m o. c c - Oco O o ,„ r O m a < o m o X 3 a v o o A a A > > 0 < n vw m M. No 9 W o<i . 'n m c o m Y0 1 ((n --4 0 A O G v. Z \ C b 0 0 0. z a <WO c - =D a(n O -n D CL .m{ O � y C V r c Q m cn A O O w V Oa 0 > bd 0 0 �� rpt cn O cn O cn m 00 W ,t v rA O NCO go � a 4 Co (D pO O UAi A O N O 7 oy0agr ° > d r•�s vC, � A 0 = E:.s oa � I c - 7J 20 CA CA o. c c C-O A O 0 <WO c - =D a(n O -n D CL .m{ O � y C V r c Q m cn A O O w V Oa 0 > bd 0 0 �� rpt cn O cn O cn m 00 W ,t v rA O NCO go � a 4 Co (D pO O UAi A O N O 7 I Address: Offcial use only dp of write 0 this area to completed clky`oti ov�m . o yusettsThe C City: Department ofOV0. $�, � ccl�ents insurance co. policy # Office of lnvesfl atlons 13 Building Department 600 Wet et �. (•. a�'� Boston, Mass.. 02111 ❑check If. immediate response is'requlred . : + �� r. ' Workers' Compensation Insurance Affidavit ;I phorie # Insurance co, Location' i 0' `Wood R t. of e. City: o r'tl/� ay1Cio Ve r (kA phone # ❑ I am a homeowner performing all work myself, ❑ I am sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this Job. Company name: J- I ^ k4l e + 13v i Net's -T;i a - Address: 1 3 P-4 City: W u v4ci /ltii d) t 7 Z phone # SCC S Zp `i t �0 8 Insurance co. 4 oh ''� cc�+tiQ policy#. WC.(�2 `-� 13 80 •-vt° 1Z—=s-a � ❑ 1 am sole proprietor, general contractor, or homeowner, (circle one) and have hired the contractors listed below who have the following workers' compensation policies: 1 Company name: be 6y "ofBclal Address: Offcial use only dp of write 0 this area to completed clky`oti ov�m . City: phone # insurance co. policy # Company name: 13 Building Department Address: �. (•. a�'� ❑ Licensing Board ❑check If. immediate response is'requlred . : + �� r. ' City: ;I phorie # Insurance co, x. policy # F.alit re, to aeoure coverage es.`tequlr:$'464d Section. §A of Mc3L';142;can`�e.;� `to tfiq:imp ition of criminal penalties`of a fine up to $1,500.00 and/or one year's Imprisonment as wall as,oivll penalties in the form of a sTOR.WORK.ORD,R,'and,a fidkof 5100.00 a day against me. I understand that at copy or this statement maybe forwarded to the office of Investigations of the DIA fgrcoverape verification. 1 do hereby certify under the pains and penalties of polury that the lnfomiatlon pro �tded above is true and correct, Signature Date Print name Phone # 0 S- CO Z�Q l (OR be 6y "ofBclal Offcial use only dp of write 0 this area to completed clky`oti ov�m . City or.town: ; cermitfticense # 1: 13 Building Department �. (•. a�'� ❑ Licensing Board ❑check If. immediate response is'requlred . : + �� r. ' D Selectmen s Offige: ❑ Health Depaltmeht sxptad person a hone.:# �� EI Other G r= tS Jrii'^ l' art 4�' M .�" "1 .1•. ��' .�..,..,.. r,��. � a �•.+r.�t. :i.wr7.1., ... K• Y r.,�!.J��..ti:. r.:sw� :4�.' .r.. , ., i.t:•,r'f.-..jt 1. � I�h... `S t� f ih �� )tJdYsw \ t j�(/{r 8�.!rF{�\f �.�r, jr �ji1 Mr , V• ;`�jFj#i;� 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 in: f a U V-, , m o. s s (Location of Facility)' Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [M.G.L. 0152 § 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 YesJr.No SECTION S - PROFFESSIONAL DESIGN AND CONSTRUMON SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35%000 C KOF ENCLOSED SPA 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Siawture Telephone Expiration Date 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 Geneml Contmetor Not Applicable 0 Company Name: Responsible in Charge of Construction Address Signature Telephone R.� e f*'�7N', � N R" O CD L v � Z d O ca � C � c cm o.— ca 0-0 yO .O E Cam CD 0 CD CLI..+=+ O cm O OL R O d ca O CcC C co V y c C C— C c wa(A 0 U) CC W CcW U) x -rcu 0la � � U C C v •� U -coa C w W O w C w" W V W a Cd u. � w CO w A w cn cn e f*'�7N', � N R" O CD L v � Z d O ca � C � c cm o.— ca 0-0 yO .O E Cam CD 0 CD CLI..+=+ O cm O OL R O d ca O CcC C co V y c C C— C c wa(A 0 U) CC W CcW U) Location No. Date f� TOWN OF NORTH ANDOVER /«•� 'Y Certificate of Occupancy $ SMUSEt�'' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 291s' 6763 �/ Building Inspe "Yr The Commonwealth of Massachusetts 1.2 Aasessara Map and Paroel Numbs: Name (Print) State Board of Building Regulations and . TOWN OF NORTH ANDOVER Standards Lot Area (sq) Prootage(ft) BUILDING DEPARTMENT Massachusetts State Building code =S— Telephone CD ZO % 780 CMR I Q vtt� Expiration Date APPLICATION TO CONSTRUCT REPAIR, RENOVATE, •CHANGE THE USE.OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number as Date Issued: n p r1 01 _ a C) O J V� � Signature: Signature Telephone jr Building Commissioner for of Buildings Date l;Vf'rrnN 1_ QTTV TNmvmATTAN LI Property AddraL 1.2 Aasessara Map and Paroel Numbs: Name (Print) Map Number Puml Number ' I 1.3 Zoning Information: 1.4 Property Dimeaaionr Zoning District Use Lot Area (sq) Prootage(ft) 1.6 Buildin¢ Provides Rear Yard 1107 Waw Supply 9MO.L.C.4o.4 9 54i 11.5. Flood Zone Information: iw--iZ is Sew a Disposal System:Public. Private 0 11Zom n Outside FloodZone p lb on site Disposal System 2.1 Owner of Record W 00"t RLe �6r es Coo Name (Print) Address:. 1 C7 Cid ta:QFsr i d t? 1 Z c.� e/ Signature Telephone q -7 (p 82 7Q4 3 2.2 Authorized -1 . H A,'CT' (3 Name (PrintJ-v 1 _ 0. �! 1 ej Address 3 w t / 11 Q n3 k4 c� lQ vvv W !g =S— Telephone CD ZO % QWr`TANA rnN.QTQ1ilTTAN QV12VTf'VQ VAD VVATWf rQi VQQ THAN 2t trh"TUIV VVVT AV VNf9 fWIM QVAf'P 3.1 Licensed Construction Supervisor: Not Applicable Q Licensed Construction Supervisor: License Number . O 33��3 Address- Wi 1 (1 Q w1S �LP I Q vtt� Expiration Date 5 2_� 2-0 Signature Telephone jr 3.2 Rej4stered Hoe Imimement t;olactor: Not Applicable Q �� Company Name Registration Number Q Lq Address Expiration Date SO to ?_8 Signature Telephone '? to & KCVISOa IYY/ JMI: 4 SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction Dasting Building Repairs U Alterations Addition 13 Accessory Bldg, Demolition 13 1 Other 13 Specify Brief Description of Propo . 4- A-2 A-5 A-3 IA 1B Cpr nnm 7. TT.CR (3RnTTP ANT) rOMTRU TTON TYPE USE GROUP Check asapplicable) Independent Structural Engineering Structural Peer Review Required Yes No 13 CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA 1B Q 8 B Business 13 2A 2B 2C E3 0 E Educational C) F Facto F-1 F-2 H High Hazard Q 3A 3B O I Institutional Q I-1 I-2 I-3 M Mercantile El 1 4 R Residential R-1 R 2 R-3 SA 5B Q C) S Storage 13 S-1 S-2 U Utility Specify: M Mixed Use(] Specify: 113 S Special Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. AMMONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existin if applicable)Fr d Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11i I Independent Structural Engineering Structural Peer Review Required Yes No 13 SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L , As Owner of subject property hereby authonz4 T T P c i t , �n G, to act on my behalf, in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION 10b - OWNEWAUTHORIZED AGENT DECLARA L , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date L.nnmrnwr r ar rn t A TC71 rAxTeTQT V''nnV rA4ZTC 04.A ALVL\ LL Item Estimated Cost (Dollars) to Official Use Only be completed b permit applicant 1. Building (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of 0� 00 Ci Construction from 6 3. Plumbing Building Permit Fee (a)x(b) D D 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [NLG.L. c. 152 § 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 Cr SECTION S - PROFFESSIONAL DESIGN AND CONSTRUCCION SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered Professional En ' e s Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 53 General Contractor Not Applicable 13 Company Name: Responsible in Charge of Construction Address Signature Telephone . � :, ✓ ai '�Oomoxon�uec�lJ� `OQAR ✓�aa6adi<iIaO0�CTeNlt34 l.icemse: CONSTRUCTION SUPERVISOR Numb2R 033843 Tr. no: 19350 �! JOHN T HAFFE 3 WILLIAMS RO 7?; WAYLAND, MA 01 Administrator i.> • 0 11 �wol v'== D C-3 T CD D a`� -< O co � C co m �apw�r O 4 O rn O O SWC— d O �� o qp V fDaro o,� a p1 c � � w a o• � H ^; wo a H o>. y n m c a C Op co � a I v co r m x �\ O 3 a O ^ m o tin v A o o > > a p p CO N m < V 0 m M I ! O O U O -, v G m I Z d � i c � O a a �wol v'== D C-3 T CD D a`� -< O co � C co m A O O O Oma'—, cn O n Q I oo U. O Ngo a -, < 00 N d A CT1 O d O 7 �apw�r O 4 O rn O O d O �� o V fDaro o,� a p1 c � � w a o• � H ^; wo a H o>. c a C � a I C � I O I ! o � m I d � i c � A O O O Oma'—, cn O n Q I oo U. O Ngo a -, < 00 N d A CT1 O d O 7 r y • y .F���,y' ?ry r.. r t ,� S { rte h91�y" � 1 . .The Commonwealth'dr saQhusetts Department of Indccl�ents y; Office of lnvesflgat,Jons a 600 WashIn, gton; Sireet Boston, Mass. 02111 r Workers' Compensation Insurance Affidavit Location: \0'- lO ood R t. r.L e - City: N o r4', ncLo ve r ►'Yy9 phone # ❑ I am a homeowner performing all work myself, ❑ I am 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 name: Address: e r I i u in23 City:_ W a"A i' a 'vt4( tAA d) l '1 "Z Phone # SCS c o 2fJ `1 l to 8 Insurance co. A �4rwtQ policy # W Cb?-. �T 1 3 F 6 .-UJ° 12 -,s-•a ❑ I am sole proprietor, general contractor, or homeowner (clrcle one) and have hired the contractors listed below who have the following workers' compensation policies: Company name Address: City: phone # Insurance co. Policy # Company name: Address: City: ;+ Ph6Ae # Insurance co. __policy to saci�re coveragq ps. (�quI-'o midi( Sectlon:;Z5A of MOL�;152:cai�`�q� .'toahq:�rrip itlon of criminal penalties of a fine up to $1,500,00 and/or one years imprlsonment as well as.clyil penalties In the form of a 3TOP.WORK:ORD,E.R;and.a fidkof $100.00 a day against me. I understand that at copy of this statement may be forwarded to the Offioe of Investigations of the DIA-forcoverago 4eriticatlon. .. •;:;tiff:,,,.',;, .,.., : ,. I do hereby certify under the pains and penaides of pedury that the Infomiatiori;proylded above Is true and correct. Signature Date Print name PIiOPe # S Z-0 l (0 8 dq of write•iri this area to. be completed by clay oi� dv(m official . Offclal use only City or town: ! r y Dertnitense # ,. ❑ Building Department Board . ' .. O Ucensing Selectmen's Office: & eck if immediate response is required : �+` ; . ❑ Health Department tach arson �" tir' P hone::# ❑ Other �. t.`cs1�'dY•+�y • �C. f i 1 f �;,r>. .::+:Gr,X r^,"(►s�i:;��,.:•t:�. si>i,• F;�F . z..: ` µ " r :•.:f.' w,r F �'t: + t4rt.i•4r1.d y� •;.t;.;�w�,�r,;q•, ��e�-:r.,: iiti tiv�i .7;r y�e�tr yh r7 1. h r r 1' �r r'i �t t y(r � '�a�r �aS tr�,r '�' r <�SAt`,hr G. ;�j,i.r.•. ,, � ,:y ��,+ .v�f� 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 c 11, S 150 A. The debris will be disposed of in: I a u u-)-6V-t mot.ss ►00 S0.. I (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Cf) m m C/) CD0 m CO) .0 az � O d� O.� a� •v .O O o p CL cr %esu .._ CD o CO) CD 0 CA d CD CO) C CO) d CD O CD CD a• y CD CA 0 CD 0 CD OS. dy C c H CAA 7 mO m C) CL m O H m C Z �� H o a?m = y O OCD O . O o IE o o -GO a O m Z cm) t m CD : : V c ?h ig m O o m cn m y d cn c • : 'T1 n m. ,A n yam. Oju O pa ti zJ� y CL Cwt $ C 0 pp C!1 0 _ _.V n . CL 6*6 3E SO COD CA co m m !� F o V o p m .� _ .. cc') O zo -mCzw CD p p► O.* A o m CD, to CL ccla :0 o O m d o 0 x n Pd Irlb y g M 1 90 H 0 9 0 Tis z, lO 1 S NORTH ANDOVER BUILDING DEPARTMENT 27 CHARLES STREET Tel: 978-688-9545 Fax: 978-688-9542 DATE: ,1 / 'j �� C/ NAME" ADDRESS ZONING DISTRICT: TYPE OF B BUILDING LAYOUT PROVIDED: AVAILABLE PARKING SPACES: / / ZONING BY LAW USAGE: rYES,,) NO BUILDING INSPECTOR SIGNATURE _ n --N p - A -0 T)p_U e r -u-) J - - -- Tel � - ACVO_h_� C _M e 4110'-_ ST' r-- 0 WOOD RIDGE HOMES, INC. A Cooperative Community 10 Wood Ridge Drive North Andover, MA 01845 978-682-7093 Fax 978-687-6616 June 1, 2004 To Whom It May Concern: Francisco Hernandez of 5 Gibson Court, North Andover, MA 01845 has received permission from Barkan Management Co., Inc. to use his home address as his business address. We anticipate NO FOOT TRAFFIC or business vehicles to be housed on site. Please do not h" t le\contacting me with any questions your may have. S . Watson Manager Cc: resident file Managed by Barkan Management Co., Inc. a A r e V / �7 4 ",f _— Date..: .......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ ...................................... �A«`' has permission to perform . "" " �"^ �� Q �-' '~ 1 ` / wiring in the building of ....... -�� :::�� �;_.. .. rte �: -: � ................ --�� North Andover Mass. Feec;;�r...�....... Lic. No/ .9?4'. /. ,/.r: Pl ........................... ELECTRICAL INSPECTOR Check # 0� 95-m-1 (..amtnonwaa[� o�rr/as�ac�ttt9st� _ cc�� cc77 _ - a 1JaPar�nrsttE o�.}irs �sevica� BOARD OF FiRE PREVENTION REGULATIONS Offrci:il Use Only Permit No. Occupancy and Fee Checked �2z Lev. 11/99] arum 11..1.1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perl'ornled in accordance with the Massachusetts Electrical Code (NIEC). 527 CMR 12.00.. (PLEASE PRhVT 1N INK OR TY!'G : l LL /iV!'021L.11'ION) lla f e:� d 2 City or Town of. jgy�J01_>.�IZ To the inspector o Wires: By this application the undersigned g,vcs uohcc Mlis or her iutentiou to perform the electrical work described below. Location (Street & Number)— C-4 Owner or Tenant (,L)4t�� R.td {,�nyH S —. Telephone No. Owner's Address /1% r��oadrtagz a2e° Is this permit in conjunction with a building permit? Yes rl ❑ No Lnpvj '(CheckApproprialc Box)Purposc of lluiiding Utility Authorization No.- Existing Scryicc Amps �12 �rolis Oycncead ❑ Und rd g Nu. of 1lIctcrs.. Nen• Service SArqE Anlps / Volts Overhead ❑. Undord b ❑ No: of Meters= Number of Feeders and Ampacily Location and Nature of Proposed Electrical !fork: Completion o%the follenritle table play be wailed b + the inspector orivires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans 1 0.0 otal Transformers KVA No. of bighting Outlets No. of I -lot Tubs Generators KNrA No. of Lighting Fixtures No. of Receptacle Outlets No. of Switches No. of Ranges N'o. of Waste Disposers No. of Dislrivashers No. of Dryers o. of Water K1V Heaters No. Hydromassage Bathtubs OTHER: wimming Pool A'Dove ❑ Irl -NO. o mergent grad. rnd. Battery Units o. of Oil Burners FIRE ALARiIS o. of Gas Burners 1 0. o Detection o. of Air Cond. 1012. Tons eat Punrp I Number 1 -1 -ons Space/Area Heating KW Heating Appliances KIV 110.01 Ballasts o. of tllotors Total !-IP of Zones o. of Alerting Devices ❑nrinarcipat Connection Other o, of Detiices or E uivalenl Wiring - o: of Devices or Equivalent lmmunications l virtu,•' o. of Devices or.Eauivait'll t Attach additional detail ijdesired, or as required by the Inspector ofWires. Ii`iSUR-'ONCE 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 9/ BOND ❑ OTI-IE•R ❑ (Specify:) 03 Estimated Value of Electrical Work:- (Mien required by municipal policy.) (E. pi ation Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, router the paints awn! penalties of perjury; that the information oil this application is trite aitd complete. FIIbAl NAAIE:- iG� tJt t ad i-e..�' Licensee: 1 �liLe_ �tC C' Signature LIC. N0.:��o5'3U (f applicable. C111cn• ••evenlpt.. ill [lie licence n unber line Address': �a�c a r 3 Bus. Tel. `lo.• Alt. Tel. No., OWNER' INSURANCE WAIVER: 1 am aware that the Licensee floes not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. I am the (check onc) ❑ ownei❑owner's as•cut; O►vner/Agent Signature 'Telephone No. =PjHT T -E -r. Ir' 4 �� Date ...... , .... . :otic TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 3�ss.��ty This certifies that ....% ....... .....�'L�`'�.. p..-.......... . has permission to perform a � ..lf 7�.L... . plumbing 'n the buildings of��f�!!��1��. at..f.x�„/...Lft....(,:/%%/ , North Andover, Mass. Fee/!l%. Lic. � /�� // PLUMBING INSPECTOR r Check # vJ{ '6383 MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS �BBuuilding Location/),J �'r 4:2;A %'q eoug % New Renovation APPLICATION FOR PERMIT TO DO PLUMBING /� � Date �— J C� Name «JGYJ,fi�,e/dcae Permit # Lj Amount . ipancy Replacement FIXTURES Plans Submitted Yes No (Print or type)a� Check one: Certificate Installing Company Name /: ?i 2enf�i tJQ Rekr N6— r] Corp. Partner. Firm/Co. Name of Licensed Plumber: -�y (//o aj/ tSCS n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy rM - Other type of indemnityE]Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I ubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work install 'ons rformed under P t Issued for this application will be in compliance with all pertinent provisions of thesachuse S Plu ng o d Chapter 142 of the General Laws. By Signature or Licenseau Type of Plumbing License Title 6 3/ 3 City/Town Ic nse 19111715er Master Journeyman j APPROVED (OFFICE USE ONLY ICY